Quantification of left ventricular myocardial strain: Comparison between MRI tagging, MRI feature tracking, and ultrasound speckle tracking.

Ultrasound speckle tracking is frequently used to quantify myocardial strain, and magnetic resonance imaging (MRI) feature tracking is rapidly gaining interest. Our aim is to validate cardiac MRI feature tracking by comparing it with the gold standard method (i.e., MRI tagging) in healthy subjects and patients. Furthermore, we aim to perform an indirect validation by comparing ultrasound speckle tracking with MRI feature tracking. Forty-two subjects (17 formerly preeclamptic women, three healthy women, and 22 left bundle branch block patients of both sexes) received 3-T cardiac MRI and echocardiography. Cine and tagged MRI, and B-mode ultrasound images, were acquired. Intrapatient global and segmental left ventricular circumferential (MRI tagging vs. MRI feature tracking) and longitudinal (MRI feature tracking vs. ultrasound speckle tracking) peak strain and time to peak strain were compared between the three techniques. Intraclass correlation coefficient (ICC) (< 0.50 = poor, 0.50-0.75 = moderate, > 0.75-0.90 = good, > 0.90 = excellent) and Bland-Altman analysis were used to assess correlation and bias; p less than 0.05 indicates a significant ICC or bias. Global peak strain parameters showed moderate-to-good correlations between methods (ICC = 0.71-0.83, p < 0.01) with no significant biases. Global time to peak strain parameters showed moderate-to-good correlations (ICC = 0.56-0.82, p < 0.01) with no significant biases. Segmental peak strains showed significant biases in all parameters and moderate-to-good correlation (ICC = 0.62-0.77, p < 0.01), except for lateral longitudinal peak strain (ICC = 0.23, p = 0.22). Segmental time to peak strain parameters showed moderate-to-good correlation (ICC = 0.58-0.74, p < 0.01) with no significant biases. MRI feature tracking is a valid method to examine myocardial strain, but there is bias in absolute segmental strain values between imaging techniques. MRI feature tracking shows adequate comparability with ultrasound speckle tracking.

Evaluating a Phase-Specific Approach to Aortic Flow: A 4D Flow MRI Study.

BACKGROUND: Aortic flow parameters can be quantified using 4D flow MRI. However, data are sparse on how different methods of analysis influence these parameters and how these parameters evolve during systole. PURPOSE: To assess multiphase segmentations and multiphase quantification of flow-related parameters in aortic 4D flow MRI. STUDY TYPE: Prospective. POPULATION: 40 healthy volunteers (50% male, 28.9 ± 5.0 years) and 10 patients with thoracic aortic aneurysm (80% male, 54 ± 8 years). FIELD STRENGTH/SEQUENCE: 4D flow MRI with a velocity encoded turbo field echo sequence at 3 T. ASSESSMENT: Phase-specific segmentations were obtained for the aortic root and the ascending aorta. The whole aorta was segmented in peak systole. In all aortic segments, time to peak (TTP; for flow velocity, vorticity, helicity, kinetic energy, and viscous energy loss) and peak and time-averaged values (for velocity and vorticity) were calculated. STATISTICAL TESTS: Static vs. phase-specific models were assessed using Bland-Altman plots. Other analyses were performed using phase-specific segmentations for aortic root and ascending aorta. TTP for all parameters was compared to TTP of flow rate using paired t-tests. Time-averaged and peak values were assessed using Pearson correlation coefficient. P < 0.05 was considered statistically significant. RESULTS: In the combined group, velocity in static vs. phase-specific segmentations differed by 0.8 cm/sec for the aortic root, and 0.1 cm/sec (P = 0.214) for the ascending aorta. Vorticity differed by 167 sec-1 mL-1 (P = 0.468) for the aortic root, and by 59 sec-1 mL-1 (P = 0.481) for the ascending aorta. Vorticity, helicity, and energy loss in the ascending aorta, aortic arch, and descending aorta peaked significantly later than flow rate. Time-averaged velocity and vorticity values correlated significantly in all segments. DATA CONCLUSION: Static 4D flow MRI segmentation yields comparable results as multiphase segmentation for flow-related parameters, eliminating the need for time-consuming multiple segmentations. However, multiphase quantification is necessary for assessing peak values of aortic flow-related parameters. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY STAGE: 3.

