SSFP Cine Images Research Articles

Estimate of the hydraulic force in the aging heart: a cardiovascular magnetic resonance imaging study

BackgroundCoupling between left ventricle (LV) and left atrium (LA) plays a central role in the process of cardiac remodeling during aging and development of cardiac disease. The hydraulic force (HyF) is related to variation in size between LV and LA. The objectives of this study were to: (1) derive an estimate of left atrioventricular HyF using cine- Magnetic Resonance Imaging (MRI) in healthy subjects with a wide age range, and (2) study its relationship with age and conventional diastolic function parameters, as estimated by reference echocardiography.MethodsWe studied 119 healthy volunteers (mean age 44 ± 17 years, 58 women) who underwent Doppler echocardiography and MRI on the same day. Conventional transmitral flow early (E) and late (A) LV filling peak velocities as well as mitral annulus diastolic longitudinal peak velocity (E’) were derived from echocardiography. MRI cine SSFP images in longitudinal two and four chamber views were acquired, and analyzed using feature tracking (FT) software. In addition to conventional LV and LA strain measurements, FT-derived LV and LA contours were further used to calculate chamber cross-sectional areas. HyF was approximated as the difference between the LV and LA maximal cross-sectional areas in the diastasis phase corresponding to the lowest LV-LA pressure gradient. Univariate and multivariate analyses while adjusting for appropriate variables were used to study the associations between HyF and age as well as diastolic function and strain indices.ResultsHyF decreased significantly with age (R²=0.34, p < 0.0001). In addition, HyF was significantly associated with conventional indices of diastolic function and LA strain: E/A: R²=0.24, p < 0.0001; E’: R²=0.24, p < 0.0001; E/E’: R²=0.12, p = 0.0004; LA conduit longitudinal strain: R²=0.27, p < 0.0001. In multivariate analysis, associations with E/A (R2 = 0.39, p = 0.03) and LA conduit strain (R2 = 0.37, p = 0.02) remained significant after adjustment for age, sex, and body mass index.ConclusionsHyF, estimated using FT contours, which are primarily used to quantify LV/LA strain on standard cardiac cine MRI, varied significantly with age in association with subclinical changes in ventricular filling. Its usefulness in cohorts of patients with left heart disease to detect LV-LA uncoupling remains to be evaluated.

Evaluation of left atrial function and tissue after pulmonary vein isolation - initial results of The EVALUATE-PVI STUDY

Abstract Background Pulmonary vein (PV) isolation (PVI) by catheter ablation is a well-established treatment for atrial fibrillation (AF). Currently, the direct and long-term impact of ablation injury on left atrial (LA) function and tissue is poorly understood. Purpose The aim of this study is to evaluate the acute and long-term impact of radiofrequency (RF) PVI ablation on LA function and corresponding tissue changes as assessed with cardiac magnetic resonance imaging (CMR). Methods Seventeen patients (76.5% male, 60.8±9.7 years) with AF who underwent primo RF PVI as part of the EVALUATE-PVI STUDY underwent three sequential CMR scans prior to PVI, and &amp;lt;72 hours and 3 months after PVI ablation. T2-weighted turbo spin echo imaging was applied to assess post-ablation edema. High-resolution three-dimensional (3D) late gadolinium-enhancement (LGE) images were acquired to study acute LA wall injury and chronic fibrosis formation. LA volume and function were derived from two-chamber and four-chamber SSFP cine images. Maximum and minimal LA volume was indexed to body surface area to compute LAVimax and LAVimin. Longitudinal LA strain was calculated using feature tracking, and subdivided into reservoir, conduit, and contractile strain. Results Acutely post-PVI, T2w images showed increased signal intensity and thickening throughout the entire LA wall. LGE images showed diffuse increased signal intensity, without distinct focal high signal intensity areas (Fig. 1). Functional assessment at this stage showed significantly reduced LA emptying fraction (EF), LA reservoir, and contractile strain compared to pre-PVI (54.8±11.1% vs. 48.5±7.9%, p=0.01; 18.6±5.6% vs. 14.6±2.0%, p&amp;lt;0.01; 8.5±3.5% vs. 5.2±1.8%, p&amp;lt;0.001, respectively), while LA conduit strain, LAVimin, and LAVimax did not differ significantly (Fig. 2). The LGE images acquired at 3 months, displayed clear, focal, high signal intensity areas surrounding the PVs. At this stage post-PVI, a significant increase in LA strain was observed (LA reservoir strain 14.6±2.0% vs. 16.9±3.5%, p&amp;lt;0.01; and contractile strain 5.2±1.8% vs. 6.7±2.9%, p&amp;lt;0.01; respectively). LAVimax was significantly reduced at 3 months compared to acutely post-PVI (Fig. 2). LAVimin and LA conduit strain did not differ between the pre- and post-PVI stages. Conclusion PVI ablation resulted in temporary reduced LA function acutely post-PVI, likely due to edema and thickening of the LA wall. At three months, LGE images revealed clearly visible increased signal intensity in the ablated segments. At this stage, LA function improved, though full recovery did not occur as evidenced by the persistent slightly reduced contractile strain, possibly due to the ablation-induced loss of LA myocardium and formation of fibrosis. The decrease in LAVimax indicates reverse remodeling as a result of the ablation.

