Use Of Cardiac Magnetic Resonance Research Articles

Evaluating myocardial involvement in patients with multiple myeloma at different stages a cardiac MR T1 mapping study

Abstract Background At present, the International criteria for diagnosis multiple myeloma（MM） do not specifically highlight the use of cardiac magnetic resonance (CMR) to detect abnormal myocardial infiltration in patients at different clinical stages of MM. Extracellular volume fraction (ECV) based on CMR T1 mapping indicates expansion of the extracellular space or deposition of material in infiltrative heart diseases. Purpose To detect whether myocardial involvement in patients with MM at different clinical stages based on CMR T1 mapping. Methods A cohort consisting of 20 patients with diagnosed MM and 15 sex- and age-matched controls (Cs) were recruited for this study. All participants underwent CMR examination to obtain native T1 and ECV. The patients with MM were stratified into three groups based on the International Staging System (ISS): Stage I (n=5), Stage II (n=7), and Stage III (n=8). Cardiac amyloidosis (CA) is diagnosed based on the patient's clinical presentation and tissue biopsy. The baseline biochemical indices were collected before CMR examination. Result Among patients with MM, there were a total of 9 patients diagnosed with CA, comprising 3 patients in stage II and 6 patients in stage III. The ECV in stage III patients (45.13±11.89%) was significantly higher compared to that in stage I (26.65±4.22%), stage II (34.09±8.90%), and controls (25.40±2.52%) (p < 0.05). Furthermore, the ECV in stage II patients (34.09±8.90%) was higher compared to controls (25.40±2.52%), though not significantly different from stage I patients (26.65±4.22%). Correlation analysis revealed a positive correlation between brain natriuretic peptide (BNP) levels and ECV (r=0.606, p=0.013). Receiver operating characteristic (ROC) curve analysis demonstrated that ECV had good predictive value for CA, with an area under the curve (AUC) of 0.898 (p < 0.01), and the optimal cutoff value for ECV was determined to be 33.7%. Conclusions ECV derived from CRM T1 mapping holds promise for identifying amyloid accumulation, which deteriorates progressively with the advancement of disease stages in patients with MM. It is recommended that patients diagnosed with Stage II and Stage III MM should undergo CMR to facilitate the early detection of myocardial infiltrative damage.

The 2023 European Task Force Criteria for Diagnosis of Arrhythmogenic Cardiomyopathy: Historical Background and Review of Main Changes.

Arrhythmogenic cardiomyopathy (ACM) is a cardiac disease featured by non-ischemic myocardial scarring linked to ventricular electrical instability. As there is no single gold-standard test, diagnosing ACM remains challenging and a combination of specific criteria is needed. The diagnostic criteria were first defined and widespread in 1994 and then revised in 2010, approaching and focusing primarily on right ventricular involvement without considering any kind of left ventricular variant or phenotype. Years later, in 2020, with the purpose of overcoming previous limitations, the Padua Criteria were introduced by an international expert report. The main novel elements were the introduction of specific criteria for left ventricular variants as well as the use of cardiac magnetic resonance for tissue characterization and scar detection. The last modifications and refinement of these criteria were published at the end of 2023 as the European Task Force criteria, by a "head-quarter" of ACM international experts, proving the emerging relevance of this condition besides its difficult diagnosis. In this review, emphasizing the progress in understanding the aetiology of the cardiomyopathy, an analysis of the new criteria is presented. The introduction of the term "scarring/arrhythmogenic cardiomyopathy" sets an important milestone in this field, underlying how non-ischemic myocardial scarring-typical of ACM-and arrhythmic susceptibility could be the main pillars of numerous different phenotypic variants regardless of etiology.

Diffuse Interstitial Fibrosis of the Myocardium Predicts Outcome in Moderate and Asymptomatic SevereAortic Stenosis.

