Use Of Cardiac Magnetic Resonance Imaging Research Articles

P31 The evolving role of cardiac MRI in the patient with connective tissue disease

Abstract Background An atypical presentation of a new diagnosis of undifferentiated CTD highlights the use of cardiac MRI in CTD. In comparison to echocardiogram it can better establish cardiac involvement in CTD which is associated with significant morbidity and mortality. Methods A 49 year old previously well man was referred to rheumatology clinic with symptoms of inflammatory sounding arthralgia, new onset Raynauds, fatigue and 1 stone weight loss. In the interim he presented acutely with dyspnoea and chest pain and was found to be in atrial fibrillation. A chest X-ray was suggestive of pneumonitis and bibasal patchy consolidation. Despite antibiotics the AF persisted, and anticoagulation and rate control was initiated. He represented two weeks later with severe arthralgia, joint swelling and malaise. Bloods showed: CRP 283, ESR 87, lymphopenia but normal renal and liver function. He was pyrexial and tachycardic, but a septic screen was negative and he had limited response to antibiotic therapy. A CT Chest showed extensive lymphadenopathy, bilateral pleural effusions and an enhancing pericardial effusion suggestive of pericarditis, confirmed by echocardiogram. A provisional diagnosis of systemic inflammation secondary to an undifferentiated CTD was made and after initiation of oral prednisolone and colchicine he had significant improvement in symptoms. A repeat CT chest one month later has shown resolution of the mediastinal lymphadenopathy and interstitial changes. Cardiac MRI has confirmed likely infiltrative cardiomyopathy consistent with a connective tissue disease. His ANA is 1:2560 speckled/ nucleolar pattern, ENA negative, anti CCP 55 and Ra Latex 65, DsDNA and complements normal. ACE and ANCA negative and the formal diagnosis of an undifferentiated CTD has been made. Methotrexate was introduced causing resolution of symptoms by 6 months of treatment. Follow up imaging is planned. Results Cardiac MRI (CMR) in CTD is a relatively new imaging modality. Increasingly we are recognising that patients can have abnormalities seen on CMR despite a normal echo. CMR has identified occult cardiac disease in patients with treatment naive CTD which is potentially reversible with immunosuppresion. We also know that despite serological normalisation and systemic improvement of symptoms cardiac involvement can be subclinical. CMR as a non-radiating and non-invasive imaging modality is ideally placed to assess response to treatment in those with CTD related cardiac involvement. Indications for CMR in CTD has been further delineated in guidance from the International consensus group of Cardiac MRI in CTD. Conclusion In our patient identification of his new atrial arrhythmia prompted the instigation of cardiac investigations which culminated in CMR. Close working with cardiology colleagues and subsequent access to their tertiary MDT has meant we have better characterised our patient’s cardiac involvement translating to rapid immunosuppression and planned treatment monitoring with further CMR. Disclosures R. Benson None. L. Waters None. P. Magapu None. H. Sadik None.

Right ventricular function during and after thoracic surgery.

Right ventricular (RV) dysfunction following thoracotomy and pulmonary resection is a known phenomenon but questions remain about its mechanism, risk factors, and clinical significance. Acute RV dysfunction can present intraoperatively and postoperatively, persisting for 2 months after surgery. Recently, the pulmonology literature has emphasized pulmonary arterial capacitance, rather than pulmonary vascular resistance, as a marker to predict disease progression and outcome in patients with pulmonary hypertension and heart failure. Diagnostic focus has emerged on the use of cardiac MRI and new echocardiographic parameters to better quantify the presence of RV dysfunction and the role of pulmonary capacitance in its development. In this review, we examine the most recent literature on RV dysfunction following lung resection, including possible mechanisms, time span of RV dysfunction, and available diagnostic modalities. The clinical relevance of these factors on preoperative assessment and risk stratification are presented.

Integrated use of cardiac MRI and the CardioMEMS™ HF system in PAH: the utility of coincident pressure and volume in RV failure-the NHLBI-VITA trial.

