Natural History of Functional Tricuspid Regurgitation Quantified by Cardiovascular Magnetic Resonance.

BACKGROUND: Quantitation of tricuspid regurgitant (TR) severity can be challenging with conventional echocardiographic imaging and may be better evaluated using cardiovascular magnetic resonance (CMR). OBJECTIVES: In patients with functional TR, this study sought to examine the relationship between TR volume (TRVol) and TR fraction (TRF) with all-cause mortality. METHODS: We examined 547 patients with functional TR using CMR to quantify TRVol and TRF. The primary outcome was all-cause mortality. Thresholds for mild, moderate, and severe TR were derived based on natural history outcome data. RESULTS: During a median follow-up of 2.6 years (interquartile range: 1.7 to 3.3 years), there were 93 deaths, with an estimated 5-year survival of 79% (95% confidence interval [CI]: 73% to 83%). After adjustment of clinical and imaging variables, including RV function, both TRF (adjusted hazard ratio [AHR] per 10% increment: 1.26; 95% CI: 1.10 to 1.45; p = 0.001) and TRVol (AHR per 10-ml increment: 1.15; 95% CI: 1.04 to 1.26; p = 0.004) were associated with mortality. Patients in the highest-risk strata of TRVol ≥45 ml or TRF ≥50% had the worst prognosis (AHR: 2.26; 95% CI: 1.36 to 3.76; p = 0.002 for TRVol and AHR: 2.60; 95% CI: 1.45 to 4.66; p = 0.001 for TRF). CONCLUSIONS: This is the first study to use CMR to assess independent prognostic implications of functional TR. Both TRF and TRVol were associated with increased mortality after adjustment for clinical and imaging covariates, including right ventricular ejection fraction. A TRVol of ≥45 ml or TRF of ≥50% identified patients in the highest-risk strata for mortality. These CMR thresholds should be used for patient selection in future trials to determine if tricuspid valve intervention improves outcomes in this high-risk group.

Long term cardiovascular magnetic resonance phenotyping of anthracycline cardiomyopathy.

BACKGROUND: Anthracycline cardiomyopathy contributes to the morbidity and mortality of cancer survivors but long-term data are lacking. This study sought to describe the phenotype of long-term anthracycline cardiomyopathy, the prevalence of myocardial fibrosis and its association with cardiac remodeling, systolic function and clinical outcomes. METHODS AND RESULTS: We undertook contrast-enhanced CMR in 81 cancer survivors at median 5 years after anthracycline (mean dose 279 SD 89 mg/m2). Participants were aged 55 SD 14 years; 68% were female. Mean LVEF was impaired (49 SD 12%), driven by a pathological increase in iLVESV (47 SD 23 ml/m2). 19% of participants exhibited LGE, which was associated with significant adverse left ventricular remodeling and reduced systolic function (iLVEDV: 102 SD 34 vs 83 SD 21 ml/m2, p = 0.03; iLVESV 61 SD 32 vs 43 SD 20 ml/m2, p = 0.03; LVEF: 43 SD 11 vs 50 SD 12%, p = 0.03). In subgroup analysis of 36 patients, 36% had elevated native T1 measurements, which was associated with significant adverse left ventricular remodeling (iLVEDV: 97 SD 22 vs 74 SD 19 ml/m2, p = 0.002; iLVESV: 56 SD 22 vs 35 SD 15 ml/m2, p = 0.005), reduced systolic function (LVEF 44 SD 13 vs 55 SD 9%, p = 0.01), and hospitalizations for heart failure (38% vs 9%, p = 0.03). Absolute native T1 measurements correlated significantly with iLVEDV (p ≤ 0.001, R2 0.33), iLVESV (p < 0.001, R2 0.36), LVEF (p < 0.001, R2 0.35), LAVi (p = 0.04, R2 0.12) and MAPSE (p = 0.02, R2 0.14). CONCLUSIONS: Long-term anthracycline cardiomyopathy is characterized by pathologically increased iLVESV. Both LGE and elevated native T1 measurements were associated with significant adverse cardiac remodeling and reduced systolic function, and the latter with heart failure hospitalizations.

