RESUMO
The CSANZ/RANZCR Position Statement on Cardiac Magnetic Resonance Imaging (CMRI) is intended to support and foster the provision of quality, safe CMRI services in Australia and New Zealand. This document specifically pertains to CMRI in adults, as distinct from general vascular MRI or paediatric imaging, and provides certification and recertification requirements.
RESUMO
Coronary artery disease (CAD) remains the leading cause of adult mortality globally. Targeting known modifiable risk factors has had substantial benefit, but there remains a need for new approaches. Improvements in invasive and noninvasive imaging techniques have enabled an increasing recognition of distinct quantitative phenotypes of coronary atherosclerosis that are prognostically relevant. There are marked differences in plaque phenotype, from the high-risk, lipid-rich, thin-capped atheroma to the low-risk, quiescent, eccentric, nonobstructive calcified plaque. Such distinct phenotypes reflect different pathophysiologic pathways and are associated with different risks for acute ischemic events. Noninvasive coronary imaging techniques, such as computed tomography, positron emission tomography, and coronary magnetic resonance imaging, have major potential to accelerate cardiovascular drug development, which has been affected by the high costs and protracted timelines of cardiovascular outcome trials. This may be achieved through enrichment of high-risk phenotypes with higher event rates or as primary end points of drug efficacy, at least in phase 2 trials, in a manner historically performed through intravascular coronary imaging studies. Herein, we provide a comprehensive review of the current technology available and its application in clinical trials, including implications for sample size requirements, as well as potential limitations. In its effort to accelerate drug development, the US Food and Drug Administration has approved surrogate end points for 120 conditions, but not for CAD. There are robust data showing the beneficial effects of drugs, including statins, on CAD progression and plaque stabilization in a manner that correlates with established clinical end points of mortality and major adverse cardiovascular events. This, together with a clear mechanistic rationale for using imaging as a surrogate CAD end point, makes it timely for CAD imaging end points to be considered. We discuss the importance of global consensus on these imaging end points and protocols and partnership with regulatory bodies to build a more informed, sustainable staged pathway for novel therapies.
Assuntos
Fármacos Cardiovasculares , Doença da Artéria Coronariana , Placa Aterosclerótica , Estados Unidos , Humanos , Placa Aterosclerótica/diagnóstico por imagem , Placa Aterosclerótica/tratamento farmacológico , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/tratamento farmacológico , Coração , Desenvolvimento de MedicamentosRESUMO
BACKGROUND: TEXTMEDS (Text Messages to Improve Medication Adherence and Secondary Prevention After Acute Coronary Syndrome) examined the effects of text message-delivered cardiac education and support on medication adherence after an acute coronary syndrome. METHODS: TEXTMEDS was a single-blind, multicenter, randomized controlled trial of patients after acute coronary syndrome. The control group received usual care (secondary prevention as determined by the treating clinician); the intervention group also received multiple motivational and supportive weekly text messages on medications and healthy lifestyle with the opportunity for 2-way communication (text or telephone). The primary end point of self-reported medication adherence was the percentage of patients who were adherent, defined as >80% adherence to each of up to 5 indicated cardioprotective medications, at both 6 and 12 months. RESULTS: A total of 1424 patients (mean age, 58 years [SD, 11]; 79% male) were randomized from 18 Australian public teaching hospitals. There was no significant difference in the primary end point of self-reported medication adherence between the intervention and control groups (relative risk, 0.93 [95% CI, 0.84-1.03]; P=0.15). There was no difference between intervention and control groups at 12 months in adherence to individual medications (aspirin, 96% vs 96%; ß-blocker, 84% vs 84%; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, 77% vs 80%; statin, 95% vs 95%; second antiplatelet, 84% vs 84% [all P>0.05]), systolic blood pressure (130 vs 129 mmâ Hg; P=0.26), low-density lipoprotein cholesterol (2.0 vs 1.9 mmol/L; P=0.34), smoking (P=0.59), or exercising regularly (71% vs 68%; P=0.52). There were small differences in lifestyle risk factors in favor of intervention on body mass index <25 kg/m2 (21% vs 18%; P=0.01), eating ≥5 servings per day of vegetables (9% vs 5%; P=0.03), and eating ≥2 servings per day of fruit (44% vs 39%; P=0.01). CONCLUSIONS: A text message-based program had no effect on medical adherence but small effects on lifestyle risk factors. REGISTRATION: URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=364448; Unique identifier: ANZCTR ACTRN12613000793718.
