Positive Late Gadolinium Enhancement Research Articles

Coexistence of cardiac sarcoidosis and genetic cardiomyopathies: a conundrum

Abstract Introduction Cardiac sarcoidosis (CS) is a chronic inflammatory disease characterized histologically by the formation of non-caseating granuloma in the myocardium, however, causes remain largely unknown. Genetic arrhythmogenic cardiomyopathy (ACM) is an important differential diagnosis of CS. Until now, few data are available about the coexistence of CS in a patient with genetic ACM harboring a desmoglein-2 (DSG2) variant. Purpose We report a case series of patients who demonstrate coexistence of histologically proven CS and genetic ACM. Methods This is a multicentric study, which included patients from four high-volume cardiology referral centres for heart failure and ACM in Switzerland, Italy, and Austria. Patients with both a biopsy-proven diagnosis of sarcoidosis with cardiac involvement (according to the 2014 HRS criteria) also harboring a pathogenic/likely pathogenic (P/LP) variant for cardiomyopathy-associated genes were 1:1 matched for age, gender and genetic variant with patients with genetic ACM without CS (Gen-only). Clinical and imaging data (echocardiography (TTE), cardiac magnetic resonance (CMR) and positron-emission tomography (18FFDG-PET/CT) were collected. Results Each group included 5 patients (Gen+CS: age 48 ± 11 years, Gen only: age 52 ± 13.7 years, n=3 (60%) female in both groups). For each group, the following genes with P/LP variants were found: PKP2: n=2 (40%), DSG2: n=1 (20%), DSP: n=1 (20%), TTN: n=1 (20%). In patients with Gen+CS, atrio-ventricular block (AVB) I° (80% vs 20%, p=0.05) and paroxysmal atrial fibrillation (80% vs 0%, p=0.004) were more frequent, and median NT-proBNP levels (1346ng/l, IQR:103-4276 vs. 214ng/l, IQR:131-326, p=0.046), as well as high-sensitive C-reactive protein levels were higher (3.1g/dl, IQR:1.1-24.2 vs. 0.7g/dl, IQR:0.3-0.95, p=0.016). On imaging, Gen+CS patients were more likely to have septal involvement (60% vs 0%, p=0.021), as highlighted by positive late-gadolinium enhancement on CMR, metabolic activity on PET, or focal wall motion anomalies on TTE. Conclusions CS and genetic ACM can coexist. Hence, detection of a P/LP genetic variant associated with ACM should not lead to exclusion of CS, which more frequently presents with AVB, septal involvement, heart failure, and metabolic activity on imaging. On the contrary, CS can be associated with genetic variants in cardiomyopathy-associated genes.FDG-PET/CT

Evaluating the predictive value of late gadolinium enhancement assessed by cardiac magnetic resonance on sudden cardiac death in patients selected for implantable cardioverter defibrillator and cardiac resynchronization therapy implantation: a systematic review and meta-analysis.

Late gadolinium enhancement (LGE) assessed by cardiovascular magnetic resonance (CMR) can evaluate myocardial scar associated with a higher risk of sudden cardiac death (SCD), which can guide the selection between cardiac resynchronization therapy with or without a defibrillator (CRT-P/CRT-D). Our aim was to investigate the association between LGE and SCD risk in patients with CRT using the LGE-CMR technique. We performed a systematic literature search using four databases. The target population was CRT candidates. The primary endpoint was SCD. The risk of bias was assessed using the QUIPS tool. Fifteen eligible articles were included with a total of 2494 patients, of whom 27%, 56%, and 19% had an implantable cardioverter defibrillator (ICD), CRT-D, and CRT-P, respectively. Altogether, 54.71% of the cohort was LGE positive, who had a 72% higher risk for SCD (HR 1.72; 95% CI 1.18-2.50) compared to LGE negatives. In non-ischemic patients, the proportion of LGE positivity was 46.6%, with a significantly higher risk for SCD as compared to LGE negatives (HR 2.42; 95% CI 1.99-2.94). The subgroup of CRT-only patients showed no difference between the LGE-positive vs. negative candidates (HR 1.17; 95% CI 0.82-1.68). Comparable SCD risk was observed between articles with short- (OR 7.47; 95% CI 0.54-103.12) vs. long-term (OR 6.15; 95% CI 0.96-39.45) follow-up time. LGE-CMR positivity was associated with an increased SCD risk; however, in CRT candidates, the difference in risk reduction between LGE positive vs. negative patients was statistically not significant, suggesting a role of reverse remodeling. LGE-CMR before device implantation could be crucial in identifying high-risk patients even in non-ischemic etiology.