Aortic angle is associated with neo-aortic root dilatation and regurgitation following arterial switch operation.

INTRODUCTION: Neo-aortic root dilatation and regurgitation are common progressive long-term complications of the arterial switch operation (ASO) for transposition of the great arteries (TGA) with increasing clinical burden. While several risk factors have been identified, most are constitutional. The acute aortic angle commonly seen after ASO might alter aortic dynamics and facilitate progression of the neo-aortic root dilatation and aortic regurgitation, but insufficient data is available. We intend to assess the effect of the aortic angle in the extent of neo-aortic root dilatation and presence of regurgitation. METHODS: Retrospective analysis of TGA patients undergoing CMR after ASO at a single tertiary centre from November 2010 to July 2017. RESULTS: 180 patients were analysed, 157 of which having adequate imaging of the aortic arch and root. Neo-aortic root Z score was normally distributed with 73% of patients having a Z score > 2. The aortic angle had a significant (p < 0,001) inverse relationship with the neo-aortic root Z score both in univariate and multivariate linear regression. Other significant associations were male gender and the concomitant presence of a VSD or a dysplastic neo-aortic valve. The presence of neo-aortic regurgitation was also inversely correlated with the aortic angle. The presence of a bicuspid neo-aortic valve was another significant association, further correlating with the more severe forms. CONCLUSIONS: Acute aortic angles associate more extensive neo-aortic root dilatation and higher incidence of regurgitation. We believe a surgical technique promoting less acute aortic angles has potential for ameliorating the long-term outcomes of TGA.

Echocardiographic Screening for Pulmonary Hypertension in Congenital Heart Disease: JACC Review Topic of the Week.

Echocardiography is the mainstay in screening for pulmonary hypertension (PH). International guidelines suggest echocardiographic parameters for suspecting PH, but these may not apply to many adults with congenital heart disease (ACHD). PH is relatively common in ACHD patients and can significantly affect their exercise capacity, quality of life, and prognosis. Identification of patients who have developed PH and who may benefit from further investigations (including cardiac catheterization) and treatment is thus extremely important. A systematic review and survey of experts from the United Kingdom and Ireland were performed to assess current knowledge and practice on echocardiographic screening for PH in ACHD. This paper presents the findings of the review and expert statements on the optimal approaches when using echocardiography to assess ACHD patients for PH, with particular focus on major subgroups: patients with right ventricular outflow tract obstruction, patients with systemic right ventricles, patients with unrepaired univentricular circulation, and patients with tetralogy of Fallot with pulmonary atresia.

Late characterisation of cardiac effects following anthracycline and trastuzumab treatment in breast cancer patients.

BACKGROUND: Anthracycline (A) and trastuzumab (T) chemotherapy have well-recognized cardiac toxicity, potentially leading to significant morbidity and mortality. Our previous work in 46 prospectively enrolled breast cancer patients showed early left ventricular (LV) and right ventricular (RV) function decline at 1 and 3 months, but only persistent RV dysfunction at 12 months which correlated with myocardial oedema observed early (1 and 3 months) after administration of chemotherapy regimes. METHOD: To investigate late cardiac effects, the same cohort were re-imaged with advanced Cardiovascular Magnetic Resonance (CMR) imaging including T1 mapping 5 ±â€¯1 year post chemotherapy. RESULTS: Twenty-six out of 46 (50%) patients underwent follow-up imaging. A statistical but non-clinically significant decrease was observed in LV ejection fraction (EF) from baseline to 5 years (72.2 ±â€¯6.6 to 65.4 ±â€¯9.3, p < 0.005). Subjects with initial drop of LVEF by >10% at 3 months (n = 5) or at 12 months (n = 3) did not demonstrate any difference in LV or RVEF at 5 years. No correlation was observed between myocardial oedema and LV or RVEF at 5 years. At 5 years, T1 values were within normal limits overall (935 ±â€¯48 ms). One patients had significantly elevated (>1000 ms) T1 values with no correlation to LV or RVEF. No subjects demonstrated replacement myocardial fibrosis at 5 years. CONCLUSION: Using advanced CMR, contemporary chemotherapy regimes demonstrate minimal long-term cardiac toxicity. There is minimal diffuse and no replacement fibrosis as demonstrated by LGE, following chemotherapy. This study suggests limiting serial imaging in these patients at 12 months post chemotherapy.