Comprehensive sex-specific and age-dependent analysis of 4D-flow MRI assessed aortic blood flow-related parameters in normal subjects using single-vendor MR systems and single-vendor software.

BACKGROUND: Aortic blood flow characterization by 4D flow MRI is increasingly performed in aneurysm research. A limited number of studies have established normal values that can aid the recognition of abnormal flow at an early stage. This study aims to establish additional sex-specific and age-dependent reference values for flow-related parameters in a large cohort of healthy adults. METHODS: 212 volunteers were included, and 191 volunteers completed the full study protocol. All underwent 4D flow MRI of the entire aorta. Quantitative values for velocity, vorticity, helicity, as well as total, circumferential, and axial wall shear stress [WSS] were determined for the aortic root [AoR], ascending aorta [AAo], aortic arch [AoA], descending [DAo], suprarenal [SRA], and infrarenal aorta [IRA]. Vorticity and helicity were indexed for segment volume (mL). RESULTS: The normal values were estimated per sex- and age-group, where significant differences between males (M) and females (F) were found only for specific age groups. More specifically, the following variables were significantly different after applying the false discovery rate correction for multiple testing: 1) velocity in the AAo and DAo in the 60-70 years age group (mean±SD: (M) 47.0 ± 8.2cm/s vs. (F) 38.4 ± 6.9cm/s, p=0.001 and, (M) 55.9 ± 9.9cm/s vs. (F) 46.5 ± 5.5cm/s, p=0.002), 2) normalized vorticity in AoR in the 50-59 years age group ((M) 27539 ± 5042s-1mL-1 vs. (F) 30849 ± 7285s-1mL-1, p=0.002), 3) axial WSS in the Aao in the 18-29 age group ((M) 1098 ± 203 mPa vs. (F) 921 ± 121 mPa, p=0.002). Good to strong negative correlations with age were seen for almost all variables, in different segments, and for both sexes. CONCLUSION: This study describes reference values for aortic flow-related parameters as acquired by 4D flow MRI. We observed limited differences between males and females. A negative relationship with age was seen for almost all flow-related parameters and segments.

Editor's Choice - Extending Aortic Replacement Beyond the Proximal Arch in Acute Type A Aortic Dissection: A Meta-Analysis of Short Term Outcomes and Long Term Actuarial Survival.

OBJECTIVE: The extent of aortic replacement during surgery for acute type A aortic dissection (ATAAD) is an important matter of debate. This meta-analysis aimed to evaluate the short and long term outcomes of a proximal aortic repair (PAR) vs. total arch replacement (TAR) in the treatment of ATAAD. DATA SOURCES: A systematic search of PubMed and Embase was performed. Studies comparing PAR to TAR for ATAAD were included. REVIEW METHODS: The primary outcomes were early death and long term actuarial survival at one, five, and 10 years. Random effects models in conjunction with relative risks (RRs) were used for meta-analyses. RESULTS: Nineteen studies were included, comprising 5 744 patients (proximal: n = 4 208; total arch: n = 1 536). PAR was associated with reduced early mortality (10.8% [95% confidence interval (CI) 8.4 - 13.7] vs. 14.0% [95% CI 10.4 - 18.7]; RR 0.73 [95% CI 0.63 - 0.85]) and reduced post-operative renal failure (10.4% [95% CI 7.2 - 14.8] vs. 11.1% [95% CI 6.7 - 17.5]; RR 0.77 [95% CI 0.66 - 0.90]), but there was no difference in stroke (8.0% [95% CI 5.9 - 10.7] vs. 7.3% [95% CI 4.6 - 11.3]; RR 0.87 [95% CI 0.69 - 1.10]). No statistically significant difference was found for survival after one year (83.2% [95% CI 77.5 - 87.7] vs. 78.6% [95% CI 69.7 - 85.5]; RR 1.05 [95% CI 0.99 - 1.11]), which persisted after five years (75.4% [95% CI 71.2 - 79.2] vs. 74.5% [95% CI 64.7 - 82.3]; RR 1.02 [95% CI 0.91 - 1.14]). After 10 years, there was a significant survival benefit for patients who underwent TAR (64.7% [95% CI 61.1 - 68.1] vs. 72.4% [95% CI 67.5 - 76.7]; RR 0.91 [95% CI 0.84 - 0.99]). CONCLUSION: PAR appears to lead to an improved early mortality rate and a reduced complication rate. In the current meta-analysis, the suggestion of an improved 10 year survival benefit of TAR was found, which should be interpreted in the context of potential confounders such as age at presentation, comorbidities, and haemodynamic stability. In any case, PAR seems to be intuitive in older patients with limited dissections, and in those presenting in less stable conditions.