CMR 2-35 - Comparison of Compressed Sensing and SSFP Cine Imaging Ventricular Measurements and Strain Values

CMR 2-35 - Comparison of Compressed Sensing and SSFP Cine Imaging Ventricular Measurements and Strain Values

Abstract 18920: Left Atrial Function is Associated With Left Ventricular Mass in Women With Preserved Left Ventricular Ejection Fraction and Late Gadolinium Enhancement on Cardiac MRI

Introduction: Myocardial fibrosis detected by late gadolinium enhancement (LGE) on cardiac MRI may be related to conditions with increased left ventricular (LV) mass and diastolic dysfunction. Women have an increased incidence of LV diastolic dysfunction and poorer clinical outcomes compared to men. Aim: To examine gender-based associations between LV mass and left atrial total emptying fraction (LATEF), a surrogate for diastolic function, in patients with LGE on cardiac MRI. Methods: We analyzed 134 consecutive patients undergoing cardiac MRI and LGE sequences on a 1.5T GE scanner. LV mass and LV/LA volumes (indexed by BSA) were measured offline from cine SSFP images using Precession software. Presence of LGE was reported. Nonparametric analyses were performed. Results: 40 patients with more than mild mitral regurgitation, pericardial disease, or LVEF &lt;50% were excluded. 94 patients studied (49% women) had a median age of 51 years [IQR 38-67] with no gender-based difference. Median LV mass index (LVMi) for all patients was 69.5 g/m2 [IQR 57-82] and was higher in LGE vs no-LGE patients (p&lt;0.001) and higher in men vs women (p&lt;0.05). Median LATEF for all patients was 0.50 [IQR 0.41-0.54] and was lower in LGE vs no-LGE patients (p&lt;0.001) with no gender-based difference. LVMi had a strong inverse correlation with LATEF for all patients and for the LGE group (r=-0.58, p&lt;0.001 and r=-0.51, p&lt;0.001 respectively). LVMi had a very strong inverse correlation with LATEF (r=-0.74, p&lt;&lt;0.001) in women with LGE and moderate inverse correlation in women with no-LGE (r=-0.45, p=0.02). LVMi had a moderate inverse correlation with LATEF in men with LGE (r=-0.48, p. &lt;0.01) and no correlation in men with no-LGE (Figure). Conclusions: LA function inversely correlates with indexed LV mass, most strongly in women with LV LGE. Further exploration of these parameters may allow earlier detection of LV diastolic dysfunction and improved risk stratification.

Association of left ventricular ejection fraction and long axis function across health and disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Global longitudinal shortening (GLSh) 1,2 and left ventricular ejection fraction (LVEF) are different measures of left ventricular function. LVEF is well-established, but can miss early or mild disease. GLSh, which quantifies long-axis shortening, is easy to measure, and has been shown to have superior reproducibility and prognostication ability than global longitudinal strain3,4. Purpose To assess the relationship between GLSh and EF measured using CMR in a large cohort representing health (healthy volunteers, athletes) and disease (hypertension, aortic stenosis, hypertrophic cardiomyopathy(HCM),cardiac amyloidosis, Fabry disease). Methods CMR scans from a study cohort of 932 subjects were analysed (121 healthy volunteers, 278 athletes, 40 patients with hypertension, 76 severe aortic stenosis, 164 HCM, 51 cardiac amyloidosis, 202 Fabry). EF and GLSh were automatically measured from standard CMR SSFP cine images using machine learning methods described previously3,5. Correlation coefficients between GLSh and LVEF were calculated for each disease category. Normal reference ranges for LVEF and GLSh were estimated from a subset of n=4,342 healthy subjects from the UK Biobank, who had no history of cardiovascular disease or medication use. Results The lower limit of normal in the UK Biobank healthy subjects was 55% for EF and 13% for GLSh. Across the study cohort, for subjects with normal LVEF, only a small minority of healthy volunteers (n=1, 0.8%) and athletes(n=2; 0.7%) had low GLSh, whereas rates increased progressively in hypertension(n=3;9%), Fabry(n=61;31%), aortic stenosis(n=26;44%), HCM (n=87; 56%), and cardiac amyloidosis(N=28; 93%). Conversely, few subjects (n=8/932;0.1%) have the opposite: normal LGSh but low LVEF(Figure 1). The relationship between LVEF and GLSh is shown in Figure 2. Apart from HCM (r=0.019,p = 0.8), all other diseases show a significant association between GLSh and LVEF, with progressively higher correlation from healthy volunteers (r=0.33 p&amp;lt;0.001) to cardiac amyloidosis (r=0.33; p = 0.0016), athletes (r=0.44; p&amp;lt;0.001), and hypertension (R=0.6; p&amp;lt;0.001), with aortic stenosis showing highest correlation (r=0.68,p&amp;lt;0.001). Fabrys patients showed the reverse trend, with an inverse correlation between GLSh and LVEF (r=-0.34; p&amp;lt;0.001). Conclusions In health, impaired GLSh is rare when LVEF is normal, however across diseases with hypertrophy, GLSh impairment is common, illustrating the potential of GLSh to detecting early or mild systolic impairment. There are unexpectedly different associations between GLS and EF. In some diseases, these appears to measure the same aspects (health/AS/hypertension), but in others they are not well correlated with GLS providing new information. In Fabry, there is an unexpected inverse relationship. Further work is needed to understand this.