Patients with moderate or asymptomatic severe aortic stenosis (AS) are at risk of cardiovascular events. The authors investigated the utility of cardiac magnetic resonance (CMR) to identify drivers of outcome in patients with moderate or asymptomatic severe AS. A prospective, international, multicenter cohort (n=457) of patients with moderate (aortic valve area [AVA]: 1.0-1.5cm2) or asymptomatic severe AS (AVA≤1.0cm2 and NYHA functional class I-II) patients underwent CMR. Diffuse interstitial fibrosis and scar in the myocardium were analyzed with extracellular volume fraction (ECV%) and late gadolinium enhancement (LGE). The outcome was a composite of mortality and heart failure admission. Median ECV% was 26.6% (IQR: 24.4%-29.9%), and LGE was present in 31.5% (median 0.8%; IQR: 0.1%-1.7%). Greater AS severity was associated with greater left ventricular mass and diastolic dysfunction, but not with ECV% or LGE. During a median 5.7 years of follow-up, 83 events occurred. Patients with events had higher ECV% (median ECV% 26.3% vs 28.2%; P = 0.003). Patients in the highest ECV% tertiles (ECV% >28.6%) had worse outcomes both in the entire cohort and in those with NYHA functional class I moderate or severe AS, and ECV% was independently associated with outcome (adjusted HR: 1.05; P = 0.039). The ECV% had significant incremental prognostic value when added to parameters of AS severity and cardiac function, comorbidities, aortic valve replacement, and LGE (P< 0.05). Increased diffuse interstitial fibrosis of the myocardium is associated with poor outcomes in patients with moderate and asymptomatic severe AS and can help identify those who require closer surveillance for adverse outcomes.

Cardiac magnetic resonance imaging in the evaluation and management of mitral valve prolapse - a comprehensive review.

Mitral valve prolapse is a common valve disorder that usually has a benign prognosis unless there is significant regurgitation or LV impairment. However, a subset of patients are at an increased risk of ventricular arrhythmias and sudden cardiac death, which has led to the recognition of "arrhythmic mitral valve prolapse" as a clinical entity. Emerging risk factors include mitral annular disjunction and myocardial fibrosis. While echocardiography remains the primary method of evaluation, cardiac magnetic resonance has become crucial in managing this condition. Cine magnetic resonance sequences provide accurate characterization of prolapse and annular disjunction, assessment of ventricular volumes and function, identification of early dysfunction and remodeling, and quantitative assessment of mitral regurgitation when integrated with flow imaging. However, the unique strength of magnetic resonance lies in its ability to identify tissue changes. T1 mapping sequences identify diffuse fibrosis, in turn related to early ventricular dysfunction and remodeling. Late gadolinium enhancement sequences detect replacement fibrosis, an independent risk factor for ventricular arrhythmias and sudden cardiac death. There are consensus documents and reviews on the use of cardiac magnetic resonance specifically in arrhythmic mitral valve prolapse. However, in this article, we propose an algorithm for the broader use of cardiac magnetic resonance in managing this condition in various scenarios. Future advancements may involve implementing techniques for tissue characterization and flow analysis, such as 4D flow imaging, to identify patients with ventricular dysfunction and remodeling, increased arrhythmic risk, and more accurate grading of mitral regurgitation, ultimately benefiting patient selection for surgical therapy.

Cardiac magnetic resonance reveals concealed structural heart disease in patients with frequent premature ventricular contractions and normal echocardiography: A systematic review

Premature ventricular contractions (PVCs) are a common form of arrhythmic events, often representing an idiopathic and benign condition without further therapeutic interventions. However, in certain circumstances PVCs may represent the epiphenomenon of a concealed structural heart disease (SHD). Surface 12‑leads EKG and 24-h dynamic EKG are necessary to assess their main characteristics such as site of origin, frequency and complexity. Echocardiography represents the first-line imaging tool recommended to evaluate cardiac structures and function. Cardiac Magnetic Resonance (CMR) is recognized as a superior modality for detecting structural cardiac alterations, that might evade detection by conventional echocardiography. Moreover, in specific populations such as athletes, CMR may have a crucial role to exclude a concealed SHD and the risk of serious arrhythmic events during sport activity. Some clinical characteristics such as male sex, older age or family history of sudden cardiac death (SCD) or cardiomyopathy, and some electrocardiographic features of PVCs, in particular a right branch bundle block (RBBB) with superior/intermediate axis morphology, the reproducibility of VAs during exercise test (ET) or the evidence of complex ventricular arrhythmias, may warrant a CMR evaluation, due to the high probability of SHD. In this systematic review our objective was to provide an exhaustive overview on the role of CMR in detecting a concealed SHD in patients with high daily burden of PVCs and a normal echocardiographic evaluation, paving the way for a more extensive utilization of CMR in presence of certain high-risk clinical and/or EKG features identified during the diagnostic workup.