Assuntos
Síndrome Coronariana Aguda , Envio de Mensagens de Texto , Síndrome Coronariana Aguda/tratamento farmacológico , Síndrome Coronariana Aguda/prevenção & controle , Austrália , Feminino , Humanos , Masculino , Adesão à Medicação , Pessoa de Meia-Idade , Prevenção Secundária , Método Simples-CegoRESUMO
The cardiovascular benefits of omega-3 polyunsaturated fatty acids (O3FA) remain a point of confusion in clinical medicine. Recently two large, randomised trials were published with discordant findings regarding the overall benefits of omega-3 supplementation, resulting in unnecessary confusion and therapeutic nihilism. Epidemiological studies clearly show high intake of fish and measured O3FA (mainly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA)) in tissues are inversely associated with cardiovascular events and total mortality. These fatty acids are 'essential' and depend almost entirely on intake with very little production from within the body. The efficacy of supplementation depends on background tissue levels, in contradistinction to drug therapy. Insufficient dosing of omega-3 supplementation using less than 1 g/day and lack of titration to target by failing to measure O3FA levels in the blood may explain these conflicting trial outcomes. We review the current evidence regarding O3FA supplementation and cardiovascular outcomes, describe possible reasons for the discrepant results in the literature including recent controversial data around the mineral oil comparator used in REDUCE-IT and discuss the potential use of the omega-3 index to guide management and optimise supplementation in those at greatest risk.
Assuntos
Doenças Cardiovasculares , Ácidos Graxos Ômega-3 , Animais , Humanos , Doenças Cardiovasculares/tratamento farmacológico , Suplementos Nutricionais , Ácidos Docosa-Hexaenoicos/uso terapêutico , Ácido Eicosapentaenoico/uso terapêutico , Ácidos Graxos Ômega-3/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
The Australian Cardiovascular Alliance (ACvA), the Cardiac Society of Australia and New Zealand (CSANZ) and the National Heart Foundation of Australia (NHFA) recently joined forces to bring the cardiovascular and stroke community together to convene and document a national discussion and propose a national CVD Implementation and Policy agenda and action plan. This includes prevention and screening, acute care and secondary prevention.
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Doenças Cardiovasculares , Humanos , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/prevenção & controle , Austrália/epidemiologia , Políticas , Nova Zelândia/epidemiologiaRESUMO
Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allow for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia.
Assuntos
Doença da Artéria Coronariana , Reserva Fracionada de Fluxo Miocárdico , Humanos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Angiografia Coronária/métodos , Austrália/epidemiologia , Tomografia Computadorizada por Raios X/métodos , Dor no Peito/diagnóstico por imagem , Dor no Peito/etiologia , Valor Preditivo dos TestesRESUMO
This position statement provides guidance to cardiologists and related specialists on the management of adult patients with elevated lipoprotein(a) [Lp(a)]. Elevated Lp(a) is an independent and causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and calcific aortic valve disease (CAVD). While circulating Lp(a) levels are largely determined by ancestry, they are also influenced by ethnicity, hormones, renal function, and acute inflammatory events, such that measurement should be done after accounting for these factors. Further, circulating Lp(a) concentrations should be estimated using an apo(a)-isoform independent assay that employs appropriate calibrators and reports the results in molar units (nmol/L). Selective screening strategies of high-risk patients are recommended, but universal screening of the population is currently not advised. Testing for elevated Lp(a) is recommended in all patients with premature ASCVD and those considered to be at intermediate-to-high risk of ASCVD. Elevated Lp(a) should be employed to assess and stratify risk and to enable a decision on initiation or intensification of preventative treatments, such as cholesterol lowering therapy. In adult patients with elevated Lp(a) at intermediate-to-high risk of ASCVD, absolute risk should be reduced by addressing all modifiable behavioural, lifestyle, psychosocial and clinical risk factors, including maximising cholesterol-lowering with statin and ezetimibe and, where appropriate, PCSK9 inhibitors. Apheresis should be considered in patients with progressive ASCVD. New ribonucleic acid (RNA)-based therapies which directly lower Lp(a) are undergoing clinical trials.