This study aims to study the feasibility and safety of measuring volumetric and pressure parameters noninvasively using simultaneous cardiovascular magnetic resonance (cMR) volumetric data and time-resolved pressure waveforms from previously implanted CardioMEMS devices in pulmonary arterial hypertension (PAH) patients. Opportunities to intervene during clinically occult phases in PAH promise to herald a key transformation in our current practice for treating this complex population. Currently, it is possible and convenient to monitor daily pulmonary arterial (PA) pressures in PAH patients using the CardioMEMS device to determine clinically silent progression. Supplementation of these pressures with other prognostic measurements of right ventricular (RV) contractility, PA resistance and RV/PA coupling could add further predictive capabilities. PAH patients (n=17) with New York Hospital Association (NYHA) class III or IV heart failure (HF) and recent HF related hospitalizations were implanted with the CardioMEMS device as part of a NHLBI sponsored Trial. Implanted patients were then assessed using cMR imaging of the right ventricle (RV) along with measurement of pulmonary artery flow. Patients were imaged at one-month post implant (baseline) and at 4-month follow-up time (n=12). At baseline, patients were studied at rest and then under three different physiologic conditions: inhaled nitric oxide (INO), dobutamine (Dob) stress and volumetric stress (Vol), using a multiple slice short-axis imaging and a rapid imaging protocol. All patients were safely imaged, with no artifacts obscuring the cMR images. RV volumes were measured successfully at rest and under each stress condition using a reduced scan approach that required calibration for each patient which achieved a correlation r2 of 0.98. Variables measured included the maximal pulmonary artery elastance (Ea), maximal RV myocardial elastance (Emax) and ventricular-vascular coupling ratio (VVC). The response to stressors was determined on a patient basis. No complications occurred during the cMRI examination. It is safe and feasible to perform cMR imaging with simultaneous pulmonary artery pressure readings from the CardioMEMS device. A reduced scan approach was developed to allowed measurement of RV volumes during stress conditions. Volumetric and pressure measurements can be combined to assess fundamental myocardial properties (e.g., Emax, Ea and VVC) in PAH patients serially over time. In the future, these parameters can be tested as serial predictors of outcome and response to therapies in PAH.

Challenges and diagnosis of isolated left ventricular non-compaction: A case series of 4 patients with echocardiographic diagnosis of possible ILVNC

Isolated left ventricular non-compaction (ILVNC) is a rare, congenital, idiopathic cardiomyopathy that may present in adulthood. There is no true gold standard for the diagnosis of ILVNC. Two-dimensional echocardiography with colour Doppler is the modality of choice to diagnose the condition. However, the diagnosis should be confirmed with cardiac magnetic resonance imaging (CMRI), as well as either a positive family history, complications of ILVNC or confirmatory genetic testing.We describe the clinical and echocardiographic features in 4 patients, each with a possible diagnosis of ILVNC, in the setting of potential alternative aetiologies for heart failure. Approval to present these cases was obtained from the institutional ethics committee and the patients also provided consent. Sufficient transthoracic echocardiographic (TTE) evidence of ILVNC according to previously published criteria was found in all the cases, although it was not confirmed with CMRI.This case series highlights the importance of routine echocardiography in all patients who present with heart failure – irrespective of associated risk factors. We caution against over-diagnosis of ILVNC with TTE alone, and recommend the use of CMRI as a second-line diagnostic investigation. Screening of family members and prevention of complications of confirmed cases of ILVNC are important.

State of the art: Evaluation and prognostication of myocarditis using cardiac MRI.

Myocarditis encompasses both primary and secondary processes causing inflammation of the myocardium. Viral infections are a common secondary cause of myocarditis with important clinical relevance. Viral myocarditis has a varied clinical presentation, potentially resulting in significant morbidity and mortality. Acutely, systolic dysfunction and sudden cardiac death may ensue; chronically, myocarditis may result in a dilated cardiomyopathy requiring heart transplantation. Myocarditis is thought to be one of the most common causes of myocardial infarction with nonobstructive coronary arteries (MINOCA), with important consequences for cardiovascular outcomes. Patients with myocarditis are currently underdiagnosed. Cardiac MRI has evolved as the noninvasive test of choice, with cardiac MRI-specific diagnostic requirements defined in the Lake Louise Criteria (LLC). Detecting the presence of tissue edema, hyperemia, and necrosis in both acute and chronic stages form the foundation of the LLC. Cardiac MR for chronic myocarditis (greater than 8 weeks from symptom onset) has decreased sensitivity for diagnosis. Emerging sequences such as T1 and T2 parametric maps provide tissue characterization regarding inflammation without reliance on reference tissue, overcoming limitations of the LLC. Beyond diagnostic criteria, these imaging techniques have proven useful in further characterizing the diseased tissue, prognostication, and clinical decision-making. This review describes the utility and evolving use of cardiac MRI in clinical practice. Level of Evidence: 1 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2018;47:1061-1071.