Cardiovascular Magnetic Resonance Before Invasive Coronary Angiography in Suspected Non–ST-Segment Elevation Myocardial Infarction

BackgroundIn suspected non–ST-segment elevation myocardial infarction (NSTEMI), this presumed diagnosis may not hold true in all cases, particularly in patients with nonobstructive coronary arteries (NOCA). Additionally, in multivessel coronary artery disease, the presumed infarct-related artery may be incorrect. ObjectivesThis study sought to assess the diagnostic utility of cardiac magnetic resonance (CMR) before invasive coronary angiogram (ICA) in suspected NSTEMI. MethodsA total of 100 consecutive stable patients with suspected acute NSTEMI (70% male, age 62 ± 11 years) prospectively underwent CMR pre-ICA to assess cardiac function (cine), edema (T2-weighted imaging, T1 mapping), and necrosis/scar (late gadolinium enhancement). CMR images were interpreted blinded to ICA findings. The clinical care and ICA teams were blinded to CMR findings until post-ICA. ResultsEarly CMR (median 33 hours postadmission and 4 hours pre-ICA) confirmed only 52% (52 of 100) of patients had subendocardial infarction, 15% transmural infarction, 18% nonischemic pathologies (myocarditis, takotsubo, and other forms of cardiomyopathies), and 11% normal CMR; 4% were nondiagnostic. Subanalyses according to ICA findings showed that, in patients with obstructive coronary artery disease (73 of 100), CMR confirmed only 84% (61 of 73) had MI, 10% (7 of 73) nonischemic pathologies, and 5% (4 of 73) normal. In patients with NOCA (27 of 100), CMR found MI in only 22% (6 of 27 true MI with NOCA), and reclassified the presumed diagnosis of NSTEMI in 67% (18 of 27: 11 nonischemic pathologies, 7 normal). In patients with CMR-MI and obstructive coronary artery disease (61 of 100), CMR identified a different infarct-related artery in 11% (7 of 61). ConclusionsIn patients presenting with suspected NSTEMI, a CMR-first strategy identified MI in 67%, nonischemic pathologies in 18%, and normal findings in 11%. Accordingly, CMR has the potential to affect at least 50% of all patients by reclassifying their diagnosis or altering their potential management.

Current Insights and Novel Cardiovascular Magnetic Resonance-Based Techniques in the Prognosis of Non-Ischemic Dilated Cardiomyopathy.

Cardiac magnetic resonance (CMR) imaging has an important emerging role in the evaluation and management of patients with cardiomyopathies, especially in patients with dilated cardiomyopathy (DCM). It allows a non-invasive characterization of myocardial tissue, thus assisting early diagnosis and precise phenotyping of the different cardiomyopathies, which is an essential step for early and individualized treatment of patients. Using imaging techniques such as late gadolinium enhancement (LGE), standard and advanced quantification as well as quantitative mapping parameters, CMR-based tissue characterization is useful in the differential diagnosis of DCM and risk stratification. The purpose of this article is to review the utility of CMR in the diagnosis and management of idiopathic DCM, as well as risk prediction and prognosis based on standard and emerging CMR contrast and non-contrast techniques. This is consistent with current evidence and guidance moving beyond traditional prognostic markers such as ejection fraction.

The use of cardiac magnetic resonance in hypertrophic cardiomyopathy over the past 10 years [2013-2023]: a CiteSpace-based bibliometric analysis.

