Cardiovascular Magnetic Resonance of Myocardial Fibrosis, Edema, and Infiltrates in Heart Failure.

Cardiac magnetic resonance (CMR) imaging is a unique imaging modality, which provides accurate noninvasive tissue characterization. Various CMR sequences can be utilized to identify and quantify patterns of myocardial edema, fibrosis, and infiltrates, which are important determinants for diagnosis and prognostication of heart failure. This article describes available methods of tissue characterization imaging applied in CMR. The presence and patterns of abnormal tissue characterization are related to common etiologies of heart failure and the techniques employed to demonstrate this. CMR provides the opportunity to identify the etiology of heart failure based on the recognition of different patterns of myocardial abnormalities.

Hypertensive heart disease versus hypertrophic cardiomyopathy: multi-parametric cardiovascular magnetic resonance discriminators when end-diastolic wall thickness ≥ 15 mm.

OBJECTIVES: European guidelines state left ventricular (LV) end-diastolic wall thickness (EDWT) ≥15mm suggests hypertrophic cardiomyopathy (HCM), but distinguishing from hypertensive heart disease (HHD) is challenging. We identify cardiovascular magnetic resonance (CMR) predictors of HHD over HCM when EDWT ≥15mm. METHODS: 2481 consecutive clinical CMRs between 2014 and 2015 were reviewed. 464 segments from 29 HCM subjects with EDWT ≥15mm but without other cardiac abnormality, hypertension or renal impairment were analyzed. 432 segments from 27 HHD subjects with EDWT ≥15mm but without concomitant cardiac pathology were analyzed. Magnitude and location of maximal EDWT, presence of late gadolinium enhancement (LGE), LV asymmetry (>1.5-fold opposing segment) and systolic anterior motion of the mitral valve (SAM) were measured. Multivariate logistic regression was performed. Significance was defined as p<0.05. RESULTS: HHD and HCM cohorts were age-/gender-matched. HHD had significantly increased indexed LV mass (110±27g/m2 vs. 91±31g/m2, p=0.016) but no difference in site or magnitude of maximal EDWT. Mid-wall LGE was significantly more prevalent in HCM. Elevated indexed LVM, mid-wall LGE and absence of SAM were significant multivariate predictors of HHD, but LV asymmetry was not. CONCLUSIONS: Increased indexed LV mass, absence of mid-wall LGE and absence of SAM are better CMR discriminators of HHD from HCM than EDWT ≥15mm. KEY POINTS: • Hypertrophic cardiomyopathy (HCM) is often diagnosed with end-diastolic wall thickness ≥15mm. • Hypertensive heart disease (HHD) can be difficult to distinguish from HCM. • Retrospective case-control study showed that location and magnitude of EDWT are poor discriminators. • Increased left ventricular mass and midwall fibrosis are independent predictors of HHD. • Cardiovascular magnetic resonance parameters facilitate a better discrimination between HHD and HCM.

Implementation of NICE clinical guideline 95 on chest pain of recent onset: experience in a district general hospital.

The National Institute for Health and Care Excellence (NICE) CG95 clinical guideline on chest pain of recent onset was published in 2010. There is debate over whether the proposed strategy improves patient care and its implications on service costs. Following a six-month pilot, 472 consecutive patient records were audited for pre-test probability of significant coronary artery disease, investigations performed and outcomes. Low- and moderate-risk patients had an unexpectedly low rate of coronary disease and revascularisation. Computerised tomography coronary angiography (CTCA) and stress echocardiography performed similarly, though the latter was more resource intensive. High-/very high-risk patients frequently required revascularisation and greater than 10% of each group had prognostically significant disease, going against the recommendation that very high risk patients do not undergo angiography. There were frequent protocol deviations and training clinic staff in the new approach was challenging. In conclusion, implementing NICE CG95 is feasible but presents challenges. Staff require training to follow the protocol consistently. Functional testing had no benefits over anatomical testing with CTCA, which may allow cost savings in some departments.

Metastatic Renal Cell Carcinoma Presenting as an Intracardiac Tumour Without Involving the Inferior Vena Cava.

