Cardiac MRI in Pulmonary Hypertension: From Magnet to Bedside.

Pulmonary hypertension (PH) is a disease characterized by progressive rise of pulmonary artery (PA) pressure, which can lead to right ventricular (RV) failure. It is usually diagnosed late because of the nonspecificity of its symptoms. RV performance and adaptation to an increased afterload, reflecting the interaction of the PA and RV as a morphofunctional unit, constitute a critical determinant of morbidity and mortality in these patients. Therefore, early detection of dysfunction may prevent treatment failure. Cardiac MRI constitutes one of the most complete diagnostic modalities for diagnosing PH. It allows evaluation of the morphology and hemodynamics of the PA and RV. Several cine steady-state free-precession (SSFP)-derived parameters (indexed RV end-diastolic volume or RV systolic volume) and phase-contrast regional area change have been suggested as powerful biomarkers for prognosis and treatment. Recently, new cardiac MRI sequences have been added to clinical protocols for PH evaluation, providing brand-new information. Strain analysis with myocardial feature tracking can help detect early RV dysfunction, even with preserved ejection fraction. Four-dimensional flow cardiac MRI can enhance assessment of advanced RV and PA hemodynamics. Late gadolinium enhancement (LGE) imaging may allow detection of replacement fibrosis in PH patients, which is associated with poor outcome. T1 mapping may help detect interstitial fibrosis, even with normal LGE imaging results. The authors analyze the imaging workup of PH with a focus on the role of morphologic and functional cardiac MRI in diagnosis and management of PH, including some of the newer techniques. Online supplemental material is available for this article. ©RSNA, 2020.

Deep learning from atrioventricular plane displacement in patients with Takotsubo syndrome: lighting up the black-box.

Aims: The spatiotemporal deep convolutional neural network (DCNN) helps reduce echocardiographic readers' erroneous 'judgement calls' on Takotsubo syndrome (TTS). The aim of this study was to improve the interpretability of the spatiotemporal DCNN to discover latent imaging features associated with causative TTS pathophysiology. Methods and results: We applied gradient-weighted class activation mapping analysis to visualize an established spatiotemporal DCNN based on the echocardiographic videos to differentiate TTS (150 patients) from anterior wall ST-segment elevation myocardial infarction (STEMI, 150 patients). Forty-eight human expert readers interpreted the same echocardiographic videos and prioritized the regions of interest on myocardium for the differentiation. Based on visualization results, we completed optical flow measurement, myocardial strain, and Doppler/tissue Doppler echocardiography studies to investigate regional myocardial temporal dynamics and diastology. While human readers' visualization predominantly focused on the apex of the heart in TTS patients, the DCNN temporal arm's saliency visualization was attentive on the base of the heart, particularly at the atrioventricular (AV) plane. Compared with STEMI patients, TTS patients consistently showed weaker peak longitudinal displacement (in pixels) in the basal inferoseptal (systolic: 2.15 ± 1.41 vs. 3.10 ± 1.66, P < 0.001; diastolic: 2.36 ± 1.71 vs. 2.97 ± 1.69, P = 0.004) and basal anterolateral (systolic: 2.70 ± 1.96 vs. 3.44 ± 2.13, P = 0.003; diastolic: 2.73 ± 1.70 vs. 3.45 ± 2.20, P = 0.002) segments, and worse longitudinal myocardial strain in the basal inferoseptal (-8.5 ± 3.8% vs. -9.9 ± 4.1%, P = 0.013) and basal anterolateral (-8.6 ± 4.2% vs. -10.4 ± 4.1%, P = 0.006) segments. Meanwhile, TTS patients showed worse diastolic mechanics than STEMI patients (E'/septal: 5.1 ± 1.2 cm/s vs. 6.3 ± 1.5 cm/s, P < 0.001; S'/septal: 5.8 ± 1.3 cm/s vs. 6.8 ± 1.4 cm/s, P < 0.001; E'/lateral: 6.0 ± 1.4 cm/s vs. 7.9 ± 1.6 cm/s, P < 0.001; S'/lateral: 6.3 ± 1.4 cm/s vs. 7.3 ± 1.5 cm/s, P < 0.001; E/E': 15.5 ± 5.6 vs. 12.5 ± 3.5, P < 0.001). Conclusion: The spatiotemporal DCNN saliency visualization helps identify the pattern of myocardial temporal dynamics and navigates the quantification of regional myocardial mechanics. Reduced AV plane displacement in TTS patients likely correlates with impaired diastolic mechanics.

Right ventricular outflow tract obstruction by lymphoma: case series and review of the literature.

External compression of the right ventricular outflow tract (RVOT) by lymphoma is a rare clinical entity. We present a series of three adult patients with varying clinical presentations, in which RVOT compression by lymphoma was diagnosed using echocardiogram. Review of the literature identified a total of 13 prior cases of RVOT obstruction by lymphoma diagnosed with echocardiogram. We have summarized the clinical features and echocardiographic findings of this disorder, and comment on the role of echocardiography in diagnosis and follow-up.

Spatio-temporal hybrid neural networks reduce erroneous human "judgement calls" in the diagnosis of Takotsubo syndrome.

