Cardiovascular Magnetic Resonance Reference Ranges From the Healthy Hearts Consortium.

BACKGROUND: The absence of population-stratified cardiovascular magnetic resonance (CMR) reference ranges from large cohorts is a major shortcoming for clinical care. OBJECTIVES: This paper provides age-, sex-, and ethnicity-specific CMR reference ranges for atrial and ventricular metrics from the Healthy Hearts Consortium, an international collaborative comprising 9,088 CMR studies from verified healthy individuals, covering the complete adult age spectrum across both sexes, and with the highest ethnic diversity reported to date. METHODS: CMR studies were analyzed using certified software with batch processing capability (cvi42, version 5.14 prototype, Circle Cardiovascular Imaging) by 2 expert readers. Three segmentation methods (smooth, papillary, anatomic) were used to contour the endocardial and epicardial borders of the ventricles and atria from long- and short-axis cine series. Clinically established ventricular and atrial metrics were extracted and stratified by age, sex, and ethnicity. Variations by segmentation method, scanner vendor, and magnet strength were examined. Reference ranges are reported as 95% prediction intervals. RESULTS: The sample included 4,452 (49.0%) men and 4,636 (51.0%) women with average age of 61.1 ± 12.9 years (range: 18-83 years). Among these, 7,424 (81.7%) were from White, 510 (5.6%) South Asian, 478 (5.3%) mixed/other, 341 (3.7%) Black, and 335 (3.7%) Chinese ethnicities. Images were acquired using 1.5-T (n = 8,779; 96.6%) and 3.0-T (n = 309; 3.4%) scanners from Siemens (n = 8,299; 91.3%), Philips (n = 498; 5.5%), and GE (n = 291, 3.2%). CONCLUSIONS: This work represents a resource with healthy CMR-derived volumetric reference ranges ready for clinical implementation.

Quality assurance of late gadolinium enhancement cardiac magnetic resonance images: a deep learning classifier for confidence in the presence or absence of abnormality with potential to prompt real-time image optimization.

BACKGROUND: Late gadolinium enhancement (LGE) of the myocardium has significant diagnostic and prognostic implications, with even small areas of enhancement being important. Distinguishing between definitely normal and definitely abnormal LGE images is usually straightforward, but diagnostic uncertainty arises when reporters are not sure whether the observed LGE is genuine or not. This uncertainty might be resolved by repetition (to remove artifact) or further acquisition of intersecting images, but this must take place before the scan finishes. Real-time quality assurance by humans is a complex task requiring training and experience, so being able to identify which images have an intermediate likelihood of LGE while the scan is ongoing, without the presence of an expert is of high value. This decision-support could prompt immediate image optimization or acquisition of supplementary images to confirm or refute the presence of genuine LGE. This could reduce ambiguity in reports. METHODS: Short-axis, phase-sensitive inversion recovery late gadolinium images were extracted from our clinical cardiac magnetic resonance (CMR) database and shuffled. Two, independent, blinded experts scored each individual slice for "LGE likelihood" on a visual analog scale, from 0 (absolute certainty of no LGE) to 100 (absolute certainty of LGE), with 50 representing clinical equipoise. The scored images were split into two classes-either "high certainty" of whether LGE was present or not, or "low certainty." The dataset was split into training, validation, and test sets (70:15:15). A deep learning binary classifier based on the EfficientNetV2 convolutional neural network architecture was trained to distinguish between these categories. Classifier performance on the test set was evaluated by calculating the accuracy, precision, recall, F1-score, and area under the receiver operating characteristics curve (ROC AUC). Performance was also evaluated on an external test set of images from a different center. RESULTS: One thousand six hundred and forty-five images (from 272 patients) were labeled and split at the patient level into training (1151 images), validation (247 images), and test (247 images) sets for the deep learning binary classifier. Of these, 1208 images were "high certainty" (255 for LGE, 953 for no LGE), and 437 were "low certainty". An external test comprising 247 images from 41 patients from another center was also employed. After 100 epochs, the performance on the internal test set was accuracy = 0.94, recall = 0.80, precision = 0.97, F1-score = 0.87, and ROC AUC = 0.94. The classifier also performed robustly on the external test set (accuracy = 0.91, recall = 0.73, precision = 0.93, F1-score = 0.82, and ROC AUC = 0.91). These results were benchmarked against a reference inter-expert accuracy of 0.86. CONCLUSION: Deep learning shows potential to automate quality control of late gadolinium imaging in CMR. The ability to identify short-axis images with intermediate LGE likelihood in real-time may serve as a useful decision-support tool. This approach has the potential to guide immediate further imaging while the patient is still in the scanner, thereby reducing the frequency of recalls and inconclusive reports due to diagnostic indecision.

