MRI Assessment of Myocardial Deformation for Risk Stratification of Major Arrhythmic Events in Patients With Non-Ischemic Cardiomyopathy Eligible for Primary Prevention Implantable Cardioverter Defibrillators.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) intervention is an established prophylactic measure. Identifying high-benefit patients poses challenges. PURPOSE: To assess the prognostic value of cardiac magnetic resonance imaging (MRI) parameters including myocardial deformation for risk stratification of ICD intervention in non-ischemic cardiomyopathy (NICM) while accounting for competing mortality risk. STUDY TYPE: Retrospective and prospective. POPULATION: One hundred and fifty-nine NICM patients eligible for primary ICD (117 male, 54 ± 13 years) and 49 control subjects (38 male, 53 ± 5 years). FIELD STRENGTH/SEQUENCE: Balanced steady state free precession (bSSFP) and three-dimensional phase-sensitive inversion-recovery late gadolinium enhancement (LGE) sequences at 1.5 T or 3 T. ASSESSMENT: Patients underwent MRI before ICD implantation and were followed up. Functional parameters, left ventricular global radial, circumferential and longitudinal strain, right ventricular free wall longitudinal strain (RV FWLS) and left atrial strain were measured (Circle, cvi42). LGE presence was assessed visually. The primary endpoint was appropriate ICD intervention. Models were developed to determine outcome, with and without accounting for competing risk (non-sudden cardiac death), and compared to a baseline model including LGE and clinical features. STATISTICAL TESTS: Wilcoxon non-parametric test, Cox's proportional hazards regression, Fine-Gray competing risk model, and cumulative incidence functions. Harrell's c statistic was used for model selection. A P value <0.05 was considered statistically significant. RESULTS: Follow-up duration was 1176 ± 960 days (median: 896). Twenty-six patients (16%) met the primary endpoint. RV FWLS demonstrated a significant difference between patients with and without events (-12.5% ± 5 vs. -16.4% ± 5.5). Univariable analyses showed LGE and RV FWLS were significantly associated with outcome (LGE: hazard ratio [HR] = 3.69, 95% CI = 1.28-10.62; RV FWLS: HR = 2.04, 95% CI = 1.30-3.22). RV FWLS significantly improved the prognostic value of baseline model and remained significant in multivariable analysis, accounting for competing risk (HR = 1.73, 95% CI = 1.12-2.66). DATA CONCLUSIONS: In NICM, RV FWLS may provide additional predictive value for predicting appropriate ICD intervention. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY: Stage 5.

Mitral Regurgitation and Mortality Risk in Medicare Beneficiaries With Heart Failure and Preserved Ejection Fraction.

The association of mitral regurgitation (MR) severity and mortality in heart failure with preserved ejection fraction (HFpEF) is uncertain. We sought to evaluate the relation between MR severity on transthoracic echocardiography (TTE) and subsequent all-cause mortality in Medicare beneficiaries with HFpEF. We linked 57,608 patients referred for TTE at Beth Israel Deaconess Medical Center to Medicare inpatient claims from 2003 to 2017. In those with a history of HF and a physician-reported left ventricular ejection fraction ≥50%, we evaluated the relation of MR severity and time to the primary end point of all-cause mortality using Kaplan-Meier methods. A total of 7,778 individuals (14.5%) met inclusion criteria (mean age 75.5 years ± 11.9, 55.9% female). Over a median follow-up of 8.1 years, 2,016 (25.9%) died at a median (interquartile range) of 1.7 (0.3 to 4.1) years. At 1 year, 15.8% with 3 to 4+ MR had died versus 10.5% with 0 to 2+ MR (hazard ratio 1.54, 95% confidence interval 1.22 to 1.95, p <0.001). After multivariable adjustment, 3 to 4+ MR continued to be associated with increased all-cause mortality (hazard ratio 1.48, 95% confidence interval 1.14 to 1.94, p = 0.004) except in the subset with atrial fibrillation (interaction p = 0.03) or recent (<3 months) HF hospitalization (p = 0.54). In conclusion, in this large, single-institution retrospective study of Medicare beneficiaries with HFpEF who underwent TTE, moderate-to-severe and severe MR were significantly associated with an increased risk of all-cause mortality after multivariable adjustment, except in those with atrial fibrillation or recent HF. Prospective studies are needed to assess the role of MR reduction in mitigating this risk.