Renal cell carcinoma (RCC) is an aggressive tumour, with 25% of the cases presenting with distant metastases at the time of diagnosis. Approximately 33% of the patients with RCC eventually develop metastatic spread. RCC can metastasize to various sites including the lung, liver, bone, brain, adrenal gland, and more. Cardiac metastasis is rare in RCC, but even rarer in the absence of inferior vena cava (IVC) involvement. This case report presents a 60-year-old male patient who was referred by his general practitioner due to breathing difficulties. An initial echocardiogram revealed a right ventricular outflow tract obstruction caused by a mass. A subsequent cardiac MRI showed a right ventricular mass with features suggestive of a metastatic spread. A CT scan of the thorax, abdomen and pelvis was done to ascertain the primary tumour which revealed RCC, without involving the IVC. Due to the presence of metastases, advanced disease, and heavy tumour burden, the multidisciplinary team concluded that there were almost negligible treatment options available at that stage and recommended the best supportive care and community hospice support. The patient was discharged once his symptoms improved, as per his request, and he passed away peacefully at home within a month. This case highlights the very rare occurrence of cardiac metastasis of RCC without IVC involvement. It also illustrates the approach and investigations involved in the evaluation of complex cardiac masses.

Prospective multiparametric CMR characterization and MicroRNA profiling of anthracycline cardiotoxicity: A pilot translational study.

Background: Anthracycline cardiotoxicity is a significant clinical challenge. Biomarkers to improve risk stratification and identify early cardiac injury are required. Objectives: The purpose of this pilot study was to prospectively characterize anthracycline cardiotoxicity using cardiovascular magnetic resonance (CMR), echocardiography and MicroRNAs (MiRNAs), and identify baseline predictors of LVEF recovery. Methods: Twenty-four patients (age 56 range 18-75 years; 42 % female) with haematological malignancy scheduled to receive anthracycline chemotherapy (median dose 272 mg/m2 doxorubicin equivalent) were recruited and evaluated at three timepoints (baseline, completion of chemotherapy, and 6 months after completion of chemotherapy) with multiparametric 1.5 T CMR, echocardiography and circulating miRNAs sequencing. Results: Seventeen complete datasets were obtained. CMR left ventricular ejection fraction (LVEF) fell significantly between baseline and completion of chemotherapy (61 ± 3 vs 53 ± 3 %, p < 0.001), before recovering significantly at 6-month follow-up (55 ± 3 %, p = 0.018). Similar results were observed for 3D echocardiography-derived LVEF and CMR-derived longitudinal, circumferential and radial feature-tracking strain. Patients were divided into tertiles according to LVEF recovery (poor recovery, partial recovery, good recovery). CMR-derived mitral annular plane systolic excursion (MAPSE) was significantly different at baseline in patients exhibiting poor LVEF recovery (11.7 ± 1.5 mm) in comparison to partial recovery (13.7 ± 2.7 mm), and good recovery (15.7 ± 3.1 mm; p = 0.028). Furthermore, baseline miRNA-181-5p and miRNA-221-3p expression were significantly higher in this group. T2 mapping increased significantly on completion of chemotherapy compared to baseline (54.0 ± 4.6 to 57.8 ± 4.9 ms, p = 0.001), but was not predictive of LVEF recovery. No changes to LV mass, extracellular volume fraction, T1 mapping or late gadolinium enhancement were observed. Conclusions: Baseline CMR-derived MAPSE, circulating miRNA-181-5p, and miRNA-221-3p were associated with poor recovery of LVEF 6 months after completion of anthracycline chemotherapy, suggesting their potential predictive role in this context. T2 mapping increased significantly on completion of chemotherapy but was not predictive of LVEF recovery.

Cardiovascular magnetic resonance characterisation of anthracycline cardiotoxicity in adults with normal left ventricular ejection fraction.

BACKGROUND: Anthracycline therapy may lead to changes in cardiac structure and function not detectable by solely evaluating left ventricular ejection fraction (LVEF). OBJECTIVES: We hypothesized that cardiovascular magnetic resonance (CMR) would identify structural and functional myocardial abnormalities in anthracycline-treated cancer survivors with normal LVEF, compared to a matched control population. METHODS: Forty-five cancer survivors (56 ± 16 yrs., 60% female) with normal LVEF (59.5 ± 4.1%) were studied a median of 11 months (range 3-36) following administration of 237 ± 83 mg/m2 anthracycline, and compared with forty-five healthy control subjects of similar age and sex (53 ± 16 yrs., 60% female) with normal LVEF (60.8 ± 2.4%) using 1.5 T CMR. RESULTS: Significantly smaller indexed left ventricular mass (45.6 ± 8.7 vs 50.3 ± 10.1 g/m2, p = 0.02) and indexed myocardial cell volume (30.5 ± 5.7 vs 34.8 ± 7.2 ml/m2, p = 0.002) were evident in cancer survivors and the latter was inversely associated with cumulative anthracycline dose (r = -0.31, p = 0.02). Surrogate CMR markers of myocardial fibrosis were significantly increased in cancer survivors (native myocardial T1: 1021 ± 40 vs 996 ± 35 ms, p = 0.002; extracellular volume: 29.5 ± 4.5 vs 27.4 ± 2.3%, p = 0.006). CMR-derived feature-tracking global longitudinal strain (GLS) was significantly impaired in cancer survivors (2D GLS -18.3 ± 2.6 vs -20.0 ± 2.0%, p < 0.001; 3D GLS -14.5 ± 2.3 vs -16.4 ± 2.6%, p < 0.001). Parameters exhibited good to excellent (ICC = 0.86-0.98) inter- and intra-observer reproducibility. CONCLUSIONS: Anthracycline-treated cancer survivors with normal LVEF have significant perturbations of LV mass, myocardial cell volume, native myocardial T1, ECV, CMR-derived 2D and 3D GLS, compared to controls, with good to excellent levels of inter- and intra-observer reproducibility.

