Recommendations for cardiovascular magnetic resonance and computed tomography in congenital heart disease: a consensus paper from the CMR/CCT Working Group of the Italian Society of Pediatric Cardiology and the Italian College of Cardiac Radiology endorsed by the Italian Society of Medical and Interventional Radiology (Part II).

Cardiovascular magnetic resonance (CMR) and computed tomography (CCT) are advanced imaging modalities that recently revolutionized the conventional diagnostic approach to congenital heart diseases (CHD), supporting echocardiography and often replacing cardiac catheterization. This is the second of two complementary documents, endorsed by experts from the Working Group of the Italian Society of Pediatric Cardiology and the Italian College of Cardiac Radiology of the Italian Society of Medical and Interventional Radiology, aimed at giving updated indications on the appropriate use of CMR and CCT in different clinical CHD settings, in both pediatrics and adults. In this article, support is also given to radiologists, pediatricians, cardiologists, and cardiac surgeons for indications and appropriateness criteria for CMR and CCT in the most referred CHD, following the proposed new criteria presented and discussed in the first document. This second document also examines the impact of devices and prostheses for CMR and CCT in CHD and additionally presents some indications for CMR and CCT exams when sedation or narcosis is needed.

Pediatric Cardiovascular Computed Tomography: Clinical Indications, Technique, and Standardized Reporting. Recommendations From the Cardiothoracic Taskforce of the European Society of Pediatric Radiology.

Congenital heart diseases affect 1% of all live births in the general population. The prognosis of these children is increasingly improving due to advances in medical care and surgical treatment. Imaging is also evolving rapidly to assess accurately complex cardiac anomalies prenatally and postnatally. Transthoracic echocardiography is the gold-standard imaging technique to diagnose and follow-up children with congenital heart disease. Cardiac computed tomography imaging plays a key role in the diagnosis of children with congenital heart defects that require intervention, due to its high temporal and spatial resolution, with low radiation doses. It is challenging for radiologists, not primarily specialized in this field, to perform and interpret these studies due to the difficult anatomy, physiology, and postsurgical changes. Technical challenges consist of necessary electrocardiogram gating and contrast bolus timing to obtain an optimal examination. This article aims to define indications for pediatric cardiac computed tomography, to explain how to perform and report these studies, and to discuss future applications of this technique.

MR imaging of primary benign cardiac tumors in the pediatric population.

Primary cardiac tumors are rare in all ages, especially in children, with a reported prevalence range of 0.0017-0.28% in autopsy series. Due to their rarity, the diagnostic and therapeutic pathways reserved to them are usually described by single case reports, leading to the point where a common diagnostic protocol is imperative to obtain a differential diagnosis. The first diagnostic approach is done with transthoracic echocardiogram (TTE), due to its wide availability, low cost, absence of ionizing radiations and non-invasiveness. Several tumors are discovered incidentally and, in many cases, TTE is helpful to determine location, size and anatomical features, playing a key role in the differential diagnosis. In the last few years, cardiac magnetic resonance imaging (CMR) has had an increased role in the diagnostic pathway of pediatric cardiac masses, due to its high accuracy in characterizing mass tissue properties (especially for soft tissue), and in detecting tumor size, extent, pericardial/pleural effusion, leading to the correct diagnosis, treatment and follow-up. Therefore, nowadays, several consensus statements consider CMR as a leading imaging technique, thanks to its non-invasive tissue characterization, without the use of ionizing radiation, in an unrestricted field of view. As suggested by the most recent literature, the pediatric protocol is not so different from the adult one, adapted to the size and cardiac frequency of the patient, sometimes requiring special conditions such as free-breathing sequences and/or sedation or general anesthesia in non-cooperating patients.

Relapsing myocarditis following initial recovery of post COVID-19 vaccination in two adolescent males - Case reports.