Cardiovascular magnetic resonance myocardial feature tracking for the determination of left atrial strain in hypertensive left ventricular hypertrophy and hypertrophic cardiomyopathy.

AIM: To measure the left atrial (LA) function in patients with hypertrophic cardiomyopathy (HCM; with [OHCM] and without obstruction [NOHCM]) and hypertension-related left ventricular hypertrophy (H-LVH) using cardiovascular magnetic resonance imaging feature tracking (CMR-FT). MATERIALS AND METHODS: Patients who met the criteria for HCM (n=68), H-LVH (n=46), and 30 healthy controls participated. Left atrial strain was analysed using CMR-FT in cine images with two and four chambers. RESULTS: The strain rate and LA strain measurements showed that patients with HCM, and H-LVH had impaired conduit and reservoir functions (versus controls). These capacities were more severely impaired in OHCM than those seen in NOHCM and H-LVH. The LA volume parameters (LAVIpac, LAVImin and LAVImax) from the OHCM group were higher than both the NOHCM and H-LVH groups (all p<0.05). There were differences between the OHCM and H-LVH groups in terms of the parameters for LA reservoir function (εs), booster pump function (SRa), and conduit function (SRe, LA passive EF, εe; p<0.05). The strongest correlations included the associations between LA total EF and εs, εe and LA passive EF, and SRe and LA passive EF. CONCLUSION: CMR-FT can reliably identify LA dysfunction and deformation in the early stages of HCM and H-LVH.

Segment Length in Cine Strain Analysis Predicts Cardiac Resynchronization Therapy Outcome Beyond Current Guidelines.

BACKGROUND: Patients with a class I recommendation for cardiac resynchronization therapy (CRT) are likely to benefit, but the effect of CRT in class II patients is more heterogeneous and additional selection parameters are needed in this group. The recently validated segment length in cine strain analysis of the septum (SLICE-ESSsep) measurement on cardiac magnetic resonance cine imaging predicts left ventricular functional recovery after CRT but its prognostic value is unknown. This study sought to evaluate the prognostic value of SLICE-ESSsep for clinical outcome after CRT. METHODS: Two hundred eighteen patients with a left bundle branch block or intraventricular conduction delay and a class I or class II indication for CRT who underwent preimplantation cardiovascular magnetic resonance examination were enrolled. SLICE-ESSsep was manually measured on standard cardiovascular magnetic resonance cine imaging. The primary combined end point was all-cause mortality, left ventricular assist device, or heart transplantation. Secondary end points were (1) appropriate implantable cardioverter defibrillator therapy and (2) heart failure hospitalization. RESULTS: Two-thirds (65%) of patients had a positive SLICE-ESSsep ≥0.9% (ie, systolic septal stretching). During a median follow-up of 3.8 years, 66 (30%) patients reached the primary end point. Patients with positive SLICE-ESSsep were at lower risk to reach the primary end point (hazard ratio 0.36; P<0.001) and heart failure hospitalization (hazard ratio 0.41; P=0.019), but not for implantable cardioverter defibrillator therapy (hazard ratio, 0.66; P=0.272). Clinical outcome of class II patients with a positive ESSsep was similar to those of class I patients (hazard ratio, 1.38 [95% CI, 0.66-2.88]; P=0.396). CONCLUSIONS: Strain assessment of the septum (SLICE-ESSsep) provides a prognostic measure for clinical outcome after CRT. Detection of a positive SLICE-ESSsep in patients with a class II indication predicts improved CRT outcome similar to those with a class I indication whereas SLICE-ESSsep negative patients have poor prognosis after CRT implantation.