Characteristics and changes of cardiac injury with age in children of Duchenne muscular dystrophy: a prospective cohort study

Objective: To explore the characteristics and changes of cardiac injury with age in Duchenne muscular dystrophy (DMD) and its clinical significance. Methods: A prospective cohort study was conducted. The 215 patients diagnosed with DMD in West China Second Hospital from January 2019 to November 2022 and aged from 6 to 18 years were enrolled. Their clinical data, myocardial injury markers, routine electrocardiogram, cardiac magnetic resonance (CMR) and echocardiography were collected. The patients were divided into five age groups: 6-<8, 8-<10, 10-<12, 12-<14 and 14-18 years of age, and matched with healthy boys respectively. Independent sample t test or Mann-Whitney U test was used to compare the clinical data and CMR indexes between DMD patients and controls in all age subgroups, and to compare the value of left ventricular ejection fraction (LVEF) measured by echocardiography and CMR in each subgroup of DMD patitents. Pearson correlation analysis or Spearman correlation analysis was used to explore the relation between the CMR indexes and age in DMD patients. Results: A total of 215 patients with DMD (all male) and 122 healthy boys were included in the study. There were 75 DMD patients and 23 controls in 6-<8 years of age group, 77 DMD and 28 controls in 8-<10 years of age group, 39 DMD and 23 controls in 10-<12 years of age group, 10 DMD and 31 controls in the 12-<14 years of age group, and 14 DMD and 17 controls in 14-18 years of age group. In the DMD patients, the older the age, the lower the levels of creatine kinase (CK) and creatine kinase isoenzyme (CK-MB). In the 6-<8 years of age group, the CK level was 10 760 (7 800, 15 757) U/L, while in the group of 14-18 years of age, it was 2 369 (1 480, 6 944) U/L. As for CK-MB, it was (189±17) μg/L in the 6-<8 years of age group and (62±16) μg/L in the 14-18 years of age group. Cardiac troponin I remained unchanged in <12 years of age groups, but significantly increased in 12-<14 years of age group, reaching the highest value of 0.112 (0.006, 0.085) μg/L. In the DMD patients, the older the age, the higher the proportion of abnormal electrocardiogram (ECG). In the 6-<8 years of age group, the proportion is 29.3% (22/75), while in the 14-18 years of age group, it was 10/14. Correlation analysis showed that the left ventricular end-diastolic volume index was positively related with age (r=0.18, P=0.015), and the left ventricular stroke volume index and cardiac output index were negatively related with age (r=-0.34 and -0.31, respectively, both P<0.001). In the DMD patients, the older the age, the lower LVEF, with the LVEF decreasing to (49.3±3.1)% in the 14-18 years of age group. The LVEF of DMD cases was significantly lower than that of controls in the age subgroups of 8-<10, 10-<12, 12-<14 and 14-18 years of age groups ((57.9±5.2) % vs. (63.6±0.8)%, 60.7% (55.9%, 61.9%) vs. 63.7% (60.2%, 66.0%), 57.1% (51.8%, 63.4%) vs. 62.1 % (59.5%, 64.5)%, (49.3±3.1) % vs. (61.6±1.3)%, respectively; all P<0.01). In the DMD patients, the older the age, the higher the proportion of positive late gadolinium enhancement (LGE). In the 6-<8 years of age group, it was 22% (11/51), in the 12-<14 years of age group, it was 13/14, and in the 14-18 years of age group, all DMD showed positive LGE. The value of LVEF of DMD cases measured by echocardiography was significantly higher than that measured by CMR in 6-<8 years of age group and 8-<10 years of age group (63.2% (60.1%, 66.4%) vs. 59.1 % (55.4%, 62.9%), and (62.8±5.2) % vs. (57.9±5.2)%, all P<0.001). Conclusion: DMD patients develop cardiac injury in the early stage of the disease, and the incidence of cardiac damage gradually increases with both age and the progression of disease.

Association between subclinical atherosclerosis burden and unrecognized myocardial infarction detected by cardiac magnetic resonance in middle-aged adults.

Evidence on the association between subclinical atherosclerosis (SA) and cardiovascular (CV) events in low-risk populations is scant. To study the association between SA burden and an ischemic scar (IS), identified by cardiac magnetic resonance (CMR), as a surrogate of CV endpoint, in a low-risk population. A cohort of 712 asymptomatic middle-aged individuals from the Progression of Early SA (PESA-CNIC-Santander) study (median age 51 years, 84% male, median SCORE2 3.37) were evaluated on enrollment and at 3-year follow-up with 2D/3D vascular ultrasound (VUS) and coronary artery calcification scoring (CACS). A cardiac magnetic study (CMR) was subsequently performed, and IS defined as the presence of subendocardial or transmural late gadolinium enhancement (LGE). On CMR, 132 (19.1%) participants had positive LGE, and IS was identified in 20 (2.9%) participants. Individuals with IS had significantly higher SCORE2 at baseline and higher CACS and peripheral SA burden (number of plaques by 2DVUS and plaque volume by 3DVUS) at both SA evaluations. High CACS and peripheral SA (number of plaques) burden were independently associated with the presence of IS, after adjusting for SCORE2 (OR for 3rd tertile, 8.31; 95% CI 2.85-24.2; p<0.001; and 2.77; 95% CI, 1.02-7.51; p=0.045, respectively) and provided significant incremental diagnostic value over SCORE2. In a low-risk middle-aged population, SA burden (CAC and peripheral plaques) was independently associated with a higher prevalence of IS identified by CMR. These findings reinforce the value of SA evaluation to early implement preventive measures.

Association of increased epicardial adipose tissue derived from cardiac magnetic resonance imaging with myocardial fibrosis in Duchenne muscular dystrophy: a clinical prediction model development and validation study in 283 participants.