1076 AN UNUSUAL PAPILLARY MUSCLE PRESENTATION AT CARDIAC-MRI.

Abstract Background Cardiac-MRI is the gold-standard non-invasive imaging modality to evaluate cardiac masses. Case Summary A 58-year-old man underwent surgical excision of a sacral chordoma. At the time of surgery, there was neoplastic infiltration of bones and soft tissues (immunophenotype: CKMNF116+, EMA+, S100 +/-) and radiotherapy was performed. The patient underwent superior-lobectomy of the left lung six years later because of pulmonary metastasis of the chordoma. Nine years later, the patient was asymptomatic and referred to us for Cardiac-MRI because a suspected cardiac mass at echocardiography. At Cardiac-MRI, we found normal bi-ventricular volumes, wall thickness, wall motion and ejection fraction. Atria, heart valves and pericardium were normal too. In ssFP-cine images, an oval, hypointense mass with sharp margins (26×18 mm) was evident in the context of the posteromedial papillary muscle (Panel, A-B). Compared to the myocardium, the lesion was hyperintense at T2-weighted (Panel, C), native T1-(Panel, D) and T2-mapping sequences (Panel, E). After contrast injection, there was no increased mass signal at first-pass perfusion (Panel, F), whereas the late sequences revealed a soft, heterogeneous enhancement of the central core of the lesion, and a bright peripheral rim (Panel, G-H). These findings were interpreted as a cardiac metastasis of the chordoma and systematic treatment with imatinib was started. Discussion Six cases of cardiac metastasis secondary to chordoma were previously described. The present case is the first to provide advanced, multiparametric Cardiac-MRI assessment and represents the first description of a location within the context of a papillary muscle. Cardiac-MRI was essential to identify cardiac metastasis, leading patient's management and targeting appropriate treatment.

Emerging Role of 3.0 Tesla Cardiac Magnetic Resonance Imaging in Differentiating Cardiac Masses

Objective: To evaluate the role of Cardiac Magnetic Resonance Imaging in differentiating cardiac masses (thrombus vs tumor and benign tumor vs malignant tumor) in local population.&#x0D; Study Design: Analytical cross-sectional study.&#x0D; Place and Duration of Study: Tertiary Cardiac Care Center, Department of Cardiac Magnetic Resonance Imaging, Rawalpindi Pakistan, from Oct 2017 to Jun 2021.&#x0D; Methodology: This retrospective study included (n=56) patients via universal sampling, enrolled for Cardiovascular magnetic resonance imaging with a suspicion of cardiac masses either on echocardiography or Computed Tomography scan. Cardiovascular magnetic resonance imaging sequences were reviewed as SSFP cine images for mass location, size and mobility.T1 weighted turbo spin echo, T2 weighted turbo spin echo with and without fat saturation and TIRM sequences told their intensity as compared to normal myocardium, myomaps evaluated the relaxation time, while contrast first pass perfusion indicated the vascularity and delayed gadolinium enhancement images with standard and long TI were analyzed for contrast enhancement.&#x0D; Results: Total n=56 patients with a confirmed diagnosis of mass were included for the analysis. Mean age of participants was found to be 45.21(18.3%), height 168.4(8.69%) and weight 68.6(14.94%). There were 47(83.9%) males and females were 9(16.1%). 22(39.3%) had hypertension, 12(21.4%) had diabetes mellitus, 24(42.9%) had previous myocardial infarction. Maximum number of masses were found in LV 31(55.4%) followed by RV 11(19.6%). Sensitivity of T1 map to detect fibrosis intumor is 100%. Sensitivity of T2 map to detect edema in tumor is 82%.&#x0D; Conclusion: Cardiac masses like thrombi and tumors accurately diagnosed by cardiac MRI with etiology..

Early myocardial oedema can predict subsequent cardiomyopathy in high-dose anthracycline therapy.

This study aims to assess subclinical changes in functional and morphologic myocardial MR parameters very early into a repetitive high-dose anthracycline treatment (planned cumulative dose >650mg/m2 ), which may predict subsequent development of anthracycline-induced cardiomyopathy (aCMP). Thirty sarcoma patients with previous exposition of 300-360mg/m2 doxorubicin-equivalent chemotherapy who were planned for a second treatment of anthracycline-based chemotherapy (360mg/m2 doxorubicin-equivalent) were recruited. Enrolled individuals received three CMR studies (before treatment, 48h after first anthracycline treatment and upon completion of treatment). Native T1 mapping (MOLLI 5s(3s)3s), T2 mapping, and extracellular volume (ECV) maps were acquired in addition to a conventional CMR with SSFP-cine imaging at 1.5T. Patients were given 0.2mmol/kg gadoteridol for ECV quantification and LGE imaging. Blood samples for cardiac biomarkers were obtained before each scan. Development of relevant aCMP was defined as drop of left ventricular ejection fraction (LVEF) by >10% compared with baseline. Twenty-three complete datasets were available for analysis. Median treatment time was 20.7±3.0weeks. Eight patients developed aCMP with LVEF reduction >10% until end of chemotherapy. Baseline LVEF was not different between patients with and without subsequent aCMP. Patients with aCMP had decreased LV mass upon completion of therapy (99.4±26.5g vs. 90.3±24.8g; P=0.02), whereas patients without aCMP did not show a change in LV mass (91.5±20.0g vs. 89.0±23.6g; P>0.05). On strain analysis, GLS (-15.3±1.3 vs. -13.4±1.6; P=0.02) and GCS (-16.7±2.1 vs. -14.9±2.6; P=0.04) were decreased in aCMP patients upon completion of therapy, whereas non-aCMP individuals showed no change in GLS (-15.4±3.3 vs. -15.4±3.4; P=0.97). When assessed 48h after first dose of anthracyclines, patients with subsequent aCMP had significantly elevated myocardial T2 times compared with before therapy (53.0±2.8ms vs. 49.3±5.2ms, P=0.02) than patients who did not develop aCMP (50.7±5.1ms vs. 51.1±3.9ms, P>0.05). Native T1 times decreased at 48h after first dose irrespective of development of subsequent aCMP (1020.2±28.4ms vs. 973.5±40.3ms). Upon completion of therapy, patients with aCMP had increased native T1 compared with baseline (1050.8±17.9ms vs. 1022.4±22.0ms; P=0.01), whereas non-aCMP patients did not (1034.5±46.6ms vs. 1018.4±29.7ms; P=0.15). No patient developed new myocardial scars or compact myocardial fibrosis under chemotherapy. Cardiac biomarkers were elevated independent of development of aCMP. With high cumulative anthracycline doses, early increase of T2 times 48h after first treatment with anthracyclines can predict the development of subsequent aCMP after completion of chemotherapy. Early drop of native T1 times occurs irrespective of development of aCMP in high-dose anthracycline therapy.