Novel Z Scores to Correct Biases Due to Ventricular Volume Indexing to Body Surface Area in Adolescents and Young Adults.

BACKGROUND: Reference values for cardiac magnetic resonance imaging (cMRI) in children and young adults are scarce. This leads to risk stratification of patients with congenital heart diseases being based on volumes indexed to body surface area (BSA). We aimed to produce cMRI Z score equations for ventricular volumes in children and young adults and to test whether indexing to BSA resulted in an incorrect assessment of ventricular dilation according to sex, body composition, and growth. METHODS: We retrospectively included 372 subjects aged < 26 years with either normal hearts or conditions with no impact on ventricular volumes (reference group), and 205 subjects with repaired tetralogy of Fallot (TOF) aged < 26 years. We generated Z score equations by means of multivariable regression modelling. Right ventricular dilation was assessed with the use of Z scores and compared with indexing to BSA in TOF subjects. RESULTS: Ventricular volume Z scores were independent from age, sex, and anthropometric measurements, although volumes indexed to BSA showed significant residual association with sex and body size. In TOF subjects, indexing overestimated dilation in growing children and underestimated dilation in female compared with male subjects, and in overweight compared with lean subjects. CONCLUSIONS: Indexed ventricular volumes measured with cMRI did not completely adjust for body size and resulted in a differential error in the assessment of ventricular dilation according to sex and body size. Our proposed Z score equations solved this problem. Future studies should evaluate if ventricular volumes expressed as Z scores have a better prognostic value than volumes indexed to BSA.

Society for Cardiovascular Magnetic Resonance (SCMR) recommended CMR protocols for scanning patients with active or convalescent phase COVID-19 infection.

The aim of this document is to provide specific recommendations on the use of cardiovascular magnetic resonance (CMR) protocols in the era of the COVID-19 pandemic. In patients without COVID-19, standard CMR protocols should be used based on clinical indication as usual. Protocols used in patients who have known / suspected active COVID-19 or post COVID-19 should be performed based on the specific clinical question with an emphasis on cardiac function and myocardial tissue characterization. Short and dedicated protocols are recommended.

Prognostic Value of Magnetic Resonance Phenotype in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy.

BACKGROUND: Cardiac magnetic resonance (CMR) is widely used to assess tissue and functional abnormalities in arrhythmogenic right ventricular cardiomyopathy (ARVC). Recently, a ARVC risk score was proposed to predict the 5-year risk of malignant ventricular arrhythmias in patients with ARVC. However, CMR features such as fibrosis, fat infiltration, and left ventricular (LV) involvement were not considered. OBJECTIVES: The authors sought to evaluate the prognostic role of CMR phenotype in patients with definite ARVC and to evaluate the effectiveness of the novel 5-year ARVC risk score to predict cardiac events in different CMR presentations. METHODS: A total of 140 patients with definite ARVC were enrolled (mean age 42 ± 17 years, 97 males) in this multicenter prospective registry. As per study design, CMR was performed in all the patients at enrollment. The novel 5-year ARVC risk score was retrospectively calculated using the patient's characteristics at the time of enrollment. During a median follow-up of 5 years (2 to 8 years), the combined endpoint of sudden cardiac death, appropriate implantable cardioverter-defibrillator intervention, and aborted cardiac arrest was considered. RESULTS: CMR was completely negative in 14 patients (10%), isolated right ventricular (RV) involvement was found in 58 (41%), biventricular in 52 (37%), and LV dominant in 16 (12%). During the follow-up, 48 patients (34%) had major events, but none occurred in patients with negative CMR. At Kaplan-Meier analysis, patients with LV involvement (LV dominant and biventricular) had a worse prognosis than those with lone RV (p < 0.0001). At multivariate analysis, the LV involvement, a LV-dominant phenotype, and the 5-year ARVC risk score were independent predictors of major events. The estimated 5-year risk was able to predict the observed risk in patients with lone RV but underestimated the risk in those with LV involvement. CONCLUSIONS: Different CMR presentations of ARVC are associated with different prognoses. The 5-year ARVC risk score is valid for the estimation of risk in patients with lone-RV presentation but underestimated the risk when LV is involved.

