Value Of Cardiac Magnetic Resonance Research Articles

Diagnostic Accuracy of Cardiac Magnetic Resonance Imaging in the Evaluation of Newly Diagnosed Heart Failure With Reduced Left Ventricular Ejection Fraction

The aim of this study was to determine the diagnostic value of cardiac magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE), cine imaging, and resting first-pass perfusion (FPP) in the evaluation for ischemic (IC) versus nonischemic (NIC) cardiomyopathy in new-onset heart failure with reduced (≤40%) left ventricular ejection fraction (HFrEF). A retrospective chart review analysis identified 83 patients from January 2009 to June 2012 referred for CMR imaging evaluation for new-onset HFrEF with coronary angiography performed within 6months of CMR. The diagnosis of IC was established using Felker criteria on coronary angiography. CMR sequences were evaluated for the presence of patterns suggestive of severe underlying coronary artery disease as the cause of HFrEF (subendocardial and/or transmural LGE, regional wall motion abnormality on cine, regional hypoperfusion defect on resting FPP). Discriminative power was assessed using receiver operator characteristics curve analysis. Coronary angiography identified 36 patients (43%) with IC. Presence of subendocardial and/or transmural LGE alone demonstrated good discriminative power (C-statistic 0.85, 95% confidence interval 0.76 to 0.94) for the diagnosis of IC. The presence of an ischemic pattern on both LGE and cine sequences resulted in a specificity of 87% for the diagnosis of IC, whereas the absence of an ischemic pattern on both LGE and cine sequences resulted in a specificity of 94% for the diagnosis of NIC. Addition of resting FPP on a subset of patients did not improve diagnostic values. In conclusion, CMR has potential value in the diagnostic evaluation of IC versus NIC.

Six-Year Prognostic Value of Microvascular Obstruction After Reperfused ST-Elevation Myocardial Infarction as Assessed by Contrast-Enhanced Cardiovascular Magnetic Resonance

Although recent studies showed the prognostic value of cardiac magnetic resonance (CMR) parameters especially microvascular obstruction (MO) after reperfused ST-elevation myocardial infarction (STEMI), a study assessing their prognostic significance for long-term follow-up is missing so far. The objective of this study was to determine the prognostic impact of MO on long-term prognosis after reperfused first STEMI in a setting allocating CMR-assessed parameters to hard clinical events only. In 249 patients, CMR was performed after reperfused STEMI, and hereby, left ventricular ejection fraction (LVEF), infarct size (IS), and the amount of MO were quantified. Follow-up (median 6.0years) was obtained regarding occurrence of major adverse cardiac events (MACE). MACE occurred more often in patients showing presence of MO (MO vs no MO: n= 61 [54%] vs n= 12 [9%], p <0.0001). By multivariate analysis, the extent of MO remained the strongest predictor (p <0.001) for occurrence of MACE and provided incremental prognostic value over clinical variables and LVEF (p= 0.028, c-index increase from 0.723 to 0.817). In conclusion, CMR-assessed MO proves predictive for assessment of 6-year prognosis in patients after reperfused first STEMI and provides incremental prognostic information over clinical variables and LVEF in a setting based on hard end points.

Diagnostic value of contrast-enhanced cardiac magnetic resonance in patients with acute coronary syndrome with normal coronary arteries.

To evaluate retrospectively the diagnostic value of cardiac magnetic resonance (CMR) in patients with acute coronary syndromes (ACS) with normal coronary arteries, without pre-existing comorbidities. We retrospectively reviewed the contrast-enhanced (CE) CMR images of 143 patients (70 males and 73 females, mean age 63 years, age range 37-87), within a server of 1590 patients, between January 2012 and January 2014. Only patients with ACS (anginal episode lasting at least 30 min) with normal coronary arteries were included, as well as patients with serologic assay of positive troponin I (TnI) and possible changes in ECG, particularly ST elevation. All patients with a history of ACS, or chronic troponin elevation, dyslipidemia, smoking, patients with cardiomyopathies or preexisting comorbidities such as diabetes, hereditary collagenopathies, amyloidosis, sarcoidosis, hemosiderosis or other infiltrative diseases were excluded to avoid possible bias. The CMR LGE pattern attributable to AMI occurred in 40/143 cases (28 %) and in particular involved only a myocardial segment (60 %). The MR pattern of acute myocarditis occurred in 16/143 (11.2 %); in 6/143 cases, Tako-Tsubo cardiomyopathy was present. Eighty-one cases out of 143 presented a CMR with no LGE, parietal edema or morphological alterations (56.6 %). In patients with a first episode of ACS with normal coronary arteries, in the absence of pre-existing comorbidities, CMR has a high negative predictive value, often without significant alterations. In particular, the CMR LGE for AMI is infrequent and has predominantly focal distribution. However, further multidisciplinary studies are needed to define the prognostic value of CMR.