Race, sex and age disparities in echocardiography among Medicare beneficiaries in an integrated healthcare system.

OBJECTIVE: To identify potential race, sex and age disparities in performance of transthoracic echocardiography (TTE) over several decades. METHODS: TTE reports from five academic and community sites within a single integrated healthcare system were linked to 100% Medicare fee-for-service claims from 1 January 2005 to 31 December 2017. Multivariable Poisson regression was used to estimate adjusted rates of TTE utilisation after the index TTE according to baseline age, sex, race and comorbidities among individuals with ≥2 TTEs. Non-white race was defined as black, Asian, North American Native, Hispanic or other categories using Medicare-assigned race categories. RESULTS: A total of 15 870 individuals (50.1% female, mean 72.2±12.7 years) underwent a total of 63 535 TTEs (range 2-55/person) over a median (IQR) follow-up time of 4.9 (2.4-8.5) years. After the index TTE, the median TTE use was 0.72 TTEs/person/year (IQR 0.43-1.33; range 0.12-26.76). TTE use was lower in older individuals (relative risk (RR) for 10-year increase in age, 0.91, 95% CI 0.89 to 0.92, p<0.001), women (RR 0.97, 95% CI 0.95 to 0.99, p<0.001) and non-white individuals (RR 0.95, 95% CI 0.93 to 0.97, p<0.001). Black women in particular had the lowest relative use of TTE (RR 0.92, 95% CI 0.88 to 0.95, p<0.001). The only clinical conditions associated with increased TTE use after multivariable adjustment were heart failure (RR 1.04, 95% CI 1.00 to 1.08, p=0.04) and chronic obstructive pulmonary disease (RR 1.05, 95% CI 1.00 to 1.10, p=0.04). CONCLUSIONS: Among Medicare beneficiaries with multiple TTEs in a single large healthcare system, the median TTE use after the index TTE was 0.72 TTEs/person/year, although this varied widely. Adjusted for comorbidities, female sex, non-white race and advancing age were associated with decreased TTE utilisation.

Risk assessment of acute pulmonary embolism utilizing coronary artery calcifications in patients that have undergone CT pulmonary angiography and transthoracic echocardiography.

OBJECTIVE: To evaluate the relation of coronary artery calcifications (CAC) on non-ECG-gated CT pulmonary angiography (CTPA) with short-term mortality in patients with acute pulmonary embolism (PE). METHODS: We retrospectively included all in-patients between May 2007 and December 2014 with an ICD-9 code for acute PE and CTPA and transthoracic echocardiography available. CAC was qualitatively graded as absent, mild, moderate, or severe. Relations of CAC with overall and PE-related 30-day mortality were assessed using logistic regression analyses. The independence of those relations was assessed using a nested approach, first adjusting for age and gender, then for RV strain, peak troponin T, and cardiovascular risk factors for an overall model. RESULTS: Four hundred seventy-nine patients were included (63 ± 16 years, 52.8% women, 47.2% men). In total, 253 (52.8%) had CAC-mild: 143 (29.9%); moderate: 89 (18.6%); severe: 21 (4.4%). Overall mortality was 8.8% (n = 42) with higher mortality with any CAC (12.6% vs. 4.4% without; odds ratio [OR] 3.1 [95%CI 2.1-14.5]; p = 0.002). Mortality with severe (19.0%; OR 5.1 [95%CI 1.4-17.9]; p = 0.011), moderate (11.2%; OR 2.7 [95%CI 1.1-6.8]; p = 0.031), and mild CAC (12.6%; OR 3.1 [95%CI 1.4-6.9]; p = 0.006) was higher than without. OR adjusted for age and gender was 2.7 (95%CI 1.0-7.1; p = 0.050) and 2.6 (95%CI 0.9-7.1; p = 0.069) for the overall model. PE-related mortality was 4.0% (n = 19) with higher mortality with any CAC (5.9% vs. 1.8% without; OR 3.5 [95%CI 1.1-10.7]; p = 0.028). PE-related mortality with severe CAC was 9.5% (OR 5.8 [95%CI 1.0-34.0]; p = 0.049), with moderate CAC 6.7% (OR 4.0 [95%CI 1.1-14.6]; p = 0.033), and with mild 4.9% (OR 2.9 [95%CI 0.8-9.9]; p = 0.099). OR adjusted for age and gender was 4.2 (95%CI 0.9-20.7; p = 0.074) and 3.4 (95%CI 0.7-17.4; p = 0.141) for the overall model. Patients with sub-massive PE showed similar results. CONCLUSION: CAC is frequent in acute PE patients and associated with short-term mortality. Visual assessment of CAC may serve as an easy, readily available tool for early risk stratification in those patients. KEY POINTS: • Coronary artery calcification assessed on computed tomography pulmonary angiography is frequent in patients with acute pulmonary embolism. • Coronary artery calcification assessed on computed tomography pulmonary angiography is associated with 30-day overall and PE-related mortality in patients with acute pulmonary embolism. • Coronary artery calcification assessed on computed tomography pulmonary angiography may serve as an additional, easy readily available tool for early risk stratification in those patients.