Assuntos
Aterosclerose , Doenças Cardiovasculares , Adulto , Humanos , Aterosclerose/diagnóstico , Aterosclerose/prevenção & controle , Austrália/epidemiologia , Doenças Cardiovasculares/complicações , Colesterol , Lipoproteína(a) , Pró-Proteína Convertase 9 , Fatores de RiscoRESUMO
PURPOSE: Left ventricular mechanical dispersion (LVMD) is a novel speckle tracking parameter for prognostic assessment of arrhythmic risk prediction. There is growing evidence to support its use in a variety of cardiomyopathic processes. There is paucity of data addressing any presence of inter-vendor discrepancies for LVMD. The aim of this study was to assess inter-vendor variability of LVMD in vendor specific software (VSS) and vendor independent software (VIS) in subjects with preserved and reduced left ventricular function. METHODS: Fifty-nine subjects (14 normal subjects and 45 subjects with cardiac disease) were recruited and 2D speckle tracking echocardiographic images were acquired on two different ultrasound machines (GE and Philips). LVMD was measured by two different VSS (EchoPac GE and QLAB Philips) and one VIS (TomTec Arena). RESULTS: There was significant bias and wide limits of agreement (LOA) in the overall cohort observed between two different VSS (17.6 ms; LOA: -29.6 to 64.8; r: .47). There was acceptable bias and narrower LOA with good agreement for LVMD between images obtained on different vendors when performed on VIS (-3.1 ms; LOA: -27.6 to 21.4; r: .75). QLAB LVMD was consistently higher than GE LVMD and TomTec LVMD in both preserved and reduced left ventricular function. LVMD measurements have high intra-vendor reproducibility with excellent inter and intra-observer agreement. CONCLUSIONS: There was acceptable bias and narrower LOA for LVMD assessment on a VIS. Inter-vendor variability exists for LVMD assessment between VSS. Serial measurements of LVMD should be performed using a single vendor for consistent and reliable results.
Assuntos
Ecocardiografia , Ventrículos do Coração , Ecocardiografia/métodos , Ventrículos do Coração/diagnóstico por imagem , Humanos , Reprodutibilidade dos Testes , Software , Função Ventricular EsquerdaRESUMO
The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). The SCMR web site ( https://www.scmr.org ) hosts a case series designed to present case reports demonstrating the unique attributes of CMR in the diagnosis or management of cardiovascular disease. Each clinical presentation is followed by a brief discussion of the disease and unique role of CMR in disease diagnosis or management guidance. By nature, some of these are somewhat esoteric, but all are instructive. In this publication, we provide a digital archive of the 2019 Case of the Week series as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar search engine.
Assuntos
Síndrome de Churg-Strauss/diagnóstico por imagem , Imageamento por Ressonância Magnética , Trombose/diagnóstico por imagem , Disfunção Ventricular Esquerda/diagnóstico por imagem , Antineoplásicos/efeitos adversos , Cardiotoxicidade , Síndrome de Churg-Strauss/fisiopatologia , Síndrome de Churg-Strauss/terapia , Diagnóstico Diferencial , Feminino , Neoplasias Cardíacas/diagnóstico por imagem , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Trombose/fisiopatologia , Trombose/terapia , Disfunção Ventricular Esquerda/induzido quimicamente , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda/efeitos dos fármacos , Adulto JovemRESUMO
BACKGROUND: Left ventricular non-compaction has been associated with heart failure, arrhythmia, thromboembolism and sudden death. The prevalence of non-compaction in patients with coarctation of the aorta and its clinical significance remains unknown, although obstructive left heart disease is common in patients with non-compaction. We sought to evaluate the prevalence of left ventricular non-compaction in patients with repaired aortic coarctation as well as its effect on left ventricular size and systolic function. METHODS AND RESULTS: In total, 268 patients (Mean age 26 (inter-quartile range 21-37) years, 63% male) undergoing cardiac magnetic resonance imaging for clinical follow-up were included from three tertiary centres for adult congenital heart disease. Clinical data was obtained from medical records and correlated with ventricular volumes and function. Left ventricular non-compaction was defined as a diastolic non-compacted:compacted dimension ratio >2.3 in the worst affected segment on a long-axis view. Left ventricular non-compaction was present in 8.2% of patients with repaired coarctation. Left ventricular end-diastolic volumes and stroke volumes were significantly higher in patients with non-compaction compared to those without. There were no significant differences in ventricular mass or ejection fraction in these two groups. CONCLUSIONS: Left ventricular non-compaction is relatively common in patients with repaired coarctation of the aorta and correlates with increased left ventricular end-diastolic volumes.
