Multiparametric Cardiovascular Magnetic Resonance Research Articles

Cardiac magnetic resonance T2 mapping and feature tracking in athlete\u2019s heart and HCM

ObjectivesDistinguishing hypertrophic cardiomyopathy (HCM) from left ventricular hypertrophy (LVH) due to systematic training (athlete’s heart, AH) from morphologic assessment remains challenging. The purpose of this study was to examine the role of T2 mapping and deformation imaging obtained by cardiovascular magnetic resonance (CMR) to discriminate AH from HCM with (HOCM) or without outflow tract obstruction (HNCM).MethodsThirty-three patients with HOCM, 9 with HNCM, 13 strength-trained athletes as well as individual age- and gender-matched controls received CMR. For T2 mapping, GRASE-derived multi-echo images were obtained and analyzed using dedicated software. Besides T2 mapping analyses, left ventricular (LV) dimensional and functional parameters were obtained including LV mass per body surface area (LVMi), interventricular septum thickness (IVS), and global longitudinal strain (GLS).ResultsWhile LVMi was not significantly different, IVS was thickened in HOCM patients compared to athlete’s. Absolute values of GLS were significantly increased in patients with HOCM/HNCM compared to AH. Median T2 values were elevated compared to controls except in athlete’s heart. ROC analysis revealed T2 values (AUC 0.78) and GLS (AUC 0.91) as good parameters to discriminate AH from overall HNCM/HOCM.ConclusionDiscrimination of pathologic from non-pathologic LVH has implications for risk assessment of competitive sports in athletes. Multiparametric CMR with parametric T2 mapping and deformation imaging may add information to distinguish AH from LVH due to HCM.Key Points• Structural analyses using T2 mapping cardiovascular magnetic resonance imaging (CMR) may help to further distinguish myocardial diseases.• To differentiate pathologic from non-pathologic left ventricular hypertrophy, CMR including T2 mapping was obtained in patients with hypertrophic obstructive/non-obstructive cardiomyopathy (HOCM/HNCM) as well as in strength-trained athletes.• Elevated median T2 values in HOCM/HNCM compared with athlete’s may add information to distinguish athlete’s heart from pathologic left ventricular hypertrophy.

Extreme electrocardiographic changes in congenital complete absence of pericardium with complex coronary artery disease: multiparametric cardiovascular magnetic resonance imaging guiding diagnosis and treatment.

Extreme electrocardiographic changes in congenital complete absence of pericardium with complex coronary artery disease: multiparametric cardiovascular magnetic resonance imaging guiding diagnosis and treatment.

The myocardial phenotype of Fabry disease pre-hypertrophy and pre-detectable storage.

AimsCardiac involvement in Fabry disease (FD) occurs prior to left ventricular hypertrophy (LVH) and is characterized by low myocardial native T1 with sphingolipid storage reflected by cardiovascular magnetic resonance (CMR) and electrocardiogram (ECG) changes. We hypothesize that a pre-storage myocardial phenotype might occur even earlier, prior to T1 lowering.Methods and resultsFD patients and age-, sex-, and heart rate-matched healthy controls underwent same-day ECG with advanced analysis and multiparametric CMR [cines, global longitudinal strain (GLS), T1 and T2 mapping, stress perfusion (myocardial blood flow, MBF), and late gadolinium enhancement (LGE)]. One hundred and fourteen Fabry patients (46 ± 13 years, 61% female) and 76 controls (49 ± 15 years, 50% female) were included. In pre-LVH FD (n = 72, 63%), a low T1 (n = 32/72, 44%) was associated with a constellation of ECG and functional abnormalities compared to normal T1 FD patients and controls. However, pre-LVH FD with normal T1 (n = 40/72, 56%) also had abnormalities compared to controls: reduced GLS (−18 ± 2 vs. −20 ± 2%, P < 0.001), microvascular changes (lower MBF 2.5 ± 0.7 vs. 3.0 ± 0.8 mL/g/min, P = 0.028), subtle T2 elevation (50 ± 4 vs. 48 ± 2 ms, P = 0.027), and limited LGE (%LGE 0.3 ± 1.1 vs. 0%, P = 0.004). ECG abnormalities included shorter P-wave duration (88 ± 12 vs. 94 ± 15 ms, P = 0.010) and T-wave peak time (Tonset – Tpeak; 104 ± 28 vs. 115 ± 20 ms, P = 0.015), resulting in a more symmetric T wave with lower T-wave time ratio (Tonset – Tpeak)/(Tpeak – Tend) (1.5 ± 0.4 vs. 1.8 ± 0.4, P < 0.001) compared to controls.ConclusionFD has a measurable myocardial phenotype pre-LVH and pre-detectable myocyte storage with microvascular dysfunction, subtly impaired GLS and altered atrial depolarization and ventricular repolarization intervals.