Retrospective evaluation of echocardiographic variables for prediction of heart failure hospitalization in heart failure with preserved versus reduced ejection fraction: A single center experience.

BACKGROUND: Limited data exist on the differential ability of variables on transthoracic echocardiogram (TTE) to predict heart failure (HF) readmission across the spectrum of left ventricular (LV) systolic function. METHODS: We linked 15 years of TTE report data (1/6/2003-5/3/2018) at Beth Israel Deaconess Medical Center to complete Medicare claims. In those with recent HF, we evaluated the relationship between variables on baseline TTE and HF readmission, stratified by LVEF. RESULTS: After excluding TTEs with uninterpretable diastology, 5,900 individuals (mean age: 76.9 years; 49.1% female) were included, of which 2545 individuals (41.6%) were admitted for HF. Diastolic variables augmented prediction compared to demographics, comorbidities, and echocardiographic structural variables (p < 0.001), though discrimination was modest (c-statistic = 0.63). LV dimensions and eccentric hypertrophy predicted HF in HF with reduced (HFrEF) but not preserved (HFpEF) systolic function, whereas LV wall thickness, NT-proBNP, pulmonary vein D- and Ar-wave velocities, and atrial dimensions predicted HF in HFpEF but not HFrEF (all interaction p < 0.10). Prediction of HF readmission was not different in HFpEF and HFrEF (p = 0.93). CONCLUSIONS: In this single-center echocardiographic study linked to Medicare claims, left ventricular dimensions and eccentric hypertrophy predicted HF readmission in HFrEF but not HFpEF and left ventricular wall thickness predicted HF readmission in HFpEF but not HFrEF. Regardless of LVEF, diastolic variables augmented prediction of HF readmission compared to echocardiographic structural variables, demographics, and comorbidities alone. The additional role of medication adherence, readmission history, and functional status in differential prediction of HF readmission by LVEF category should be considered for future study.

How well do we represent ourselves: an analysis of cardiology fellowships website content.

Background: The Internet is the primary source of information for prospective cardiology fellowship aspirants. The objective of this study was to evaluate cardiology fellowship programs' online profile. Materials & methods: Two independent reviewers accessed 221 US based cardiology fellowship program websites obtained through Fellowship and Residency Electronic Interactive Database for pre-selected 20 criteria. The update status of websites was assessed using 6-point criteria. Results: Only 25 (11.3%) websites were fully up-to-date; 23 (10.4%) fulfilled 80% of the 20-point criteria and 85 (38.5%) program websites had fewer than 50% of the criteria listed. Conclusion: Most cardiology fellowship program websites lack crucial details. In this technology driven age, efforts should be made to ensure updated websites.

Aortic regurgitation assessment by cardiovascular magnetic resonance imaging and transthoracic echocardiography: intermodality disagreement impacting on prediction of post-surgical left ventricular remodeling.

