Assessment of long-term cardiac adaptation in adult patients with type II atrial septal defect : A cardiovascular magnetic resonance (CMR) study.

OBJECTIVES: In type II atrial septal defect (ASD) patients, the left-to-right (LR) shunt causes adaptation of the heart and circulation. The study objective was to evaluate with cardiovascular magnetic resonance imaging (CMR) the impact of LR shunt on left (LV) and right ventricular (RV) volumes, function, and myocardial strain. METHODS: Thirty-five patients (42 ± 17 years, 17 male) were compared to a control group (n = 40). Cine imaging was used to calculate ventricular volumes and ejection fraction (EF), global longitudinal (GLS) and circumferential strain (GCS), and longitudinal free wall (FWS) and interventricular septal (IVS) strain. Phase-contrast imaging was used to calculate pulmonary flow to systemic flow ratio (Qp/Qs). RESULTS: The LR shunt (Qp/Qs 2.2 ± 0.6) resulted in larger RV end-diastolic volume (EDVi) (152 ± 42 vs 82 ± 11 ml/m2), lower LV EDVi (72 ± 16 vs 83 ± 9 ml/m2), and higher RV/LV EDVi ratio (2.2 ± 0.5 vs 1.0 ± 0.1) than controls (all p < 0.001). Functionally, stroke volumes were larger in RV and lower in LV (both p < 0.001) with a strong trend toward lower RV EF in patients (p = 0.08). The LR shunt negatively impacted RV GLS (p = 0.03) but not RV GCS. Longitudinal IVS but not RV FWS were significantly lower in patients, i.e., p < 0.001, of longitudinal IVS. Shunt severity correlated with RV size and stroke volume, right atrial size, and pulmonary trunk diameter (all p < 0.001), but not with functional nor strain parameters. CONCLUSION: Long-term cardiac adaptation in ASD patients, with RV overfilling and LV underfilling, has a negative impact on systolic RV performance, a phenomenon which likely can be attributed to longitudinal dysfunction of the interventricular septum. KEY POINTS: • An LR shunt in type II ASD patients causes cardiac remodeling characterized by RV overfilling and conversely underfilling of the left ventricle. • At the long term, there is evidence of systolic dysfunction of the right ventricle in this group of patients. • Septal dysfunction underlies the observed impairment in RV function.

Cardiovascular magnetic resonance myocardial feature tracking using a non-rigid, elastic image registration algorithm: assessment of variability in a real-life clinical setting.

BACKGROUND: Cardiovascular magnetic resonance myocardial feature tracking (CMR-FT) is a promising technique for quantification of myocardial strain from steady-state free precession (SSFP) cine images. We sought to determine the variability of CMR-FT using a non-rigid elastic registration algorithm recently available in a commercial software package (Segment, Medviso) in a real-life clinical setting. METHODS: Firstly, we studied the variability in a healthy volunteer who underwent 10 CMR studies over five consecutive days. Secondly, 10 patients were selected from our CMR database yielding normal findings (normal group). Finally, we prospectively studied 10 patients with known or suspected myocardial pathology referred for further investigation to CMR (patient group). In the patient group a second study was performed respecting an interval of 30 min between studies. All studies were manually segmented at the end-diastolic phase by three observers. In all subjects left ventricular (LV) circumferential and radial strain were calculated in the short-axis direction (EccSAX and ErrSAX, respectively) and longitudinal strain in the long-axis direction (EllLAX). The level of CMR experience of the observers was 2 weeks, 6 months and >20 years. RESULTS: Mean contouring time was 7 ± 1 min, mean FT calculation time 13 ± 2 min. Intra- and inter-observer variability was good to excellent with an coefficient of reproducibility (CR) ranging 1.6% to 11.5%, and 1.7% to 16.0%, respectively and an intraclass correlation coefficient (ICC) ranging 0.89 to 1.00 and 0.74 to 0.99, respectively. Variability considerably increased in the test-retest setting with a CR ranging 4.2% to 29.1% and an ICC ranging 0.66 to 0.95 in the patient group. Variability was not influenced by level of expertise of the observers. Neither did the presence of myocardial pathology at CMR negatively impact variability. However, compared to global myocardial strain, segmental myocardial strain variability increased with a factor 2-3, in particular for the basal and apical short-axis slices. CONCLUSIONS: CMR-FT using non-rigid, elastic registration is a reproducible approach for strain analysis in patients routinely scheduled for CMR, and is not influenced by the level of training. However, further improvement is needed to reliably depict small variations in segmental myocardial strain.