Right ventricular free wall longitudinal strain and strain rate quantification with cardiovascular magnetic resonance based tissue tracking.

Cardiovascular magnetic resonance based tissue tracking (CMR-TT) was reported to provide detailed insight into left ventricular mechanical features. However, inadequate knowledge of the right ventricle (RV) mechanical deformation has been acquired by this advanced technique so far. It was the aim of this study to establish reference values of RV free wall (RVFW) global, regional and segmental longitudinal peak strain and strain rate (LS and LSR), and to investigate the gender- and age-related difference as well as the base-to-apex gradient of RVFW-LS and LSR with CMR-TT. 150 healthy volunteers (75 males/females) were retrospectively and continuously recruited and subdivided into three age groups (G20-40, G41-60 and G61-80). RVFW global, regional (basal, middle-cavity and apical) and segmental LS (GLS, RLS, SLS) along with systolic and diastolic LSR were generated by post-hoc CMR-TT analysis of standard steady-state free precession long-axis four-chamber view cine images acquired at 1.5T field strength. The reference value of myocardial RVFW-GLS was - 24.9 ± 5.2%. We found that females showed more negative GLS than males except in the youngest group, and no age-related difference of GLS was observed in both gender groups. RLS and SLS presented with the same age-related tendency as GLS. The basal and middle-cavity LS were similar between each other and significantly larger than apical LS. RVFW-GLSR resulted as - 1.73 ± 0.58 s-1 and 1.69 ± 0.65 s-1 during systolic and diastolic phases, respectively. The diastolic GLSR of males tended to decline with the ageing and was significantly lower than that of females in G61-80 group. Regional and segmental LSR showed significant gender-related differences in certain basal and apical region/segments without any age-related effects. CMR-TT overcomes the difficulty in measuring RV global and segmental deformation. The establishment of the vendor-, gender- and segment-specific reference values of RVFW-LS and LSR is essential for the rapid and efficient utilization of CMR-TT modality in the clinical routine.

Right Ventricular Systolic Function After the Cone Procedure for Ebstein's Anomaly: Comparison Between Echocardiography and Cardiac Magnetic Resonance.

Although the Cone procedure has improved outcomes for patients with Ebstein´s anomaly (EA), neither RV systolic function recovery in long-term follow-up nor the best echocardiographic parameters to assess RV function are well established. Thus, we evaluated RV performance after the Cone procedure comparing two-dimensional (2DEcho) and three-dimensional (3DEcho) echocardiography to cardiac magnetic resonance (CMR). We assessed 27 EA patients after the Cone procedure (53% female, median age of 20 years at the procedure, median post-operative follow-up duration of 8 years). Echocardiography was performed 4 h apart from the CMR. RV global longitudinal strain (GLS), fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index and tissue Doppler S' velocity were assessed using 2DEcho, whereas 3DEcho was used to evaluate RV volumes and ejection fraction (RVEF). Echocardiographic variables were compared to CMR-RVEF. All patients were in the NYHA functional class I. Median TAPSE was 15.9 mm, FAC 30.2%, and RV-GLS -15%; median RVEF by 3DEcho was 31.9% and 43% by CMR. Among 2DEcho parameters, RV-GLS and FAC had a substantial correlation with CMR-RVEF (r = - 0.63 and r = 0.55, respectively); from 3DEcho, the indexed RV volumes and RVEF were closely correlated with CMR (RV-EDVi, r = 0.60, RV-ESVi, r = 0.72; and RVEF r = 0.60). RV systolic function is impaired years after the Cone procedure, despite a good clinical status. FAC and RV-GLS are useful 2DEcho tools to assess RV function in these patients; however, 3DEcho measurements appear to provide a better RV assessment.

CINeMA: An approach for assessing confidence in the results of a network meta-analysis.