Cardiovascular magnetic resonance accurately detects obstructive coronary artery disease in suspected non-ST elevation myocardial infarction: a sub-analysis of the CARMENTA Trial.

BACKGROUND: Invasive coronary angiography (ICA) is still the reference test in suspected non-ST elevation myocardial infarction (NSTEMI), although a substantial number of patients do not have obstructive coronary artery disease (CAD). Early cardiovascular magnetic resonance (CMR) may be a useful gatekeeper for ICA in this setting. The main objective was to investigate the accuracy of CMR to detect obstructive CAD in NSTEMI. METHODS: This study is a sub-analysis of a randomized controlled trial investigating whether a non-invasive imaging-first strategy safely reduced the number of ICA compared to routine clinical care in suspected NSTEMI (acute chest pain, non-diagnostic electrocardiogram, high sensitivity troponin T > 14 ng/L), and included 51 patients who underwent CMR prior to ICA. A stepwise approach was used to assess the diagnostic accuracy of CMR to detect (1) obstructive CAD (diameter stenosis ≥ 70% by ICA) and (2) an adjudicated final diagnosis of acute coronary syndrome (ACS). First, in all patients the combination of cine, T2-weighted and late gadolinium enhancement (LGE) imaging was evaluated for the presence of abnormalities consistent with a coronary etiology in any sequence. Hereafter and only when the scan was normal or equivocal, adenosine stress-perfusion CMR was added. RESULTS: Of 51 patients included (63 ± 10 years, 51% male), 34 (67%) had obstructive CAD by ICA. The sensitivity, specificity and overall accuracy of the first step to diagnose obstructive CAD were 79%, 71% and 77%, respectively. Additional vasodilator stress-perfusion CMR was performed in 19 patients and combined with step one resulted in an overall sensitivity of 97%, specificity of 65% and accuracy of 86%. Of the remaining 17 patients with non-obstructive CAD, 4 (24%) had evidence for a myocardial infarction on LGE, explaining the modest specificity. The sensitivity, specificity and overall accuracy to diagnose ACS (n = 43) were 88%, 88% and 88%, respectively. CONCLUSION: CMR accurately detects obstructive CAD and ACS in suspected NSTEMI. Non-obstructive CAD is common with CMR still identifying an infarction in almost one-quarter of patients. CMR should be considered as an early diagnostic approach in suspected NSTEMI. TRIAL REGISTRATION: The CARMENTA trial has been registered at ClinicalTrials.gov with identifier NCT01559467.

Clinical assessment of aortic valve stenosis: Comparison between 4D flow MRI and transthoracic echocardiography.

BACKGROUND: The prevalence of valvular aortic stenosis (AS) increases as the population ages. Echocardiographic measurements of peak jet velocity (Vpeak ), mean pressure gradient (Pmean ), and aortic valve area (AVA) determine AS severity and play a pivotal role in the stratification towards valvular replacement. A multimodality imaging approach might be needed in cases of uncertainty about the actual severity of the stenosis. PURPOSE: To compare four-dimensional phase-contrast magnetic resonance (4D PC-MR), two-dimensional (2D) PC-MR, and transthoracic echocardiography (TTE) for quantification of AS. STUDY TYPE: Prospective. POPULATION: Twenty patients with various degrees of AS (69.3 ± 5.0 years). FIELD STRENGTH/SEQUENCES: 4D PC-MR and 2D PC-MR at 3T. ASSESSMENT: We compared Vpeak , Pmean , and AVA between TTE, 4D PC-MR, and 2D PC-MR. Flow eccentricity was quantified by means of normalized flow displacement, and its influence on the accuracy of TTE measurements was investigated. STATISTICAL TESTS: Pearson's correlation, Bland-Altman analysis, paired t-test, and intraclass correlation coefficient. RESULTS: 4D PC-MR measured higher Vpeak (r = 0.95, mean difference + 16.4 ± 10.7%, P <0.001), and Pmean (r = 0.92, mean difference + 14.9 ± 16.0%, P = 0.013), but a less critical AVA (r = 0.80, mean difference + 19.9 ± 20.6%, P = 0.002) than TTE. In contrast, unidirectional 2D PC-MR substantially underestimated AS severity when compared with TTE. Differences in Vpeak between 4D PC-MR and TTE showed to be strongly correlated with the eccentricity of the flow jet (r = 0.89, P <0.001). Use of 4D PC-MR improved the concordance between Vpeak and AVA (from 0.68 to 0.87), and between PGmean and AVA (from 0.68 to 0.86). DATA CONCLUSION: 4D PC-MR improves the concordance between the different AS parameters and could serve as an additional imaging technique next to TTE. Future studies should address the potential value of 4D PC-MR in patients with discordant echocardiographic parameters. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:472-480.