Churg-Strauss syndrome with cardiac involvement: case illustration and contribution of CMR in the diagnosis and clinical follow-up.

This report summarises three cases of Churg-Strauss syndrome (CSS) illustrating the diagnostic challenges associated with the cardiac manifestation of this disease. Here, we illustrate the role of cardiac magnetic resonance (CMR) for diagnosis and follow-up of CSS with a focus on new non-contrast T2-weighted imaging sequences for quantification of myocardial scar tissue and quantitative T2 mapping techniques, which allow the detection of myocardial edema.

Evaluation of gastrointestinal motility with MRI: Advances, challenges and opportunities.

Dynamic magnetic resonance imaging (MRI) of gastrointestinal motility has developed rapidly over the past few years. The non-invasive and non-ionizing character of MRI is an important advantage together with the fact that it is fast and can visualize the entire gastrointestinal tract. Advances in imaging and quantification techniques have facilitated assessment of gastric, small intestinal, and colonic motility in a clinical setting. Automated quantitative motility assessment using dynamic MRI meets the need for non-invasive techniques. Recently, studies have begun to examine this technique in patients, including those with IBD, pseudo-obstruction and functional bowel disorders. Remaining challenges for clinical implementation are processing the large amount of data, standardization and validation of the numerous MRI metrics and subsequently assessment of the potential role of dynamic MRI. This review examines the methods, advances, and remaining challenges of evaluation of gastrointestinal motility with MRI. It accompanies an article by Khalaf et al. in this journal that describes a new protocol for assessment of pan-intestinal motility in fasted and fed state in a single MRI session.

Multimodality Imaging for Interventional Cardiology.

BACKGROUND: In the last decades, interventional cardiology has received fast and wide implementation as an effective alternative treatment to surgery for several congenital and acquired diseases. In this scenario, imaging provides solutions for most clinical needs, from diagnosis to prognosis and risk stratification, as well as anatomical and functional assessment. METHODS: In this review article, we present recent innovations in medical imaging for structural heart disease and coronary artery disease, emphasizing the progress achieved in the field of multimodality imaging and the solutions proposed to some as-yet unresolved technical problems for safe and effective procedural performance. RESULTS: Intra-procedural guidance can be facilitated by established multimodality cardiac imaging such as transesophageal 2D and 3D echocardiography and by novel techniques as echo-fluoroscopy overlay and 3D modeling/printing. Computed tomography and magnetic resonance imaging are particularly helpful for preprocedural morphology assessment and device sizing. CONCLUSION: Successful planning, performance, and aftercare of interventions depend heavily on accurate imaging for both structural heart disease and coronary artery disease.

Systematic review: Impact of the new task force criteria in the diagnosis of arrhythmogenic right ventricular cardiomyopathy.

BACKGROUND: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited disorder of cardiac desmosomes associated with ventricular arrhythmias and sudden cardiac death. The clinical diagnosis is problematic and relies on a complex criteria composed of clinical and non-clinical parameters. In 2010, the original 1994 Task Force Criteria (TFC) was revised with particular attention given to the imaging parameters. METHODS: Five retrospective studies compared the diagnostic concordance between the 1994 and 2010 TFC. Three studies used cardiac magnetic resonance (CMR) and compared major and minor CMR criteria and three studies compared definite ARVC cases; one study assessed both. RESULTS: Three studies with 1435 patients compared the 1994 imaging and the 2010 CMR criteria. Using the 1994 criteria, 123 (8.6%) and 419 (29.2%) patients satisfied major and minor criteria compared to only 52 (3.6%) and 28 (1.9%) using the 2010 criteria; 57.7% and 94.3% reduction in major and minor criteria (p value, 0.0001 and 0.0001). Three studies with 611 patients assessed for definite ARVC. Using the 1994 and 2010 criteria, 207 (33.9%) and 243 (39.8%) patients satisfied the parameters respectively. This resulted in a statistically significant 17.4% (p value, 0.0379) increase in ARVC cases driven largely by two sub-groups. CONCLUSIONS: The 2010 revised TFC have resulted in a significant reduction in the number of patients that satisfy CMR criteria particularly those that satisfied minor imaging abnormalities using the 1994 criteria. In addition, in certain groups the revised criteria have significantly increased the number of patients diagnosed with definite ARVC.