Whilst there has been significant public health benefits associated with global use of COVID-19 spike protein vaccines, potential serious adverse events following immunization have been reported. Acute myocarditis is a rare complication of COVID19 vaccines and often it is self-limiting. We describe two cases experiencing recurrent myocarditis following mRNA COVID-19 vaccine despite a prior episode with full clinical recovery. Between September 2021-September 2022 we observed two male adolescents with recurrent myocarditis related to mRNA-based-COVID19 vaccine. During the first episode both patients presented with fever and chest pain few days after their second dose of BNT162b2 mRNA Covid-19 Vaccine (Comirnaty®). The blood exams showed increased cardiac enzymes. In addition, complete viral panel was run, showing HHV7 positivity in a single case. The left ventricular ejection fraction (LVEF) was normal at echocardiogram but cardiac magnetic resonance scanning (CMR) was consistent with myocarditis. They were treated with supportive treatment with full recovery. The 6 months follow-up demonstrated good clinical conditions with normal cardiological findings. The CMR showed persistent lesions in left ventricle 's wall with LGE. After some months the patients presented at emergency department with fever and chest pain and increased cardiac enzymes. No decreased LVEF was observed. The CMR showed new focal areas of edema in the first case report and stable lesions in the second one. They reached full recovery with normalization of cardiac enzymes after few days. These case reports outline the need of strict follow-up in patients with CMR consistent with myocarditis after mRNA-based-COVID19 vaccine. More efforts are necessary to depict the underlying mechanisms of myocarditis after SARS-CoV2 vaccination to understand the risk of relapsing and the long-term sequelae.

Cardiac Imaging in Patients After Fontan Palliation: Which Test and When?

The Fontan operation represents the final stage of a series of palliative surgical procedures for children born with complex congenital heart disease, where a "usual" biventricular physiology cannot be restored. The palliation results in the direct connection of the systemic venous returns to the pulmonary arterial circulation without an interposed ventricle. In this unique physiology, systemic venous hypertension and intrathoracic pressures changes due to respiratory mechanics play the main role for propelling blood through the pulmonary vasculature. Although the Fontan operation has dramatically improved survival in patients with a single ventricle congenital heart disease, significant morbidity is still a concern. Patients with Fontan physiology are in fact suffering from a multitude of complications mainly due to the increased systemic venous pressure. Consequently, these patients need close clinical and imaging monitoring, where cardiac exams play a key role. In this article, we review the main cardiac imaging modalities available, summarizing their main strengths and limitations in this peculiar setting. The main purpose is to provide a practical approach for all clinicians involved in the care of these patients, even for those less experienced in cardiac imaging.

Recommendations for cardiovascular magnetic resonance and computed tomography in congenital heart disease: a consensus paper from the CMR/CCT working group of the Italian Society of Pediatric Cardiology (SICP) and the Italian College of Cardiac Radiology endorsed by the Italian Society of Medical and Interventional Radiology (SIRM) Part I.

Cardiovascular magnetic resonance (CMR) and computed tomography (CCT) are advanced imaging modalities that recently revolutionized the conventional diagnostic approach to congenital heart diseases (CHD), supporting echocardiography and often replacing cardiac catheterization. Nevertheless, correct execution and interpretation require in-depth knowledge of all technical and clinical aspects of CHD, a careful assessment of risks and benefits before each exam, proper imaging protocols to maximize diagnostic information, minimizing harm. This position paper, written by experts from the Working Group of the Italian Society of Pediatric Cardiology and from the Italian College of Cardiac Radiology of the Italian Society of Medical and Interventional Radiology, is intended as a practical guide for applying CCT and CMR in children and adults with CHD, wishing to support Radiologists, Pediatricians, Cardiologists and Cardiac Surgeons in the multimodality diagnostic approach to these patients. The first part provides a review of the most relevant literature in the field, describes each modality's advantage and drawback, making considerations on the main applications, image quality, and safety issues. The second part focuses on clinical indications and appropriateness criteria for CMR and CCT, considering the level of CHD complexity, the clinical and logistic setting and the operator expertise.