Cardiovascular magnetic resonance imaging for inflammatory heart diseases.

Inflammatory myocardial diseases represent a diverse group of conditions in which abnormal inflammation within the myocardium is the primary driver of cardiac dysfunction. Broad causes of myocarditis include infection by cardiotropic viruses or other infectious agents, to systemic autoimmune disease, or to toxins. Myocarditis due to viral aetiologies is a relatively common cause of acute chest pain syndromes in younger and middle-aged patients and often has a benign prognosis, though this and other forms of myocarditis also cause serious sequelae, including heart failure, arrhythmia and death. Endomyocardial biopsy remains the gold standard tool for tissue diagnosis of myocarditis in living individuals, although new imaging technologies have a crucial and complementary role. This review outlines the current state-of-the-art and future experimental cardiovascular magnetic resonance (CMR) imaging approaches for the detection of inflammation and immune cell activity in the heart. Multiparametric CMR, particularly with novel quantitative T1- and T2-mapping, is a valuable and widely-available tool for the non-invasive assessment of inflammatory heart diseases. Novel CMR molecular contrast agents will enable a more targeted assessment of immune cell activity and may be useful in guiding the development of novel therapeutics for myocarditis.

Multimodality imaging in cardiac amyloidosis: a primer for cardiologists.

Amyloidosis is a systemic infiltrative disease, in which unstable proteins misfold, form aggregates and amyloid fibrils which can deposit in various organs: heart, kidneys, liver, gastrointestinal tract, nervous system structures, lungs, or soft tissue. Cardiac amyloidosis (CA) diagnosis requires awareness, high level of clinical suspicion and expertise in integrating clinical, electrocardiographic, and multimodality imaging data. The overall scenario is complex and no single test emerges over the others, but different techniques are useful at various stages of the diagnostic workup. After a clinical suspicion of CA is raised by various non-imaging red-flags, eligible patients should undergo complete echocardiography and multiparametric cardiovascular magnetic resonance imaging. Even though the clinical suspicion of CA is confirmed by cardiac imaging, the accurate differentiation between the two most frequent and treatable amyloid types, i.e. light chain (AL) and transthyretin (ATTR) requires further work-up including phosphate scintigraphy. This article reviews the latest and essential data on multimodality imaging of patients with suspected or confirmed CA in a useful and practical manner for the general and imaging cardiologists.

Multiparametric cardiovascular magnetic resonance characteristics and dynamic changes in myocardial and skeletal muscles in idiopathic inflammatory cardiomyopathy

BackgroundIdiopathic inflammatory myopathy (IIM) manifest as systematic muscle involvement. Multiparametric cardiovascular magnetic resonance (CMR) could be a useful technique to detect systemic involvement and disease progression in IIM patients. This study aimed to describe the tissue characteristics and dynamic changes in myocardial and skeletal muscles after treatment in IIM patients.MethodsForty-four consecutively recruited IIM patients (49.0 ± 12.0 years; 22 males) underwent 3 T CMR at first diagnosis, and 28 patients underwent follow-up scan after receiving standard treatment for more than 1 year. Thirty age- and sex-matched healthy subjects served as controls. The CMR protocol included: cines, T2-weighted (T2w), late gadolinium enhancement (LGE), T1 and T2 mapping, and extracellular volume (ECV) evaluated for the myocardium, and T1 and T2 mapping and ECV evaluated for skeletal muscles. Correlations between laboratory biomarkers and myocardial and skeletal tissue characteristics were analyzed. Comparisons between baseline and follow-up scans were performed using paired t-tests.ResultsAt baseline, IIM patients showed significantly decreased hematocrit, higher left ventricular (LV) mass index, right ventricular (RV) volume index, myocardial and skeletal native T1, T2 mapping, and ECV than healthy controls. Significant correlations were found among myocardial native T1, T2 mapping, and ECV values and N-terminal pro b-type natriuretic peptide (NT-proBNP) levels, and significant correlations between skeletal T2 mapping and inflammatory biomarkers in IIM patients.During the follow-up, 28 patients underwent repeated CMR scan (median interval, 14.5 months, interquartile range: 13.2–15.5 months). Significant relief from clinical symptoms and decreased inflammatory biomarkers levels were observed. Significant reduction in myocardial native T1, T2, ECV, and skeletal native T1, T2, and ECV were observed during the follow-up assessment.ConclusionsBoth myocardial and skeletal muscles in newly diagnosed IIM patients show distinct characteristics on multiparametric CMR. In addition, significant changes were observed in patients showing clinical remission after effective treatment, which suggests that quantitative T1, T2, and ECV techniques may have potential clinical value in IIM patients.