Epicardial adipose tissue (EAT) contributes to inflammation and fibrosis of the neighboring myocardial tissue via paracrine signaling. In this retrospective study, we investigated the abnormal changes in the amount of EAT in male children with Duchenne muscular dystrophy (DMD) using cardiac magnetic resonance (CMR) imaging. Furthermore, we constructed and validated a nomogram including EAT-related CMR imaging parameter for predicting the occurrence of myocardial fibrosis in patients with DMD. This study enrolled 283 patients with DMD and 57 healthy participants who underwent CMR acquisitions to measure the quantitative parameters of EAT, pericardial adipose tissue (PAT), paracardial adipose tissue, and subcutaneous adipose tissue. Late gadolinium enhancement (LGE) was performed to confirm myocardial fibrosis in patients with DMD. The DMD group consisted of 200 patients from institution 1 (the ratio of the training set and the internal validation set was 7:3) and 83 patients from four other institutions (the external validation set). Logistic and least absolute shrinkage and selection operator (LASSO) regression was used to select the optimal predictors and to develop and validate the nomogram model predicting LGE risk in the training set, internal validation set, and external validation set. Compared with those in healthy controls, some regional EAT thicknesses, areas, and global volumes were significantly higher in patients with DMD, and 41.7% of patients with DMD showed positive LGE. These LGE-positive patients with DMD showed significantly higher EAT volume (median 23.9 mL/m3; P<0.001) and PAT volume (median 31.8 mL/m3; P<0.001) compared with the LGE-negative patients with DMD. Age [odds ratio (OR) 2.0; P<0.001], body fat percentage (OR 1.3; P<0.001), and EAT volume (OR 1.4; P<0.001) were independently associated with positive LGE in the training set. The interactive dynamic nomogram showed superior prediction performance, with a high degree of the calibration, discrimination, and clinical net benefit in the training and validation of the DMD datasets. The area under the curve (AUC) values of the nomogram in the training set, internal validation set, and external validation set were 0.95 [95% confidence interval (CI): 0.91-0.98], 0.97 (95% CI: 0.92-0.99), and 0.95 (95% CI: 0.91-0.99), respectively. The onset of LGE-based myocardial fibrosis was associated with EAT volume in patients with DMD. Additionally, the nomogram with EAT volumes showed superior performance in patients with DMD for predicting the occurrence of myocardial fibrosis.

Clinical and Echocardiographic Predictors for the Presence of Late Gadolinium Enhancement on Cardiac Magnetic Resonance Imaging in Patients with Carbon Monoxide Poisoning.

Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMRI) reflects the burden of myocardial damage in carbon monoxide (CO) poisoning. This study aimed to identify the clinical and echocardiographic parameters that can predict myocardial LGE on CMRI in CO poisoning. This prospective observational study included patients who presented with acute CO poisoning and elevated troponin I and underwent echocardiography and CMRI to identify myocardial damage at a tertiary university hospital between August 2017 and May 2019 and August 2020 and July 2022. Based on the CMRI findings, participants were categorized into LGE and non-LGE groups. The median age of the 155 patients was 51.0 years, and 98 (63.2%) were males. Median times from emergency department arrival to either CMRI or echocardiography were 3.0 days each. The LGE group included 99 (63.9%) patients with LGE positivity on CMRIs. Time from rescue to hyperbaric oxygen therapy >4 h (odds ratio (OR): 3.31, 95% confidence interval (CI): 1.28-8.56, p = 0.01); serum lactate levels >2 mmol/L (OR: 2.62, 95% CI: 1.20-5.73, p = 0.02); and left ventricular global longitudinal strain >-16% (OR: 2.95, 95% CI: 1.35-6.47, p = 0.007) were significant predictors of LGE positivity. The area under the curve of these predictors was 0.711. Our prediction model, which combines the clinical parameters with left ventricular global longitudinal strain, may be helpful in the early detection of LGE positivity.

A deep learning algorithm for noise reduction in a novel respiratory-triggered single-shot phase sensitive inversion recovery myocardial delayed enhancement cardiac MRI pulse sequence