Predictive imaging for thoracic aortic dissection and rupture: moving beyond diameters.

Acute aortic syndromes comprise a group of potentially fatal conditions that result from weakening of the aortic vessel wall. Pre-emptive surgical intervention is currently reserved for patients with severe aortic dilatation, although abundant evidence describes the occurrence of dissection and rupture in aortas with diameters below surgical thresholds. Modern imaging techniques (such as hybrid PET-CT and 4D flow MRI) afford the non-invasive assessment of anatomic, hemodynamic, and molecular features of the aorta, and may provide for a more accurate selection of patients who will benefit from preventative surgical intervention. In the current review, we summarize evidence and considerations regarding predictive aortic imaging and highlight evolving imaging modalities that have shown promise to improve risk assessment for the occurrence of dissection and rupture. KEY POINTS: • Guidelines for the preventative management of aortic disease depend on maximal vessel diameters, while these have shown to be poor predictors for the occurrence of catastrophic acute aortic events. • Evolving imaging modalities (such as 4D flow MRI and hybrid PET-CT) afford a more comprehensive insight into anatomic, hemodynamic, and molecular features of the aorta and have shown promise to detect vessel wall instability at an early stage.

Left atrial function of patients with atrial fibrillation undergoing thoracoscopic hybrid ablation.

OBJECTIVES: Thoracoscopic hybrid ablation is an effective and safe rhythm control strategy for patients with complex forms of atrial fibrillation. Its effect on left atrial function has not yet been studied. METHODS: In a retrospective single-centre analysis of patients undergoing thoracoscopic hybrid ablation, the left atrial emptying fraction was calculated using the biplane modified Simpson method in the apical 2- and 4-chamber views on transthoracic echocardiography. Left atrial strain (reservoir, conduction and contractility) was quantified using dedicated software. RESULTS: Sixty-seven patients were included (mean age 64 years, long-standing persistent atrial fibrillation in 69%, median atrial fibrillation history duration 64 months). At baseline, left atrial function and contractility were poor. The reservoir and contractile strain improved postprocedure compared to baseline [15 (standard deviation (SD): 8) and 17 (SD: 6); P = 0.013; 3 (SD: 5) and 4 (SD: 4), P = 0.008], whereas the left atrial volume indexed to the body surface area was reduced [51 ml/m2 (SD: 14) and 47 ml/m2 (SD: 18), P = 0.0024]. In patients with preoperative (long-standing) persistent atrial fibrillation and in patients with rhythm restoration, improvements in the emptying fraction, (reservoir and contractile) strain and the left ventricular ejection fraction were observed, whereas the left atrial volume decreased (P < 0.05). CONCLUSIONS: In this cohort of patients with severely diseased left atria, improvement in left atrial contractility and in the emptying fraction after thoracoscopic hybrid ablation for atrial fibrillation in patients with persistent atrial fibrillation is mainly due to rhythm restoration. Interestingly, the procedure itself also results in improved left atrial reservoir strain and reversed left atrial remodelling by reducing left atrial volume.

A clinician's guide to understanding aortic 4D flow MRI.

Four-dimensional flow magnetic resonance imaging is an emerging technique which may play a role in diagnosis and risk-stratification of aortic disease. Some knowledge of flow dynamics and related parameters is necessary to understand and apply this technique in clinical workflows. The purpose of the current review is to provide a guide for clinicians to the basics of flow imaging, frequently used flow-related parameters, and their relevance in the context of aortic disease.Clinical relevance statement Understanding normal and abnormal aortic flow could improve clinical care in patients with aortic disease.