Long-term outcome of myocardial scarring and deformation with cardiovascular magnetic resonance in out of hospital cardiac arrest survivors.

AIMS: Cardiovascular magnetic resonance (CMR) is increasingly recognized as a diagnostic and prognostic tool in out of hospital cardiac arrest (OHCA) survivors. After assessing CMR findings early after ventricular fibrillation (VF) OHCA, we sought to explore the long-term outcome of myocardial scarring and deformation. METHODS AND RESULTS: We included 121 consecutive VF OHCA survivors (82% male, median 62 years) undergoing CMR within 2 weeks from cardiac arrest. Late gadolinium-enhancement (LGE) was quantified using the full width at half maximum method and tissue tracking analysis software was used to assess myocardial deformation. LGE was found in 71% of patients (median LGE mass 6.2% of the left ventricle, LV), mainly with an ischaemic pattern. Myocardial deformation was overall impaired and showed a significant correlation with LGE presence and extent (P < 0.001). A composite end-point of all-cause mortality and appropriate ICD discharge/anti-tachycardia pacing was met in 24% of patients. Patients meeting the end-point had significantly greater LGE extent (8.6% of LV myocardium vs. 4.1%, P = 0.02), while there was no difference with regards to myocardial deformation. Survival rate was significantly lower in patients with LGE (P = 0.05) and LGE mass >4.4% of the LV identified a group of patients at higher risk of adverse events (P = 0.005). CONCLUSIONS: We found a high prevalence of LGE, early after OHCA, and an overall impaired myocardial deformation. On long-term follow-up both LGE presence and extent showed a significant association with recurrent adverse events, while LV ejection fraction and myocardial deformation did not identify patients with an unfavourable outcome.

Aberrant branches of the radial digital nerve in the index and middle finger: two case-reports.

This report describes two incidental findings of aberrant branches of the radial digital nerves in the middle finger of a 52-year-old man who cut himself with a grinding machine, and in the index finger of a 45-year-old female who sustained a flexor sheath infection following a dog bite. In both patients, two equally sized radial digital nerves were found and both nerves originated from one common digital nerve.

Magnetic Resonance Imaging to Detect Cardiovascular Effects of Cancer Therapy: JACC CardioOncology State-of-the-Art Review.

This paper aims to empower and inform cardio-oncologists by providing a practical guide to the clinical application of cardiac magnetic resonance (CMR) in the rapidly evolving field of cardio-oncology. Specifically, we describe how CMR can be used to assess the cardiovascular effects of cancer therapy. The CMR literature, relevant societal guidelines, indication-specific imaging protocols, and methods to overcome some of the challenges encountered in performing and accessing CMR are reviewed.

CT imaging prior to transcatheter aortic valve implantation in the UK.

Objective: This cross-sectional observational study sought to describe variations in CT in the context of transcatheter aortic valve implantation (CT-TAVI) as currently performed in the UK. Methods: 408 members of the British Society of Cardiovascular Imaging were invited to complete a 27-item online CT-TAVI survey. Results: 47 responses (12% response rate) were received from 40 cardiac centres, 23 (58%) of which performed TAVI on-site (TAVI centres). Only six respondents (13%) performed high-volume activity (>200 scans per year) compared with 13 (28%) performing moderate (100-200 scans per year) and 27 (59%) performing low (0-99 scans per year) volume activity. Acquisition protocols varied (41% retrospective, 12% prospective with wide padding, 47% prospective with narrow padding), as did the phase of reporting (45% systolic, 37% diastolic, 11% both, 6% unreported). Median dose length product was 675 mGy.cm (IQR 477-954 mGy.cm). Compared with non-TAVI centres, TAVI centres were more likely to report minimum iliofemoral luminal diameter (n=25, 96% vs n=7, 58%, p=0.003) and optimal tube angulation for intervention (n=12, 46% vs n=1, 8%, p=0.02). Conclusions: This national survey formally describes current CT-TAVI practice in the UK. High-volume activity was only present at one in seven cardiac CT centres. There is wide variation in scan acquisition, scan reporting and radiation dose exposure in cardiac CT centres.