Recent Advances in Cardiac Magnetic Resonance Imaging.

Cardiac magnetic resonance (CMR) imaging provides accurate anatomic information and advanced soft contrast, making it the reference standard for assessing cardiac volumes and systolic function. In this review, we summarize the recent advances in CMR sequences. New technical development has widened the use of CMR imaging beyond the simple characterization of myocardial scars and assessment of contractility. These novel CMR sequences offer comprehensive assessments of coronary plaque characterization, myocardial fiber orientation, and even metabolic activity, and they can be readily applied in clinical settings. CMR imaging is able to provide new insights into understanding the pathophysiologic process of underlying cardiac disease, and it can help physicians choose the best treatment strategies. Although several limitations, including the high cost and time-consuming process, have limited the widespread clinical use of CMR imaging so far, recent advances in software and hardware technologies have made the future more promising.

Early Detection of Silent Myocardial Impairment in Drug-Naive Patients With New-Onset Systemic Lupus Erythematosus: A Three-Center Prospective Study.

Cardiac magnetic resonance imaging (MRI) has enabled the assessment of myocardial features, from tissue characteristics to functional changes, in patients with systemic lupus erythematosus (SLE). Echocardiography, however, detects cardiac decompensation. This study was undertaken to investigate the use of cardiac MRI to explore early warning signs of silent cardiac involvement and determine treatment timing in SLE. Clinical assessment and cardiac MRI studies were performed in 50 drug-naive patients with new-onset SLE, 60 patients with longstanding SLE, and 50 healthy subjects in a 3-center prospective study. Analysis of cardiac enzymes, the presence and size of regional myocardial fibrosis as indicated by late gadolinium enhancement, strain changes, and biventricular ejection fraction did not indicate cardiac impairment in the patients with new-onset SLE. Native myocardial T1 and extracellular volume (ECV), which are extracellular matrix indices, were elevated in the patients with new-onset SLE (mean ± SD 1,369 ± 79 msec versus 1,092 ± 57 msec in the control group for native T1; 32 ± 5% versus 24 ± 3% in the control group for ECV; P < 0.001 for both). The elevation was independent of SLE disease activity. This is the first study to indicate that drug-naive patients with new-onset SLE, even those with inactive disease, are likely to have silent cardiac impairment. Structural and functional changes in the myocardium are related to SLE disease stage; this finding indicates the value of early detection of myocardial involvement. Native myocardial T1 values and ECV, rather than currently used clinical rheumatic and cardiac indices, could serve as early detection markers of myocardial injury before the presence of visual fibrosis and functional decompensation.

57-Year-Old Man With Atypical Chest Pain

57-Year-Old Man With Atypical Chest Pain

Cardiac MRI in evaluation and management of pediatric pericarditis

BackgroundEvaluation of pediatric pericarditis depends on the physical examination, electrocardiography and echocardiography. However, a multimodality imaging approach which includes cardiac magnetic resonance imaging (MRI) has been adopted in the adult population. The use of such an approach in the pediatric population has not been studied well. ObjectiveThe present study was intended to describe a single institution's experience with the use of cardiac MRI in the evaluation of pericarditis in the pediatric population. Study DesignA retrospective review of patients who had a cardiac MRI before the age of 21 years, between 2005 and 2014, to evaluate for pericardial pathology including pericarditis, constrictive pericarditis, recurrent pericarditis and pericardial effusion was performed. Patients were excluded if the cardiac MRI was done for evaluation of pathologies other than those related to the pericardium. Patients with predominant myocarditis were also excluded. The cardiac MRI and the echocardiograms were reviewed by a single blinded investigator. ResultsTwenty-one patients satisfied the inclusion criteria. The study population were predominantly male (81%) older adolescents (mean age: 17 ± 3 years). The major indications for cardiac MRI included evaluation of myocardial involvement in acute pericarditis, modulation of therapy in recurrent pericarditis and confirmation of constriction. Cardiac MRI was comparable to echocardiogram in detecting constrictive physiology and was useful in determining the presence of active pericardial inflammation. Systemic inflammatory diseases demonstrated higher values on quantification of late gadolinium enhancement. ConclusionWe have reported on a relatively large series of pediatric patients with pericarditis evaluated by cardiac MRI. Cardiac MRI may be a useful adjunct to conventional imaging in selected pediatric patients with pericarditis.