Abstract Funding Acknowledgements Type of funding sources: None. Background Phase-sensitive inversion recovery improves tissue contrast by correcting for imperfect choice of inversion recovery time, however it is challenging to combine with a free-breathing acquisition. Deep learning (DL) algorithms have growing applications in cardiac MRI to improve image quality during image reconstruction. Purpose Here, we introduce a single-shot phase-sensitive myocardial delayed enhancement sequence with respiratory triggering (SShPSMDE-RT) (Figure 1). This novel sequence allows faster free-breathing acquisition of late gadolinium enhancement (LGE) images with reduced motion artifact (Figure 2.a). We combined this with a DL noise reduction algorithm to further improve image quality as compared to a standard segmented breath-hold (BH) PSMDE sequence. Methods 61 subjects (29 male, age 51±15) underwent cardiac MRI with the SShPSMDE-RT sequence and a standard BH sequence. The DL algorithm was applied at increasing levels (DL25, DL50, DL75, DL100) (Figure 2.b). Qualitative metrics were image quality, artifact severity, and diagnostic confidence, graded on a 5-point Likert scale. Quantitative metrics were sharpness of the left ventricle septum border and the LGE region (distance in mm for signal intensity to drop from 80% to 20%), blood-myocardium contrast-to-noise ratio (CNR), LGE-myocardium CNR, LGE signal-to-noise ratio (SNR), and LGE burden. 324 slices were included in the analysis. The sequences were compared via paired T-test. Results 27 subjects had positive LGE as determined by CMR experts. The average time to acquire a slice for SShPSMDE-RT is 4–7 seconds versus ∼30–40 seconds for the BH scan. The single-shot sequence had significantly better image quality (SShPSMDE-RT 2.1±0.8 vs. BH 1.5±0.6, p&amp;lt;0.001), less artifact (1.2±0.5 vs. 2.6±1.1, p&amp;lt;0.001), and better diagnostic confidence (3.4±0.7 vs. 2.6±0.8, p&amp;lt;0.001). Septum sharpness was slightly worse in SShPSMDE-RT images (4.1±1.7 mm vs. 3.8±1.6 mm, p = 0.008), but the DL algorithm improved sharpness of SShPSMDE-RT images such that there was no significant difference compared to BH images (p&amp;gt;0.5). There was no significant difference in LGE sharpness between the sequences. The SShPSMDE-RT images had superior blood-myocardium CNR (17.2±6.9 vs. 16.4±6.0, p = 0.040), LGE-myocardium CNR (12.1±7.2 vs. 10.4±6.6, p = 0.054), and LGE SNR (59.8±26.8 vs. 31.2±24.1, p&amp;lt;0.001); these metrics all improved with application of the DL algorithm. There was no significant difference in measured LGE burden (p = 0.12). Conclusions Our novel SShPSMDE-RT sequence significantly reduces scan time and motion artifact. This free-breathing sequence combined with a DL noise reduction algorithm provides better or similar image quality on both qualitative and quantitative metrics as compared to a standard BH PSMDE sequence. This technique can be used to obtain LGE imaging in patients who are unable to breath-hold or tolerate longer scan times.

Significance of Anteroseptal Late Gadolinium Enhancement Among Patients With Acute Myocarditis

Anteroseptal location of late gadolinium enhancement (LGE) in patients with acute myocarditis (AM) detected by cardiovascular magnetic resonance may indicate an independent marker of unfavorable outcomes according to recent data. We aimed to evaluate the clinical characteristics, management, and inhospital outcomes in patients with AM with positive LGE based on its presence in the anteroseptal location. We analyzed data from 262 consecutive patients hospitalized with a diagnosis of AM with positive LGE within 5days of hospitalization (n=425). Patients were divided into 2 groups: those with anteroseptal LGE (n=25, 9.5%) and those with non-anteroseptal LGE (n=237, 90.5%). Except for age that was higher in patients with anteroseptal LGE, the demographic and clinical characteristics did not differ significantly between both groups including past medical history, clinical presentation, electrocardiogram parameters, and lab values. Moreover, patients with anteroseptal LGE were more likely to present with reduced left ventricular ejection fraction and to receive congestive heart failure treatments. Although univariate analysis showed that patients with anteroseptal LGE were more likely to have inhospital major adverse cardiac events (28% vs 9%, p=0.003), there was no difference inhospital outcomes on multivariable analysis between both groups (hazard ratio, 1.17 [95% confidence interval, 0.32 to 4.22], p=0.81). A higher left ventricular ejection fraction in either echocardiography or cardiovascular magnetic resonance corresponded to better inhospital outcomes regardless of the presence or absence of anteroseptal LGE. In conclusion, the presence of anteroseptal LGE did not confer additional prognostic value for inhospital outcomes.

The prevalence and associated factors of myocardial involvement in Duchenne muscular dystrophy patients in the first decade of life.

The prevalence and associated factors of myocardial involvement in Duchenne muscular dystrophy patients in the first decade of life.

Predicting Left Ventricular Myocardial Fibrosis in Patients with Hypertrophic Cardiomyopathy by Speckle Tracking Automated Functional Imaging.

The study was performed to explore the predictive value of multiple strain parameters for myocardial fibrosis in patients with hypertrophic cardiomyopathy (HCM) by using speckle tracking automated functional imaging (AFI). A total of 61 patients diagnosed with HCM were finally enrolled in this study. All patients completed transthoracic echocardiography and cardiac magnetic resonance late gadolinium enhancement (LGE) within 1 month. Twenty age- and sex-matched healthy participants were included as the control group. Multiple parameters, including segmental longitudinal strain (LS), global longitudinal strain (GLS), post-systolic index and peak strain dispersion, were automatically analyzed by AFI. A total of 1458 myocardial segments were analyzed according to the left ventricular 18-segment model. Among the 1098 segments from HCM patients, segments with LGE had a lower absolute value of segmental LS than those without LGE (p < 0.05). The cutoff values of segmental LS for predicting positive LGE in the basal, intermediate and apical regions were -12.5%, -11.5% and -14.5%, respectively. GLS could predict significant myocardial fibrosis (≥2 positive LGE segments) at a cutoff value of -16.5% with a sensitivity of 80.9% and specificity of 76.5%. As an independent predictor of significant myocardial fibrosis, GLS was substantially associated with the severity of myocardial fibrosis and 5 years sudden cardiac death risk score in HCM patients. Speckle tracking AFI could efficiently identify left ventricular myocardial fibrosis in patients with HCM by multiple parameters. GLS predicted significant myocardial fibrosis at a cutoff value of -16.5%, which may indicate the adverse clinical outcomes in HCM patients.