Non-contrast enhanced diagnosis of acute myocarditis based on the 17-segment heart model using 2D-feature tracking magnetic resonance imaging

PurposeThe aim of this study was to investigate the diagnostic value of myocardial deformation analysis based on the 17-segment heart model using non-contrast enhanced (CE) 2D tissue feature tracking (2D-FT) technique. Material and methodsSeventy patients with suspected myocarditis underwent a cardiovascular magnetic resonance (CMR) examination at 1.5 Tesla. A contrast-agent-free part of this CMR protocol was additionally performed in forty healthy volunteers (HV). Besides standard CMR data sets, 2D-FT derived segmental and global longitudinal, radial, and circumferential deformation parameters were analyzed. The 2D-FT results were compared to the combined findings from CMR imaging and endomyocardial biopsy (EMB). ResultsPatients were assigned to three groups depending on their ejection fraction (EF) (<40%, 40–55%, ≥55%). Compared to HV, impaired EF (<55%) was significantly correlated to reduced segmental and global strain and strain rate values. The circumferential deformation analysis was more sensitive to myocardial changes than longitudinal and radial analysis. The segmental strain/strain rate had an accuracy of 84.3%/70.0% for the diagnosis of an acute myocarditis, stated by EMB and CMR in 42 of 70 patients. In patients with preserved EF, acute myocarditis could be ruled out using only segmental strain analysis with a negative predictive value of 87.5%. ConclusionIn patients with suspected myocarditis, the deformation analysis based on the 17-segment heart model provides valuable information about functional myocardial inhomogeneity. This quantitative approach could be used in addition to the clinical standard CMR protocol and represents a promising tool in the framework of a prospective automatized multiparametric CMR imaging analysis.

Cardiovascular magnetic resonance imaging characteristics and influence factors of aortic insufficiency patients with myocardial fibrosis