Effect of Bone Marrow-Derived Mononuclear Cell Treatment, Early or Late After Acute Myocardial Infarction: Twelve Months CMR and Long-Term Clinical Results.

RATIONALE: Intracoronary delivery of autologous bone marrow-derived mononuclear cells (BM-MNC) may improve remodeling of the left ventricle (LV) after acute myocardial infarction (AMI). OBJECTIVE: To demonstrate long-term efficacy of BM-MNC treatment after AMI. METHODS AND RESULTS: In a multicenter study, we randomized 200 patients with large AMI in a 1:1:1 pattern into an open-labeled control and 2 BM-MNC treatment groups. In the BM-MNC groups, cells were either administered 5 to 7 days (early) or 3 to 4 weeks (late) after AMI. Cardiac magnetic resonance imaging was performed at baseline and after 12 months. The current analysis investigates the change from baseline to 12 months in global LV ejection fraction, LV volumes, scar size, and N-terminal pro-brain natriuretic peptide values comparing the 2 treatment groups with control in a linear regression model. Besides the complete case analysis, multiple imputation analysis was performed to address for missing data. Furthermore, the long-term clinical event rate was computed. The absolute change in LV ejection fraction from baseline to 12 months was -1.9±9.8% for control (mean±SD), -0.9±10.5% for the early treatment group, and -0.7±10.1% for the late treatment group. The difference between the groups was not significant, both for complete case analysis and multiple imputation analysis. A combined clinical end point occurred equally in all the groups. Overall, 1-year mortality was low (2.25%). CONCLUSIONS: Among patients with AMI and LV dysfunction, treatment with BM-MNC either 5 to 7 days or 3 to 4 weeks after AMI did not improve LV function at 12 months, compared with control. The results are limited by an important drop out rate. CLINICAL TRIAL REGISTRATION INFORMATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00355186.

The Role of Cardiovascular Magnetic Resonance in Cardiac Resynchronization Therapy.

Randomized, controlled trials have shown that cardiac resynchronization therapy (CRT) is beneficial in patients with heart failure, impaired left ventricular (LV) systolic function, and a wide QRS complex. Other studies have shown that targeting the LV pacing site can also improve patient outcomes. Cardiovascular magnetic resonance (CMR) is a radiation-free imaging modality that provides unparalleled spatial resolution. In addition, emerging data suggest that targeted LV lead deployment over viable myocardium improves the outcome of patients undergoing CRT. This review explores the role of CMR in the preoperative workup of patients undergoing CRT.

[Imaging for urinary incontinence]. / Bildgebung bei Harninkontinenz.

BACKGROUND: Ultrasonography and functional cine magnetic resonance imaging (MRI) are noninvasive and x-ray free tools, which are currently widely used in clinical diagnostics and scientific research of male and female urinary incontinence. The increasing use and improving techniques of modern imaging tools are closely linked to rapid development of minimally invasive surgery in patients with urinary incontinence and insights gained in continence mechanisms. METHODS: Whereas ultrasonography is a cost-efficient and readily available diagnostic tool for a routine use, the more expensive functional MRI, as a tool with more precise visualization of functional interactions and spatial representation of anatomical structures of the pelvic floor, is suitable for complex diagnostic purposes and scientific research. Both tools are already well established for evaluations of the female pelvic floor. For evaluation of the male pelvic floor, and in particular postprostatectomy incontinence, perineal ultrasonography and functional cine MRI are becoming increasingly evident. CONCLUSION: Further development of both imaging tools will contribute to new insights into the continence mechanism and improve the techniques of radical prostatectomy and minimally invasive surgery of male and female urinary incontinence in the future.