BACKGROUND: The evaluation of the credibility of results from a meta-analysis has become an important part of the evidence synthesis process. We present a methodological framework to evaluate confidence in the results from network meta-analyses, Confidence in Network Meta-Analysis (CINeMA), when multiple interventions are compared. METHODOLOGY: CINeMA considers 6 domains: (i) within-study bias, (ii) reporting bias, (iii) indirectness, (iv) imprecision, (v) heterogeneity, and (vi) incoherence. Key to judgments about within-study bias and indirectness is the percentage contribution matrix, which shows how much information each study contributes to the results from network meta-analysis. The contribution matrix can easily be computed using a freely available web application. In evaluating imprecision, heterogeneity, and incoherence, we consider the impact of these components of variability in forming clinical decisions. CONCLUSIONS: Via 3 examples, we show that CINeMA improves transparency and avoids the selective use of evidence when forming judgments, thus limiting subjectivity in the process. CINeMA is easy to apply even in large and complicated networks.

Fully Automated, Quality-Controlled Cardiac Analysis From CMR: Validation and Large-Scale Application to Characterize Cardiac Function.

OBJECTIVES: This study sought to develop a fully automated framework for cardiac function analysis from cardiac magnetic resonance (CMR), including comprehensive quality control (QC) algorithms to detect erroneous output. BACKGROUND: Analysis of cine CMR imaging using deep learning (DL) algorithms could automate ventricular function assessment. However, variable image quality, variability in phenotypes of disease, and unavoidable weaknesses in training of DL algorithms currently prevent their use in clinical practice. METHODS: The framework consists of a pre-analysis DL image QC, followed by a DL algorithm for biventricular segmentation in long-axis and short-axis views, myocardial feature-tracking (FT), and a post-analysis QC to detect erroneous results. The study validated the framework in healthy subjects and cardiac patients by comparison against manual analysis (n = 100) and evaluation of the QC steps' ability to detect erroneous results (n = 700). Next, this method was used to obtain reference values for cardiac function metrics from the UK Biobank. RESULTS: Automated analysis correlated highly with manual analysis for left and right ventricular volumes (all r > 0.95), strain (circumferential r = 0.89, longitudinal r > 0.89), and filling and ejection rates (all r ≥ 0.93). There was no significant bias for cardiac volumes and filling and ejection rates, except for right ventricular end-systolic volume (bias +1.80 ml; p = 0.01). The bias for FT strain was <1.3%. The sensitivity of detection of erroneous output was 95% for volume-derived parameters and 93% for FT strain. Finally, reference values were automatically derived from 2,029 CMR exams in healthy subjects. CONCLUSIONS: The study demonstrates a DL-based framework for automated, quality-controlled characterization of cardiac function from cine CMR, without the need for direct clinician oversight.

Standardized image post-processing of cardiovascular magnetic resonance T1-mapping reduces variability and improves accuracy and consistency in myocardial tissue characterization.

BACKGROUND: Myocardial T1-mapping is increasingly used in multicentre studies and trials. Inconsistent image analysis introduces variability, hinders differentiation of diseases, and results in larger sample sizes. We present a systematic approach to standardize T1-map analysis by human operators to improve accuracy and consistency. METHODS: We developed a multi-step training program for T1-map post-processing. The training dataset contained 42 left ventricular (LV) short-axis T1-maps (normal and diseases; 1.5 and 3 Tesla). Contours drawn by two experienced human operators served as reference for myocardial T1 and wall thickness (WT). Trainees (n = 26) underwent training and were evaluated by: (a) qualitative review of contours; (b) quantitative comparison with reference T1 and WT. RESULTS: The mean absolute difference between reference operators was 8.4 ±â€¯6.3 ms (T1) and 1.2 ±â€¯0.7 pixels (WT). Trainees' mean discrepancy from reference in T1 improved significantly post-training (from 8.1 ±â€¯2.4 to 6.7 ±â€¯1.4 ms; p < 0.001), with a 43% reduction in standard deviation (SD) (p = 0.035). WT also improved significantly post-training (from 0.9 ±â€¯0.4 to 0.7 ±â€¯0.2 pixels, p = 0.036), with 47% reduction in SD (p = 0.04). These experimentally-derived thresholds served to guide the training process: T1 (±8 ms) and WT (±1 pixel) from reference. CONCLUSION: A standardized approach to CMR T1-map image post-processing leads to significant improvements in the accuracy and consistency of LV myocardial T1 values and wall thickness. Improving consistency between operators can translate into 33-72% reduction in clinical trial sample-sizes. This work may: (a) serve as a basis for re-certification for core-lab operators; (b) translate to sample-size reductions for clinical studies; (c) produce better-quality training datasets for machine learning.