Identification of fibrosis in hypertrophic cardiomyopathy: a radiomic study on cardiac magnetic resonance cine imaging

ObjectivesHypertrophic cardiomyopathy (HCM) often requires repeated enhanced cardiac magnetic resonance (CMR) imaging to detect fibrosis. We aimed to develop a practical model based on cine imaging to help identify patients with high risk of fibrosis and screen out patients without fibrosis to avoid unnecessary injection of contrast.MethodsA total of 273 patients with HCM were divided into training and test sets at a ratio of 7:3. Logistic regression analysis was used to find predictive image features to construct CMR model. Radiomic features were derived from the maximal wall thickness (MWT) slice and entire left ventricular (LV) myocardium. Extreme gradient boosting was used to build radiomic models. Integrated models were established by fusing image features and radiomic models. The model performance was validated in the test set and assessed by ROC and calibration curve and decision curve analysis (DCA).ResultsWe established five prediction models, including CMR, R1 (based on the MWT slice), R2 (based on the entire LV myocardium), and two integrated models (ICMR+R1 and ICMR+R2). In the test set, ICMR+R2 model had an excellent AUC value (0.898), diagnostic accuracy (89.02%), sensitivity (92.54%), and F1 score (93.23%) in identifying patients with positive late gadolinium enhancement. The calibration plots and DCA indicated that ICMR+R2 model was well-calibrated and presented a better net benefit than other models.ConclusionsA predictive model that fused image and radiomic features from the entire LV myocardium had good diagnostic performance, robustness, and clinical utility.Key Points• Hypertrophic cardiomyopathy is prone to fibrosis, requiring patients to undergo repeated enhanced cardiac magnetic resonance imaging to detect fibrosis over their lifetime follow-up.• A predictive model based on the entire left ventricular myocardium outperformed a model based on a slice of the maximal wall thickness.• A predictive model that fused image and radiomic features from the entire left ventricular myocardium had excellent diagnostic performance, robustness, and clinical utility.

The initial experience of left bundle branch area pacing in patients with hypertrophic cardiomyopathy.

Whether left bundle branch area pacing (LBBAP) could be achieved in patients with hypertrophic cardiomyopathy (HCM) requiring ventricular pacing remains unknown. The present study aimed to investigate the feasibility and effect of LBBAP in HCM. Patients with HCM who underwent LBBAP were recruited from November 2018 to September 2021. Clinical characteristics, echocardiographic, and pacing parameters were prospectively collected at baseline and during follow-up. Eleven consecutive HCM patients who attempted LBBAP were included (mean age 64.0±8.7 years, female 45.5%, mean interventricular septum 16.7mm). The success rate of LBBAP was 36.4% (4/11) and the reason for failed LBBAP in other seven HCM patients was the inability to screw the lead into the deep septum or capture the left bundle branch. Patients with successful LBBAP had significantly narrower QRS duration than those with failed cases (118.0±3.7ms vs. 140.9±9.4ms, p=.01) while the capture thresholds, sensing amplitudes, and pacing impedances were similar. Successful cases presented with less positive late gadolinium enhancement (25.0%vs. 71.4%, p=.02) and thinner interventricular septum thickness (14.5±1.0mm vs. 18.0±2.5mm, p=.02) compared with failed cases. Pacing parameters remained stable and no procedure-related complications occurred during a mean follow-up of 8.9± 7.3 months. LBBAP may be successfully achieved in less than half of HCM patients due to thick interventricular septum and heavy burden of myocardial fibrosis. Pacing strategies should be cautiously considered in patients with HCM.

Combination of late gadolinium enhancement and genotype improves prediction of prognosis in non‐ischaemic dilated cardiomyopathy

AimsGenotype and left ventricular scar on cardiac magnetic resonance (CMR) are increasingly recognized as risk markers for adverse outcomes in non‐ischaemic dilated cardiomyopathy (DCM). We investigated the combined influence of genotype and late gadolinium enhancement (LGE) in assessing prognosis in a large cohort of patients with DCM.Methods and resultsOutcomes of 600 patients with DCM (53.3 ± 14.1 years, 66% male) who underwent clinical CMR and genetic testing were retrospectively analysed. The primary endpoints were end‐stage heart failure (ESHF) and malignant ventricular arrhythmias (MVA). During a median follow‐up of 2.7 years (interquartile range 1.3–4.9), 24 (4.00%) and 48 (8.00%) patients had ESHF and MVA, respectively. In total, 242 (40.3%) patients had pathogenic/likely pathogenic variants (positive genotype) and 151 (25.2%) had LGE. In survival analysis, positive LGE was associated with MVA and ESHF (both, p < 0.001) while positive genotype was associated with ESHF (p = 0.034) but not with MVA (p = 0.102). Classification of patients according to genotype (G+/G−) and LGE presence (L+/L−) revealed progressively increasing events across L−/G−, L−/G+, L+/G− and L+/G+ groups and resulted in optimized MVA and ESHF prediction (p < 0.001 and p = 0.001, respectively). Hazard ratios for MVA and ESHF in patients with either L+ or G+ compared with those with L−/G− were 4.71 (95% confidence interval: 2.11–10.50, p < 0.001) and 7.92 (95% confidence interval: 1.86–33.78, p < 0.001), respectively.ConclusionClassification of patients with DCM according to genotype and LGE improves MVA and ESHF prediction. Scar assessment with CMR and genotyping should be considered to select patients for primary prevention implantable cardioverter‐defibrillator placement.