Transthoracic echocardiography (TTE) is the primary clinical imaging modality for the assessment of patients with isolated aortic regurgitation (AR) in whom TTE's linear left ventricular (LV) dimension is used to assess disease severity to guide aortic valve replacement (AVR), yet TTE is relatively limited with regards to its integrated semi-quantitative/qualitative approach. We therefore compared TTE and cardiovascular magnetic resonance (CMR) assessment of isolated AR and investigated each modality's ability to predict LV remodeling after AVR. AR severity grading by CMR and TTE were compared in 101 consecutive patients referred for CMR assessment of chronic AR. LV end-diastolic diameter and end-systolic diameter measurements by both modalities were compared. Twenty-four patients subsequently had isolated AVR. The pre-AVR estimates of regurgitation severity by CMR and TTE were correlated with favorable post-AVR LV remodeling. AR severity grade agreement between CMR and TTE was moderate (ρ = 0.317, P = 0.001). TTE underestimated CMR LV end-diastolic and LV end-systolic diameter by 6.6 mm (P < 0.001, CI 5.8-7.7) and 5.9 mm (P < 0.001, CI 4.1-7.6), respectively. The correlation of post-AVR LV remodeling with CMR AR grade (ρ = 0.578, P = 0.004) and AR volumes (R = 0.664, P < 0.001) was stronger in comparison to TTE (ρ = 0.511, P = 0.011; R = 0.318, P = 0.2). In chronic AR, CMR provides more prognostic relevant information than TTE in assessing AR severity. CMR should be considered in the management of chronic AR patients being considered for AVR.

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons.

This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document1 addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities. Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines. A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario. The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.

Women in Leadership Positions in Academic Cardiology: A Study of Program Directors and Division Chiefs.

BACKGROUND: Gender difference in the workplace continues to be a subject of great discussion. Cross-sectional studies demonstrate that women are often underrepresented in key leadership roles. We sought to examine the proportion of women in cardiology leadership positions and to compare the findings with the differences prevalent in the overall cardiology faculty. Furthermore, we aspired to compare the proportion of women in leadership positions to the proportion in which they entered the cardiology field. METHODS: This is a cross-sectional online study of Cardiology fellowship programs identified by American Medical Association's Fellowship and Residency Electronic Interactive Database (AMA FREIDA), conducted from March to April 2017. Data of all (n = 512) cardiology fellowship program directors as well as 69% (n = 140) cardiology division chiefs were collected. RESULTS: A lower percentage of women held the role of division chief (5% vs. 95%) and program director (14% vs. 86%). However, when compared to the proportion of women in the 1992 fellowship cohort, women were significantly overrepresented in the role of program directors, with no significant difference in representation at the level of division chief. When compared to the overall cardiology faculty, program directors had significantly more publications and were more likely to have an academic rank of full professor (40% vs. 28%) or associate professor (37% vs. 23%). Male program directors had a significantly higher number of research publications, H-index, and academic rank than their female counterparts; however, such difference was not seen at the level of division chief. CONCLUSIONS: Gender difference is present in both program director and division chief roles. However, when compared to the historical cohort, significant overrepresentation of women was seen in the program director position, while proportionate representation was seen in the division chief role.

Effect of isolated left bundle-branch block on biventricular volumes and ejection fraction: a cardiovascular magnetic resonance assessment.

BACKGROUND: Left bundle branch block (LBBB) is associated with abnormal left ventricular (LV) contraction, and is frequently associated with co-morbid cardiovascular disease, but the effect of an isolated (i.e. in the absence of cardiovascular dissease) LBBB on biventricular volumes and ejection fraction (EF) is not well characterized. The objective of this study was to compare LV and right ventricular (RV) volumes and EF in adults with an isolated LBBB to matched healthy controls and to population-derived normative values, using cardiovascular magnetic resonance (CMR) imaging. METHODS: We reviewed our clinical echocardiography database and the Framingham Heart Study Offspring cohort CMR database to identify adults with an isolated LBBB. Age-, sex-, hypertension-status, and body-surface area (BSA)-matched controls were identified from the Offspring cohort. All study subjects were scanned using the same CMR hardware and imaging sequence. Isolated-LBBB cases were compared with matched controls using Wilcoxon paired signed-rank test, and to normative reference values via Z-score. RESULTS: Isolated-LBBB subjects (n = 18, 10F) ranged in age from 37 to 82 years. An isolated LBBB was associated with larger LV end-diastolic and end-systolic volumes (both p < 0.01) and lower LVEF (56+/- 7% vs. 68+/- 6%; p <0.001) with similar myocardial contraction fraction. LVEF in isolated LBBB was nearly two standard deviations (Z = - 1.95) below mean sex and age-matched group values. LV stroke volume, cardiac output, and mass, and all RV parameters were similar (p = NS) between the groups. CONCLUSIONS: Adults with an isolated LBBB have greater LV volumes and markedly reduced LVEF, despite the absence of overt cardiovascular disease. These data may be useful toward the clinical interpretation of imaging studies performed on patients with an isolated LBBB.