Hypertrophic cardiomyopathy (HCM) is a common genetic cardiac disorder characterized by the hypertrophy of a segment of the myocardium. Cardiac magnetic resonance (CMR) has been widely used in the assessment of HCM. However, no bibliometric assessment has been conducted on the progress of research in this field. This study thus aimed to examine the current state of research into the application of CMR in HCM and the hotspots and trends that have emerged in this field over the past decade. A systematic search was conducted on the Web of Science regarding CMR in the assessment of HCM. The databases were searched from 2013 to June 2023. CiteSpace is an application that can be used to characterize the underlying knowledge of the scientific literature in a given field. We used it to analyze the relationship between publication year and country, institution, journal, author, bibliography, and keywords in the field of CMR for the assessment of HCM. A total of 1,427 articles were included in the analysis. In the assessment of HCM, the findings from the past decade have consistently demonstrated a progressive rise in the quantity of articles pertaining to CMR. The country with the largest number of publications was the United States [310], and the institution with the greatest number of publications was the University College London [45]. The analysis of keywords revealed the diagnosis and management of HCM with CMR to be the current research focus and emerging trend within this academic field. This study used a novel approach to visually analyze the use of CMR in HCM assessment. The current research trajectory in CMR consists of the diagnosis and management of patients with HCM. Although most studies confirmed the indispensability of CMR in the assessment of HCM, larger-scale cohorts are still needed to more comprehensively evaluate the role of CMR in the differential diagnosis, pre- and post-treatment assessment, and long-term management of patients with HCM.

Kiosk 4Q-FA-03 - Right Atrial Floating Thrombus with Chronic Pulmonary Embolism, the Utility of Cardiac Magnetic Resonance: A Case Report

Kiosk 4Q-FA-03 - Right Atrial Floating Thrombus with Chronic Pulmonary Embolism, the Utility of Cardiac Magnetic Resonance: A Case Report

Abstract 17372: Cardiac Magnetic Resonance in Takotsubo Disease: Impact on Outcomes and Resource Utilization

Introduction: Takotsubo cardiomyopathy (CM), characterized by transient left ventricular dysfunction, presents diagnostic and management challenges. The utility of cardiac magnetic resonance (CMR) in Takotsubo CM is uncertain. We investigate CMR's impact on outcomes and resource utilization in Takotsubo CM. Methods: A retrospective analysis was conducted with TriNetX. Two cohorts with Takotsubo CM, with and without CMR within 1 month of diagnosis, were matched for lipidemias, hypertension, diabetes, sarcoidosis, and heart diseases (n=1,422 per cohort), Risks assessed 30-day, 1- and 5-year outcomes, resource utilization, and medication/procedure usage. Results: The CMR group had 3.9% (1.5% vs 5.4%, p=0.000) lower risk of mortality within 30 days and 2.6% (4.6% vs 7.2%, p=0.003) lower risk between 1 and 5 years. Hospitalization rates were similar, while complication risks (cardiomyopathy, heart failure) were higher in the CMR group at 1 and 5 years. The CMR group had higher utilization of GDMT, with similar usage for some treatments. Risk of pacemaker or implantable defibrillator usage were 4.9% higher within 30 days (5.8% vs 0.8%, p=0.000) and 5.8% higher within 1 year (8.2% vs 2.5% p=0.000) in the CMR group. Conclusions: Takotsubo patients undergoing CMR exhibited increased risk of concomitant diagnoses of CM/heart failure/pericarditis, received treatments earlier in the disease course, and experienced lower risk of mortality. These results support utilization of CMR as a routine diagnostic imaging modality in patients with suspected Takotsubo CM for comprehensive evaluation to guide treatment decisions and improve patient prognosis.

Usefulness of cardiac magnetic resonance in the assessment of septal myocardial infarction with non-obstructive coronary arteries.

Usefulness of cardiac magnetic resonance in the assessment of septal myocardial infarction with non-obstructive coronary arteries.

Role of Cardiac Magnetic Resonance Imaging and TroponinT in Definitive Diagnosis of Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA).