Cardiac MRI after first episode of acute pericarditis: A pilot study for better identification of high risk patients

BackgroundCardiac magnetic resonance (CMR) was proposed as an accurate non-invasive tool to evaluate pericardial inflammation. Aim of the present study was to evaluate the role of CMR early in the course of the first episode of acute pericarditis. Material and methodsA clinical registry of consecutive patients who underwent clinical indicated CMR due to pericardial disease from January 2014 to January 2020 was screened. We analyzed patients with the clinical diagnosis of first episode of acute pericarditis needing hospitalization less than 7 days before CMR. Outcome measures were obtained using a single combined end-point, defined as pericardial event, including all the following: recurrent pericarditis, chronic constrictive pericarditis, surgery for pericardial disease. ResultsTwenty-six patients meet the study criteria and were enrolled. A mean follow-up of 34 ± 7 months was obtained and a second episode of pericardial event were recorded in 9 patients. At multivariate analysis adjusted for propensity score, based on clinical significative variable (younger age and higher CRP) the association between pericardial inflammation identified by CMR (positive late gadolinium enhancement on pericardium) and recurrence of pericardial events was confirmed [OR (95%CI) 8.94 (1.74–45.80), p = 0.008]. ConclusionPericardial inflammation identified by CMR, with LGE images, has a prognostic value independently from clinical and bio-humoral variables.

Quantitative analysis of late iodine enhancement using dual-layer spectral detector computed tomography: comparison with magnetic resonance imaging.

To evaluate the segmental myocardial extracellular volume (ECV) fraction and to define a threshold ECV value that can be used to distinguish positive late gadolinium enhancement (LGE) segments from negative myocardial segments using dual-layer spectral detector computed tomography (SDCT), with magnetic resonance imaging (MRI) as a reference. Fifty-six subjects with cardiac disease or suspected cardiac disease, underwent both late iodine enhancement on CT (CT-LIE) scanning and late gadolinium enhancement on MRI (MRI-LGE) scanning. Each procedure occurred within a week of the other. Global and segmental ECVs of the left ventricle were measured by CT and MRI images. According to the location and pattern of delayed enhancement on MRI image, myocardial segments were classified into 3 groups: ischemic LGE segments (group 1), nonischemic LGE segments (group 2) and negative LGE segments (group 3). The correlation and agreement between CT-ECV and MRI-ECV were compared on a per-segment basis. Receiver operating characteristic (ROC) curve analysis was performed to establish a threshold for LIE detection. Among the 56 patients, 896 segments were analyzed, and of these, 73 segments were in group 1, 229 segments were in group 2, and 594 segments were in group 3. In segmental analysis, CT-ECV in group 3 (27.0%; 24.9-28.9%) was significantly lower than that in group 1 (33.2%; 30.7-36.3%) and group 2 (34.9%; 32.3-39.8%; all P<0.001). Good correlations were seen between CT-ECV and MRI-ECV for all groups (group 1: r=0.920; group 2: r=0.936; group 3: r=0.799; all P<0.001). Bland-Altman analysis between CT-ECV and MRI-ECV showed a small bias in all 3 groups (group 1: -2.1%, 95% limits of agreement -11.3-7.1%; group 2: -0.6%, 95% limits of agreement -13.1-11.9%; group 3: 1.0%, 95% limits of agreement -12.7-14.7%). CT-ECV could differentiate between LGE-positive and LGE-negative segments with 83.1% sensitivity and 93.3% specificity at a cutoff of 31%. ECV values derived from CT imaging showed good correlation and agreement with MR imaging findings, and CT-ECV provided high diagnostic accuracy for discriminating between LGE-positive and LGE-negative segments. Thus, cardiac CT imaging might be a suitable noninvasive imaging technique for myocardial ECV quantification.

The Role of Cardiovascular Magnetic Resonance Imaging in the Assessment of Myocardial Fibrosis in Young and Veteran Athletes: Insights From a Meta-Analysis.

Background: Cardiac magnetic resonance (CMR) combined with late gadolinium enhancement (LGE) has revealed a non-negligible increased incidence of myocardial fibrosis (MF) in athletes compared to healthy sedentary controls.Objective: The aim of this systematic research and meta-analysis is to investigate and present our perspective regarding CMR indices in athletes compared to sedentary controls, including T1 values, myocardial extracellular volume (ECV) and positive LGE indicative of non-specific fibrosis, also to discuss the differences between young and veteran athletes.Methods: The protocol included searching, up to October 2021, of MEDLINE, EMBASE, SPORTDiscus, Web of Science and Cochrane databases for original studies assessing fibrosis via CMR in athletes. A mean age of 40 years differentiated studies' athletic populations to veteran and young.Results: The research yielded 14 studies including in total 1,312 individuals. There was a statistically significant difference in LGE fibrosis between the 118/759 athletes and 16/553 controls (Z = 5.2, P < 0.001, I2 = 0%, PI = 0.45). Notably, LGE fibrosis differed significantly between 546 (14.6%) veteran and 140 (25.7%) young athletes (P = 0.002). At 1.5T, T1 values differed between 117 athletes and 48 controls (P < 0.0001). A statistically significant difference was also shown at 3T (110 athletes vs. 41 controls, P = 0.0004), as well as when pooling both 1.5T and 3T populations (P < 0.00001). Mean ECV showed no statistically significant difference between these groups.Conclusions: Based on currently available data, we reported that overall LGE based non-specific fibrosis and T1 values differ between athletes and sedentary controls, in contrast to ECV values. Age of athletes seems to have impact on the incidence of MF. Future prospective studies should focus on the investigation of the underlying pathophysiological mechanisms.