Objective: To investigate the cardiovascular magnetic resonance (CMR) imaging characteristics and influence factors of aortic insufficiency (AI) patients with myocardial fibrosis. Method: This retrospective study included 59 AI patients who received CMR and transthoracic echocardiography (TTE) examinations from June 2011 to February 2015. AI patients were divided into 2 groups: bicuspid aortic valve (BAV) group (n=30) and non-BAV group (n=29). Patients were also divided into late gadolinium enhancement (LGE) group (n=27) and non-LGE group (n=32). The baseline clinical characteristics were collected through electronic medical records. Hemodynamic parameters such as grade of AI, cardiac functional parameters and LGE mass fraction (LGE%) were measured by CMR post-processing analysis. Kappa test was used to assess the consistency of AI severity between CMR and TTE, and the multivariate logistic regression analysis was performed to evaluate influence factors of myocardial fibrosis in AI patients. Results: (1) 56 (94.9%) patients were male, and the mean age was (44.2±11.0) years old. There was no significant difference in age and gender, hypertension, hyperlipidemia, alcoholic consumption between BAV and non-BAV group (all P>0.05). There were a higher proportion of smoking history (P=0.008), a lower body mass index (BMI) (P=0.020) in the LGE group than in the non-LGE group. (2) The accuracy of CMR in diagnosis of BAV was 96.7% (29/30) compared to the gold standard. In the BAV group, 20 patients (66.7%) were with fusion of left and right cusp (L-R), 5 patients (16.7%) were with fusion of right and noncoronary cusp (R-N), 5 patients (16.7%) were with fusion of left and noncoronary cusp (L-N); patients with BAV had larger left ventricular end diastolic volume index (LVEDVi), left ventricular end systolic volume index (LVESVi), higher proportion of LGE and lower left ventricular ejection fraction (LVEF) than those in non-BAV group (all P<0.05). There were 19 patients with BAV in the LGE group, the cases of L-R, R-N, L-N were 10 (52.6%), 5 (26.3%), and 4 (21.1%), respectively. In the non-LGE group, patients with BAV of L-R, R-N, L-N were 10 (90.9%), 0, and 1 (9.1%), respectively. Patients with LGE had lower body surface area (BSA), LVEF and larger LVEDVi, LVESVi, left ventricular mass index (LVMi) and higher proportion of BAV compared patients without LGE. In addition, the proportion of moderate and severe AI patients was significantly higher in BAV group than in non-BAV group (P=0.009). (3) The consistency of CMR and TTE in evaluating the severity of AI patients: the agreement between TTE and CMR regarding AI severity was satisfactory (kappa value was 0.624, 95%CI 0.402-0.831, P<0.001). (4) The linear regression analysis demonstrated a negative correlation between LVEF and LGE% in BAV and non-BAV group (P<0.001). The multivariate logistic regression analysis showed that the presence of BAV was an independent risk factor of left ventricucar fibrosis (OR=5.050, 95%CI 1.220-20.908, P=0.025) after adjustment for LVEF, hypertension, LVEDVi and LVMi. Conclusion: Multi-parametric CMR provides a satisfactory noninvasive tool for estimation of myocardial fibrosis and ventricular remodeling in patients with AI, and BAV is an independent risk factor for myocardial fibrosis in patients with AI.

Quantitative Myocardial Perfusion in Fabry Disease.

Fabry disease (FD) is an X-linked lysosomal storage disease resulting in tissue accumulation of sphingolipids. Key myocardial processes that lead to adverse outcomes in FD include storage, hypertrophy, inflammation, and fibrosis. These are quantifiable by multiparametric cardiovascular magnetic resonance. Recent developments in cardiovascular magnetic resonance perfusion mapping allow rapid in-line perfusion quantification permitting broader clinical application, including the assessment of microvascular dysfunction. We hypothesized that microvascular dysfunction in FD would be associated with storage, fibrosis, and edema. A prospective, observational study of 44 FD patients (49 years, 43% male, 24 [55%] with left ventricular hypertrophy [LVH]) and 27 healthy controls with multiparametric cardiovascular magnetic resonance including vasodilator stress perfusion mapping. Myocardial blood flow (MBF) was measured and its associations with other processes investigated. Compared with LVH- FD, LVH+ FD had higher left ventricular ejection fraction (73% versus 68%), more late gadolinium enhancement (85% versus 15%), and a lower stress MBF (1.76 versus 2.36 mL/g per minute). The reduction in stress MBF was more pronounced in the subendocardium than subepicardium. LVH- FD had lower stress MBF than controls (2.36 versus 3.00 mL/g per minute; P=0.002). Across all FD, late gadolinium enhancement and low native T1 were independently associated with reduced stress MBF. On a per-segment basis, stress MBF was independently associated with wall thickness, T2, extracellular volume fraction, and late gadolinium enhancement. FD patients have reduced perfusion, particularly in the subendocardium with greater reductions with LVH, storage, edema, and scar. Perfusion is reduced even without LVH suggesting it is an early disease marker.

Interrogation of the infarcted and salvaged myocardium using multi-parametric mapping cardiovascular magnetic resonance in reperfused ST-segment elevation myocardial infarction patients