It is unknown whether the degree of high-sensitivity troponin T (hsTropT) elevation in patients with suspected myocardial infarction without obstructive coronary arteries (MINOCA) presentations can help predict the likelihood of an abnormal cardiac magnetic resonance (CMR) scan. In this study we describe the diagnostic utility of CMR in patients with MINOCA and assesses the effect of peak hsTropT levels at presentation on CMR diagnostic yield. Records of consecutive patients (n= 1407) referred for CMR at a tertiary referral hospital between January 2016 and September 2021 were reviewed. A total of 70 patients met the criteria of MINOCA including ischemic chest pain, elevated peak hsTropT, and nonobstructive coronary artery disease (< 50% stenosis). The peak hsTropT levels within 72 hours of admission were identified. CMR images were generated using a 3.0 T Siemens scanner. Predictors of having an abnormal CMR were evaluated. CMR established a diagnosis in 71% (n= 50) of patients, with the most common CMR diagnosis being myopericarditis (n= 27; 39%). Time to CMR was an independent predictor of a normal CMR scan (odds ratio, 0.98; 95% confidence interval, 0.97-0.999). Peak hsTropT had a high diagnostic accuracy for identifying patients with an abnormal CMR scan (area under the receiver operator characteristic curve, 0.81; P < 0.001). The optimal hsTropT cutoff was 166 ng/L, with 72% sensitivity and specificity. A troponin value ≥ 166 ng/L was independently predictive of an abnormal CMR scan (odds ratio, 4.76; 95% confidence interval, 1.32-17.11). HsTropT and early CMR imaging are independently predictive of an abnormal CMR scan in patients with MINOCA. Additionally, the use of a hsTropT cutoff provides incremental predictive value to clinical parameters and time to CMR scanning in determining an abnormal scan.

Evolving spectrum of arrhythmogenic cardiomyopathy: Implications for Sports Cardiology.

Arrhythmogenic cardiomyopathy (ACM) is a genetic heart muscle disease, structurally characterized by progressive fibro-fatty replacement of the normal myocardium and clinically by ventricular arrhythmias (VAs). Predominantly thanks to the use of cardiac magnetic resonance, we have learnt that the spectrum of the disease encompasses not only the classical right ventricular phenotype, but also biventricular and left dominant variants.Sport activity contributes to the phenotypic expression and progression of ACM and may trigger life-threatening VAs and sudden cardiac death (SCD).We conducted a review of the literature about ACM and its implications in Sport Cardiology and summarized the main findings in this topic.Early identification of affected athletes through preparticipation screening (PPS) is fundamental but, while classical right-ventricular or biventricular phenotypes are usually suspected because of electrocardiogram (ECG) and echocardiographic abnormalities, variants with predominant left ventricular involvement are often characterized by normal ECG and unremarkable echocardiography. Usually the only manifestations of such variants are exercise-induced VAs and for this reason exercise testing may empower the diagnostic yield of the PPS.Patients with ACM are not eligible to competitive sports activity, but low-to-moderate intensity physical activity under medical supervision is possible in most cases.

Cardiac magnetic resonance for prophylactic implantable-cardioverter defibrillator therapy international study in ischemic cardiomyopathy: international DERIVATE-ICM Registry