4D flow MRI versus conventional 2D for measuring pulmonary flow after Tetralogy of Fallot repair.

BACKGROUND: After tetralogy of Fallot (TOF) repair, pulmonary regurgitation and right ventricular function must be monitored. Conventional (2D) cardiac magnetic resonance (CMR) is currently the clinical reference method for measuring pulmonary regurgitation. However, 4DFlow CMR has been reported to provide a more comprehensive flow analysis than 2D CMR. We aimed to compare 4DFlow CMR to 2D CMR for assessing pulmonary regurgitation and flow, as well as aortic flow, in children and adults after surgical repair of TOF. METHODS: Retrospective analysis of patients with repaired TOF admitted for cardiac MRI with 4DFlow acquisition from 2016 to 2018. Linear regression was used to assess correlations and Bland-Altman analyses were performed. RESULTS: The 60 included patients had a mean age of 18.2 ±â€¯10.4 years (range, 2-54 years). Significant correlations between the two techniques were found for pulmonary regurgitant fraction (R [2] = 0.6642, p < 0.0001), net pulmonary flow (R [2] = 0.6782, p < 0.0001), forward pulmonary flow (R [2] = 0.6185, p < 0.0001), backward pulmonary flow (R [2] = 0.8192, p < 0.0001), and aortic valve flow (R [2] = 0.6494, p < 0.0001). The Bland-Altman analysis showed no significant bias, narrow limits of agreement, and few scattered points. The correlation between pulmonary and aortic flow was better with 4DFlow CMR than with 2D CMR (R [2] = 0.8564, p < 0.0001 versus R [2] = 0.4393, p < 0,0001, respectively). Interobserver reliability was good. CONCLUSION: These results establish the feasibility and reliability of 4DFlow CMR for assessing pulmonary flow in a large paediatric and adult population with repaired TOF. 4DFlow CMR may be more reliable than 2D MRI for pulmonary flow assessment after TOF repair.

Impact of baseline calibration on semiquantitative assessment of myocardial perfusion reserve by adenosine stress MRI.

In this study, we sought to investigate the impact of baseline calibration, which is used in quantitative cardiac MRI perfusion analysis to correct for surface coil inhomogeneity and noise, on myocardial perfusion reserve index (MPRI) and its contribution to previously reported paradoxical low MPRI < 1.0 in patients with unobstructed coronary arteries. Semiquantitative perfusion analysis was performed in 20 patients with unobstructed coronary arteries undergoing stress/rest perfusion CMR and in ten patients undergoing paired rest perfusion CMR. The following baseline calibration settings were compared: (1) baseline division, (2) baseline subtraction and (3) no baseline calibration. In uncalibrated analysis, we observed ~ 20% segmental dispersion of signal intensity (SI)-over-time curves. Both baseline subtraction and baseline division reduced relative dispersion of t0-SI (p < 0.001), but only baseline division corrected for dispersion of peak-SI and maximum upslope also (p < 0.001). In the assessment of perfusion indices, however, baseline division resulted in paradoxical low MPRI (1.01 ± 0.23 vs. 1.63 ± 0.38, p < 0.001) and rest perfusion index (RPI 0.54 ± 0.07 vs. 0.94 ± 0.12, p < 0.001), respectively. This was due to a reversed ratio of blood-pool and myocardial baseline-SI before the second perfusion study caused by circulating contrast agent from the first injection. In conclusion, baseline division reliably corrects for inhomogeneity of the surface coil sensitivity profile facilitating comparisons of regional myocardial perfusion during hyperemia or at rest. However, in the assessment of MPRI, baseline division can lead to paradoxical low results (even MPRI < 1.0 in patients with unobstructed coronary arteries) potentially mimicking severely impaired perfusion reserve. Thus, in the assessment of MPRI we propose to waive baseline calibration.