Role of tissue characterization by Cardiac Magnetic Resonance in the diagnosis of constrictive pericarditis.

Cardiac Magnetic Resonance (CMR) allows evaluation of the functional and flow changes in pericardial constriction as well as detection of acute pericardial inflammation, fusion and thickening of pericardial layers and pericardial effusion. We sought to evaluate the diagnostic role of tissue characterization by CMR in constrictive pericarditis (CP). We performed a CMR exam in 70 patients (mean age 58 ± 16) with clinical suspicion of constrictive pericarditis and constrictive pattern at echocardiography and/or catheterization. A multiparametric CMR approach was used to evaluate the initial diagnostic suspicion. A clinical follow-up was performed in all patients for a median of 551 days. The diagnosis of CP was confirmed in 53 patients while 12 patients presented signs of predominant pericardial active inflammation suggesting a diagnosis of transient constrictive pericarditis and five presented effusive-constrictive pericarditis. Patients with a final diagnosis of CP had worse prognosis than those with transient constrictive or effusive constrictive pericarditis. The presence of myocardial late gadolinium enhancement was associated to adverse events. Results of the current study confirmed the value of CMR in the differential diagnosis of pericardial disease. A multiparametric CMR approach allowed to distinguish between active inflammation, chronic pericarditis with constriction and effusion without inflammation.

The value of cardiac magnetic resonance in the prediction of left ventricular function improvement following acute myocarditis

Methods All patients admitted with an acute coronary syndrome (ACS)-like presentation of myocarditis, with confirmed diagnosis at baseline according to standard CMR criteria and follow-up examination available, were retrospectively identified in our database. CMR images were analyzed to determine left ventricular (LV) dimensions, LV mass and total amount of late gadolinium enhancement. LGE was quantified using signal intensity >5 SD above normal myocardium and was expressed as percentage of LV mass. Improvement of LV function (LVF) was defined as in increase in ejection fraction (EF) of ≥5%. Results Fifteen consecutive patients were included in the present study. Follow-up CMR was performed at a mean of 282 ± 187 days after admission. At baseline, mean EF was 51 ± 7% and was impaired in 11 patients (47 ± 4 %). EF improved in 8 of these 11 patients (73%). Total indexed myocardial mass (TMM) and the extent of LGE at baseline did not differ between patients that improved and those that did not (52.9 ± 12.4 vs. 56.9 ± 21.2, p = 0.697; 8.2 ± 6.3 vs. 9.2 ± 6.8, p = 0.821). At follow-up, the extent of LGE decreased in patients with and patients without LV improvement (-3.0±5.0 vs. -5.0±4.9, p=0.570). However, TMM decreased in patients that showed EF improvement, and not in patients without improvement (-10.8±7.9 vs. 1.9±4.1, p=0.029). Conclusions The majority of patients with an ACS-like presentation of myocarditis have a good prognosis. The improvement of LVF was accompanied by a decrease in myocardial mass. This decrease in myocardial mass likely reflects the resolution of acute inflammatory changes in acute myocarditis.

Relationship between clinical features and the diagnostic value of CMR tissue characterisation in patients with clinically suspected myocarditis

Background Myocarditis can present with acute coronary syndromelike (ACS) symptoms, new-onset heart failure (NOHF) or life threatening arrhythmias (LTA) with various ECG and laboratory test abnormalities. Cardiac magnetic resonance (CMR) tissue characterization using Late Gadolinium Enhancement (LGE) and T2 weighted (T2W) imaging is the non-invasive diagnostic tool of choice. The relationship between the clinical features of myocarditis and the diagnostic value of CMR however is unclear.