Assuntos
Coartação Aórtica , Cardiopatias Congênitas , Adulto , Coartação Aórtica/complicações , Coartação Aórtica/diagnóstico por imagem , Coartação Aórtica/epidemiologia , Feminino , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/epidemiologia , Humanos , Masculino , Prevalência , Volume Sistólico , Função Ventricular Esquerda , Adulto JovemRESUMO
Atherosclerosis is the commonest cause of death in Australia. Cardiovascular (CV) risk calculators have an important role in preventative cardiology, although they are are strongly age-dependent and designed to identify individuals at high risk of an imminent event. The imprecision around "intermediate" or "low" risk generates therapeutic uncertainty, and a significant proportion of patients presenting with myocardial infarction come from these groups, often with no warning. This highlights a conundrum: "Low" risk does not mean "no" risk. A fresh approach may be required to address the clinical conundrum around CV preventative approaches in non-high-risk individuals. While probabilistic calculators do not measure atherosclerosis, calculation of Coronary Artery Calcium (CAC) scores by low-dose computed tomography (CT) can provide a snapshot of atherosclerotic burden. In intermediate-risk individuals, CAC is well-established as an aid to CV risk prediction. Although CAC scoring in low-risk asymptomatic people may be considered controversial, CAC has emerged as the single best predictor of CV events in asymptomatic individuals, independent of traditional risk factor calculators. Therefore, apart from the contribution of age and sex, the somewhat arbitrary distinction between "intermediate" and "low" CV risk using probabilistic calculators may need to be reconsidered. A zero CAC score has a very low future event rate and non-zero CAC scores are associated with a progressive, graded increase in risk as the CAC score rises. Here, we examine the evidence for CAC screening in low-risk individuals, and propose more widespread use of CAC using simple new model intended to enhance established CV risk prediction equations.
Assuntos
Doenças Cardiovasculares , Doença da Artéria Coronariana , Calcificação Vascular , Cálcio , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/epidemiologia , Vasos Coronários/diagnóstico por imagem , Fatores de Risco de Doenças Cardíacas , Humanos , Medição de Risco , Fatores de Risco , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/epidemiologiaRESUMO
BACKGROUND: Coronary artery disease (CAD) remains a major public health problem in Australia and globally. A variety of imaging techniques allow for both anatomical and functional assessment of CAD and selection of the optimal investigation pathway is challenging. Cardiovascular magnetic resonance (CMR) is not widely used in Australia, partly due to perceived cost and lack of Federal Government reimbursement compared to the alternative techniques. The aim of this study was to estimate the cost-effectiveness of different diagnostic strategies in identifying significant CAD in patients with chest pain suggestive of angina using the evidence gathered in the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease 2 (CE-MARC trial), analysed from the Australian health care perspective. METHODS: A decision analytic model coupled with three distinct Markov models allowed eight potential clinical investigation strategies to be considered; combinations of exercise electrocardiogram stress testing (EST), single-photon emission computed tomography (SPECT), stress CMR, and invasive coronary angiography (ICA). Costs were from the Australian health care system in Australian dollars, and outcomes were measured in terms of quality-adjusted life-years. Parameter estimates were derived from the CE-MARC and EUropean trial on Reduction Of cardiac events with Perindopril in patients with stable coronary Artery disease (EUROPA) trials, and from reviews of the published literature. RESULTS: The most cost-effective diagnostic strategy, based on a cost-effectiveness threshold of $45,000 to $75,000 per QALY gained, was EST, followed by stress CMR if the EST was positive or inconclusive, followed by ICA if the stress CMR was positive or inconclusive; this held true in the base case and the majority of scenario analyses. CONCLUSIONS: This economic evaluation shows that an investigative strategy of stress CMR if EST is inconclusive or positive is the most cost-effective approach for diagnosing significant coronary disease in chest pain patients within the Australian health care system.