Connection between the heart and the gut.

CLINICAL INTRODUCTION: A 45-year-old man with ulcerative colitis was admitted with bloody diarrhoea and chest pain. Inflammatory markers and high-sensitivity troponin were elevated (C reactive protein 57 mg/L, white cell count 10.65×109/L, neutrophil 6.6×109/L, Troponin-I 663 mmol/L). The ECG showed inferior ST-elevation. Urgent coronary angiography revealed unobstructed coronary arteries. Inpatient cardiovascular magnetic resonance (CMR) was arranged to determine the aetiology of the myocardial infarction with non-obstructive coronary arteries. The imaging protocol at 1.5 T included balanced steady-state free precession cine images, T2-weighted oedema sequences, and early and late gadolinium enhancement (LGE). Native T1 and T2 mapping images provided advanced tissue characterisation (figure 1). QUESTION: What is the most likely diagnosis based on the MRI findings? Multiple embolic myocardial infarctions in the right coronary artery territory.Acute autoimmune myocarditis.Cardiac sarcoidosis.Stress (Takotsubo) cardiomyopathy.Multiple embolic myocardial infarctions in the left circumflex coronary artery territory. heartjnl;105/15/1148/F1F1F1Figure 1(A) Balanced steady-state free precession (bSSFP) left ventricular long-axis, three-chamber view. (B) T2 short-tau inversion recovery. (C) Early gadolinium enhancement demonstrating high signal intensity indicative of hyperaemia with capillary leakage (arrowed). (D) Late gadolinium enhancement with high signal intensity indicative of increased extracellular space (arrowed). (E) bSSFP left ventricular short-axis view. (F) Native myocardial T1 mapping with elevated native T1 mapping values in the inferior wall (arrowed). (G) Native myocardial T2 mapping with elevated native T2 values in the inferior wall, indicative of oedema (arrowed). (H) Late gadolinium enhancement with high signal intensity indicative of increased extracellular space (arrowed).

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.

Native T1 mapping to detect extent of acute and chronic myocardial infarction: comparison with late gadolinium enhancement technique.

Investigate whether native-T1 mapping can assess the transmural extent of myocardial infarction (TEI) thereby differentiating viable from non-viable myocardium without the use of gadolinium-contrast in both acute and chronic myocardial infarction (aMI and cMI). Sixty patients (30 cMI > 1 year and 30 aMI day 2 STEMI) and 20 healthy-controls underwent 1.5 T CMR to assess left ventricular function (cine), native-T1 mapping (MOLLI sequence 5(3)3, motion-corrected) and the presence and TEI from late gadolinium enhancement (LGE) images. Segments with TEI > 75% was considered non-viable. Gold-standard LGE-TEI was compared with corresponding segmental native-T1. Segmental native-T1 correlated significantly with TEI (R = 0.74, p < 0.001 in cMI and R = 0.57, p < 0.001 in aMI). Native-T1 differentiated segments with no LGE (1031 ± 31 ms), LGE positive but viable (1103 ± 57 ms) and LGE positive but non-viable (1206 ± 118 ms) in cMI (p < 0.01). It also differentiated segments with no LGE (1054 ± 65 m), LGE positive but viable (1135 ± 73 ms) and LGE positive but non-viable (1168 ± 71 ms) in aMI (p < 0.01). ROC analysis demonstrated excellent accuracy of native-T1 mapping compared to LGE-TEI (AUC - 0.88, p < 0.001 in cMI, vs AUC - 0.83, p < 0.001 in aMI). Native-T1 performed better in cMI than aMI (p < 0.01). In cMI a segmental T1 threshold of 1085 ms differentiated viable from non-viable segments with a sensitivity 88% and specificity of 88% whereas a T1 of 1110 ms differentiated viable from nonviable with 79% sensitivity and 79% specificity in aMI. Native-T1 mapping correlates significantly with TEI thereby differentiating between normal, viable, and non-viable myocardium with distinctive T1 profiles in aMI and cMI. Native T1-mapping to detect MI performed better in cMI compared to aMI due to absence of myocardial oedema. Native-T1 mapping holds promise for viability assessment without the need for gadolinium-contrast agent.

Noctural dipping status and left ventricular hypertrophy: A cardiac magnetic resonance imaging study.