Abstract 9957: Utility of Cardiac MRI Assessment of Right Ventricle Function Before LVAD Implantation

Introduction: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a feared complication. Right ventricle (RV) dysfunction by echocardiogram prior to LVAD implant is a significant risk factor for post-LVAD RVF. However, RV’s unique crescent shape makes it difficult for accurate assessment through echocardiogram. Cardiac MRI can image RV in its entirety and is the gold standard for evaluating RV size and function. Hypothesis: Our study aimed to assess RV comprehensively through cardiac MRI before LVAD implantation to predict severe RVF post-LVAD. Methods: This retrospective cohort study included 231 consecutive patients who underwent LVAD from January 2015 to July 2021. We utilized the commercially available QStrain Application (Medis Suite, the Netherlands) for feature-tracking myocardial strain using gated cine SSFP images. We also assessed for quantitative measurements of RV (systolic/ diastolic volume, stroke volume, and systolic function). Results: There were 12 patients with cardiac MRI before LVAD, of which 4 patients developed severe RVF after LVAD. There were 9 cardiac MRIs available for strain analysis (image quality and old studies before 2012). The RV end-systolic volume (ESV) was higher in severe RVF post-LVAD, but not RV ejection fraction. Endocardial and myocardial global longitudinal strain and global radial strain of RV were not different in severe RVF. Conclusions: In this small series investigating RV function before LVAD implant, we have shown that ESV was higher with severe RVF. Although feature tracking strain of RV was not different in patients with severe RVF, a larger cohort study is warranted to investigate this.

Comparing cardiac MRI and lung PET/CT after completion of tuberculosis treatment – preliminary findings of participants co-enrolled into the StatinTB trial and Cardiac Imaging After TB (CIA-TB) study

Abstract Introduction Mortality rates after successful tuberculosis (TB) treatment remain elevated and healthy survival is impaired by chronic pulmonary disease and persistent inflammation. Inflammation leads to a complex cascade of events and has been associated with cardiovascular disease (CVD). Recent epidemiological work described an increased risk of CVD in persons with history of TB. Aims and objectives In our ongoing StatinTB trial (NCT04147286), we evaluate safety and efficacy of 40 mg atorvastatin to reduce persistent lung inflammation (PLI) after TB treatment in HIV−/HIV+ adults measured by 18F-FDG-PET/CT. Participants are co-enrolled into the Cardiac Imaging After Tuberculosis (CIA-TB) study. Here we report preliminary findings of participants enrolled into the StatinTB trial and CIA-TB study with the aim to correlate PLI with cardiac magnetic resonance imaging (CMR) parameters. Methods Participants with clinical response to TB treatment and a negative sputum culture at 16 weeks were screened at the end of a 24-week course of treatment for drug-sensitive TB. PET/CT was performed on a Philips Gemini TF scanner and analysed using MIM®Software. PLI was defined as total lung glycolysis (TLG) ≥50 SUV·mL (Figure 1). CMR was performed using a 3T Siemens Magnetom Skyra scanner and parameters were derived from the following acquisitions: SSFP cine imaging of the short and long axes, T1 mapping (MOLLI, 5 (3) 3), T2 mapping and late gadolinium enhancement (LGE) imaging. StatinTB trial is conducted according to ICH-GCP. Results 26 participants (mean age 37.8±13.8 years, 38.5% women) underwent PET/CT and CMR. 23.1% were infected with HIV, 34.6% smokers, and 26.9% had a previous history of TB. Median BMI was 21.3 (IQR 19.7; 24.3). One participant reported hypertension. Common symptoms at enrollment were cough (26.9%), shortness of breath (11.5%), and chest pain (3.9%). On CT scan, 73.1% had pulmonary nodules, 57.7% scarring, 50.0% cavities, 42.3% bronchiectasis, 19.2% centrilobular disease, 19.2% distorted lung architecture, and 11.5% consolidations. On PET/CT, PLI was detected among 11 (42.3%) participants with a mean TLG of 216.0 (IQR 78.2; 384.0). In a multivariable regression analysis, left ventricular end systolic volume (LVESV) (−1.46; 95% CI: −2.89, −0.23; p=0.047) and distorted lung architecture (2.84; 95% CI: 1.17, 4.52; p=0.003) were significantly associated with TLG. Native T1 relaxation time showed a strong, but not significant association with TLG (15.01; 95% CI: −8.08, 38.10; p=184). Conclusion We present data of a young cohort at the end of TB treatment without significant cardiac risk factors. Structural lung disease is affecting at least half of participants, and many remain symptomatic. PLI is present in more than one-third of participants and our preliminary findings suggest an association with cardiac impairment. Further enrolment and ongoing laboratory studies will shed more light into post-TB cardio-pulmonary sequelae. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EDCTP

Ferumoxytol-enhanced 4D multiphase, steady-state imaging with magnetic resonance in congenital heart disease: ventricular volume and function across 2D and 3D software platforms.