We used multi-parametric cardiovascular magnetic resonance (CMR) mapping to interrogate the myocardium following ST-segment elevation myocardial infarction (STEMI). Forty-eight STEMI patients underwent CMR at 4 ± 2 days. One matching short-axis slice of native T1 map, T2 map, late gadolinium enhancement (LGE), and automated extracellular volume fraction (ECV) maps per patient were analyzed. Manual regions-of-interest were drawn within the infarcted, the salvaged and the remote myocardium. A subgroup analysis was performed in those without MVO and with ≤75% transmural extent of infarct. For the whole cohort, T1, T2 and ECV in both the infarcted and the salvaged myocardium were significantly higher than in the remote myocardium. T1 and T2 could not differentiate between the salvaged and the infarcted myocardium, but ECV was significantly higher in the latter. In the subgroup analysis of 15 patients, similar findings were observed for T1 and T2. However, there was only a trend towards ECVsalvage being higher than ECVremote. In the clinical setting, current native T1 and T2 methods with the specific voxel sizes at 1.5 T could not differentiate between the infarcted and salvaged myocardium, whereas ECV could differentiate between the two. ECV was also higher in the salvaged myocardium when compared to the remote myocardium.

284An accurate, multi-parametric cardiovascular magnetic resonance model to predict mean pulmonary artery pressure in pulmonary hypertension

284An accurate, multi-parametric cardiovascular magnetic resonance model to predict mean pulmonary artery pressure in pulmonary hypertension

Multiparametric cardiovascular magnetic resonance imaging in acute myocarditis: a comparison of different measurement approaches

BackgroundMyocardial T1 and T2 mapping are reliable diagnostic markers for the detection and follow up of acute myocarditis. The aim of this study was to compare the diagnostic performance of current mapping measurement approaches to differentiate between myocarditis patients and healthy individuals.MethodsFifty patients with clinically defined acute myocarditis and 30 healthy controls underwent cardiovascular magnetic resonance (CMR). Myocardial T1 relaxation times, T2 relaxation times, left ventricular (LV) function, T2 ratio, early gadolinium enhancement ratio, and presence of late gadolinium enhancement (LGE) were analysed. Native T1 and T2 relaxation times, as well as extracellular volume fraction (ECV) were measured for the entire LV myocardium (global), within the midventricular short axis slice (mSAX), within the midventricular septal wall (ConSept), and within the remote myocardium (remote). Receiver operating characteristics analysis was performed to compare diagnostic performance.ResultsAll measurement approaches revealed significantly higher native T1 and T2 relaxation times as well as ECV values in patients compared to healthy controls (p < 0.05 for all parameters). The global measurement approach showed highest diagnostic performance regarding all mapping parameters (AUCs, native T1: 0.903, T2: 0.847, ECV: 0.731). Direct comparison of the different measurement approaches revealed significant differences in diagnostic performance between the global and the remote approach regarding T1 relaxation times and ECV (p = 0.001 and p = 0.002 respectively). Further, the global measurement approach revealed significantly higher T1 relaxation times compared to the ConSept approach (AUCs: 0.903 vs. 0.783; p = 0.003) and nearly significant differences compared to the mSAX approach (AUC: 0.850; p = 0.051).T2 relaxation times showed no significant differences between all measurement approaches (p > 0.050 for all parameters).ConclusionsNative T1 and T2 mapping allow for accurate detection of acute myocarditis irrespective of the measurement approach used. Even measurements performed exclusively within remote myocardium allow for reliable detection of acute myocarditis, demonstrating diffuse involvement of disease despite a mostly regional or patchy distribution pattern of visible pathologies. The global measurement approach provides the overall best diagnostic performance in acute myocarditis for both T1 and T2 mapping.

Rationale and design of the Coronary Microvascular Angina Cardiac Magnetic Resonance Imaging (CorCMR) diagnostic study: the CorMicA CMR sub-study.