Compressed Sensing Cardiac Cine Imaging Compared with Standard Balanced Steady-State Free Precession Cine Imaging in a Pediatric Population.

Purpose: To compare real-time compressed sensing (CS) and standard balanced steady-state free precession (bSSFP) cardiac cine imaging in children. Materials and Methods: Twenty children (mean age, 15 years ± 5 [SD], range, 7-21 years; 10 male participants) with biventricular congenital heart disease (n = 11) or cardiomyopathy (n = 9) were prospectively included. Examinations were performed with 1.5-T imagers by using both bSSFP and CS sequences in all participants. Quantification of ventricular volumes and function was performed for all images by two readers blinded to patient diagnosis and type of sequence. Values were correlated with phase-contrast flow measurements by one reader. Intra- and interreader agreement were analyzed. Results: There were no significant differences between ventricular parameters measured on CS compared with those of bSSFP (P > .05) for reader 1. Only ejection fraction showed a significant difference (P = .02) for reader 2. Intrareader agreement was considerable for both sequences (bSSFP: mean difference range, +1 to -2.6; maximum CI, +7.9, -13; bias range, 0.1%-4.1%; intraclass correlation coefficient [ICC] range, 0.931-0.997. CS: mean difference range, +7.4 to -5.6; maximum CI, +37.2, -48.8; bias range, 0.5%-7.5%; ICC range, 0.717-0.997). Interreader agreement was acceptable but less robust, especially for CS (bSSFP: mean difference range, +2.6 to -5.6; maximum CI, +60.7, -65.3; bias range, 1.6%-6.2%; ICC range, 0.726-0.951. CS: mean difference range, +10.7 to -9.1; maximum CI, +87.5, -84.6; bias range, 1.1%-17.3%; ICC range, 0.509-0.849). The mean acquisition time was shorter for CS (20 seconds; range, 17-25 seconds) compared with that for bSSFP (160 seconds; range, 130-190 seconds) (P < .001). Conclusion: CS cardiac cine imaging provided equivalent ventricular volume and function measurements with shorter acquisition times compared with those of bSSFP and may prove suitable for the pediatric population.Keywords: Compressed Sensing, Balanced Steady-State Free Precession, Cine Imaging, Cardiovascular MRI, Pediatrics, Cardiac, Heart, Cardiomyopathies, Congenital, Segmentation© RSNA, 2022.

Blood flow characteristics after aortic valve neocuspidization in paediatric patients: a comparison with the Ross procedure.

AIMS: The aortic valve (AV) neocuspidization (Ozaki procedure) is a novel surgical technique for AV disease that preserves the natural motion and cardiodynamics of the aortic root. In this study, we sought to evaluate, by 4D-flow magnetic resonance imaging, the aortic blood flow characteristics after AV neocuspidization in paediatric patients. METHODS AND RESULTS: Aortic root and ascending aorta haemodynamics were evaluated in a population of patients treated with the Ozaki procedure; results were compared with those of a group of patients operated with the Ross technique. Cardiovascular magnetic resonance studies were performed at 1.5 T using a 4D flow-sensitive sequence acquired with retrospective electrocardiogram-gating and respiratory navigator. Post-processing of 4D-flow analysis was performed to calculate flow eccentricity and wall shear stress. Twenty children were included in this study, 10 after Ozaki and 10 after Ross procedure. Median age at surgery was 10.7 years (range 3.9-16.5 years). No significant differences were observed in wall shear stress values measured at the level of the proximal ascending aorta between the two groups. The analysis of flow patterns showed no clear association between eccentric flow and the procedure performed. The Ozaki group showed just a slightly increased transvalvular maximum velocity. CONCLUSION: Proximal aorta flow dynamics of children treated with the Ozaki and the Ross procedure are comparable. Similarly to the Ross, Ozaki technique restores a physiological laminar flow pattern in the short-term follow-up, with the advantage of not inducing a bivalvular disease, although further studies are warranted to evaluate its long-term results.