We investigate the impact of dipper status on cardiac structure with cardiovascular magnetic resonance (CMR). Ambulatory blood pressure monitoring and 1.5T CMR were performed in 99 tertiary hypertension clinic patients. Subgroup analysis by extreme dipper (n = 9), dipper (n = 39), non-dipper (n = 35) and reverse dipper (n = 16) status was performed, matched in age, gender and BMI. Left ventricular (LV) mass was significantly higher for extreme dippers than dippers after correction for covariates (100 ± 6 g/m2 vs 79 ± 3 g/m2 , P = .004). Amongst extreme dippers and dippers (n = 48), indexed LV mass correlated positively with the extent of nocturnal blood pressure dipping (R = .403, P = .005). On post-hoc ANCOVA, the percentage of nocturnal dip had significant effect on indexed LV mass (P = .008), but overall SBP did not (P = .348). In the tertiary setting, we found a larger nocturnal BP drop was associated with more LV hypertrophy. If confirmed in larger studies, this may have implications on nocturnal dosing of anti-hypertensive medications.

Radial scar lesions of the breast diagnosed by needle core biopsy: analysis of cases containing occult malignancy.

AIM: To identify and review cases of false negative needle core biopsy (NCB) in the preoperative investigation of radial scar/complex sclerosing lesion (RS/CSL) lesions - that is, benign NCB from RS/CSL which contained malignancy on excision. METHODS AND RESULTS: A total of 11 false negative NCB in RS/CSL lesions from 281 (3.9%) were identified (6 cases: B1, 2 cases: B2 and 3 cases: B3). In 6 of 11 cases a radial scar or stromal sclerosis was seen in NCB. Localisation biopsy showed duct carcinoma in situ in six cases, duct carcinoma in situ with invasive carcinoma in three and invasive carcinoma in two. In all 11 cases, needle tracks were identified as missing the malignant epithelium by a mean of 5 mm (median:4 mm; range:1-20 mm). In 9 of 11 cases, the malignancy was missed by <6 mm. CONCLUSIONS: Despite evidence of accurate targeting of lesions, the use of NCB instead of fine needle aspiration cytology has not eliminated the problem of false negative biopsy in RS/CSL, and excision is recommended.

Iatrogenic mitral stenosis following transcatheter aortic valve replacement (TAVR).

A 57 year old female underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Mild iatrogenic mitral stenosis was noted intraoperatively. Attempts to reposition the device were hampered by aortic angulation. One year later, severe mitral stenosis was confirmed on transoesophageal echocardiography. It is important to recognise that iatorgenic mitral stenosis due to TAVR may progress over time. Care should be taken to minimise the risk of this rare complication.

Long-term predictors of mortality after percutaneous coronary intervention in the era of drug-eluting stents.

The aim was to examine timing, causes, and predictors of death during long-term follow-up after contemporary percutaneous coronary intervention (PCI) using a large multicenter Australian registry. The cohort consisted of 10,682 consecutive patients from the Melbourne Interventional Group registry undergoing PCI (February 2004 through November 2009). For the first time in Australia, long-term mortality rates of a PCI cohort were defined by linkage to the National Death Index database. The cohort (mean age 64 ± 12 years) comprised 75% men, 24% diabetics, 59% with multivessel disease, 4.4% with renal failure, 25% with ST-elevation myocardial infarction (STEMI), 2.5% with cardiogenic shock, and 5.1% with heart failure. Drug-eluting stents (DES) were used in 43% of cases. Mean follow-up was 3.2 ± 0.5 years. In-hospital, 30-day, 12-month, and long-term (3.2 ± 0.5 years) mortalities were 1.6% (80% cardiac), 2.1% (79%), 3.9% (61%), and 8.2% (50%), respectively. Independent predictors of long-term mortality included age (hazard ratio 1.05, 95% confidence interval 1.04 to 1.06), cardiogenic shock (4.58, 3.60 to 5.83), renal failure (3.14, 2.58 to 3.82), previous heart failure (1.97, 1.60 to 2.41), STEMI (1.79, 1.47 to 2.18), peripheral vascular disease (1.72, 1.4 to 2.11), non-STEMI (1.58, 1.32 to 1.90), multivessel disease (1.47, 1.24 to 1.74), current smoking (1.39, 1.12 to 1.71), diabetes (1.36, 1.16 to 1.59), and cerebrovascular disease (1.33, 1.06 to 1.60, p <0.01 for all comparisons). DES deployment appeared protective against late mortality (hazard ratio 0.85, 0.73 to 0.99, p = 0.04); however, after 30 days, there was no difference in mortality rates between those who received a bare metal stent and those who received a DES. In conclusion, different clinical variables such as renal and heart failure predicted long-term mortality after PCI, whereas DES use in this large registry was not associated with late mortality risk.