BackgroundQuantitative ventricular volumetry and function are important in the management of congenital heart disease (CHD). Ferumoxytol-enhanced (FE) 4D multiphase, steady state imaging with contrast enhancement (MUSIC) enables high-resolution, 3D cardiac phase-resolved magnetic resonance imaging (MRI) of the beating heart and extracardiac vessels in a single acquisition and without concerns about renal impairment. We aim to evaluate the semi-automatic quantification of ventricular volumetry and function of 4D MUSIC MRI using 2D and 3D software platforms.MethodsThis HIPAA-compliant and IRB-approved study prospectively recruited 50 children with CHD (3 days to 18 years) who underwent 4D MUSIC MRI at 3.0T between 2013–2017 for clinical indications. Each patient was either intubated in the neonatal intensive care unit (NICU) or underwent general anesthesia at MRI suite. For 2D analysis, we reformatted MUSIC images in Digital Imaging and Communications in Medicine (DICOM) format into ventricular short-axis slices with zero interslice gap. For 3D analysis, we imported DICOMs into a commercially available 3D software platform. Using semi-automatic thresholding, we quantified biventricular volume and ejection fraction (EF). We assessed the bias between MUSIC-derived 2D vs. 3D measurements and correlation between MUSIC vs. conventional 2D balanced steady-state free precession (bSSFP) cine images. We evaluated intra- and inter-observer agreement.ResultsThere was a high degree of correlation between MUSIC-derived volumetric and functional measurements using 2D vs. 3D software (r=0.99, P<0.001). Volumes derived using 3D software platforms were larger than 2D by 0.2 to 2.0 mL/m2 whereas EF measurements were higher by 1.2–3.0%. MUSIC volumetric and functional measures derived from 2D and 3D software platforms corresponded highly with those derived from multi-slice SSFP cine images (r=0.99, P<0.001). The mean difference in volume for reformatted 4D MUSIC relative to bSSFP cine was 1.5 to 3.9 mL/m2. Intra- and inter-observer reliability was excellent.ConclusionsAccurate and reliable ventricular volumetry and function can be derived from FE 4D MUSIC MRI studies using commercially available 2D and 3D software platforms. If fully validated in multicenter studies, the FE 4D-MUSIC pulse sequence may supercede conventional multislice 2D cine cardiovascular MRI acquisition protocols for functional evaluation of children with complex CHD.

Annotation and quality assessment of left ventricular filling and relaxation pattern using one-dimensional convolutional neural network

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute For Health Research (NIHR), UK Introduction Aberrations in left ventricular (LV) filling or relaxation – known as diastolic dysfunction – occur in heart failure with preserved ejection fraction. CMR is the reference modality for the assessment of ventricular systolic function, however, its role in evaluation of diastolic function is limited at present. One promising technique to assess diastolic function by CMR is the derivation of LV filling and emptying rates from the volume-time curves of cine images. Purpose To automatically assess the quality of LV filling-rate curves and annotate the peak emptying and filling rates. Methods A previously-described deep-learning network was used to automatically segment the entire cardiac cycle captured by short-axis SSFP cine images from the UK Biobank1. The LV filling-rate curves derived from the volume-time data were smoothed with Savitzky–Golay filter. The peak emptying rate (PER), early peak filling rate (PFR-E) and late peak filling rate (PFR-A) were first annotated by a simple peak finding algorithm from Python Scipy signal module. The preliminary annotated curves were reviewed by five human experts (i) to check for peak-annotation errors and (ii) to provide the curve quality score ranging from 1 to 3 for each peak (score 1 denotes good quality, score 2 represents moderate quality and score 3 indicates poor quality). Higher total score (minimum = 3, maximum = 9), therefore, represents poorer overall curve quality. This expert-annotated dataset was used to train two separate one-dimensional convolutional neural networks (1D-CNN) (Figure 1) for peak annotation and curve quality assessment (QA) using Tensorflow library in Python. Results The data from 6,328 LV filling-rate curves were split into the training and testing sets (80:20). The fine-tuned 1D-CNN comprising six hidden layers with two residual connections annotated the PER, PFR-E and PFR-A with the test-set accuracy of 95%, 95% and 98%, respectively. A second trained 1D-CNN for QA based on similar architecture predicted the overall curve quality score with a small error rate (mean absolute error: 0.46, mean squared error: 0.68). These two networks were used to quality check and label 19,409 UK Biobank CMR studies (See Figure 2 for exemplary results). After removing data from poor-quality curves (quality score ≥ 5), 18,735 studies remained. The mean±standard deviation of PER, PFR-E and PFR-A are 461±110 ml/s, 359±117 ml/s and 336±120 ml/s, respectively. Ageing is associated with lower PFR-E (−58.4 ml/s, 95% confidence interval [CI]: −56.1 to −60.7 ml/s per decade increment) and higher PFR-A (18.3 ml/s, 95% CI: 15.8 to 20.8 ml/s per decade increment). Conclusion The 1D-CNN models can be used to automatically grade the quality of LV filling rate curves and label important diastolic parameters with a high level of accuracy. The derived data recapitulate impaired LV relaxation pattern associated with ageing and can be used as surrogate indices of diastology by CMR. Figure 1Figure 2