Risk Factors of Right Ventricular Dysfunction and Adverse Cardiac Events in Patients with Repaired Tetralogy of Fallot.

AIM: This study evaluates the risk factors associated with right ventricular (RV) dilation and dysfunction leading to pulmonary valve replacement (PVR) or adverse cardiac events in repaired Tetralogy of Fallot (rToF) patients. METHODS: Data from all rToF patients who underwent magnetic resonance imaging (MRI) evaluation at our hospital between February 2007 and September 2020 were collected. RESULTS: Three hundred and forty-two patients (60% males, 42% older than 18 years), with a median age of 16 years (IQR 13-24) at the time of MRI, were included. All patients underwent complete repair at a median age of 8 months (IQR 5-16), while palliation was performed in 56 patients (16%). One hundred and forty-four patients (42%) subsequently received pulmonary valve replacement (PVR). At the multivariate analysis, male gender was an independent predictor for significant RV dilation, RV and left ventricular (LV) dysfunction. Transventricular ventricular septal defect (VSD) closure and previous palliation significantly affected LV function and RV size, respectively. Male gender and the transventricular VSD closure were independent predictors for PVR. CONCLUSIONS: Male gender and surgical history (palliation, VSD closure approach) significantly affected the long-term outcomes in rToF patients and should be taken into consideration in the follow-up management and in PVR timing in this patient population.

Tracheal trifurcation: new cases and review of the literature.

BACKGROUND: Tracheal trifurcation is an uncommon and often unknown type of anomalous tracheobronchial arborization, characterized by three main bronchi originating at the level of the carina. Diagnosis is important due to its clinical implications. OBJECTIVE: To highlight the anatomical, clinical and diagnostic aspects of tracheal trifurcation by reporting our experience and reviewing the literature. MATERIALS AND METHODS: We retrospectively evaluated pediatric patients referred to our institution from January 2018 to May 2020 with a diagnosis of tracheal trifurcation. All patients underwent chest radiographs, computed tomography (CT) (with/without dynamic airway scanning) and bronchoscopy. Clinical and anatomical data were collected. RESULTS: Three patients with tracheal trifurcation were identified (1 female, median age: 7.6±0.4 months). All had associated anomalies: two had tetralogy of Fallot, one with esophageal atresia/tracheoesophageal fistula and one with an atrioventricular septal defect, and the other had skeletal ciliopathy. Chest radiographs were not diagnostic for tracheal trifurcation. Bronchoscopy could not fully evaluate the trachea and main bronchi in two cases. CT detected tracheal trifurcation in all of the patients and also demonstrated other lung parenchymal and congenital anomalies. Two of the three main bronchi were directed to the right lung in all cases. Ostial stenosis of either the central (two patients) or right upper bronchus (one patient) was present. No signs of tracheobronchomalacia were found. CONCLUSION: Tracheal trifurcation is rare and often associated with additional disorders, such as other tracheobronchial anomalies, cardiovascular defects or esophageal malformations, responsible for clinical manifestations and earlier detection. Bronchoscopy is often used for diagnosis, but is invasive and may be incomplete or inconclusive, while CT allows for a noninvasive and correct diagnosis, while also highlighting additional findings in the thorax.

Radiogenomics prediction for MYCN amplification in neuroblastoma: A hypothesis generating study.