IntroductionAngina with no obstructive coronary artery disease (ANOCA) is a common syndrome with unmet clinical needs. Microvascular and vasospastic angina are relevant but may not be diagnosed without measuring coronary vascular function. The relationship between cardiovascular magnetic resonance (CMR)-derived myocardial blood flow (MBF) and reference invasive coronary function tests is uncertain. We hypothesise that multiparametric CMR assessment will be clinically useful in the ANOCA diagnostic pathway.Methods/analysisThe Stratified Medical Therapy Using Invasive Coronary Function Testing In Angina (CorMicA) trial is a prospective, blinded, randomised, sham-controlled study comparing two management approaches in patients with ANOCA. We aim to recruit consecutive patients with stable angina undergoing elective invasive coronary angiography. Eligible patients with ANOCA (n=150) will be randomised to invasive coronary artery function-guided diagnosis and treatment (intervention group) or not (control group). Based on these test results, patients will be stratified into disease endotypes: microvascular angina, vasospastic angina, mixed microvascular/vasospastic angina, obstructive epicardial coronary artery disease and non-cardiac chest pain. After randomisation in CorMicA, subjects will be invited to participate in the Coronary Microvascular Angina Cardiac Magnetic Resonance Imaging (CorCMR) substudy. Patients will undergo multiparametric CMR and have assessments of MBF (using a novel pixel-wise fully quantitative method), left ventricular function and mass, and tissue characterisation (T1 mapping and late gadolinium enhancement imaging). Abnormalities of myocardial perfusion and associations between MBF and invasive coronary artery function tests will be assessed. The CorCMR substudy represents the largest cohort of ANOCA patients with paired multiparametric CMR and comprehensive invasive coronary vascular function tests.Ethics/disseminationThe CorMicA trial and CorCMR substudy have UK REC approval (ref.16/WS/0192).Trial registration numberNCT03193294.

105 Differences in myocardial mechanics between ischaemic and non-ischaemic cardiomyopathy assessed by cmr: a sub-group analysis of the vindicate trial

BackgroundPrognosis and treatment of patients with chronic heart failure (CHF) differs according to whether it is ischaemic (ICM) or non-ischaemic cardiomyopathy (NICM). Multi-parametric cardiovascular magnetic resonance (CMR) can distinguish these...

Assessment of stable coronary artery disease by cardiovascular magnetic resonance imaging: Current and emerging techniques

Coronary artery disease (CAD) is a leading cause of death and disability worldwide. Cardiovascular magnetic resonance (CMR) is established in clinical practice guidelines with a growing evidence base supporting its use to aid the diagnosis and management of patients with suspected or established CAD. CMR is a multi-parametric imaging modality that yields high spatial resolution images that can be acquired in any plane for the assessment of global and regional cardiac function, myocardial perfusion and viability, tissue characterisation and coronary artery anatomy, all within a single study protocol and without exposure to ionising radiation. Advances in technology and acquisition techniques continue to progress the utility of CMR across a wide spectrum of cardiovascular disease, and the publication of large scale clinical trials continues to strengthen the role of CMR in daily cardiology practice. This article aims to review current practice and explore the future directions of multi-parametric CMR imaging in the investigation of stable CAD.

A novel multiparametric imaging approach to acute myocarditis using T2-mapping and CMR feature tracking

BackgroundThe aim of this study was to evaluate the diagnostic potential of a novel cardiovascular magnetic resonance (CMR) based multiparametric imaging approach in suspected myocarditis and to compare it to traditional Lake Louise criteria (LLC).MethodsCMR data from 67 patients with suspected acute myocarditis were retrospectively analyzed. Seventeen age- and gender-matched healthy subjects served as control. T2-mapping data were acquired using a Gradient-Spin-Echo T2-mapping sequence in short-axis orientation. T2-maps were segmented according to the 16-segments AHA-model and segmental T2 values and pixel-standard deviation (SD) were recorded. Afterwards, the parameters maxT2 (the highest segmental T2 value) and madSD (the mean absolute deviation (MAD) of the pixel-SDs) were calculated for each subject. Cine sequences in three long axes and a stack of short-axis views covering the left and right ventricle were analyzed using a dedicated feature tracking algorithm.ResultsA multiparametric imaging model containing madSD and LV global circumferential strain (GCSLV) resulted in the highest diagnostic performance in receiver operating curve analyses (area under the curve [AUC] 0.84) when compared to any model containing a single imaging parameter or to LLC (AUC 0.79). Adding late gadolinium enhancement (LGE) to the model resulted in a further increased diagnostic performance (AUC 0.93) and yielded the highest diagnostic sensitivity of 97% and specificity of 77%.ConclusionsA multiparametric CMR imaging model including the novel T2-mapping derived parameter madSD, the feature tracking derived strain parameter GCSLV and LGE yields superior diagnostic sensitivity in suspected acute myocarditis when compared to any imaging parameter alone and to LLC.