Abstract Funding Acknowledgements Type of funding sources: None. Background Implantable cardioverter–defibrillator (ICD) therapy is the most effective sudden cardiac death (SCD) event prophylactic-strategy in ischemic cardiomyopathy (ICM) patients with transthoracic echocardiographic (TTE) left ventricular ejection fraction (LVEF) ≤35%. This approach has been recently questioned due to the low rate of ICD interventions in patients who received implantation and the not negligible percentage of patients who experienced SCD event despite not fulfilling criteria for implantation. Purpose The DERIVATE-ICM registry (RCT#NCT03352648) is an international, multicenter and multivendor study to assess the net reclassification improvement (NRI) for the indication of ICD implantation by the use of cardiac magnetic resonance (CMR) as compared to standard of care based on TTE in ICM patients. Methods We enrolled 861 ICM patients (mean age 65±11 years, 86% male) with chronic heart failure and TTE-LVEF&amp;lt;50%. Major adverse arrhythmic cardiac events (MAACE), defined as the combination of SCD, aborted SCD event, and sustained ventricular tachycardia were the primary endpoint. Independent predictors were used to calculate a CMR risk score for each patient. Risk levels were defined as low (quantile 1 [Q1]), medium (Q2 and Q3) and high (Q4). Results During a median follow-up of 1054 days, MAACE occurred in 88 (10.2%). Left ventricular end-diastolic volume index (HR: 1.007, 95%CI:1.000–1.011, p = 0.050), CMR-LVEF (HR: 0.972, 95%CI: 0.945–0.999, p = 0.045) and late gadolinium enhancement (LGE) mass (HR: 1.010, 95%CI: 1.002–1.018, p = 0.015) were independent predictors of MAACE. Based on the multivariable analysis, CMR weighted risk score was developed according to the following equation [0.005 * EDV/BSA (mL/m²) – 0.029 * LVEF (%) + 0.010 * LGE ischemic mass (g)]. Figure 1 (top) shows the Kaplan-Meier curves according to the guidelines-based TTE-LVEF model and the CMR risk score. Moreover, the table of reclassification of the CMR versus TTE predictive model is reported in Figure 1 (bottom). This multiparametric CMR weighted predictive derived score effectively identifies subjects at high risk for MAACE as compared to TTE-LVEF cut-off of 35% with a NRI of 31.7% (p = 0.007). The distribution of CMR predictive score in patients with TTE-LVEF≤35% (panel A) and with TTE LVEF&amp;gt;35% (panel C) is represented in Figure 2, together with the event rate redistribution according to the CMR risk score (panel B and panel D). Conclusions The DERIVATE-ICM study is the first large multicenter registry testing the additional value of CMR to stratify the risk for MAACE in a large cohort of ICM patients as compared to standard of care. This model identifies a large number of patients with TTE-LVEF&amp;lt;35% at low risk of SCD event and on the other side it identifies a subset of patients who are at high risk of MAACE despite TTE-LVEF≥35%. Further randomized trials to test a CMR guided strategy for ICD implantation versus standard of care are now needed.

Exploring the Utility of Cardiovascular Magnetic Resonance Radiomic Feature Extraction for Evaluation of Cardiac Sarcoidosis.

The aim of this study is to explore the utility of cardiac magnetic resonance (CMR) imaging of radiomic features to distinguish active and inactive cardiac sarcoidosis (CS). Subjects were classified into active cardiac sarcoidosis (CSactive) and inactive cardiac sarcoidosis (CSinactive) based on PET-CMR imaging. CSactive was classified as featuring patchy [18F]fluorodeoxyglucose ([18F]FDG) uptake on PET and presence of late gadolinium enhancement (LGE) on CMR, while CSinactive was classified as featuring no [18F]FDG uptake in the presence of LGE on CMR. Among those screened, thirty CSactive and thirty-one CSinactive patients met these criteria. A total of 94 radiomic features were subsequently extracted using PyRadiomics. The values of individual features were compared between CSactive and CSinactive using the Mann-Whitney U test. Subsequently, machine learning (ML) approaches were tested. ML was applied to two sub-sets of radiomic features (signatures A and B) that were selected by logistic regression and PCA, respectively. Univariate analysis of individual features showed no significant differences. Of all features, gray level co-occurrence matrix (GLCM) joint entropy had a good area under the curve (AUC) and accuracy with the smallest confidence interval, suggesting it may be a good target for further investigation. Some ML classifiers achieved reasonable discrimination between CSactive and CSinactive patients. With signature A, support vector machine and k-neighbors showed good performance with AUC (0.77 and 0.73) and accuracy (0.67 and 0.72), respectively. With signature B, decision tree demonstrated AUC and accuracy around 0.7; Conclusion: CMR radiomic analysis in CS provides promising results to distinguish patients with active and inactive disease.

Utility of cardiac magnetic resonance in assessing arrhythmic risk in patients with non ischemic cardiomyopathy undergoing biventricular pacing