BACKGROUND: MYCN amplification represents a powerful prognostic factor in neuroblastoma (NB) and may occasionally account for intratumoral heterogeneity. Radiomics is an emerging field of advanced image analysis that aims to extract a large number of quantitative features from standard radiological images, providing valuable clinical information. PROCEDURE: In this retrospective study, we aimed to create a radiogenomics model by correlating computed tomography (CT) radiomics analysis with MYCN status. NB lesions were segmented on pretherapy CT scans and radiomics features subsequently extracted using a dedicated library. Dimensionality reduction/features selection approaches were then used for features procession and logistic regression models have been developed for the considered outcome. RESULTS: Seventy-eight patients were included in this study, as training dataset, of which 24 presented MYCN amplification. In total, 232 radiomics features were extracted. Eight features were selected through Boruta algorithm and two features were lastly chosen through Pearson correlation analysis: mean of voxel intensity histogram (p = .0082) and zone size non-uniformity (p = .038). Five-times repeated three-fold cross-validation logistic regression models yielded an area under the curve (AUC) value of 0.879 on the training set. The model was then applied to an independent validation cohort of 21 patients, of which five presented MYCN amplification. The validation of the model yielded a 0.813 AUC value, with 0.85 accuracy on previously unseen data. CONCLUSIONS: CT-based radiomics is able to predict MYCN amplification status in NB, paving the way to the in-depth analysis of imaging based biomarkers that could enhance outcomes prediction.

Dynamic contrast-enhanced magnetic resonance lymphangiography in pediatric patients with central lymphatic system disorders.

Central conducting lymphatics (CCLs) disorders represent a broad spectrum of clinical entities ranging from self-limiting traumatic leaks treated by conservative strategies, to complex lymphatic circulation abnormalities that are progressive and unresponsive to currently available treatments. Dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) performed by intranodal injection of gadolinium-based contrast material is a recently developed technique which allows a minimally invasive evaluation of the CCL abnormalities providing a dynamic assessment of lymph flow and its pathways. In our institution, DCMRL is performed after bilateral cannulation of inguinal lymph nodes, using a MR protocol which includes volumetric 3D T2-SPACE (sampling perfection with application-optimized contrasts using different flip-angle evolution) and free-breathing respiratory navigated sequence and TWIST (time-resolved angiography with Interleaved stochastic trajectories) MR angiography sequence, during intranodal injection of paramagnetic contrast medium. Although DCMRL applications in clinical practice are still improving, a minimally invasive assessment of lymphatic pathways is particularly important both in pediatric patients with primitive lymphatic system disorders and in children with complex congenital heart disease associated with CCL impairment.

Echocardiographic two-dimensional speckle tracking identifies acute regional myocardial edema and sub-acute fibrosis in pediatric focal myocarditis with normal ejection fraction: comparison with cardiac magnetic resonance.

The aim here was to describe the role of speckle tracking echocardiography (STE), in identifying impairment in systolic function in children and adolescents with focal myocarditis and without reduction in ejection fraction. We describe data from 33 pediatric patients (age 4-17 years) admitted for focal myocarditis, confirmed by cardiac magnetic resonance (CMR), and without impaired ejection fraction and/or wall motion abnormalities. All children underwent Doppler echocardiography examination with analysis of global (G) and segmental longitudinal strain (LS) and CMR for the quantification of edema and myocardial fibrosis. Reduction in LS was defined according to age-specific partition values. At baseline, impaired GLS was present in 58% of patients (n = 19), albeit normal ejection fraction. LS was also regionally impaired, according to the area of higher edema at CMR (i.e. most impaired at the level of the infero-lateral segments as compared to other segments (p < 0.05). GLS impairment was also moderately correlated with the percentage edema at CMR (r = - 0.712; p = 0.01). At follow-up, GLS improved in all patients (p < 0.001), and normal values were found in 13/19 patients with baseline reduction. Accordingly persistent global and regional impairment was still observed in 6 patients. Patients with persistent LS reduction demonstrated residual focal cardiac fibrosis at follow-up CMR. Both global and regional LS is able to identify abnormalities in systolic longitudinal mechanics in children and adolescents with focal myocarditis and normal ejection fraction. The reduction in LS is consistent with edema amount and localization at CMR. Furthermore, LS identifies regional recovery or persistent cardiac function impairment, possibly related to residual focal fibrosis.

Dual-source computed tomography coronary artery imaging in children.