The Use of Cardiac MRI to Detect Myocardial Fibrosis and Development of Restrictive Cardiac Physiology After HTx

The Use of Cardiac MRI to Detect Myocardial Fibrosis and Development of Restrictive Cardiac Physiology After HTx

Effect of oxygen therapy on myocardial salvage in ST elevation myocardial infarction: the randomized SOCCER trial.

Recent studies suggest that administration of O2 in patients with acute myocardial infarction may have negative effects. With the use of cardiac MRI (CMR), we evaluated the effects of supplemental O2 in patients with ST elevation myocardial infarction (STEMI) accepted for acute percutaneous coronary intervention (PCI). This study was a randomized-controlled trial conducted at two university hospitals in Sweden. Normoxic STEMI patients were randomized in the ambulance to either supplemental O2 (10 l/min) or room air until the conclusion of the PCI. CMR was performed 2-6 days after the inclusion. The primary endpoint was the myocardial salvage index assessed by CMR. The secondary endpoints included infarct size and myocardium at risk. At inclusion, the O2 (n=46) and air (n=49) patient groups had similar patient characteristics. There were no significant differences in myocardial salvage index [53.9±25.1 vs. 49.3±24.0%; 95% confidence interval (CI): -5.4 to 14.6], myocardium at risk (31.9±10.0% of the left ventricle in the O2 group vs. 30.0±11.8% in the air group; 95% CI: -2.6 to 6.3), or infarct size (15.6±10.4% of the left ventricle vs. 16.0±11.0%; 95% CI: -4.7 to 4.1). In STEMI patients undergoing acute PCI, we found no effect of high-flow oxygen compared with room air on the size of ischemia before PCI, myocardial salvage, or the resulting infarct size. These results support the safety of withholding supplemental oxygen in normoxic STEMI patients.

Appropriate utilization of cardiac magnetic resonance for the assessment of heart failure and potential associated cost savings.

The rapid growth in cardiac imaging utilization has led to the development of appropriate use criteria (AUC) in an effort to control costs. Recently, cardiac MRI has developed into a valuable modality in the evaluation of cardiac disease. However, there are no studies examining the appropriate use of cardiac MRI in clinical practice. To determine the appropriate utilization of cardiac MRI in a large quaternary care institution and to compare percentages of appropriate utilization pre- and postpublication of the AUC document. We hypothesized that percentages of appropriate cardiac MRI utilization will be similar to those of other comparable cardiac imaging modalities and that there would be a significant change in appropriate use pre- and post-AUC publication. Retrospective cohort study. In all, 2032 consecutive patients undergoing cardiac MRI for the assessment of heart failure between 2012-2016. 1.5T. Data were collected and an appropriateness category was assigned for each cardiac MRI. Rates of major cardiac risk factors were compared between those undergoing cardiac MRIs pre- and post-AUC using the chi-square and the Mann-Whitney tests for categorical and continuous variables, respectively. Appropriateness classification was compared pre- and post-AUC publication using the chi-square test. There were no significant differences in the prevalence of major cardiovascular risk factors before and after publication of the AUC. 95.5% of all cardiac MRIs were appropriate based on the AUC. Further, there was a significant difference when comparing the appropriateness classification before and after publication of the AUC (P = 0.0003), potentially associated with annual cost savings of ∼$14.8 million. We report a very high percentage of appropriate use of cardiac MRI and a significant increase in the proportion of tests classified as appropriate after AUC publication. 3 Technical Efficacy: Stage 5 J. Magn. Reson. Imaging 2019;49:e132-e138.