Association of ANK2 Mutation and Massive Myocardial Calcification: A Case Report

<h3>Introduction</h3> A 35-year-old man with no prior history of cardiovascular diseases was admitted with progressive exertional chest discomfort. Physical examination revealed irregular heart rhythm and an ejection murmur at the aortic area. EKG showed atrial fibrillation, and chest X-ray, calcification within the cardiac silhouette. Laboratory tests were all within normal ranges, including serological and inflammatory tests. <h3>Case Report</h3> An echocardiogram demonstrated diffuse myocardium calcification and intense mitral- aortic fibrocalcification, causing severe stenosis and moderate regurgitation, with a dilated left ventricle (LV) and moderate systolic dysfunction, akinesia of the inferolateral walls and hypokinesia of the anterior walls. A 128-row multidetector CT showed massive calcification affecting the aortic and mitral valves, the right ventricle, the left atrium wall and all the segments of the LV, preserving only the basal septum. Cardiovascular magnetic resonance imaging 1.5T revealed diffuse myocardial thickening, matching the areas seen on CT (figure). These areas were hypointense on the SSFP cine images and on T1- and T2-weighted images and had no late gadolinium enhancement (LGE). However, there was LGE in the underlying myocardium, in a non-ischemic distribution. Pericardium and coronary arteries were preserved. Genetic analysis identified a rare heterozygous variant of uncertain significance, c.10702C>T(p.Arg3568Trp), in ANK2 gene. <h3>Summary</h3> Ankyrin-B, also known as Ankyrin-2, is encoded by the ANK2 gene, which plays critical roles in the localization and stabilization of ion transporters and ion channels in cardiomyocytes. The Ankyrin-B syndrome has been associated to long QT syndrome and torsades depointes, but there are no reports of myocardial calcification. The patient was found to be a candidate for cardiac transplantation and is currently on the waiting list.

Ultrafast Computation of Left Ventricular Ejection Fraction by Using Temporal Intensity Variation in Cine Cardiac Magnetic Resonance.

Cardiac magnetic resonance enables comprehensive cardiac evaluation; however, intense time and labor requirements for data acquisition and processing have discouraged many clinicians from using it. We have developed an alternative image-processing algorithm that requires minimal user interaction: an ultrafast algorithm that computes left ventricular ejection fraction (LVEF) by using temporal intensity variation in cine balanced steady-state free precession (bSSFP) short-axis images, with or without contrast medium. We evaluated the algorithm's performance against an expert observer's analysis for segmenting the LV cavity in 65 study participants (LVEF range, 12%-70%). In 12 instances, contrast medium was administered before cine imaging. Bland-Altman analysis revealed quantitative effects of LV basal, midcavity, and apical morphologic variation on the algorithm's accuracy. Total computation time for the LV stack was <2.5 seconds. The algorithm accurately delineated endocardial boundaries in 1,132 of 1,216 slices (93%). When contours in the extreme basal and apical slices were not adequate, they were replaced with manually drawn contours. The Bland-Altman mean differences were <1.2 mL (0.8%) for end-diastolic volume, <5 mL (6%) for end-systolic volume, and <3% for LVEF. Standard deviation of the difference was ≤4.1% of LV volume for all sections except the midcavity in end-systole (8.3% of end-systolic volume). We conclude that temporal intensity variation-based ultrafast LVEF computation is clinically accurate across a range of LV shapes and wall motions and is suitable for postcontrast cine SSFP imaging. Our algorithm enables real-time processing of cine bSSFP images on a commercial scanner console within 3 seconds in an unobtrusive automated process.

Impaction of regurgitation jet on anterior mitral leaflet is associated with diastolic dysfunction in patients with bicuspid aortic valve and mild insufficiency: a cardiovascular magnetic resonance study

To assess the impact of regurgitant jet direction on left ventricular function and intraventricular hemodynamics in asymptomatic patients with bicuspid aortic valve (BAV) and mild aortic valve regurgitation (AR), using cardiac magnetic resonance (CMR) feature tracking and 4D flow imaging. Fifty BAV individuals were retrospectively selected: 15 with mild AR and posterior regurgitation jet (Group-PJ), 15 with regurgitant jet in other directions (Group-nPJ) and 20 with no regurgitation (Controls). CMR protocol included cine steady state free precession (SSFP) sequences and 4D Flow imaging covering the entire left ventricle (LV) cavity and the aortic root. Cine-SSFP images were analyzed to assess LV volumes, longitudinal and circumferential myocardial strain. Circumferential and longitudinal peak diastolic strain rate (PDSR) and peak diastolic velocity (PDV) were reduced in group PJ if compared to group nPJ and control group (PDSR = 1.10 ± 0.2 1/s vs. 1.34 ± 0.5 1/s vs. 1.53 ± 0.3 1/s, p:0.001 and 0.68 ± 0.2 1/s vs. 1.17 ± 0.2 1/s vs. 1.05 ± 0.4 1/s ; p < 0.001, PDV = − 101.6 ± 28.1 deg/s vs. − 201.4 ± 85.9 deg/s vs. − 221.6 ± 67.1 deg/s; p < 0.001 and − 28.1 ± 8 mm/s vs. − 38.9 ± 11.1 mm/s vs. − 43.6 ± 14.3 mm/s, p < 0.001, respectively), whereas no differences have been found in systolic strain values. 4D Flow images (available only in 9 patients) showed deformation of diastolic transmitral streamlines direction in group PJ compared to other groups. In BAV patients with mild AR, the posterior direction of the regurgitant jet may hamper the complete mitral valve opening, disturbing transmitral flow and slowing the LV diastolic filling.

Technical Note: Fully automatic segmental relaxometry (FASTR) for cardiac magnetic resonance T1 mapping.