Long-term cardiopulmonary effects after Covid-19 infection

Abstract Introduction The severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic of 2020 has an influence on people's lives worldwide, impacting global health and putting pressure on health care systems. Multiple studies have described acute effects of the Covid-19 infection on the heart, but little is known about the long-term cardiac effects and complications after recovery. The aim of this analysis was to deliver a comprehensive report of symptoms and long-term impairment after Covid-19 infection. Methods This study was a prospective, multicenter registry study. Patients with verified COVID-19 infection, who were treated at our dedicated COVID hospital (Klinik Favoriten), have been included in this study. In all patients, testing was performed approximately 6 months post discharge. During each study visit the following tests and investigations were performed: detailed patient history and clinical examination, transthoracic echocardiography, electrocardiography, cardiac magnetic resonance imaging (MRI), pulmonary computed tomography (CT) scan, lung function test, spiroergometry and six-minute walk test (6MWT), and a comprehensive list of laboratory parameters including cardiac bio markers such as brain natriuretic peptide (NTpro BNP) and troponin T. Results In this interim analysis of an ongoing trial, the first 65 patients are presented. Baseline values are shown in table 1: 34 (59%) were male and the median age was 48.5 years (36.4–59.3). 86% of all patients included so far had an only mild to moderate course of disease and 14% of them had a severe course and were admitted to our intensive care unit. At the time of the study visit, the majority of patients still complained about symptoms: 40% presented with fatigue and weakness, 36% with exertional dyspnea, 21% with vertigo, 17% had an impaired taste or smell. Only 28% were completely asymptomatic (figure 1). From a cardiac perspective, the only abnormal findings noted in echocardiography studies were reduced left ventricular global longitudinal strain. Cardiac MRI revealed pericardial effusion in 19%, however, these were only minimal (≤9mm) and not visible in echocardiography. Furthermore, cardiac MRI showed positive late gadolinium enhancement in 11%. Pulmonary function tests were abnormal in 16%. Pulmonary CT scans showed post infectious residues like bilateral ground glass opacities and fibrosis in 45%. Exercise capacity as measured by the 6-minute walk test with BORG Dyspnea Score and by spiroergometry was reduced in almost 40% of our study participants. Conclusions This interim analysis showed that most previously hospitalized patients still suffer from chronic fatigue, exertional dyspnea and impaired cardiopulmonary function after Covid-19 infection. Furthermore, even though cardiac and pulmonary imaging revealed numerous pathologic findings, and exercise capacity was reduced, no correlations could be found with persisting symptoms. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Klink Favoriten and Medical University hospital Vienna

T1 Mapping and Extracellular Volume Fraction in Dilated Cardiomyopathy: A Prognosis Study

ObjectivesThe aim of this study is to examine the prognostic value of T1 mapping and the extracellular volume (ECV) fraction in patients with dilated cardiomyopathy (DCM). BackgroundPatients with DCM with functional left ventricular remodeling have poorer prognoses. Noninvasive assessment of myocardial fibrosis using T1 mapping and the ECV fraction may improve risk stratification of patients with DCM; however, this has not yet been systematically evaluated. MethodsA total of 659 consecutive patients with DCM (498 men; 45 ± 15 years) who underwent cardiac magnetic resonance with T1 mapping and late gadolinium enhancement (LGE) imaging with a 1.5-T magnetic resonance scanner were enrolled in this study. Primary endpoints were cardiac-related death and heart transplantation. Secondary endpoints were hospitalization for heart failure, ventricular arrhythmias, and implantable cardioverter-defibrillator or cardiac resynchronization therapy implantation. Survival estimates were calculated by Kaplan-Meier curves with the log-rank test. ResultsDuring a mean follow-up of 66.3 ± 20.9 months, 122 and 205 patients with DCM reached the primary and secondary endpoints, respectively. The presence of LGE had an association with both of the primary and secondary endpoints observed in the patients with DCM (both P < 0.001). The maximum native T1 (HR: 1.04; 95% CI: 1.02-1.09) and maximum ECV fraction (HR: 1.14; 95% CI: 1.08-1.21) had associations with the primary endpoints in the patients with positive LGE (both P < 0.001), whereas the mean native T1 (HR: 1.13; 95% CI: 1.10-1.36) and mean ECV fraction (HR: 1.32; 95% CI: 1.12-1.53) had the best associations in the patients with negative LGE (all P < 0.001). ConclusionsT1 mapping and the ECV fraction had prognostic value in patients with DCM and were particularly important in patients with DCM without LGE. Using a combination of T1 mapping, ECV fraction, and LGE provided optimal risk stratification for patients with DCM.