Comprehensive study of routine clinical use of cardiac MRI in a district general hospital setting

Comprehensive study of routine clinical use of cardiac MRI in a district general hospital setting

073_16808-L5 Analysis of VT Substrate in Chagas Disease Patients Using 3D-LGE MRI and Automatic Detection Arrhythmia Substrate (ADAS) Software

The use of cardiac MRI has been an interesting tool to substrate identification and ablation planning. ADAS software has been developed to identify conducting channels using 3D LGE MRI. Chagas disease is an infectious disease that lead to specific abnormalities that are substrate to scar related VT

The Role of Clinical Cardiac Magnetic Resonance Imaging in China: Current Status and the Future

Cardiac magnetic resonance (CMR) imaging plays an important role in the diagnosis and management of cardiovascular diseases. The state-of-the-art CMR imaging has many advantages in cardiac imaging, including excellent spatial and temporal resolution, unrestricted imaging field, no exposure to ionizing radiation, excellent tissue contrast, and unique myocardial tissue characterization. Clinical CMR imaging is used during the cardiovascular diagnostic workup in the United States and some European countries. Use of CMR imaging is emerging in hospitals in China and has a promising future. This review briefly describes the real-world clinical application of CMR imaging in China and discuss obstacles for its future development.

Mediterranean diet score and left ventricular structure and function: the Multi-Ethnic Study of Atherosclerosis ,

Background: Data are limited on the relation between dietary patterns and left ventricular (LV) structure and function.Objective: We examined cross-sectional associations of a diet-score assessment of a Mediterranean dietary pattern with LV mass, volume, mass-to-volume ratio, stroke volume, and ejection fraction.Design: We measured LV variables with the use of cardiac MRI in 4497 participants in the Multi-Ethnic Study of Atherosclerosis study who were aged 45–84 y and without clinical cardiovascular disease. We calculated a Mediterranean diet score from intakes of fruit, vegetables, nuts, legumes, whole grains, fish, red meat, the monounsaturated fat:saturated fat ratio, and alcohol that were self-reported with the use of a food-frequency questionnaire. We used linear regression with adjustment for body size, physical activity, and cardiovascular disease risk factors to model associations and assess the shape of these associations (linear or quadratic).Results: The Mediterranean diet score had a slight U-shaped association with LV mass (adjusted means: 146, 145, 146, and 147 g across quartiles of diet score, respectively; P-quadratic trend = 0.04). The score was linearly associated with LV volume, stroke volume, and ejection fraction: for each +1-U difference in score, LV volume was 0.4 mL higher (95% CI: 0.0, 0.8 mL higher), the stroke volume was 0.5 mL higher (95% CI: 0.2, 0.8 mL higher), and the ejection fraction was 0.2 percentage points higher (95% CI: 0.1, 0.3 percentage points higher). The score was not associated with the mass-to-volume ratio.Conclusions: A higher Mediterranean diet score is cross-sectionally associated with a higher LV mass, which is balanced by a higher LV volume as well as a higher ejection fraction and stroke volume. Participants in this healthy, multiethnic sample whose dietary patterns most closely conformed to a Mediterranean-type pattern had a modestly better LV structure and function than did participants with less–Mediterranean-like dietary patterns. This trial was registered at clinicaltrials.gov as NCT00005487.

Sarcoïdose cardiaque : avancées diagnostiques et thérapeutiques

Sarcoidosis is a granulomatous disorder of unknown cause characterized by non-caseating granuloma in young adults. Cardiac involvement is rare and range from 2 to 75% depending on diagnostic criteria. Cardiac involvement in sarcoidosis may be asymptomatic or may manifest as rhythm/conduction troubles or congestive heart failure. The diagnosis and treatment of cardiac sarcoidosis may be challenging. However, advances have come in recent years from the use of cardiac MRI and 18FDG-TEP scanner, as well as from the stratification of the risk of ventricular tachycardia/fibrillation. Due to the rarity of the disease, there is no reliable prospective large study to guide therapeutic strategy for cardiac sarcoidosis. Corticosteroids are probably efficacious, in particular in case of atrio-ventricular block or moderate heart failure. Immunosuppressive drugs have not been largely studied but methotrexate could be helpful. In refractory forms, TNF-α antagonists have been used with success.