Computed tomography (CT) has a well-established diagnostic role in the assessment of coronary arteries in adults. However, its application in a pediatric setting is still limited and often impaired by several technical issues, such as high heart rates, poor patient cooperation, and radiation dose exposure. Nonetheless, CT is becoming crucial in the noninvasive approach of children affected by coronary abnormalities and congenital heart disease. In some circumstances, CT might be preferred to other noninvasive techniques such as echocardiography and MRI for its lack of acoustic window influence, shorter acquisition time, and high spatial resolution. The introduction of dual-source CT has expanded the role of CT in the evaluation of pediatric cardiovascular anatomy and pathology. Furthermore, technical advances in the optimization of low-dose protocols represent an attractive innovation. Dual-source CT can play a key role in several clinical settings in children, namely in the evaluation of children with suspected congenital coronary artery anomalies, both isolated and in association with congenital heart disease. Moreover, it can be used to assess acquired coronary artery abnormalities, as in children with Kawasaki disease and after surgical manipulation, especially in case of transposition of the great arteries treated with arterial switch operation and in case of coronary re-implantation.

Inter-vendor reproducibility and accuracy of segmental left ventricular strain measurements using CMR feature tracking.

OBJECTIVES: Our aim was to evaluate the inter-vendor reproducibility of cardiovascular MR feature tracking (CMR-FT) for the measurement of segmental strain (SS) of the left ventricle (LV) as well as to test the accuracy of CMR-FT to detect regional myocardial pathology. METHODS: We selected 45 patients: 15 with normal CMR findings, 15 with dilated cardiomyopathy, and 15 with acute myocardial infarction. Segmental longitudinal, circumferential, and radial strains were assessed with 4 different software. The inter-vendor difference as well as intra- and inter-observer variability was investigated. Furthermore, the accuracy of CMR-FT for the detection of structural (infarcted segments) as well as functional pathology (septal vs. lateral wall strain in left bundle branch block) was tested. RESULTS: Between vendors, there were significant differences in values for all strains (p < 0.001). The software using a non-rigid algorithm for image registration and segmentation demonstrated the best intra- as well as inter-observer variability with interclass correlation coefficient (ICC) > 0.962 and coefficient of variation (CV) < 24%. For infarct location, the same software yielded the highest area under the curve values for radial and circumferential SS (0.872 and 0.859, respectively). One of the other three software using optical flow technology performed best for longitudinal SS (0.799) and showed the largest differences in SS between septum and lateral wall in the dilated cardiomyopathy group. CONCLUSION: SS values obtained by CMR-FT are not interchangeable between vendors, and intra- and inter-observer reproducibility shows substantial variability among vendors. Overall, the different packages score relatively well to depict focal structural or functional LV pathology. KEY POINTS: • Segmental myocardial strain values obtained by CMR feature tracking are not interchangeable between different vendors. • Intra- and inter-observer reproducibility shows substantial variability among vendors. • Segmental myocardial strains measured by CMR feature tracking score relatively well to depict focal structural or functional LV pathology.

Role of cardiovascular magnetic resonance end-systolic 3D-SSFP sequence in repaired tetralogy of Fallot patients eligible for transcatheter pulmonary valve implantation.

To evaluate the usefulness of cardiovascular magnetic resonance (CMR) 3D steady state free precession (SSFP) sequence acquired at end-systole (ES) in repaired Tetralogy of Fallot (rToF) patients eligible for percutaneous pulmonary valve implantation (PPVI). Between 2012 and 2018, 78 rToF patients were selected for pulmonary valve replacement (PVR) according to CMR criteria. CMR protocol included 3D-SSFP sequence used to assess the right ventricle outflow tract (RVOT) diameters at three levels (pulmonary valve remnant, mid-portion, bifurcation) in mid-diastole (MD) or ES, RVOT length and coronary artery anatomy. In 20 rToF patients without indications for PVR (controls), 3D SSFP sequence was acquired at both cardiac phases (MD and ES) to evaluate RVOT dimension throughout the cardiac cycle. Invasive balloon sizing was recorded in patients undergoing PPVI. The 3D-SSFP sequence was performed in MD on 39 patients and in ES on other 39, of whom 26 patients met the criteria for PPVI. The latter was unsuccessful in ten patients (38%), mainly due (80% of cases) to significant size discrepancy at PV remnant and bifurcation levels (p = 0.019 and 0.037 respectively) between the measurements by 3D-SSFP in MD and those by the balloon size in systole. Significant RVOT size difference between MD and ES was present at mid-portion and bifurcation levels in the PVR candidate group, and at all three-levels in the control group (all p < 0.001). ES 3D-SSFP sequence is able to quantify RVOT dilation in rToF patients at its maximum expansion, thus improving selection of PPVI candidates.