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Doença da Artéria Coronariana/diagnóstico , Atenção à Saúde/economia , Imagem Cinética por Ressonância Magnética/economia , Modelos Econômicos , Idoso , Austrália , Doença da Artéria Coronariana/economia , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: The T1 Mapping and Extracellular volume (ECV) Standardization (T1MES) program explored T1 mapping quality assurance using a purpose-developed phantom with Food and Drug Administration (FDA) and Conformité Européenne (CE) regulatory clearance. We report T1 measurement repeatability across centers describing sequence, magnet, and vendor performance. METHODS: Phantoms batch-manufactured in August 2015 underwent 2 years of structural imaging, B0 and B1, and "reference" slow T1 testing. Temperature dependency was evaluated by the United States National Institute of Standards and Technology and by the German Physikalisch-Technische Bundesanstalt. Center-specific T1 mapping repeatability (maximum one scan per week to minimum one per quarter year) was assessed over mean 358 (maximum 1161) days on 34 1.5 T and 22 3 T magnets using multiple T1 mapping sequences. Image and temperature data were analyzed semi-automatically. Repeatability of serial T1 was evaluated in terms of coefficient of variation (CoV), and linear mixed models were constructed to study the interplay of some of the known sources of T1 variation. RESULTS: Over 2 years, phantom gel integrity remained intact (no rips/tears), B0 and B1 homogenous, and "reference" T1 stable compared to baseline (% change at 1.5 T, 1.95 ± 1.39%; 3 T, 2.22 ± 1.44%). Per degrees Celsius, 1.5 T, T1 (MOLLI 5s(3s)3s) increased by 11.4 ms in long native blood tubes and decreased by 1.2 ms in short post-contrast myocardium tubes. Agreement of estimated T1 times with "reference" T1 was similar across Siemens and Philips CMR systems at both field strengths (adjusted R2 ranges for both field strengths, 0.99-1.00). Over 1 year, many 1.5 T and 3 T sequences/magnets were repeatable with mean CoVs < 1 and 2% respectively. Repeatability was narrower for 1.5 T over 3 T. Within T1MES repeatability for native T1 was narrow for several sequences, for example, at 1.5 T, Siemens MOLLI 5s(3s)3s prototype number 448B (mean CoV = 0.27%) and Philips modified Look-Locker inversion recovery (MOLLI) 3s(3s)5s (CoV 0.54%), and at 3 T, Philips MOLLI 3b(3s)5b (CoV 0.33%) and Siemens shortened MOLLI (ShMOLLI) prototype 780C (CoV 0.69%). After adjusting for temperature and field strength, it was found that the T1 mapping sequence and scanner software version (both P < 0.001 at 1.5 T and 3 T), and to a lesser extent the scanner model (P = 0.011, 1.5 T only), had the greatest influence on T1 across multiple centers. CONCLUSION: The T1MES CE/FDA approved phantom is a robust quality assurance device. In a multi-center setting, T1 mapping had performance differences between field strengths, sequences, scanner software versions, and manufacturers. However, several specific combinations of field strength, sequence, and scanner are highly repeatable, and thus, have potential to provide standardized assessment of T1 times for clinical use, although temperature correction is required for native T1 tubes at least.
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Imageamento por Ressonância Magnética/instrumentação , Imageamento por Ressonância Magnética/normas , Imagens de Fantasmas/normas , Consenso , Humanos , Variações Dependentes do Observador , Valor Preditivo dos Testes , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: Left ventricular non-compaction is an architectural abnormality of the myocardium, associated with heart failure, systemic thromboembolism, and arrhythmia. We sought to assess the prevalence of left ventricular non-compaction in patients with single ventricle heart disease and its effects on ventricular function. METHODS: Cardiac MRI of 93 patients with single ventricle heart disease (mean age 24 ± 8 years; 55% male) from three tertiary congenital centres was retrospectively reviewed; 65 of these had left ventricular morphology and are the subject of this report. The presence of left ventricular non-compaction was defined as having a non-compacted:compacted (NC:C) myocardial thickness ratio >2.3:1. The distribution of left ventricular non-compaction, ventricular volumes, and function was correlated with clinical data. RESULTS: The prevalence of left ventricular non-compaction was 37% (24 of 65 patients) with a mean of 4 ± 2 affected segments. The distribution was apical in 100%, mid-ventricular in 29%, and basal in 17% of patients. Patients with left ventricular non-compaction had significantly higher end-diastolic (128 ± 44 versus 104 ± 46 mL/m2, p = 0.047) and end-systolic left ventricular volumes (74 ± 35 versus 56 ± 35 mL/m2, p = 0.039) with lower left ventricular ejection fraction (44 ± 11 versus 50 ± 9%, p = 0.039) compared to those with normal compaction. The number of segments involved did not correlate with ventricular function (p = 0.71). CONCLUSIONS: Left ventricular non-compaction is frequently observed in patients with left ventricle-type univentricular hearts, with predominantly apical and mid-ventricular involvement. The presence of non-compaction is associated with increased indexed end-diastolic volumes and impaired systolic function.