The role of cardiac magnetic resonance imaging in the assessment of right ventricular function in patients with pulmonary arterial hypertension

Background Cardiac Magnetic Resonance (CMR) is the gold standard technique for the assessment of right ventricular (RV) function. There is, however, scarce data on its use in the assessment of patients with pulmonary arterial hypertension (PAH). The aim of our study is to reveal the potential value of CMR in the evaluation of RV dysfunction as expressed by the pulmonary and the tricuspid annular plane systolic excursion (PAPSE and CMRTAPSE respectively).

Diagnostic contribution of cardiac magnetic resonance in patients with acute coronary syndrome and culprit-free angiograms.

BackgroundIn spite of robust knowledge about underlying ischemic myocardial damage, acute coronary syndromes (ACS) with culprit-free angiograms raise diagnostic concerns. The present study aimed to evaluate the additional value of cardiac magnetic resonance (CMR) over commonly available non-CMR standard tests, for the differentiation of myocardial injury in patients with ACS and non-obstructed coronary arteries.Material/MethodsPatients with ACS, elevated hs-TnT, and a culprit-free angiogram were prospectively enrolled into the study between January 2009 and July 2013. After initial evaluation with standard tests (ECG, echocardiography, hs-TnT) and provisional exclusion of acute myocardial infarction (AMI) in coronary angiogram, patients were referred for CMR with the suspicion of myocarditis or Takotsubo cardiomyopathy (TTC). According to the result of CMR, patients were reclassified as having myocarditis, AMI, TTC, or non-injured myocardium as assessed by late gadolinium enhancement.ResultsOut of 5110 patients admitted with ACS, 75 had normal coronary angiograms and entered the study; 69 of them (92%) were suspected for myocarditis and 6 (8%) for TTC. After CMR, 49 patients were finally diagnosed with myocarditis (65%), 3 with TTC (4%), 7 with AMI (9%), and 16 (21%) with non-injured myocardium. The provisional diagnosis was changed or excluded in 23 patients (31%), with a 9% rate of unrecognized AMI.ConclusionsThe study results suggest that the evaluation of patients with ACS and culprit-free angiogram should be complemented by a CMR examination, if available, because the initial work-up with non-CMR tests leads to a significant proportion of misdiagnosed AMI.

Case-based session: cardiac masses: Wednesday 3 December 2014, 11:00-12:30 * Location: Agora

Case-based session: cardiac masses: Wednesday 3 December 2014, 11:00-12:30 * Location: Agora

"No culprit" ST-elevation myocardial infarction: role of cardiac magnetic resonance imaging.

Patients with presumed ST-elevation myocardial infarction (STEMI) have no clear culprit artery in approximately 10-15% of cases. We examined the value of cardiac magnetic resonance (CMR) for diagnosis in patients with "no culprit" STEMI. Data from a comprehensive prospective registry of STEMI patients were reviewed from March 2003 to December 2009. "No culprit" patients were followed for diagnosis and clinical outcome. CMR was performed at the discretion of the attending cardiologist. Of 2728 consecutive presumed STEMI patients, 412 (15%) had no clear culprit artery. Of these, 202 (49%) had abnormal cardiac biomarkers with a definitive diagnosis in 157 (78%). Diagnoses in this group included myocardial infarction without a culprit lesion (24%), myopericarditis (22%), and stress cardiomyopathy (21%). In 210 (51%) patients with normal biomarkers, only 84 (40%) received a definitive diagnosis. Diagnoses in this group included myopericarditis (27%), noncardiac causes (21%), and cardiomyopathy (14%). CMR was performed in 123 (30%) "no culprit" patients. Patients who had CMR were more likely to have a definitive diagnosis than those who did not (95/123 [77%] vs. 144/289 [50%]; P=0.01). In particular, "no culprit" patients with abnormal biomarkers were more likely to have a definitive diagnosis with CMR. CMR led to a diagnosis different from the presumptive clinical diagnosis in 53% of all cases. CMR is a valuable diagnostic tool to improve diagnostic accuracy in patients with "no culprit" STEMI.