Cardiac relaxometry techniques, particularly T1 mapping, have recently gained clinical importance in various cardiac pathologies. Myocardial T1 and extracellular volume are usually calculated from manual identification of left ventricular epicardial and endocardial regions. This is a laborious process, particularly for large volume studies. Here we present a fully automated relaxometry framework (FASTR) for segmental analysis of T1 maps (both native and postcontrast) and partition coefficient (λ). Patients (N=11) were imaged postacute myocardial infarction on a 1.5T clinical scanner. The scan protocol involved CINE-SSFP imaging, native, and post-contrast T1 mapping using the Modified Look-Locker Inversion (MOLLI) recovery sequence. FASTR consisted of automatic myocardial segmentation of spatio-temporally coregistered CINE images as an initial guess, followed by refinement of the contours on the T1 maps to derive segmental T1 and λ. T1 and λ were then compared to those obtained from two trained expert observers. Robust endocardial and epicardial contours were achieved on T1 maps despite the presence of infarcted tissue. Relative to experts, FASTR resulted in myocardial Dice coefficients (native T1: 0.752±0.041; postcontrast T1: 0.751±0.057) that were comparable to interobserver Dice (native T1: 0.803±0.045; postcontrast T1: 0.799±0.054). There were strong correlations observed for T1 and λ derived from experts and FASTR (native T1: r=0.83; postcontrast T1: r=0.87; λ: r=0.78; P<0.0001), which were comparable to inter-expert correlation coefficients (native T1: r=0.90; postcontrast T1: r=0.93; λ: r=0.80; P<0.0001). Our fully automated framework, FASTR, can generate accurate myocardial segmentations for native and postcontrast MOLLI T1 analysis without the need for manual intervention. Such a design is appealing for high volume clinical protocols.

Wave decomposition applied to LA phasic longitudinal strain evaluated from MRI feature tracking to estimate a true LA booster strain index

Abstract Funding Acknowledgements Type of funding sources: None. Background. Feature tracking (FT) is an emerging approach for the evaluation of both left atrium (LA) and left ventricular (LV) myocardial strain from the same cine MRI dataset. We hypothesized that the LA active contraction longitudinal strain, is a merge of an intrinsic LA booster contraction with the early diastolic LA emptying, especially when this latter is extended because of a poor LV relaxation (Figure 1, bottom). Such index can be estimated through LA phasic strain wave-decomposition as conventionally done for pressure curves to estimate forward and reflected components. Purpose. To compare the newly proposed LA intrinsic or "true" booster index (Sla_fit) against the conventional index (Sla) in terms of associations with LV remodeling (LV mass/ LV volume), LV systolic longitudinal strain (LV_GLS), and transmitral LV filling indices in healthy controls and aortic valve stenosis (AVS) patients with preserved LV ejection fraction. Methods. We studied 55 patients (34 AVS:71 ± 11years, 21 controls:66 ± 9years) who had an MRI exam with cine SSFP and phase contrast (PC) images. FT was applied to cine images to extract LV and LA phasic longitudinal strain and strain rates. Transmitral flow early (E, cm/s) and late (A, cm/s) filling peak velocities were calculated from PC data. To estimate intrinsic LA booster index, the LA longitudinal strain curve corresponding to the reservoir and conduit phases was fitted using two half cosine waves, to account for an eventual LA filling to LA early emptying asymmetry, while fitting the LA contraction with a full cosine wave (Figure 1). The peak of this latter wave was defined as the intrinsic LA booster strain index (Sla_fit), while the second peak of the measured LA strain was defined as the conventional LA booster strain (Sla). Results. While conventional Sla was significantly higher than intrinsic LA booster Sla_fit in AVS patients (13.55 ± 4.26 vs. 8.09 ± 6.07, p = 0.0002), it was nearly equivalent in controls (14.34 ± 4.30 vs.13.43 ± 4.23, p =.49). But the newly proposed LA booster strain index was significantly related to LV_GLS (r=-48,p=.0004); to LV remodeling (r=-.44,p = 0.0012) as well as to transmitral flow A wave ( r=-.49, p=.0005) none of these associations were significant when considering conventional LA booster strain. Interestingly our intrinsic LA booster index Sla_fit was significantly associated with LV longitudinal strain in both controls (r=-.55,p = 0.009) and asymptomatic AVS (N = 10) (r=-.77,p = 0.0081) but not in symptomatic AVS (N = 24) (p&amp;gt;.70). This may reveal a maintained LA-LV coupling in the asymptomatic phase and an uncoupling in the symptomatic phase, caused by elevated LV filling pressures. Conclusions. A promising index for the quantitative evaluation of intrinsic LA booster function was proposed and its consistency was demonstrated through its significant associations with LV remodeling, LV longitudinal strain and transmitral late filling peak. Abstract Figure.

Serial MRI-based right ventricular mechanical wall stress measurements and their association with right ventricle function in patients with repaired Tetralogy of Fallot

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Stichting Hartekind en Thorax Foundation Background Optimal timing of pulmonary valve replacement (PVR) in Tetralogy of Fallot (TOF) patients remains challenging. Wall stress is considered to be a possible early marker of right ventricular (RV) dysfunction. With patient-specific computational models, wall stress can be determined regionally and with high accuracy, especially in complex shaped ventricles such as in TOF patients. We aimed to 1) develop patient-specific computational models to assess RV diastolic wall stresses and 2) investigate the association of wall stresses and their change over time with functional parameters in TOF patients. Methods Repaired TOF patients with at least moderate pulmonary regurgitation (PR) and prior to PVR were included. MRI-based patient-specific computational ventricular models were created (figure). The ventricular geometry was created by stacking endo- and epicardial contours traced on short axis SSFP cine images. Pressure in the right ventricle was estimated from echocardiography. Mid-diastolic wall stress in the RV free wall was analysed globally and regionally (basal, mid, apical, anterior, lateral and posterior) at two time points. RV ejection fraction (RVEF), NT-proBNP and exercise tests (% maximum predicted workload) were used as outcomes for RV function. Associations between wall stresses and outcomes were investigated using linear mixed models adjusted for follow-up duration. Results Five males and five females were included with an age at baseline of 24 (IQR 16-28) years and RV end-diastolic volume of 140 (IQR 127-144) ml/m2. The period between the two time points was 7.0 (IQR 5.8-7.3) years. Global wall stress of the RV free wall combining both time points was 5.8 kPa (IQR 5.2-7.2). There was no statistical difference between baseline and follow-up global wall stress. The mean wall stresses in the mid region was 1.69 kPa (p &amp;lt; 0.01) higher than in the basal region and was 1.05 kPa (p = 0.03) higher than in the apical region cross-sectionally. The wall stress also increased more in the mid region compared to basal and apical region, corrected for duration of follow-up. Patients with more severe PR at baseline demonstrated a higher increase of global wall stress over time (p = 0.02), especially in lateral free wall. Higher global free wall stresses were cross-sectionally independently associated with lower RVEF, adjusted for LVEF and RVEDV (β=-1.29 % RVEF per kPa increase in wall stress, p = 0.01). This association was most prominent in the anterior, basal and mid part. No statistically significant association was found between wall stress, NT-proBNP, and exercise capacity. Conclusions This study generated a novel MRI-based method to calculate wall stress in geometrically complex ventricles. Wall stress associated negatively with RVEF in patients with TOF and PR. This promising tool for RV wall stress analysis can be used in future larger studies to validate these preliminary findings and to assess the predictive value of wall stress in TOF. Abstract Figure.