Multimodality Assessment of Right Ventricular Strain in Patients With Acute Pulmonary Embolism.

Optimal risk stratification is essential in managing patients with an acute pulmonary embolism (PE). There are limited data evaluating the potential additive value of various methods of evaluation of right ventricular (RV) strain in PE. We retrospectively evaluated RV strain by computed tomography (CT), transthoracic echocardiography (TTE), electrocardiography (ECG), and troponin levels in consecutive hospitalized patients with acute PE (May 2007 to December 2014). Four-hundred and seventy-seven patients met inclusion criteria. RV strain on ECG (odds ratio [OR] 1.9, confidence interval [CI] 1.1 to 3.3; p = 0.03), CT (OR 2.7, CI 1.5 to 4.8, p <0.001), TTE (OR 2.8, CI 1.5 to 5.4, p <0.001), or a positive troponin (OR 2.7, CI 2.0 to 6.9, p <0.001) were associated with adverse events. In patients with ECG, CT, and TTE data, increased risk was only elevated with RV strain on all 3 parameters (OR 4.6, CI 1.8 to 11.3, p <0.001). In all patients with troponin measurements, risk was only elevated with RV strain on all 3 parameters plus a positive troponin (OR 8.8, CI 2.8 to 28.1, p <0.001) and was similar in intermediate-risk PE (OR 11.1, CI 1.2 to 103.8, p = 0.04). In conclusion, in patients with an acute PE and evaluation of RV strain by ECG, CT, and TTE, risk of adverse events is only elevated when RV strain is present on all 3 modalities. Troponin further aids in discriminating high-risk patients. Multimodality assessment of RV strain is identified as a superior approach to risk assessment.

Evaluation of Industrial Compensation to Cardiologists in 2015.

The categorization and characterization of pharmaceutical and device manufacturers or group purchasing organization payments to clinicians is an important step toward assessing conflicts of interest and the potential impact of these payments on practice patterns. Payments have not previously been compared among the subspecialties of cardiology. This is a retrospective analysis of the Open Payments database, including all installments and payments made to doctors in the calendar year 2015 by pharmaceutical and device manufacturers or group purchasing organization. Total payments to individual physicians were then aggregated based on specialty, geographic region, and payment type. The Gini Index was further employed to calculate within each specialty to measure income disparity. In 2015, a total of $166,089,335 was paid in 943,744 payments (average $175.00 per payment) to cardiologists, including 23,372 general cardiologists, 7,530 interventional cardiologists, and 2,293 cardiac electro-physiologists. Payments were mal-distributed across the 3 subspecialties of cardiology (p <0.01), with general cardiology receiving the largest number (73.5%) and total payments (62.6%) and cardiac electrophysiologists receiving significantly higher median payments ($1,662 vs $361 for all cardiologists; p <0.01). The Medtronic Company was the largest single payer for all 3 subspecialties. In conclusion, pharmaceutical and device manufacturers or group purchasing organizations continue to make substantial payments to cardiac practitioners with a significant variation in payments made to different cardiology subspecialists. The largest number and total payments are to general cardiologists, whereas the highest median payments are made to cardiac electrophysiologists. The impact of these payments on practice patterns remains to be examined.

Derivation and Validation of Prognosis-Based Age Cutoffs to Define Elderly in Cardiac Surgery.