Biomarkers of Collagen Metabolism Are Associated with Left Ventricular Function and Prognosis in Dilated Cardiomyopathy: A Multi-Modal Study.

BACKGROUND: Collagen cross-linking is a fundamental process in dilated cardiomyopathy (DCM) and occurs when collagen deposition exceeds degradation, leading to impaired prognosis. This study investigated the associations of collagen-metabolism biomarkers with left ventricular function and prognosis in DCM. METHODS: DCM patients who underwent endomyocardial biopsy, blood sampling, and cardiac MRI were included. The primary endpoint included death, heart failure hospitalization, or life-threatening arrhythmias, with a follow-up of 6 years (5-8). RESULTS: In total, 209 DCM patients were included (aged 54 ± 13 years, 65% male). No associations were observed between collagen volume fraction, circulating carboxy-terminal propeptide of procollagen type-I (PICP), or collagen type I carboxy-terminal telopeptide [CITP] and matrix metalloproteinase [MMP]-1 ratio and cardiac function parameters. However, CITP:MMP-1 was significantly correlated with global longitudinal strain (GLS) in the total study sample (R = -0.40, p < 0.0001; lower CITP:MMP-1 ratio was associated with impaired GLS), with even stronger correlations in patients with LVEF > 40% (R = -0.70, p < 0.0001). Forty-seven (22%) patients reached the primary endpoint. Higher MMP-1 levels were associated with a worse outcome, even after adjustment for clinical and imaging predictors (1.026, 95% CI 1.002-1.051, p = 0.037), but CITP and CITP:MMP-1 were not. Combining MMP-1 and PICP improved the goodness-of-fit (LHR36.67, p = 0.004). CONCLUSION: The degree of myocardial cross-linking (CITP:MMP-1) is associated with myocardial longitudinal contraction, and MMP-1 is an independent predictor of outcome in DCM patients.

Imaging surveillance for complications after primary surgery for type A aortic dissection.

Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergency surgery to avert fatal outcome. Conventional surgical procedures comprise excision of the entry tear and replacement of the proximal aorta with a synthetic vascular graft. In patients with DeBakey type I dissection, this approach leaves a chronically dissected distal aorta, putting them at risk for progressive dilatation, dissection propagation and aortic rupture. Therefore, ATAAD survivors should undergo serial imaging for evaluation of the aortic valve, proximal and distal anastomoses, and the aortic segments beyond the distal anastomosis. The current narrative review aims to describe potential complications in the early and late phases after ATAAD surgery, with focus on their specific imaging findings.

Correlation between Cardiac MRI and Voltage Mapping in Evaluating Atrial Fibrosis: A Systematic Review.

Purpose: To provide an overview of existing literature on the association between late gadolinium enhancement (LGE) cardiac MRI and low voltage areas (LVA) obtained with electroanatomic mapping (EAM) or histopathology when assessing atrial fibrosis. Materials and Methods: A systematic literature search was conducted in the PubMed, Embase, and Cochrane Library databases to identify all studies published until June 7, 2022, comparing LGE cardiac MRI to LVA EAM and/or histopathology for evaluation of atrial fibrosis. The study protocol was registered at PROSPERO (registration no. CRD42022338243). Two reviewers independently evaluated the studies for inclusion. Risk of bias and applicability for each included study were assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) criteria. Data regarding demographics, electrophysiology, LGE cardiac MRI, and study outcomes were extracted. Results: The search yielded 1048 total results, of which 22 studies were included. Nineteen of the 22 included studies reported a significant correlation between high signal intensity at LGE cardiac MRI and LVA EAM or histopathology. However, there was great heterogeneity between included studies regarding study design, patient samples, cardiac MRI performance and postprocessing, and EAM performance. Conclusion: Current literature suggests a correlation between LGE cardiac MRI and LVA EAM or histopathology when evaluating atrial fibrosis but high heterogeneity between studies, demonstrating the need for uniform choices regarding cardiac MRI and EAM acquisition in future studies.Keywords: Cardiac, MR Imaging, Left Atrium Supplemental material is available for this article. © RSNA, 2022.

Precision Phenotyping of Dilated Cardiomyopathy Using Multidimensional Data.