Value of CMR for the Differential Diagnosis of Cardiac Masses

ObjectivesThe goal of this study was to evaluate the diagnostic value of CMR features for the differential diagnosis of cardiac masses. BackgroundDifferentiation of cardiac tumors and thrombi and differentiation of benign from malignant cardiac neoplasms is often challenging but important in clinical practice. Studies assessing the value of cardiac magnetic resonance (CMR) in this regard are scarce. MethodsWe reviewed the CMR scans of patients with a definite cardiac thrombus or tumor. Mass characteristics on cine, T1-weighted turbo spin echo (T1w-TSE) and T2-weighted turbo spin echo (T2w-TSE), contrast first-pass perfusion (FPP), post-contrast inversion time (TI) scout, and late gadolinium enhancement (LGE) sequences were analyzed. ResultsThere were 84 thrombi, 17 benign tumors, and 25 malignant tumors in 116 patients. Morphologically, thrombi were smaller (median area 1.6 vs. 8.5 cm2; p < 0.0001), more homogeneous (99% vs. 46%; p < 0.0001), and less mobile (13% vs. 33%; p = 0.007) than tumors. Hyperintensity compared with normal myocardium on T2w-TSE, FPP, and LGE were more common in tumors than in thrombi (85% vs. 42%, 70% vs. 4%, and 71% vs. 5%, respectively; all p < 0.0001). A pattern of hyperintensity/isointensity (compared with normal myocardium) with short TI and hypointensity with long TI was very frequent in thrombi (94%), rare in tumors (2%), and had the highest accuracy (95%) for the differentiation of both entities. Regarding the characterization of neoplastic masses, malignant tumors were larger (median area 11.9 vs. 6.3 cm2; p = 0.006) and more frequently exhibited FPP (84% vs. 47%; p = 0.03) and LGE (92% vs. 41%; p = 0.001). The ability of CMR features to distinguish benign from malignant neoplasms was moderate, with LGE showing the highest accuracy (79%). ConclusionsCMR features demonstrated excellent accuracy for the differentiation of cardiac thrombi from tumors and can be helpful for the distinction of benign versus malignant neoplasms.

Combined identification of septal flash and absence of myocardial scar by cardiac magnetic resonance imaging improves prediction of response to cardiac resynchronization therapy

Septal flash (SF) describes early inward motion of the ventricular septum in patients with left bundle branch block (LBBB), and correction corresponds to increased response to cardiac resynchronization therapy (CRT). SF has traditionally been assessed by echocardiography. We sought to determine if cardiac magnetic resonance (CMR) imaging could identify SF and if the additional assessment of scar would improve the ability of CMR to predict CRT response. Fifty-two patients with LBBB and heart failure underwent prospective CMR scanning prior to CRT implantation. The presence of SF was assessed visually and by using endocardial contour-tracking software. Presence and extent of myocardial scar was assessed by delayed enhancement imaging during CMR. The association between SF, scar and reverse remodelling (RR) at 6 months was explored. RR rate to CRT at 6 months was 52%. CMR-derived SF was identified in 24 (46%) patients. RR was seen in more patients with SF than those without (88% vs 21%; P < 0.001). The absence of scar combined with the presence of SF had 96% specificity for predicting RR. In a multivariate regression model, the presence of SF was the only independent predictor of RR. SF can be assessed by CMR and predicts increased response to CRT. The additional value of CMR is the assessment of scar. The presence of SF with no scar is a highly specific predictor of CRT response.

Added value of cardiac magnetic resonance in a case of multiple congenital abnormalities

Sub-infundibular stenosis is a rare form of congenital heart disease, difficult to precisely diagnose, especially in adult patients. We report a case of an adult patient, referred to our hospital with long-standing dyspnea on exertion. She was finally diagnosed with sub-infundibular stenosis. During cardiovascular magnetic resonance imaging, right-sided aortic arch and left pulmonary artery agenesis were also identified.<Learning objective: The case described illustrates that cardiovascular magnetic resonance study is a powerful imaging technique in the congenital heart disease population, especially in the setting of multiple congenital abnormalities.>

Incremental value of CMR over echocardiography for assessment of LV diastolic function

Background Incidence of heart failure with preserved ejection fraction is increasing and putting the emphases on comprehensive evaluation of diastolic function. Furthermore, diastolic dysfunction even in the absence of heart failure has been shown to have prognostic significance. American Society of Echocardiography and European Association of Echocardiography (ASE/EAE) 2-level decision tree using multi-parametric approach is comprehensive, however discrepancy between the LV filling pressures and LA volume index can lead to discordance and inaccurate assessment of diastolic function. Incremental value of Cardiac Magnetic Resonance (CMR) to Echocardiography in assessment of diastolic function remains unknown. Aim: To assess incremental role of CMR derived LA volume index in classifying diastolic function by Echocardiography.