Late Gadolinium Enhancement at cardiac magnetic resonance predicts malignant ventricular arrhythmias in systemic sclerosis

Abstract Background Malignant arrhythmias due to cardiac involvement are a frequent cause of death in systemic sclerosis (SSc). Cardiac involvement, which is linked to both ischaemic and non-ischaemic fibrotic deposition, is often subclinical. Cardiovascular magnetic resonance (CMR) is the non-invasive gold standard for myocardial tissue characterization and can detect macroscopic myocardial fibrosis through late Gadolinium enhancement (LGE). Aim To evaluate the role of LGE to predict malignant arrhythmias requiring implantable cardioverter defibrillator (ICD) in SSc. Methods 289 SSc patients underwent a thorough clinical evaluation and CMR exam using a 1.5 T scanner. Biventricular function parameter by SSFP cine images, oedema by STIR T2 images, and macroscopic fibrosis by LGE were assessed. Patients were followed-up and malignant ventricular arrhythmias requiring ICD implantation was considered as event. Results Out of 289 patients, 111 (38.4%) showed LGE and 83/111 (28.7% of the total population) showed a non-junctional distribution. During the follow-up (45±27 months), 10 patients needed ICD after malignant ventricular arrhythmias (7 patients with LGE, 3 patients without LGE). CMR predictors of cardiac events by univariate analysis were left and right ventricular ejection fractions, indexed right atrial area and non-junctional LGE. At multivariate analysis, macroscopic myocardial fibrosis detected by LGE was an independent predictor (hazard ratio 5.4; 95% C.I. 1.1–28.8, p&amp;lt;0.05; see figure for Kaplan-Meier curves). Conclusions Presence of ventricular LGE at CMR may represent an independent predictor for further malignant ventricular arrhythmias requiring ICD implantation in SSc patients. Kaplan-Meier curves Funding Acknowledgement Type of funding source: None

109 Anderson Fabry disease in CMR: twins by traditional tissue characterization, different by parametric mapping

Abstract Anderson Fabry disease (AFD) is an X-linked recessive lysosomal storage disease, caused by intracellular accumulation of glycosphingolipids due to deficiency of the enzyme α-galactosidase. The cardiac involvement carries a worse prognosis. Myocardial hypertrophy is the most common manifestation due to the intracellular accumulation of glycosphingolipids in myocytes. With disease progression the deposits are replaced by fibrosis although recent data suggest a chronic inflammation also independently to glycosphingolipids accumulation. Cardiac magnetic resonance (CMR) by tissue characterization using parametric mapping is a unique technique in evaluating AFD progression and in determining enzyme treatment indications and evolution under therapy. Heterozygous females are not asymptomatic carriers of the AFD mutation, they have a variable clinical presentation; disease expression in females is the result of random inactivation of the X chromosome. Female patients have a . This case provides an example of Fabry disease in a couple of sisters with a third sister with a diagnosis of AFD with cardiac, hepatic, and renal involvement. The youngest sister with a positive genetic test was symptomatic for chest pain, without any significant coronary arteries disease by coro CT. The ECG showed atrial fibrillation and sign for LVH confirmed by echocardiography. The traditional CMR study by SSFP cine images and LGE technique showed an increased thickness in the basal infero-lateral wall (15 mm) and the anterior interventricular septum (14 mm) with midwall fibrosis in the basal infero-lateral wall (Fig. 1 A, B). The oldest sister with a positive genetic test was asyntomatic in AF. ECG and ECOC were aspecific. The traditional CMR study by SSFP cine images and LGE technique showed the same finding of the youngest sister (Fig. 2 A, B) By T1 mapping based on the normal cut off values of the Lab the older sister reported a short T1 global value (915 ms) and short T1 values in all segment with exception of lateral wall, mid and distal inferior segments and distal septum (Figure 1 C). Despite the presence of positive LGE in the basal infero-lateral wall the T1 value was normal in this segment due to a pseudo normalization related to the sphingolipid accumulation. Based on the CMR report she started the enzyme replacement therapy and the CMR follow was planned at 1 year. Conversely, the younger woman reported a long T1 value only in the basal infero-lateral wall with normal T1 value in all the other segments (Figure 2 C). The positive LGE in the basal infero-later segment (oedema/fibrosis) justifies the long T1 value in this no thickness segment. Based on the CMR report she did not start enzyme replacement therapy. Conclusion The case of this family show how quantitative parametric mapping could be a unique tool for the clinicians to adjust the therapy and plan the follow up of patients affected by AFD with cardiac involvement. Abstract 109 Figure.