Assuntos
Miocárdio Ventricular não Compactado Isolado/diagnóstico , Coração Univentricular/diagnóstico , Adolescente , Adulto , Feminino , Humanos , Miocárdio Ventricular não Compactado Isolado/patologia , Miocárdio Ventricular não Compactado Isolado/fisiopatologia , Imagem Cinética por Ressonância Magnética , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Volume Sistólico , Sístole , Coração Univentricular/patologia , Coração Univentricular/fisiopatologia , Função Ventricular Esquerda , Adulto JovemRESUMO
BACKGROUND: Right ventricular (RV) failure is the main cause of mortality in pulmonary arterial hypertension (PAH). Exercise testing helps identify early RV maladaptation and systolic dysfunction and facilitates therapy. Myocardial strain has been shown to be more sensitive than ejection fraction (EF) in detecting subclinical ventricular contractile dysfunction. Chronic pressure overload in PAH had been associated with changes in left ventricular (LV) filling. PURPOSE: To compare biventricular strains and ventriculo-ventricular interaction in PAH and controls using cardiac magnetic resonance feature tracking (cMRI-FT) and to determine the reproducibility of strain analysis. STUDY TYPE: Prospective. POPULATION: Nine PAH and nine control subjects. FIELD STRENGTH/SEQUENCE: 1.5T MRI balanced steady state free precession. ASSESSMENT: RV and LV longitudinal strain (EllRV and EllLV ) were derived using the mid-axial images. Radial (ErrLV ) and circumferential strain (EccLV ) were derived using the mid-ventricular short-axis images. Relationships between strain and volumetric parameters were assessed at rest and during submaximal in-magnet exercise. STATISTICAL TESTS: Comparison of rest-to-exercise data between PAH and controls was analyzed using two-way repeated measures analysis of variance. The relationship between volumetric parameters and cMRI-FT were assessed using Pearson's correlation. Reproducibility was assessed by using Bland-Altman plots. RESULTS: PAH had significantly lower EllRV at rest (-16.6 ± 2.7 vs. -20.1 ± 3.6, P = 0.03) despite normal RVEF. During exercise, RV systolic contractile reserve measured by EllRV was significantly reduced in PAH (PInteraction = 0.02). In PAH, indexed RV end-systolic volume (ESVi) significantly correlated with EccLV and ErrLV at rest (r = -0.65 and r = -0.70, P < 0.05) and with ErrLV during exercise (r = -0.43, P < 0.05). High observer agreement was demonstrated. DATA CONCLUSION: Despite normal resting RVEF, RV systolic function and contractile reserve as measured by EllRV was significantly reduced in PAH. The close relation between RVESVi with EccLV and ErrLV provides evidence of systolic ventriculo-ventricular interaction in PAH. Exercise cMRI-FT may provide a quantitative metric for detection of subclinical RV dysfunction in PAH. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1427-1436.
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Teste de Esforço , Imageamento por Ressonância Magnética/métodos , Hipertensão Arterial Pulmonar/complicações , Hipertensão Arterial Pulmonar/fisiopatologia , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/fisiopatologia , Adulto , Feminino , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos TestesRESUMO
LEVEL OF EVIDENCE: 5 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019;50:1336-1338.