Valor diagnóstico de la resonancia magnética cardíaca en pacientes con arritmia ventricular frecuente y ecocardiograma Doppler normal

Valor diagnóstico de la resonancia magnética cardíaca en pacientes con arritmia ventricular frecuente y ecocardiograma Doppler normal

Diagnostic Value of Cardiac Magnetic Resonance in Patients with Frequent Ventricular Arrhythmia and Normal Doppler Echocardiography

IntroductionFrequent ventricular arrhythmia can be a primary electrical disturbance or may beassociated to cardiomyopathy. The prognostic and therapeutic impact depends onthe presence of structural heart disease. Transthoracic Doppler echocardiographyhas been the most important complementary study to evaluate the presence of cardiacstructural abnormalities.ObjectivesThe aims of this study were to determine the ability of cardiac magnetic resonanceimaging to detect structural heart disease in patients with normal Doppler echocardiogramand to assess the incidence of adverse cardiovascular events during followup.MethodsThe study included 66 consecutive patients with frequent ventricular arrhythmiadefined as > 5000 ventricular extrasystoles in 24-hour Holter monitoring, ventriculartachycardia or resuscitated cardiac respiratory arrest with normal Dopplerechocardiogram. All patients underwent cardiac magnetic resonance imaging to assesscardiomyopathies.ResultsFifty-seven percent of patients had structural heart disease. The most prevalentdiagnosed pathologies were myocarditis sequelae, non-compacted myocardium andsubendocardial infarction scar. At mean follow-up of 24 ± 22 months, the incidenceof adverse cardiovascular events was 6.06 %. The number of ventricular extrasystoleswas higher in patients with abnormal cardiac magnetic resonance.DiscussionThis work demonstrates that in patients with frequent ventricular arrhythmia andnormal Doppler echocardiogram, gadolinium cardiac magnetic resonance imagingcan detect structural heart disease in more than half of the cases. Patients with frequentventricular arrhythmia during Holter monitoring, normal Doppler echocardiogramand mild alterations in the magnetic resonance present low risk of cardiovascularevents.

Abstract 18442: Long-Term Prognostic Value of Cardiac Magnetic Resonance and Echocardiography After Reperfusion Therapy in ST-Segment Elevation Myocardial Infarction

Background: The aim of this study was to determine whether adding DE-CMR and/or TTE based parameters beyond known clinical factors provides incremental improvement of predicting long-term outcomes in STEMI patients who undergo acute reperfusion therapy. Methods and Results: One hundred twenty patients with first time STEMI who underwent PCI (74%), fibrinolysis (3%), and both (19%), were studied by both delayed enhancement cardiac magnetic resonance (DE-CMR) and transthoracic echocardiogram (TTE) during the acute phase of myocardial infarction. The primary endpoint was major adverse cardiac events (MACE). There were 28 events (6 deaths, 13 recurrent ischemia, and 9 heart failure) over a median follow-up of 4 years. We defined incremental increase in prognostic value by increase in Cox proportional hazards global chi square (χ 2 ) and/or increase in c-index with the addition of TTE and/or CMR parameters after adjusting for clinical variables. Among the clinical data, heart rate (HR: 1.02, p=0.047) and troponin (HR: 1.13, p=0.013) predicted MACE (χ 2 : 12.4, P=0.002; C index 0.69). After adjusting for these clinical factors, adding TTE parameters (left ventricular end systolic volume index [HR: 1.05, p&lt;0.0001] and mitral valve deceleration time [HR: 0.99, p=0.036]), increased the global χ 2 to 24.6 and C index to 0.74 (p&lt;0.0001). When CMR parameter (infarct size [HR: 2.92, p&lt;0.0001]) was added to the clinical data alone, there was greater increase in global χ 2 to 36.8 and C index to 0.83 (p&lt;0.0001). Addition of DE- CMR to clinical data combined with TTE measures showed significant incremental value with increased χ 2 difference of 17.6 (p&lt;0.0001). There was no significant incremental value of adding TTE to clinical data combined with DE-CMR (p&gt;0.05). Conclusion: DE-CMR provides significant incremental value for prognosticating adverse cardiac events over clinical data alone (or when in combination with TTE) in STEMI patients who undergo reperfusion therapy.