BACKGROUND: Dilated cardiomyopathy (DCM) is a final common manifestation of heterogenous etiologies. Adverse outcomes highlight the need for disease stratification beyond ejection fraction. OBJECTIVES: The purpose of this study was to identify novel, reproducible subphenotypes of DCM using multiparametric data for improved patient stratification. METHODS: Longitudinal, observational UK-derivation (n = 426; median age 54 years; 67% men) and Dutch-validation (n = 239; median age 56 years; 64% men) cohorts of DCM patients (enrolled 2009-2016) with clinical, genetic, cardiovascular magnetic resonance, and proteomic assessments. Machine learning with profile regression identified novel disease subtypes. Penalized multinomial logistic regression was used for validation. Nested Cox models compared novel groupings to conventional risk measures. Primary composite outcome was cardiovascular death, heart failure, or arrhythmia events (median follow-up 4 years). RESULTS: In total, 3 novel DCM subtypes were identified: profibrotic metabolic, mild nonfibrotic, and biventricular impairment. Prognosis differed between subtypes in both the derivation (P < 0.0001) and validation cohorts. The novel profibrotic metabolic subtype had more diabetes, universal myocardial fibrosis, preserved right ventricular function, and elevated creatinine. For clinical application, 5 variables were sufficient for classification (left and right ventricular end-systolic volumes, left atrial volume, myocardial fibrosis, and creatinine). Adding the novel DCM subtype improved the C-statistic from 0.60 to 0.76. Interleukin-4 receptor-alpha was identified as a novel prognostic biomarker in derivation (HR: 3.6; 95% CI: 1.9-6.5; P = 0.00002) and validation cohorts (HR: 1.94; 95% CI: 1.3-2.8; P = 0.00005). CONCLUSIONS: Three reproducible, mechanistically distinct DCM subtypes were identified using widely available clinical and biological data, adding prognostic value to traditional risk models. They may improve patient selection for novel interventions, thereby enabling precision medicine.

Complementing sparse vascular imaging data by physiological adaptation rules.

Mathematical modeling of pressure and flow waveforms in blood vessels using pulse wave propagation (PWP) models has tremendous potential to support clinical decision making. For a personalized model outcome, measurements of all modeled vessel radii and wall thicknesses are required. In clinical practice, however, data sets are often incomplete. To overcome this problem, we hypothesized that the adaptive capacity of vessels in response to mechanical load could be utilized to fill in the gaps of incomplete patient-specific data sets. We implemented homeostatic feedback loops in a validated PWP model to allow adaptation of vessel geometry to maintain physiological values of wall stress and wall shear stress. To evaluate our approach, we gathered vascular MRI and ultrasound data sets of wall thicknesses and radii of central and arm arterial segments of 10 healthy subjects. Reference models (i.e., termed RefModel, n = 10) were simulated using complete data, whereas adapted models (AdaptModel, n = 10) used data of one carotid artery segment only, and the remaining geometries in this model were estimated using adaptation. We evaluated agreement between RefModel and AdaptModel geometries, as well as that between pressure and flow waveforms of both models. Limits of agreement (bias ± 2 SD of difference) between AdaptModel and RefModel radii and wall thicknesses were 0.2 ± 2.6 mm and -140 ± 557 µm, respectively. Pressure and flow waveform characteristics of the AdaptModel better resembled those of the RefModels as compared with the model in which the vessels were not adapted. Our adaptation-based PWP model enables personalization of vascular geometries even when not all required data are available.NEW & NOTEWORTHY To benefit personalized pulse wave propagation (PWP) modeling, we propose a novel method that, instead of relying on extensive data sets on vascular geometries, incorporates physiological adaptation rules. The developed vascular adaptation model adequately predicted arterial radius and wall thickness compared with ultrasound and MRI estimates, obtained in humans. Our approach could be used as a tool to facilitate personalized modeling, notably in case of missing data, as routinely found in clinical settings.

Characterization of Ascending Aortic Flow in Patients With Degenerative Aneurysms: A 4D Flow Magnetic Resonance Study.