Diagnostic performance of non-invasive imaging for stable coronary artery disease: A meta-analysis.

BACKGROUND: To determine diagnostic performance of non-invasive tests using invasive fractional flow reserve (FFR) as reference standard for coronary artery disease (CAD). METHODS: Medline, Embase, and citations of articles, guidelines, and reviews for studies were used to compare non-invasive tests with invasive FFR for suspected CAD published through March 2017. RESULTS: Seventy-seven studies met inclusion criteria. The diagnostic test with the highest sensitivity to detect a functionally significant coronary lesion was coronary computed tomography (CT) angiography [88%(85%-90%)], followed by FFR derived from coronary CT angiography (FFRCT) [85%(81%-88%)], positron emission tomography (PET) [85%(82%-88%)], stress cardiac magnetic resonance (stress CMR) [81%(79%-84%)], stress myocardial CT perfusion combined with coronary CT angiography [79%(74%-83%)], stress myocardial CT perfusion [77%(73%-80%)], stress echocardiography (Echo) [72%(64%-78%)] and stress single-photon emission computed tomography (SPECT) [64%(60%-68%)]. Specificity to rule out CAD was highest for stress myocardial CT perfusion added to coronary CT angiography [91%(88%-93%)], stress CMR [91%(90%-93%)], and PET [87%(86%-89%)]. CONCLUSION: A negative coronary CT angiography has a higher test performance than other index tests to exclude clinically-important CAD. A positive stress myocardial CT perfusion added to coronary CT angiography, stress cardiac MR, and PET have a higher test performance to identify patients requiring invasive coronary artery evaluation.

Soft-tissue prostate intrafraction motion tracking in 3D cine-MR for MR-guided radiotherapy.

To develop a method to automatically determine intrafraction motion of the prostate based on soft tissue contrast on 3D cine-magnetic resonance (MR) images with high spatial and temporal resolution. Twenty-nine patients who underwent prostate stereotactic body radiotherapy (SBRT), with four implanted cylindrical gold fiducial markers (FMs), had cine-MR imaging sessions after each of five weekly fractions. Each cine-MR session consisted of 55 sequentially obtained 3D data sets ('dynamics') and was acquired over an 11 s period, covering a total of 10 min. The prostate was delineated on the first dynamic of every dataset and this delineation was used as the starting position for the soft tissue tracking (SST). Each subsequent dynamic was rigidly aligned to the first dynamic, based on the contrast of the prostate. The obtained translation and rotation describes the intrafraction motion of the prostate. The algorithm was applied to 6270 dynamics over 114 scans of 29 patients and the results were validated by comparing to previously obtained fiducial marker tracking data of the same dataset. Our proposed tracking method was also retro-perspectively applied to cine-MR images acquired during MR-guided radiotherapy of our first prostate patient treated on the MR-Linac. The difference in the 3D translation results between the soft tissue and marker tracking was below 1 mm for 98.2% of the time. The mean translation at 10 min were X: 0.0 [Formula: see text] 0.8 mm, Y: 1.0 [Formula: see text] 1.8 mm and Z: [Formula: see text] mm. The mean rotation results at 10 min were X: [Formula: see text], Y: 0.1 [Formula: see text] 0.6° and Z: 0.0 [Formula: see text] 0.7°. A fast, robust and accurate SST algorithm was developed which obviates the need for FMs during MR-guided prostate radiotherapy. To our knowledge, this is the first data using full 3D cine-MR images for real-time soft tissue prostate tracking, which is validated against previously obtained marker tracking data.

Towards standardized postprocessing of global longitudinal strain by feature tracking - OptiStrain CMR-FT study.