A comparison of cardiovascular magnetic resonance and single photon emission computed tomography (SPECT) perfusion imaging in left main stem or equivalent coronary artery disease: a CE-MARC substudy

BackgroundAssessment of left main stem (LMS) stenosis has prognostic and therapeutic implications. Data on assessment of LMS disease by cardiovascular magnetic resonance (CMR) and single photon emission computed tomography (SPECT) are limited. CE-MARC is the largest prospective comparison of CMR and SPECT against quantitative invasive coronary angiography (QCA) for detection of coronary artery disease (CAD), and provided the framework for this evaluation. The aims of this study were to compare diagnostic accuracy of visual and quantitative perfusion CMR to SPECT in patients with LMS stable CAD.MethodsFifty-four patients from the CE-MARC study were included: 27 (4%) with significant LMS or LMS-equivalent disease on QCA, and 27 age/sex-matched patients with no flow-limiting CAD. All patients underwent multi-parametric CMR, SPECT and QCA. Performance of visual and quantitative perfusion CMR by Fermi-constrained deconvolution to detect LMS disease was compared with SPECT.ResultsOf 27 patients in the LMS group, 22 (81%) had abnormal CMR and 16 (59%) had abnormal SPECT. All patients with abnormal CMR had abnormal perfusion by visual analysis. CMR demonstrated significantly higher area under the curve (AUC) for detection of disease (0.95; 0.85–0.99) over SPECT (0.63; 0.49–0.76) (p = 0.0001). Global mean stress myocardial blood flow (MBF) by CMR in LMS patients was significantly lower than controls (1.77 ± 0.72 ml/g/min vs. 3.28 ± 1.20 ml/g/min, p < 0.001). MBF of <2.08 ml/g/min had sensitivity of 78% and specificity of 85% for diagnosis of LMS disease, with an AUC (0.87; 0.75–0.94) not significantly different to visual CMR analysis (p = 0.18), and more accurate than SPECT (p = 0.003).ConclusionVisual stress perfusion CMR had higher diagnostic accuracy than SPECT to detect LMS disease. Quantitative perfusion CMR had similar performance to visual CMR perfusion analysis.

Evaluation of myocardial involvement in patients with connective tissue disorders: a multi-parametric cardiovascular magnetic resonance study

BackgroundSevere arrhythmias or heart failure may be surrogates of myocardial involvement in patients with connective tissue disorders (CTD). However, most patients present with unspecific symptoms, normal ECG, and preserved left ventricular ejection fraction (LV-EF). Therefore, timely diagnosis by an accurate technique is crucial. Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) has proven value for the detection of focal processes, but due to the often diffuse character of fibrosis/inflammation in CTD patients, CMR mapping techniques might be of incremental value for the assessment of myocardial involvement. Purpose of this study was to evaluate a multi-parametric CMR protocol as a screening tool for myocardial involvement in CTD patients.MethodsForty CTD patients were prospectively enrolled and underwent CMR, twenty healthy volunteers served as control group.ResultsMean LV-EF was 62 %; LGE prevalence was low (18 %). CTD patients had higher native T1 (1008 vs. 962 ms, p = 0.001), lower post contrast T1 (494 vs. 526 ms, p = 0.008), expanded extracellular volume (ECV) (28 vs. 25 %, p = 0.001), and higher T2 values (53 vs. 49 ms, p < 0.001) compared to controls. Among patients with values higher than the 95 % percentile of healthy controls, native T1 and T2 values seem to be the most promising discriminators.ConclusionCTD patients showed higher T1, ECV, and T2 values compared to controls, with most significant differences for native T1 and T2, which seem to be independent of the presence of LGE. Our data suggest that CMR mapping techniques are of incremental value in the detection of myocardial involvement in CTD patients.

Aortic stiffening and its impact on left atrial volumes and function in patients after successful coarctation repair: a multiparametric cardiovascular magnetic resonance study.