Abstract Funding Acknowledgements Type of funding sources: None. Background Non-ischemic cardiomyopathy (NICM) is a common heart muscle disorder, which is responsible for approximately one-third of heart failure and is associated with significant morbidity and mortality. Recent data suggested the lack of mortality reduction from adding a defibrillator to cardiac resynchronization therapy (CRT) in all patients with NICM. Myocardial fibrosis detected by cardiac magnetic resonance late gadolinium enhancement (CMR-LGE) can help risk stratify patients who would benefit from adding a defibrillator to CRT in this patient population. Purpose We aim at assessing the relationship between the presence of myocardial fibrosis detected by CMR-LGE and the rate of major arrhythmic events (MAE) that included sustained VT, appropriate CRT-D intervention, VF, and SCD in patients with NICM undergoing (CRT) and to compare all-cause mortality and heart failure improvement between patients who receiving CRT-P vs those who receiving CRT-D based on the presence of myocardial fibrosis. Methods All consecutive patients with NICM satisfying a guideline directed indication for CRT implantation were included in the study after excluding patients who refused to consent, patients with acute decompensated heart failure and those contraindicated for a CMR. Patients were divided into two groups according to presence of fibrosis in cardiac MRI into (CRT-D/LGE) group and CRT-P/No LGE group and followed along for one year. Results Sixty patients were enrolled. Sixteen patients (26.6%) developed MAE during the study duration. Seven patients had myocardial fibrosis (receiving CRT-D as per protocol), while only nine patients had no myocardial fibrosis (receiving CRT-P as per protocol), (41.2% vs 20.9%, P=0.045). Presence of CMR-LGE, regardless the extent and distribution, predicted MAE with odd ratio 2.6 (CI=1.78-8.9, P=0.04). The presence of ≥7.5 % of myocardial fibrosis by CMR was associated with 54 % sensitivity and 100% specificity for MAE in the study population (Figure 1). However, All-cause mortality was significantly higher in the (CRT-P/No LGE) group vs (CRT-D/LGE) group [15 (34.9%) vs 2 (11.8%), P=0.076]. Comparison between both groups regarding symptoms of heart failure, QoL and ejection fraction is shown in Table 1. Conclusion In patients with NICM candidates for biventricular pacing, the presence of LGE on CMR, irrespective of the extent or segmental pattern, is independently associated with a major arrhythmic event and is associated with worse heart failure outcome. However, the absence of LGE did not rule out MAE and implanting CRT-P based on lack of fibrosis may result in higher all-cause mortality.

Cardiac Magnetic Resonance for Prophylactic Implantable-Cardioverter Defibrillator Therapy in Ischemic Cardiomyopathy: The DERIVATE–ICM International Registry

BackgroundImplantable cardioverter-defibrillator (ICD) therapy is the most effective prophylactic strategy against sudden cardiac death (SCD) in patients with ischemic cardiomyopathy (ICM) and left ventricle ejection fraction (LVEF) ≤35% as detected by transthoracic echocardiograpgy (TTE). This approach has been recently questioned because of the low rate of ICD interventions in patients who received implantation and the not-negligible percentage of patients who experienced SCD despite not fulfilling criteria for implantation. ObjectivesThe DERIVATE (CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy)-ICM registry (NCT03352648) is an international, multicenter, and multivendor study to assess the net reclassification improvement (NRI) for the indication of ICD implantation by the use of cardiac magnetic resonance (CMR) as compared to TTE in patients with ICM. MethodsA total of 861 patients with ICM (mean age 65 ± 11 years, 86% male) with chronic heart failure and TTE-LVEF <50% participated. Major adverse arrhythmic cardiac events (MAACE) were the primary endpoints. ResultsDuring a median follow-up of 1,054 days, MAACE occurred in 88 (10.2%). Left ventricular end-diastolic volume index (HR: 1.007 [95% CI: 1.000-1.011]; P = 0.05), CMR-LVEF (HR: 0.972 [95% CI: 0.945-0.999]; P = 0.045) and late gadolinium enhancement (LGE) mass (HR: 1.010 [95% CI: 1.002-1.018]; P = 0.015) were independent predictors of MAACE. A multiparametric CMR weighted predictive derived score identifies subjects at high risk for MAACE compared with TTE-LVEF cutoff of 35% with a NRI of 31.7% (P = 0.007). ConclusionsThe DERIVATE-ICM registry is a large multicenter registry showing the additional value of CMR to stratify the risk for MAACE in a large cohort of patients with ICM compared with standard of care.