OBJECTIVES: Degenerative thoracic aortic aneurysm (TAA) patients are known to be at risk of life-threatening acute aortic events. Guidelines recommend preemptive surgery at diameters of greater than 55 mm, although many patients with small aneurysms show only mild growth rates and more than half of complications occur in aneurysms below this threshold. Thus, assessment of hemodynamics using 4-dimensional flow magnetic resonance has been of interest to obtain more insights in aneurysm development. Nonetheless, the role of aberrant flow patterns in TAA patients is not yet fully understood. MATERIALS AND METHODS: A total of 25 TAA patients and 22 controls underwent time-resolved 3-dimensional phase contrast magnetic resonance imaging with 3-directional velocity encoding (ie, 4-dimensional flow magnetic resonance imaging). Hemodynamic parameters such as vorticity, helicity, and wall shear stress (WSS) were calculated from velocity data in 3 anatomical segments of the ascending aorta (root, proximal, and distal). Regional WSS distribution was assessed for the full cardiac cycle. RESULTS: Flow vorticity and helicity were significantly lower for TAA patients in all segments. The proximal ascending aorta showed a significant increase in peak WSS in the outer curvature in TAA patients, whereas WSS values at the inner curvature were significantly lower as compared with controls. Furthermore, positive WSS gradients from sinotubular junction to midascending aorta were most prominent in the outer curvature, whereas from midascending aorta to brachiocephalic trunk, the outer curvature showed negative WSS gradients in the TAA group. Controls solely showed a positive gradient at the inner curvature for both segments. CONCLUSIONS: Degenerative TAA patients show a decrease in flow vorticity and helicity, which is likely to cause perturbations in physiological flow patterns. The subsequent differing distribution of WSS might be a contributor to vessel wall remodeling and aneurysm formation.

The combination of carboxy-terminal propeptide of procollagen type I blood levels and late gadolinium enhancement at cardiac magnetic resonance provides additional prognostic information in idiopathic dilated cardiomyopathy - A multilevel assessment of myocardial fibrosis in dilated cardiomyopathy.

AIMS: To determine the prognostic value of multilevel assessment of fibrosis in dilated cardiomyopathy (DCM) patients. METHODS AND RESULTS: We quantified fibrosis in 209 DCM patients at three levels: (i) non-invasive late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR); (ii) blood biomarkers [amino-terminal propeptide of procollagen type III (PIIINP) and carboxy-terminal propeptide of procollagen type I (PICP)], (iii) invasive endomyocardial biopsy (EMB) (collagen volume fraction, CVF). Both LGE and elevated blood PICP levels, but neither PIIINP nor CVF predicted a worse outcome defined as death, heart transplantation, heart failure hospitalization, or life-threatening arrhythmias, after adjusting for known clinical predictors [adjusted hazard ratios: LGE 3.54, 95% confidence interval (CI) 1.90-6.60; P < 0.001 and PICP 1.02, 95% CI 1.01-1.03; P = 0.001]. The combination of LGE and PICP provided the highest prognostic benefit in prediction (likelihood ratio test P = 0.007) and reclassification (net reclassification index: 0.28, P = 0.02; and integrated discrimination improvement index: 0.139, P = 0.01) when added to the clinical prediction model. Moreover, patients with a combination of LGE and elevated PICP (LGE+/PICP+) had the worst prognosis (log-rank P < 0.001). RNA-sequencing and gene enrichment analysis of EMB showed an increased expression of pro-fibrotic and pro-inflammatory pathways in patients with high levels of fibrosis (LGE+/PICP+) compared to patients with low levels of fibrosis (LGE-/PICP-). This would suggest the validity of myocardial fibrosis detection by LGE and PICP, as the subsequent generated fibrotic risk profiles are associated with distinct cardiac transcriptomic profiles. CONCLUSION: The combination of myocardial fibrosis at CMR and circulating PICP levels provides additive prognostic value accompanied by a pro-fibrotic and pro-inflammatory transcriptomic profile in DCM patients with LGE and elevated PICP.

Evaluating the diagnostic accuracy of maximal aortic diameter, length and volume for prediction of aortic dissection.