Morphological, Functional, and Tissue Characterization of Silent Myocardial Involvement in Patients With Primary Biliary Cholangitis

Cirrhotic cardiomyopathy is a major complication and cause of morbidity in end-stage primary biliary cholangitis (PBC). However, it is unclear whether there is clinically silent myocardial involvement at the early stage of PBC before cirrhosis and cardiac manifestations. This prospective, three-center, multi-modality cardiac imaging study on the early identification of myocardial impairment in PBC (EARLY-MYO-PBC) was designed to identify silent myocardial impairment in PBC patients without cardiac manifestations. A total of 112 subjects (56 with PBC and 56 age- and sex-matched controls) undergoing cardiovascular magnetic resonance (CMR) were enrolled. Demographic, serologic, and cardiac imaging data were prospectively collected. All participants had no cardiac discomfort or previous heart disease and had normal electrocardiographic findings. Subclinical myocardial involvement, as evidenced by cardiac morphologic, functional, and tissue characterization changes on CMR, including hyperdynamic left ventricular (LV) ejection fraction (median, 75% in PBC patients vs 69% in controls, P= .029), subclinical myocardial edema by T2-short tau inversion recovery (21% vs 2% in controls, P= .001), elevated extracellular matrix indices (30% vs 26% in controls, P < .001), and impaired myocardial viability by positive late gadolinium enhancement (LGE) (36%), was detected in PBC patients. Importantly, a mid-wall "stripe" at the LV septum was identified as a PBC-specific LGE pattern that differs from other known cardiomyopathies. In multivariate analysis, gp210 positivity (odds ratio [OR]= 9.909, P= .010), lower hemoglobin (OR= 0.919, P= .004), and body mass index (OR= 0.638, P= .005) were independent predictors of cardiac abnormalities in PBC. This study demonstrates clinically silent cardiac impairment with specific CMR patterns in PBC, allowing optimal screening for early myocardial impairment and potentially timely therapies. (Trial registration no.: NCT03545672).

Cardiac MRI prediction of recovery in children with acute myocarditis

Myocarditis, defined as inflammation of myocardial tissue, is a rare disease in the pediatric population. Cardiovascular cardiac magnetic resonance (CMR) is a powerful tool for noninvasive assessment of myocardial inflammation as defined by the Lake Louise criteria, with a sensitivity of approximately 82% [1] . CMR allows tissue characterization of the myocardium, as well as accurate definition of ventricular volumes and function. Few prognostic factors have been associated with either normalization of function or progression to dilated cardiomyopathy in pediatric myocarditis. In the present study, we aimed to describe CMR findings in a large cohort of pediatric patients with acute myocarditis and to assess disease evolution. Our study received the proper ethical oversight [CNIL (Commission nationale de l’informatique et des libertés) declaration 2130271 v 0]. Sixty-eight children younger than 18 years of age with clinical myocarditis and positive acute-phase myocardial inflammation, as defined by the Lake Louise criteria [2] , underwent follow-up CMR during a 12-year period (from March 2007 to March 2019). The first follow-up CMR study was performed at a median of 5 months after the first examination (interquartile range: 1 to 6 months), and additional CMR studies were performed in 47% of the cohort (32 patients). Patient characteristics are presented in Table 1 . Most of the cohort were males (73.5%) who presented with chest pain (68%) or new-onset heart failure (33%). Fever was found in 55% of the cohort. Full recovery from acute myocarditis, as defined by normalization of ventricular function [left ventricular ejection fraction (LVEF) > 55%, right ventricular EF > 54%], ventricular dimensions (LV end-diastolic volume index < 104 ml/m 2 for males, < 95 ml/m 2 for females, right ventricular end-diastolic volume index < 108 ml/m 2 for males, < 94 ml/m 2 females), regional wall function and tissue abnormalities [absent myocardial edema and late gadolinium enhancement (LGE)], was observed in 26% of the cohort ( n ¼ 18). Fever at presentation was significantly more common in the patients who had full recovery (100% vs. 43%; P < 0.01). Although baseline LV function was not different between those who had full recovery and those who did not, a non-significantly larger LV volume (79 ml/m 2 vs. 89 ml/m 2 ) was found in those who did not recover. Concerning tissue characterization parameters, positive T2 (90% vs. 77%) and LGE (96% vs. 83%) were significantly more common in patients who did not recover. Early gadolinium enhancement followed the same pattern, without statistical significance. The prevalence of a sub-epicardial pattern of LGE was not different between groups ( P ¼ 0.11), but other LGE patterns were more frequent in patients who did not recover ( P ¼ 0.04). Conversely, acute-phase LGE extent did not differ between groups (4% vs. 3.9%; P ¼ 0.85). To the best of our knowledge, this was the largest multicenter pediatric study that assessed repeated CMR evaluation of acute myocarditis. In the present study, we confirmed the recent finding that LGE in the acute phase of myocarditis was not necessarily a marker of fibrosis. In our population, LGE disappeared completely in 26% of patients, which was higher than the 10% reported in adults [3] . This difference might translate to a higher healing ability of pediatric patients from tissue damage, as seen in other medical conditions. This complete healing of myocardial tissue abnormalities might be clinically relevant because residual fibrosis was associated with worse prognosis independently of LVEF [3] , [4] . In our study, an LGE pattern other than sub-epicardial was associated with non-recovery. This result was concordant with a recent study by Aquaro et al. [5] , who demonstrated a worse prognosis in association with a mid-wall septal pattern of LGE compared with a sub-epicardial inferior-lateral pattern. In conclusion, we found that fever at presentation was associated with full recovery from acute myocarditis, whereas specific acute-phase CMR findings (positive T2 criteria, LGE presence, and patterns other than sub-epicardial) were associated with its absence.