Osteoprotegerin in ST-elevation myocardial infarction: prognostic impact and association with markers of myocardial damage by magnetic resonance imaging.

BACKGROUND/OBJECTIVES: For osteoprotegerin (OPG), a cytokine of the tumor necrosis factor superfamily, the prognostic impact in stable coronary artery disease and acute coronary syndromes has been shown recently. In acute ST-elevation myocardial infarction (STEMI) data on the correlation to myocardial damage by cardiac magnetic resonance imaging (CMR) or clinical outcome are lacking. METHODS: We studied 221 consecutive patients with acute STEMI undergoing primary percutaneous coronary intervention (PCI) within 12h after symptom onset. Serum levels of OPG were determined from samples collected before PCI (OPG0), at 24 (OPG1) and 48 h (OPG2) after reperfusion. CMR studies for assessment of infarct size, reperfusion injury/microvascular obstruction and myocardial salvage were performed within one week after infarction. Long-term clinical follow-up for major adverse cardiovascular events (MACE), defined as death, myocardial infarction, or new onset of congestive heart failure, was performed 18.2 (interquartile range of 9.2-21.2) months after the index event. RESULTS: OPG levels ≥ 75th percentile were associated with significantly larger infarcts, lower myocardial salvage index and greater extent of microvascular obstruction in CMR as compared to OPG levels <75th percentile. The MACE rate for patients with OPG levels in the highest quartile was also significantly higher. In a multivariable model adjusted for known risk factors, OPG1 as a continuous variable was independently predictive for MACE. CONCLUSION: OPG serum levels collected 24h after infarction are independent predictors of MACE in acute STEMI patients. High OPG levels are associated with a greater extent of myocardial damage and lower myocardial salvage by CMR.

[Use of cardiac MRI in the field of electrophysiology. Present status and future aspects]. / Einsatz der kardialen MRT in der Elektrophysiologie. Aktueller Stand und Ausblicke in die Zukunft.

In recent years, ablation therapy has become the first-line treatment of modern electrophysiology in patients with cardiac arrhythmias. Today, cardiac magnetic resonance imaging (cMRI) is an important supportive imaging technique in the implementation of complex electrophysiological investigations and ablation therapy. In clinical routine, cMRI is used not only to generate accurate three-dimensional (3D) models of cavities of the heart but also for visualization of complex anatomical structures. The development of cMRI makes it possible to detect the underlying substrate of complex arrhythmias such as myocardial scar in patients with ventricular tachycardia or the structural remodeling of the left atrium in patients with atrial fibrillation. The opportunity of fusion of the different imaging modalities (e.g., fluoroscopy, cMRI) has become essential for the planning and the implementation of a safe ablation therapy. The possibility of direct visualization of induced lesions using cMRI after and in the long term after ablation can predict the success of therapy and detects potential complications. The continuous research in the field of cMRI and the development of MRI-compatible pacing and ablation catheters provided the basics for performing electrophysiological treatment in humans directly inside the MRI. The implementation of ablation using exact visualization of the anatomical substrate, precise catheter navigation and real-time visualization of lesions in cMRI promises to improve success rates and the safety of complex ablation treatment and may revolutionize electrophysiology in the future.

[Interventional electrophysiology in cardiac MRI : what is the current status?]. / Interventionelle Elektrophysiologie in der kardialen MRT : Wie ist der aktuelle Stand?

The ablation of simple and complex cardiac arrhythmias has become a first-line therapy in interventional cardiology and is mainly guided by conventional fluoroscopy. Cardiac magnetic resonance imaging (cMRI) allows exact three-dimensional (3D) visualization of complex anatomical structures and serves in the planning and implementation of ablation procedures. Post-procedural lesion visualization using cMRI can assess the success of ablation therapy and may distinguish potential complications. Performing ablation directly in the MRI scanner, with the option of anatomical substrate imagining, exact catheter navigation and real-time lesion visualization, holds the promise of improving success rates and safety in the interventional therapy of simple and complex arrhythmias.