OBJECTIVE: Management of thoracic aortic aneurysms (TAAs) comprises regular diameter follow-up until the indication criterion for prophylactic surgery is reached. However, this approach is unable to predict the majority of acute type A aortic dissections (ATAADs). The current study aims to evaluate the diagnostic accuracy of ascending aortic diameter, length and volume for occurrence of ATAAD. METHODS: This two-centre observational cohort study retrospectively screened 477 consecutive patients who presented with ATAAD between 2009 and 2018. Of those, 25 (5.2%) underwent CT angiography (CTA) within 2 years before dissection onset. Aortic diameter, length and volume of these patients ('pre-ATAAD') were compared with those of TAA controls (n=75). Receiver operating curve analysis was performed to evaluate the predictive accuracy of the three different measurements. RESULTS: 96% of patients with pre-ATAAD did not meet the surgical diameter threshold of 55 mm before dissection onset. Maximal aortic diameters (45 (40-49) mm vs 46 (44-49) mm, p=0.075) and volume (126 (95-157) cm3 vs 124 (102-136) cm3, p=0.909) were comparable between patients with pre-ATAAD and TAA controls. Conversely, ascending aortic length (84±9 mm vs 90±16 mm, p=0.031) was significantly larger in patients with pre-ATAAD. All three parameters had an area under the curve of >0.800. At the 55 mm cut-off point, the maximal diameter yielded a positive predictive value (PPV) of 20%. While maintaining same specificity levels, measurements of aortic volume and length showed superior diagnostic accuracy (PPV 55% and 70%, respectively). CONCLUSION: Measurements of aortic volume and length have superior diagnostic accuracy compared with the maximal diameter and could improve the timely identification of patients at risk for ATAAD.

Aortic elongation part I: the normal aortic ageing process.

OBJECTIVES: Differentiation between normal and abnormal features of vascular ageing is crucial, as the latter is associated with adverse outcomes. The normal aortic ageing process is accompanied by gradual luminal dilatation and reduction of vessel compliance. However, the influence of age on longitudinal aortic dimensions and geometry has not been well studied. This study aims to describe the normal evolution of aortic length and shape throughout life. METHODS: A total of 210 consecutive patients were prospectively enrolled in this cross-sectional single-centre study. All subjects underwent CT on a third-generation dual-source CT scanner. Morphometric measurements, including measurements of segmental length and tortuosity, were performed on three-dimensional models of the thoracic aorta. RESULTS: The length of the thoracic aorta was significantly related to age (r=0.54) and increased by 59 mm (males) or 66 mm (females) between the ages of 20 and 80 years. Elongation was most pronounced in the proximal descending aorta, which showed an almost 2.5-fold length increase during life. The lengthening of the thoracic aorta was accompanied by a marked change of its geometry: whereas the aortic apex was located between the branch vessels in younger patients, it shifted to a more distalward position in the elderly. CONCLUSIONS: The normal ageing process is accompanied by gradual aortic elongation and a notable change of aortic geometry. Part II of this two-part article investigates the hypothesis that excessive elongation could play a role in the occurrence of acute aortic dissection.

Aortic elongation part II: the risk of acute type A aortic dissection.

OBJECTIVES: Prophylactic surgery for prevention of acute type A aortic dissection (ATAAD) is reserved for patients with an ascending aortic aneurysm ≥55 mm. Identification of additional risk predictors is warranted since over 70% of patients presenting with ATAAD have a non-dilated aorta or an aneurysm that would not have met the diameter criterion for preventative surgery. Aim of the study was to evaluate ascending aortic elongation as a risk factor for ATAAD and to compare aortic lengths between ATAAD patients and healthy controls. METHODS: Aortic lengths and diameters of ATAAD patients were measured on three-dimensional modelled computed tomography and adjusted to predissection dimensions in this cross-sectional single-centre study. Logistic regression was used to evaluate the relation between ATAAD and aortic dimensions. Lengths of different aortic segments were compared with a healthy control group using propensity score matching. RESULTS: Two-hundred and fifty patients were included in the study (ATAAD, n=40; controls, n=210). Ascending aortic length and diameter proved to be independent predictors for ATAAD (OR=5.3, CI 2.5 to 11.4, p<0.001 and OR=8.6, CI 2.4 to 31.0, p=0.001). Eighty patients were matched based on propensity scores (ATAAD n=40, controls n=40). The ascending aorta was longer and more dilated in ATAAD patients compared with healthy controls (78.6±8.8 mm vs 68.9±7.2 mm, p<0.001, 34.4 mm ±3.2. vs 39.4 mm ±5.7, p<0.001, respectively). No differences were found in lengths of the aortic arch and descending aorta. CONCLUSIONS: Ascending aortic length could serve as an independent predictor for ATAAD. Future studies addressing indications for prophylactic surgery should also investigate aortic length.