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Cardiomiopatia Hipertrófica/diagnóstico por imagem , Cardiomiopatia Hipertrófica/patologia , Interpretação de Imagem Assistida por Computador/métodos , Imageamento por Ressonância Magnética/métodos , Cardiomiopatia Hipertrófica/fisiopatologia , Feminino , Coração/diagnóstico por imagem , Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologiaRESUMO
BACKGROUND: The clinical use of cardiac magnetic resonance (CMR) in Australian heart failure (HF) patients has limited evidence. AIM: To examine how CMR, compared with routine echocardiography, affects the diagnosis and management of patients with HF. METHODS: Single-centre retrospective study of HF patients newly referred to the Advanced Heart Failure and Transplant unit at The Prince Charles Hospital, Brisbane. Between January 2010 and December 2014, all patients clinically referred for both CMR and echocardiography in the workup of HF were analysed. Imaging results, electronic records and medical charts were reviewed for final diagnosis and changes in clinical management. RESULTS: A total of 114 new HF referrals was included. Evaluation of HF of uncertain aetiology (70%) was the most common indication for CMR. In 20% of cases, CMR led to a completely new diagnosis or diagnostic confirmation of suspicions raised by echocardiography. Clinical decision-making was altered in 48%, with the greatest impact on decisions regarding revascularisation. Overall, CMR had a significant impact on 50% of patients. In a multivariable model, the only independent variable significantly associated with clinical impact was the presence/absence of late gadolinium enhancement (P < 0.001). Importantly, body mass index, echocardiography image quality and the presence of sinus rhythm did not show statistical significance in the multivariate analysis. CONCLUSION: CMR makes a substantial contribution to both the diagnosis and management of HF patients over and above standard echocardiography. This study provides evidence of its clinical utility in the HF population in Australia and supports the role of CMR in the routine assessment of this cohort.
Assuntos
Arritmias Cardíacas/complicações , Insuficiência Cardíaca/diagnóstico por imagem , Imageamento por Ressonância Magnética , Adulto , Austrália , Serviço Hospitalar de Cardiologia , Meios de Contraste/administração & dosagem , Ecocardiografia , Feminino , Gadolínio/administração & dosagem , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Atenção Terciária , Função Ventricular EsquerdaRESUMO
BACKGROUND: The left ventricular (LV) papillary muscles are important components of the mitral valve apparatus. Catheter ablation of ventricular arrhythmias from these sites is challenging. We aim to describe the association between LV papillary muscle ventricular arrhythmias (VAs) and mitral valve prolapse (MVP), and to determine the outcomes of ablation in these patients with a focus on those with MVP and cardiomyopathy. METHODS: A total of 152 patients underwent 170 consecutive procedures for ablation of focal VAs. MVP and cardiomyopathy were diagnosed by echocardiography. Outcomes following ablation were assessed in three groups: (1) LV papillary muscle VAs versus other sites, (2) LV papillary muscle VAs by the presence of MVP, and (3) LV papillary muscle VAs in the setting of cardiomyopathy. RESULTS: Nine of 23 (39%) patients undergoing ablation of LV papillary muscle VAs had MVP compared to none of 129 (0%) patients at other sites (P < 0.001). In the former group, acute procedural success was achieved in 60% and 80% of those with and without MVP, respectively (P = 0.28). Medium-term outcomes were comparable (P = 0.75). In patients with cardiomyopathy, the median LV ejection fraction improved from 40% to 54% following ablation (P = 0.007). CONCLUSIONS: Although MVP is strongly associated with LV papillary muscle VAs, MVP does not adversely affect the acute or medium-term outcomes of ablation. Systolic function can improve following ablation in patients with ectopy-mediated cardiomyopathy due to papillary muscle VAs.