PO-04-222 OUTFLOW TRACT VERSUS NON-OUTFLOW TRACT VENTRICULAR ARRHYTHMIAS IN ATHLETES: MYOCARDIAL SUBSTRATE AND LONG-TERM CLINICAL OUTCOMES

Outflow tract ventricular arrhythmias (OT-VA) are common in healthy subjects without structural heart disease (SHD), and are generally considered benign. However, athlete-specific data on the clinical meaning of different ventricular arrhythmia (VA) morphologies are scarce. To assess the prevalence of SHD as well as long-term clinical and sports medicine outcomes in a cohort of athletes with OT-VA undergoing a comprehensive diagnostic assessment, by comparing them with athletes with non-outflow tract VAs (nOT-VA). We conducted a multi-center, observational, retrospective study enrolling athletes who were referred because of complex VAs (>500 PVCs/24 h, exercise-induced VAs, nonsustained or sustained ventricular tachycardia). Athletes were categorized into two groups: OT-VA, in case of monomorphic ventricular arrhythmias of left bundle branch block and inferior axis morphology; nOT-VA, in case of polymorphic VAs or monomorphic VAs of right bundle branch block or left bundle branch block and superior/intermediate axis. The two co-primary outcomes were survival free from all-cause death or sustained VAs and sports practice at last follow-up. 175 athletes with complex ventricular arrhythmias (OT-VA,n=82; nOT-VA,n=93) were included in the present analysis; clinical characteristics are resumed in the Table. Remarkably, the prevalence of signs of SHD was higher in nOT-VA compared to OT-VA (Table). A final diagnosis of idiopathic VA was more common in OT-VA compared to nOT-VA and, accordingly, catheter ablation was more commonly performed in the former group. Over a median follow-up of 61(43-85) months, there were 2 cardiac arrests and 1 appropriate ICD shock, all occurring in athletes in the nOT-VA group with in vivo evidence of SHD and polymorphic VAs, for an overall prevalence of a primary outcome event of 0 and 3% in the OT-VA and the nOT-VA groups, respectively (p=0.25). At last follow-up, 31 athletes (18%) practiced competitive sports (OT-VA vs. nOT-VA,p=0.23), while 92 (53%) were leisure-time athletes (OT-VA vs. nOT-VA,p=0.91). Our data confirm that the prevalence of an underlying SHD substrate is lower in athletes with OT-VA than in athletes with nOT-VA, and that all major adverse cardiac events occurred in athletes with polymorphic VAs. Nevertheless, a comprehensive workup with liberal use of cardiac magnetic resonance allowed the identification of SHD in a substantial minority of athletes with OT-VA, with clear implications for sports eligibility assessment.

Stepwise Multimodality Imaging Assists in Atrial Myxoma Diagnosis and Management

The case of a 67-year-old man who presented for elective gastroenterology procedures and was in atrial fibrillation is discussed. Transthoracic echocardiography revealed a large atrial mass. Preoperative coronary angiography revealed a heavily vascularized mass. Use of cardiac magnetic resonance identified the cardiac mass as likely an atrial myxoma. (Level of Difficulty: Beginner.)

Clinical Utilization of Multimodality Imaging for Myocarditis and Cardiac Sarcoidosis

Myocarditis is defined as inflammation of the myocardium according to clinical, histological, biochemical, immunohistochemical, or imaging findings. Inflammation can be categorized histologically by cell type or pattern, and many causes have been implicated, including infectious, most commonly viral, systemic autoimmune diseases, vaccine-associated processes, environmental factors, toxins, and hypersensitivity to drugs. Sarcoid myocarditis is increasingly recognized as an important cause of cardiomyopathy and has important diagnostic, prognostic, and therapeutic implications in patients with systemic sarcoidosis. The clinical presentation of myocarditis may include an asymptomatic, subacute, acute, fulminant, or chronic course and may have focal or diffuse involvement of the myocardium depending on the cause and time point of the disease. For most causes of myocarditis except sarcoidosis, myocardial biopsy is the gold standard but is limited due to risk, cost, availability, and variable sensitivity. Diagnostic criteria have been established for both myocarditis and cardiac sarcoidosis and include clinical and imaging findings particularly the use of cardiac magnetic resonance and positron emission tomography. Beyond diagnosis, imaging findings may also provide prognostic value. This case-based review focuses on the current state of multimodality imaging for the diagnosis and management of myocarditis and cardiac sarcoidosis, highlighting multimodality imaging approaches with practical clinical vignettes, with a discussion of knowledge gaps and future directions.