Left ventricular global myocardial strain assessment comparing the reproducibility of four commercially available CMR-feature tracking algorithms.

OBJECTIVES: To compare the reproducibility of cardiovascular magnetic resonance feature-tracking (CMR-FT) packages to assess global left ventricular (LV) myocardial strain. METHODS: In 45 subjects (i.e. 15 controls, 15 acute myocardial infarction, 15 dilated cardiomyopathy patients), we determined inter-vendor, inter-observer (two readers) and intra-observer reproducibility of peak systolic global radial, circumferential and longitudinal strain (GRS, GCS and GLS, respectively) comparing four commercially available software packages. Differences between vendors were assessed with analysis of variance (ANOVA), between observers and readings with intraclass correlation coefficient (ICC) and coefficient of variation (CV). RESULTS: The normalised end-diastolic volume was 91, 77 and 119 ml/m2 (median, Q1, Q3) and ejection fraction was 41 ± 14%, range 12-67%. Global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) values were 13.9% ± 5.4% (3.9-23.8%), 12.2% ± 5.8% (1.0-25.1%) and 32.0% ± 14.7 (3.6-67.8%), respectively. ANOVA showed significant differences between vendors for GRS (p < 0.001) and GLS (p = 0.018), not for GCS (p = 0.379). No significant bias was found for both intra- and inter-observer variability. The ICC for inter- and intra-observer reproducibility ranged 0.828-0.991 and 0.902-0.997, respectively. The CV, however, ranged considerably, i.e. 4.0-28.8% and 2.8- 27.7% for inter- and intra-observer reproducibility, respectively. In particular, for GRS differences in CV values between vendors were large, i.e. 5.2-28.8% and 2.8-27.7%, for inter- and intra-observer reproducibility, respectively. CONCLUSIONS: In a cohort of subjects with a wide range of cardiac performances, GRS and GLS values are not interchangeable between vendors. Moreover, although intra- and inter-observer reproducibility amongst vendors is excellent, some vendors encounter problems to reproducibly measure global radial strain. KEY POINTS: • Different software packages are currently available for myocardial strain assessment using routinely acquired cine CMR images. • Global myocardial strain values are not interchangeable between vendors for global longitudinal and global radial strain. • Inter- and intra-observer reproducibility for global strain assessment is excellent. However, some vendors encounter problems to reproducibly measure global radial strain.

Is MRI imaging in pediatric age totally safe? A critical reprisal.

Current radiological literature is strongly focussed on radiation imaging risks. Indeed, given there is a small but actual augment in cancer risk from exposure to ionizing radiation in children, it is important to understand what the risk of alternative techniques could be. We retrospectively review literature data concerning possible MR imaging risks, focussing on the biological effects of MR, sedation and gadolinium compound risks when dealing with infant patients. The main concerns can be summarized in: (1) Biological effects of non-ionizing electromagnetic fields (EMF) employed-whose mechanisms of interaction with human tissues are polarization, induced current, and thermal heating, respectively. (2) Risks associated with noises produced during MRI examinations. (3) Hazards from ferromagnetic external and/or implanted devices-whose risk of being unintentionally brought inside MR room is higher in children than in adults. (4) Risks associated with sedation or general anaesthesia, essential problem in performing MR in very young patients, due to the exam long-lasting. (5) Risks related to gadolinium-based contrast agents, especially considering the newly reported brain deposition.