BACKGROUND: The age cutoff to define elderly is controversial in cardiac surgery, empirically ranging from ≥65 to ≥80 years. Beyond semantics, this has important implications as a starting point for clinical care pathways and inclusion in trials. We sought to characterize the relationship between age and adverse outcomes in patients undergoing cardiac surgery and to derive and validate prognosis-based age cutoffs. METHODS AND RESULTS: Six thousand five hundred seventy one consecutive adult patients undergoing cardiac surgery at 3 hospitals in the United States and Canada were included in the cohort. Logistic regression models and generalized additive models with thin-plate splines were fit to the data. The age distribution was 50 to 59 years in 1244 (18.9%), 60 to 69 years in 2144 (32.6%), 70 to 79 years in 2000 (30.4%), ≥80 years in 1183 (18.0%) patients. After controlling for sex and type of operation, the relationship between age and 30-day operative mortality was found to be nonlinear. Receiver operating characteristic analysis showed that the optimal cutoffs to identify older patients at higher risk of operative mortality were greater than 74, 78, and 75 years for isolated coronary bypass, isolated valve surgery, and coronary bypass plus valve surgery, respectively. These age cutoffs were validated in an independent cohort. CONCLUSIONS: The relationship between age and operative mortality is not linear, manifesting a steeper rise after age 75 for coronary bypass and approaching octogenarian age for isolated valve surgery. Rather than using arbitrary age cutoffs to define elderly, the outcomes-based cutoff of ≥75 years should be used to identify the population of older adults that has higher risk and may benefit from preoperative geriatric evaluation and optimization.

Facility perception of nuclear cardiology accreditation: Results of an Intersocietal Accreditation Commission (IAC) survey.

BACKGROUND: The Medicare Improvements for Patients and Providers Act requires accreditation for all non-hospital suppliers of nuclear cardiology, nuclear medicine, and positron emission tomography (PET) studies as a condition of reimbursement. The perceptions of these facilities regarding the value and impact of the accreditation process are unknown. We conducted an electronic survey to assess the value of nuclear cardiology accreditation. METHODS: A request to participate in an electronic survey was sent to the medical and technical directors (n = 5,721) of all facilities who had received Intersocietal Accreditation Commission (IAC) Nuclear/PET accreditation. Demographic information, as well as, opinions on the value of accreditation as it relates to 16 quality metrics was obtained. RESULTS: There were 664 (11.6%) respondents familiar with the accreditation process of which 26% were hospital-based and 74% were nonhospital-based. Of the quality metrics examined, the process was perceived as leading to improvements by a majority of all respondents for 10 (59%) metrics including report standardization, report completeness, guideline adherence, deficiency identification, report timeliness, staff knowledge, facility distinction, deficiency correction, acquisition standardization, and image quality. Overall, the global perceived improvement was greater for hospital-based facilities (63% vs 57%; P < .001). Ninety-five percent of respondents felt that accreditation was important. Hospital-based facilities were more likely to feel that accreditation demonstrates a commitment to quality (43% vs 33%, P = .029), while nonhospital-based facilities were more likely to feel accreditation is important for reimbursement (50% vs 29%, P≤ .001). CONCLUSION: Although the accreditation process is demanding, the results of the IAC survey indicate that the accreditation process has a positive perceived impact for the majority of examined quality metrics, suggesting the facilities find the process to be valuable.

Free-breathing post-contrast three-dimensional T1 mapping: Volumetric assessment of myocardial T1 values.