Pulsatile Load Components, Resistive Load and Incident Heart Failure: The Multi-Ethnic Study of Atherosclerosis (MESA)

BackgroundLeft ventricular (LV) afterload is composed of systemic vascular resistance (SVR) and components of pulsatile load, including total arterial compliance (TAC), and reflection magnitude (RM). RM, which affects the LV systolic loading sequence, has been shown to strongly predict HF. Effective arterial elastance (Ea) is a commonly used parameter initially proposed to be a lumped index of resistive and pulsatile afterload. We sought to assess how various LV afterload parameters predict heart failure (HF) risk and whether RM predicts HF independently from subclinical atherosclerosis. MethodsWe studied 4345 MESA participants who underwent radial arterial tonometry and cardiac output (CO) measurements with the use of cardiac MRI. RM was computed as the ratio of the backward (Pb) to forward (Pf) waves. TAC was approximated as the ratio of stroke volume (SV) to central pulse pressure. SVR was computed as mean pressure/CO. Ea was computed as central end-systolic pressure/SV. ResultsDuring 10.3 years of follow-up, 91 definite HF events occurred. SVR (P = .74), TAC (P = .81), and Ea (P = .81) were not predictive of HF risk. RM was associated with increased HF risk, even after adjustment for other parameters of arterial load, various confounders, and markers of subclinical atherosclerosis (standardized hazard ratio [HR] 1.49, 95% confidence interval [CI] 1.18–1.88; P = .001). Pb was also associated with an increased risk of HF after adjustment for Pf (standardized HR 1.43, 95% CI 1.17–1.75; P = .001). ConclusionsRM is an important independent predictor of HF risk, whereas TAC, SVR, and Ea are not. Our findings support the importance of the systolic LV loading sequence on HF risk, independently from subclinical atherosclerosis.

Cardiac Imaging – What Do I Really Need to Know?

The pivotal role of cardiovascular (CV) imaging to the care of patients with heart disease is evident. From technical point of view CV imaging is developing very rapidly. This progress creates new demands on our profession for competence and training. Radiologists should be ready to meet these demands in order to keep cardiac imaging in their hands. Deep knowledge of CV physiology, cardiac diseases and latest advances in CV imaging technologies is a must for any radiologist performing cardiac imaging. In this aspect role of national and international (ESR and ESCR) professional organizations of radiologists becomes more and more important. It is obvious that the need for CV imaging will continue to grow over the coming years due to progress of technology, changes in incidence and scope of CV diseases, aging of population and other reasons. We are witnessing important trends in modern CV imaging, including the move toward multimodality imaging, development of international guidelines on appropriate use and technical standards on different imaging modalities. There were some statements about overuse of CV imaging. In reality more serious problems are underuse and misuse of cardiac radiology. This is why creation and promotion of appropriate use guidelines for CV imaging gains more and more importance to clinical care. More and more clinical trials about different CV imaging modalities are directed to show their additional diagnostic value and cost-effectiveness of healthcare. One of the most spectacular examples is use of coronary CT in patients with acute chest pain admitted to emergency departments. Another good example is increasing use of cardiac MRI for assessment of myocardial perfusion and viability, where this diagnostic modality favorably competes with nuclear myocardial perfusion scans. An updated knowledge about clinical and economical effectiveness of CV imaging is needed if we are to further improve care of patients with diseases of heart and vessels. Radiologists in co-operation with cardiologists and cardiac surgeons should re-design the diagnostic pathways in which imaging modalities are integrated in a cost-effective strategy in the interest of patient health and economy of health care.

Cardiac MRI and Ischemic Heart Disease: Role in Diagnosis and Risk Stratification.

Cardiac magnetic resonance imaging (CMRI) has been under development for the past four decades and has more recently become an essential tool in the evaluation of ischemic heart disease (IHD). It is the reference standard for quantification of both right and left ventricular volume and function and, after landmark work published in the New England Journal of Medicine in 2000, has proven effective in identifying hibernating myocardium, or hypokinetic myocardium that will recover after revascularization. More recent literature continues to support both delayed enhancement imaging and CMRI stress perfusion as essential tools in evaluating IHD. This review will briefly address the basics of CMRI and the scientific literature supporting the use of CMRI in IHD. It will then address more recent clinical studies establishing the clinical utility of CMRI in IHD, followed by a discussion of future directions in CMRI.