Added value of cardiac magnetic resonance in etiological diagnosis of ventricular arrhythmias

IntroductionCardiac magnetic resonance (CMR) imaging is increasingly important in the diagnostic work-up of a wide range of heart diseases, including those with arrhythmogenic potential. ObjectiveTo assess the added value of CMR in etiological diagnosis of ventricular arrhythmias after an inconclusive conventional investigation. MethodsPatients undergoing CMR between 2005 and 2011 for investigation of ventricular arrhythmias were included (n=113). All had documented arrhythmias. Those with a definite diagnosis from a previous investigation and those with evidence of coronary artery disease (acute coronary syndrome, typical angina symptoms, increase in biomarkers or positive stress test) were excluded. CMR results were considered relevant when they fulfilled diagnostic criteria. ResultsOf the 113 patients, 57.5% were male and mean age was 41.7±16.2 years. Regarding the initial arrhythmia, 38.1% had ventricular fibrillation/sustained ventricular tachycardia (VF/VT) and 61.9% had less complex ventricular ectopy. CMR imaging showed criteria of a specific diagnosis in 42.5% of patients, was totally normal in 36.3%, and showed non-specific alterations in the remainder. In VF/VT patients, specific criteria were found in 60.4%, and in 31.4% of those with less complex ectopy.The most frequent diagnoses were arrhythmogenic right ventricular dysplasia, ventricular non-compaction and myopericarditis. It is worth noting that, although there was no evidence of previous coronary artery disease, 6.2% of patients had a late gadolinium enhancement distribution pattern compatible with myocardial infarction. ConclusionCMR gives additional and important information in the diagnostic work-up of ventricular arrhythmias after an inconclusive initial investigation. The proportion of patients with diagnostic criteria was 42.5% (60.0% in those with VF/VT), and CMR was completely normal in 36.6%.

The Prognostic Value of Normal Stress Cardiac Magnetic Resonance in Patients With Known or Suspected Coronary Artery Disease

Background— Ischemia detection with stress cardiac magnetic resonance (CMR) is typically based on induction of either myocardial perfusion defect or wall motion abnormality. Single-center studies have shown the high value of stress CMR for risk stratification. The aim of this study was to define the prognostic value of stress CMR for prediction of adverse cardiac events in patients with known or suspected coronary artery disease. Methods and Results— Studies published between January 1985 and April 2012 were identified by database search. We included studies using stress CMR to evaluate subjects with known or suspected coronary artery disease and providing primary data on clinical outcomes of nonfatal myocardial infarction or cardiac death with a follow-up time ≥3 months. Total of 14 studies were finally included, recruiting 12 178 patients. The negative predictive value for nonfatal myocardial infarction and cardiac death of normal CMR was 98.12% (95% confidence interval, 97.26–98.83) during a weighted mean follow-up of 25.3 months, resulting in estimated event rate after a negative test equal to 1.88% (95% confidence interval, 1.17–2.74). The corresponding annualized event rate after a negative test was 1.03%. Comparable negative predictive values for major coronary events were obtained in studies considering the absence of inducible perfusion defect compared with those evaluating the absence of inducible wall motion abnormality (98.39% versus 97.31%, respectively; P =0.227 by meta-regression analysis). Conclusions— Stress CMR has a high negative predictive value for adverse cardiac events, and the absence of inducible perfusion defect or wall motion abnormality shows a similar ability to identify low-risk patients with known or suspected coronary artery disease.

Diagnostic value of cardiac magnetic resonance in patients presenting with chest pain, troponin elevation and unobstructed coronary arteries

Diagnostic value of cardiac magnetic resonance in patients presenting with chest pain, troponin elevation and unobstructed coronary arteries