PURPOSE: To develop a three-dimensional (3D) free-breathing myocardial T1 mapping sequence for assessment of left ventricle diffuse fibrosis after contrast administration. METHODS: In the proposed sequence, multiple 3D inversion recovery images are acquired in an interleaved manner. A mixed prospective/retrospective navigator scheme is used to obtain the 3D Cartesian k-space data with fully sampled center and randomly undersampled outer k-space. The resulting undersampled 3D k-space data are then reconstructed using compressed sensing. Subsequently, T1 maps are generated by voxel-wise curve fitting of the individual interleaved images. In a phantom study, the accuracy of the 3D sequence was evaluated against two-dimensional (2D) modified Look-Locker inversion recovery (MOLLI) and spin-echo sequences. In vivo T1 times of the proposed method were compared with 2D multislice MOLLI T1 mapping. Subsequently, the feasibility of high-resolution 3D T1 mapping with spatial resolution of 1.7 × 1.7 × 4 mm(3) was demonstrated. RESULTS: The proposed method shows good agreement with 2D MOLLI and the spin-echo reference in phantom. No significant difference was found in the in vivo T1 times estimated using the proposed sequence and the 2D MOLLI technique (myocardium, 330 ± 66 ms versus 319 ± 93 ms; blood pools, 211 ± 68 ms versus 210 ± 98 ms). However, improved homogeneity, as measured using standard deviation of the T1 signal, was observed in the 3D T1 maps. CONCLUSION: The proposed sequence enables high-resolution 3D T1 mapping after contrast injection during free-breathing with volumetric left ventricle coverage.

Accelerated aortic flow assessment with compressed sensing with and without use of the sparsity of the complex difference image.

Phase contrast (PC) cardiac MR is widely used for the clinical assessment of blood flow in cardiovascular disease. One of the challenges of PC cardiac MR is the long scan time which limits both spatial and temporal resolution. Compressed sensing reconstruction with accelerated PC acquisitions is a promising technique to increase the scan efficiency. In this study, we sought to use the sparsity of the complex difference of the two flow-encoded images as an additional constraint term to improve the compressed sensing reconstruction of the corresponding accelerated PC data acquisition. Using retrospectively under-sampled data, the proposed reconstruction technique was optimized and validated in vivo on 15 healthy subjects. Then, prospectively under-sampled data was acquired on 11 healthy subjects and reconstructed with the proposed technique. The results show that there is good agreement between the cardiac output measurements from the fully sampled data and the proposed compressed sensing reconstruction method using complex difference sparsity up to acceleration rate 5. In conclusion, we have developed and evaluated an improved reconstruction technique for accelerated PC cardiac MR that uses the sparsity of the complex difference of the two flow-encoded images.

Pulmonary hypertension and long-term mortality in aortic and mitral regurgitation.

BACKGROUND: Outcomes data in patients with aortic regurgitation or mitral regurgitation have been limited to small series with generally <10 years of follow-up. The quantitative impact of pulmonary artery hypertension has not been well described. The purpose of this study was to describe the 15-year mortality of aortic regurgitation and mitral regurgitation. METHODS: Our institution's electronic echocardiography database was queried to identify those patients examined in 1992 and reported to have at least mild aortic regurgitation or mitral regurgitation. Patients were classified by semi-quantitative degree of regurgitation. Pulmonary artery systolic pressure was categorized as normal, borderline, mild, or moderate or greater hypertension (pulmonary artery systolic pressure >40 mm Hg). Age-stratified Cox proportional hazards models compared survival among groups and adjusted for sex, depressed left ventricular ejection fraction, and pulmonary artery systolic pressure. Mortality data were obtained from the 2008 Social Security Death Index. RESULTS: Of 4984 echocardiograms performed in 4050 patients, 1156 patients (28%; aged 72±14 years) had at least mild aortic regurgitation and 1971 patients (49%; aged 69±16 years) had at least mild mitral regurgitation. Overall 15-year mortality in patients with aortic regurgitation was 74% and similar for all grades of aortic regurgitation. Overall 15-year mortality in patients with mitral regurgitation was 71% and got progressively worse with increasing severity grade of mitral regurgitation (63% for mild to 81% for at least moderate-to-severe). For both aortic and mitral regurgitation, moderate or greater pulmonary artery systolic hypertension was associated with increased mortality (in patients with aortic regurgitation, hazard ratio [HR], 1.94; 95% confidence interval [CI], 1.58-2.41, and in mitral regurgitation patients, HR, 1.48; 95% CI, 1.26-1.75). CONCLUSION: Long-term (15-year) survival of patients with aortic regurgitation is poor and is independent of regurgitation severity. In contrast, long-term survival of patients with mitral regurgitation correlates with regurgitation severity. For both groups, moderate or greater pulmonary artery systolic hypertension identified those at highest risk.