Assuntos
Arritmias Cardíacas/complicações , Arritmias Cardíacas/cirurgia , Ablação por Cateter , Prolapso da Valva Mitral/complicações , Prolapso da Valva Mitral/fisiopatologia , Músculos Papilares/cirurgia , Sístole , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
AIM: Transthoracic echocardiography (TTE) is a fundamental investigation for the noninvasive assessment of pulmonary hemodynamics and right heart function. The aim of this study was to assess the correlation and agreement of Doppler calculation of right ventricular systolic pressure (RVSP) and pulmonary vascular resistance (PVR) using "chin" and "beard" measurements of tricuspid regurgitant velocity (TRVmax ), with invasive pulmonary artery systolic pressure (PASP) and PVR. METHODS: One hundred patients undergoing right heart catheterisation (RHC) and near simultaneous transthoracic echocardiography were studied. TRVmax was recorded for "chin" measurement (distinct peak TRVmax signal) and where available (63 patients), "beard" measurement (higher indistinct peak TRVmax signal). RESULTS: Measurable TRV signal was obtained in 96 patients. Mean RVSPchin 54.7 ± 22.7 mm Hg and RVSPbeard 68.6 = 23 ± 26.3 mm Hg (P < .001). There was strong correlation between both RVSPchin and RVSPbeard with invasive PASP (Pearson's r = .9, R2 = 0.82, P < .001 - r = .88, R = .78, P < .001, respectively.). Bland-Altman analysis for RVSPchin and RVSPbeard showed a mean bias of -0.5 mm Hg (95% limits of agreement -21.4 to 20.5 mm Hg) and -10.7 (95% LOA -35.5 to 14.2 mm Hg), respectively. Receiver operator characteristics of TRVmax "chin" and "beard" for diagnosis of pulmonary hypertension was assessed with optimal cut-offs being 2.8 m/s (sensitivity 93%, specificity 87%) and 3.2 m/s (sensitivity 91%, specificity 82%), respectively. There was similar correlation between PVRchin and PVRbeard (r = .87, R2 = 0.75, P < .001 and r = .86, R2 = 0.74, P < .001, respectively). At higher PVR, there was overestimation of calculated PVR using PVRbeard . CONCLUSION: The accuracy of noninvasive measurement of right heart pressures is increased using the "chin" in estimation of both RVSP and PVR.
Assuntos
Ecocardiografia Doppler/métodos , Hipertensão Pulmonar/fisiopatologia , Pressão Propulsora Pulmonar/fisiologia , Insuficiência da Valva Tricúspide/diagnóstico por imagem , Resistência Vascular/fisiologia , Função Ventricular Direita/fisiologia , Pressão Ventricular/fisiologia , Cateterismo Cardíaco/métodos , Feminino , Seguimentos , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Valva Tricúspide/diagnóstico por imagem , Valva Tricúspide/fisiopatologia , Insuficiência da Valva Tricúspide/complicações , Insuficiência da Valva Tricúspide/fisiopatologiaRESUMO
PURPOSE: To assess the clinical feasibility of a compressed sensing cine magnetic resonance imaging (MRI) sequence of both high temporal and spatial resolution (CS_bSSFP) in comparison to a balanced steady-state free precession cine (bSSFP) sequence for reliable quantification of left ventricular (LV) volumes and mass. MATERIALS AND METHODS: Segmented MRI cine images were acquired on a 1.5T scanner in 50 patients in the LV short-axis stack orientation using a retrospectively gated conventional bSSFP sequence (generalized autocalibrating partially parallel acquisition [GRAPPA] acceleration factor 2), followed by a prospectively triggered CS_bSSFP sequence with net acceleration factor of 8. Image quality was assessed by published criteria. Comparison of sequences was made in LV volumes and mass, image quality score, quantitative regional myocardial wall motion, and imaging time using Pearson's correlation, Bland-Altman and paired 2-tailed Student's t-test. RESULTS: Differences (bSSFP minus CS_bSSFP, mean ± SD) and Pearson's correlations were 14.8 ± 16.3 (P = 0.31) and r = 0.98 (P < 0.0001) for end-diastolic volume (EDV), 8.4 ± 11.3 (P = 0.54) and r = 0.99 (P < 0.0001) for end-systolic volume (ESV), -0.4 ± 2.5 (P = 0.87) and r = 0.97 (P < 0.0001) for EF, and -0.9 ± 11.8 (P = 0.92) and r = 0.97 (P < 0.0001) for LV mass. Bland-Altman analyses [bias and (limits of agreement)] revealed strong agreement in LVEDV [8.7 ml, (-12.1, 29.6)], LVESV [4.3 ml, (-11.9, 20.6)], LVEF [-0.02%, (-5.37, 5.33)], and myocardial mass [-6.1 g, (-14.7, 26.9)]. Image quality was comparable with a similar mean score (P = 0.42), with a good correlation in image quality observed (r = 0.68, P < 0.0001). Quantitative regional myocardial wall motion demonstrated strong correlation between the sequences (r = 0.87, P < 0.0001). Imaging time was significantly shorter for the CS_bSSFP sequence (1.1 ± 0.5 versus 5.6 ± 1.6 min, P < 0.0001). CONCLUSION: The novel high-resolution cine CS_bSSFP accurately and reliably quantitates LV volumes and mass, shortens acquisition times, and is clinically feasible. LEVEL OF EVIDENCE: 1 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;45:1693-1699.