BackgroundThe increased cardiovascular morbidity of adults with late repair of aortic coarctation (CoA) has been well documented. In contrast, successful CoA repair in early childhood has a generally good prognosis, though adverse vascular and ventricular characteristics may be abnormal, which could increase long-term risk. This study sought to perform a comprehensive analysis of aortic elasticity and left ventricular (LV) function in patients with aortic coarctation (CoA) using cardiovascular magnetic resonance (CMR). In a subgroup of patients, we assessed structure and function of the common carotid arteries to probe for signs of systemic vascular remodeling.MethodsFifty-one patients (median age 17.3 years), 13.9 ± 7.5 years after CoA repair, and 54 controls (median age 19.8 years) underwent CMR.We determined distensibility and pulse wave velocity (PWV) at different aortic locations. In a subgroup, common carotid artery distensibility, PWV, wall thickness and wall area were measured. LV ejection fraction (EF), volumes, and mass were measured from short axis views. Left atrial (LA) volumes and functional parameters (LAEFPassive, LAEFContractile, LAEFReservoir) were assessed from axial cine images.ResultsIn patients distensibility of the whole thoracic aorta was reduced (p < 0.05) while PWV was only significantly higher in the aortic arch (p < 0.01). Distensibility of the descending aorta at the level of the pulmonary arteries and PWV in the descending aorta, both correlated negatively with age at CoA repair. LA volume before atrial contraction and minimal LA volume were higher in patients (p < 0.05). LAEFPassive and LAEFReservoir were reduced (p < 0.05), and LAEFReservoir correlated negatively with aortic arch PWV (p < 0.05). LVEF, volumes and mass were not different from controls. Carotid wall thickness and PWV were higher in patients compared to controls (p < 0.05).ConclusionsPatients after CoA repair have impaired bioelastic properties of the thoracic aorta with impact on LV diastolic function. Reduced descending aortic elasticity is associated with older age at time of CoA repair. The remodeling of the common carotid artery in our sub-study suggests systemic vessel wall changes.

Multi-Parametric Cardiac Magnetic Resonance for Prediction of Cardiac Complications in Thalassemia Intermedia: A Prospective Multicenter Study

▪Introduction: Cardiovascular Magnetic Resonance (CMR) has an established role in managing and predicting prognosis of patients with Thalassemia Major (TM). Thalassemia Intermedia (TI) is a milder variant of beta-thalassemia showing a different clinical and prognostic profile; pulmonary hypertension (PH) is a more common complication in TI patients. We prospectively determined the predictive value of CMR parameters, including measurement of right ventricular mass, for cardiac complications in TI.Methods: We considered 342 TI patients enrolled in the Myocardial Iron Overload in Thalassemia network; about half of them (178/302, 58.9%) were transfusion-dependent. Myocardial and liver iron overload were measured by T2* multiecho technique. Atrial dimensions, left and right ventricular mass and systolic function were quantified by cine images. Late gadolinium enhancement (LGE) images were acquired to detect myocardial fibrosis.Results: Twenty-three patients were excluded because a cardiac complication was present at the time of first CMR, so we prospectively followed 319 patients.All 319 patients were white, with a mean age at time of their first scan of 38.02±11.69 years and 165 (51.7%) of them were females.Mean follow-up time was 52.24±24.87 months (median 54.64 months).Cardiac events were recorded in 22 patients (6.9%): heart failure (HF) in 1 patient, arrhythmias in 12 patients, pulmonary hypertension (PH) in 7 patients and myocardial infarction (MI) in 2 patients.Due to the low number of events, only arrhythmias, PH and cardiac complications globally considered were taken as cardiac outcomes for univariate and multivariate analysis.In the multivariate analysis RV hypertrophy was the only independent predictive factor for arrhythmias (HR=33.83, 95% CI=6.07-188.74, P<0.0001) and PH (HR=73.33, 95% CI=10.00-537.57, P<0.0001). When cardiac complications were considered all together, RV hypertrophy (HR=24.12, 95% CI=5.09-114.12, P<0.0001) and myocardial fibrosis by LGE (HR=6.59, 95% CI=1.33-32.67, P=0.021) were independent prognostic factors in the multivariate analysis.The Figures display the Kaplan-Meier curves showing the impact of the independent predictive factors on each outcome.Conclusions: For the first time we studied the prognostic value of right ventricular mass as part of multiparametric CMR imaging in a population of TI patients. RV hypertrophy identified patients at high risk for arrhythmias and PH. Both RV hypertrophy and fibrosis detected by LGE were independent predictive factor for cardiac complications. Measurement of RV mass should be part of the multi-parametric CMR study of patient with thalassemia intermedia. [Display omitted] DisclosuresPepe:ApoPharma Inc: Speakers Bureau; Novartis: Speakers Bureau; Chiesi: Speakers Bureau.