BACKGROUND: Left ventricular global longitudinal strain (GLS) with cardiovascular magnetic resonance (CMR) is an important prognostic biomarker. Its everyday clinical use is limited due to methodological and postprocessing diversity among the users and vendors. Standardization of postprocessing approaches may reduce the random operator-dependent variability, allowing for comparability of measurements despite the systematic vendor-related differences. METHODS: We investigated the random component of variability in GLS measurements by optimization steps which incrementally improved observer reproducibility and agreement. Cine images in two-, three- and four-chamber-views were serially analysed by two independent observers using two different CMR-FT softwares. The disparity of outcomes after each series was systematically assessed after a number of stepwise adjustments which were shown to significantly reduce the inter-observer and intervendor bias, resulting standardized postprocessing approach. The final analysis was performed in 44 subjects (ischaemic heart disease n = 15, non-ischaemic dilated cardiomyopathy, n = 19, healthy controls, n = 10). All measurements were performed blind to the underlying group allocation and previous measurements. Inter- and intra-observer variability were tested using Bland-Altman analyses, intra-class correlation coefficients (ICCs) and coefficients of variation (CVs). RESULTS: Compared to controls, mean GLS was significantly lower in patients, as well as between the two subgroups (p < 0.01). These differences were accentuated by standardization procedures, with significant increase in Cohen's D and AUCs. The benefit of standardization was also evident through improved CV and ICC agreements between observers and the two vendors. Initial intra-observer variability CVs for GLS parameters were 7.6 and 4.6%, inter-observer variability CVs were 11 and 4.7%, for the two vendors, respectively. After standardization, intra- and interobserver variability CVs were 3.1 and 4.3%, and 5.2 and 4.4%, respectively. CONCLUSION: Standardization of GLS postprocessing helps to reduce the random component of variability, introduced by inconsistencies of and between observers, and also intervendor variability, but not the systematic inter-vendor bias due to differences in image processing algorithms. Standardization of GLS measurements is an essential step in ensuring the reliable quantification of myocardial deformation, and implementation of CMR-FT in clinical routine.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 2 of 2-Diagnostic Criteria and Appropriate Utilization.

Cardiac amyloidosis is emerging as an underdiagnosed cause of heart failure and mortality. Growing literature suggests that a noninvasive diagnosis of cardiac amyloidosis is now feasible. However, the diagnostic criteria and utilization of imaging in cardiac amyloidosis are not standardized. In this paper, Part 2 of a series, a panel of international experts from multiple societies define the diagnostic criteria for cardiac amyloidosis and appropriate utilization of echocardiography, cardiovascular magnetic resonance imaging, and radionuclide imaging in the evaluation of patients with known or suspected cardiac amyloidosis.

Right ventricular shape and function: cardiovascular magnetic resonance reference morphology and biventricular risk factor morphometrics in UK Biobank.

BACKGROUND: The associations between cardiovascular disease (CVD) risk factors and the biventricular geometry of the right ventricle (RV) and left ventricle (LV) have been difficult to assess, due to subtle and complex shape changes. We sought to quantify reference RV morphology as well as biventricular variations associated with common cardiovascular risk factors. METHODS: A biventricular shape atlas was automatically constructed using contours and landmarks from 4329 UK Biobank cardiovascular magnetic resonance (CMR) studies. A subdivision surface geometric mesh was customized to the contours using a diffeomorphic registration algorithm, with automatic correction of slice shifts due to differences in breath-hold position. A reference sub-cohort was identified consisting of 630 participants with no CVD risk factors. Morphometric scores were computed using linear regression to quantify shape variations associated with four risk factors (high cholesterol, high blood pressure, obesity and smoking) and three disease factors (diabetes, previous myocardial infarction and angina). RESULTS: The atlas construction led to an accurate representation of 3D shapes at end-diastole and end-systole, with acceptable fitting errors between surfaces and contours (average error less than 1.5 mm). Atlas shape features had stronger associations than traditional mass and volume measures for all factors (p < 0.005 for each). High blood pressure was associated with outward displacement of the LV free walls, but inward displacement of the RV free wall and thickening of the septum. Smoking was associated with a rounder RV with inward displacement of the RV free wall and increased relative wall thickness. CONCLUSION: Morphometric relationships between biventricular shape and cardiovascular risk factors in a large cohort show complex interactions between RV and LV morphology. These can be quantified by z-scores, which can be used to study the morphological correlates of disease.