BACKGROUND: We investigate whether deep learning (DL) neural networks can reduce erroneous human "judgment calls" on bedside echocardiograms and help distinguish Takotsubo syndrome (TTS) from anterior wall ST segment elevation myocardial infarction (STEMI). METHODS: We developed a single-channel (DCNN[2D SCI]), a multi-channel (DCNN[2D MCI]), and a 3-dimensional (DCNN[2D+t]) deep convolution neural network, and a recurrent neural network (RNN) based on 17,280 still-frame images and 540 videos from 2-dimensional echocardiograms in 10 years (1 January 2008 to 1 January 2018) retrospective cohort in University of Iowa (UI) and eight other medical centers. Echocardiograms from 450 UI patients were randomly divided into training and testing sets for internal training, testing, and model construction. Echocardiograms of 90 patients from the other medical centers were used for external validation to evaluate the model generalizability. A total of 49 board-certified human readers performed human-side classification on the same echocardiography dataset to compare the diagnostic performance and help data visualization. FINDINGS: The DCNN (2D SCI), DCNN (2D MCI), DCNN(2D+t), and RNN models established based on UI dataset for TTS versus STEMI prediction showed mean diagnostic accuracy 73%, 75%, 80%, and 75% respectively, and mean diagnostic accuracy of 74%, 74%, 77%, and 73%, respectively, on the external validation. DCNN(2D+t) (area under the curve [AUC] 0·787 vs. 0·699, P = 0·015) and RNN models (AUC 0·774 vs. 0·699, P = 0·033) outperformed human readers in differentiating TTS and STEMI by reducing human erroneous judgement calls on TTS. INTERPRETATION: Spatio-temporal hybrid DL neural networks reduce erroneous human "judgement calls" in distinguishing TTS from anterior wall STEMI based on bedside echocardiographic videos. FUNDING: University of Iowa Obermann Center for Advanced Studies Interdisciplinary Research Grant, and Institute for Clinical and Translational Science Grant. National Institutes of Health Award (1R01EB025018-01).

Right Heart Mass in Transit with a Hemorrhagic Pericardial Effusion: A Diagnostic Dilemma.

Metastatic disease to the heart is more often a post-mortem diagnosis due to non-specific symptoms and a low index of suspicion. Our case is a unique presentation of a rare case of cardiac metastasis from oropharyngeal cancer, which eluded echocardiographic diagnosis despite the presence of a hemorrhagic pericardial effusion. The cardiac metastasis, in fact, starts as pericardial seeding, as illustrated by the positron emission tomography (PET) imaging. The pericardial metastatic disease then becomes rapidly invasive into the cardiac chambers, hence presenting as a large mass on the echocardiogram and computed tomography (CT) scan of the chest. This is the first such case of pericardial metastasis from a squamous cell carcinoma of the tongue being reported and highlights the importance of an aggressive multimodality diagnostic approach in cases where such a clinical suspicion exists. While a two-dimensional (2D) echocardiogram is the most readily available modality, we recommend that this is complemented by the use of a three-dimensional (3D) echocardiogram, as well as metabolic and radiologic imaging with PET and CT scans.

Abnormal Global Longitudinal Strain Predicts Future Deterioration of Left Ventricular Function in Heart Failure Patients With a Recovered Left Ventricular Ejection Fraction.

BACKGROUND: Patients with recovery of left ventricular ejection fraction (LVEF) remain at risk for future deterioration of LVEF. However, there are no tools to risk stratify these patients. We hypothesized that global longitudinal strain (GLS) could predict sustained recovery within this population. METHODS AND RESULTS: We retrospectively identified 96 patients with a reduced LVEF <50% (screening echocardiogram), whose LVEF had increased by at least 10% and normalized (>50%) on evidence-based medical therapies (baseline echocardiogram). We examined absolute GLS on the baseline echocardiogram in relation to changes in LVEF on a follow-up echocardiogram. Patients with recovered LVEF had a wide range of GLS. The GLS on the baseline study correlated with the LVEF at the time of follow-up (r=0.33; P<0.001). The likelihood of having an LVEF >50% on follow-up increased by 24% for each point increase in absolute GLS on the baseline study (odds ratio, 1.24; P=0.001). An abnormal GLS (≤16%) at baseline had a sensitivity of 88%, a specificity of 46%, and an accuracy of 0.67 (P<0.001) as a predictor of a decrease in LVEF >5% during follow-up. A normal GLS (>16%) on the baseline study had a sensitivity of 47%, a specificity of 83%, and an accuracy of 0.65 (P=0.002) for predicting a stable LVEF (-5% to 5%) on follow-up. CONCLUSIONS: In patients with a recovered LVEF, an abnormal GLS predicts the likelihood of having a decreased LVEF during follow-up, whereas a normal GLS predicts the likelihood of stable LVEF during recovery.

The bicuspid aortic valve.

The bicuspid aortic valve affects 1 to 2% of the population and may be complicated by aortic stenosis or aortic insufficiency and infective endocarditis. The bicuspid aortic valve is associated with abnormalities of the aortic wall such as coarctation of the aorta, aortic dissection, and aortic aneurysm. Most patients with a bicuspid aortic valve will develop some complication during life. Individuals with a bicuspid valve may be unaware of its presence and are at risk for unsuspected complications. Aortic wall abnormalities associated with bicuspid aortic valve are due to cystic medial necrosis. This process is associated with increased metalloproteinase activity and apoptosis of vascular smooth muscle cells. The clinical correlates of aortopathy in the bicuspid aortic valve include significant enlargement of the ascending aorta with aneurysm formation and dissection. This process continues after valve replacement. The person with bicuspid aortic valve requires continuous surveillance to treat associated lesions and prevent complications.

Cardioversion of atrial fibrillation with ibutilide: when is it most effective?

BACKGROUND: Atrial fibrillation (AF) is found in 1% of persons above the age of 60 years. More than 5% of the population older than 69 years and about 14% of octogenarians are at risk for this arrhythmia. It is estimated that 1.5 to 3 million persons in the United States alone suffer from AF. The public health implications and attendant morbidity are a significant drain on our health care system. HYPOTHESIS: The purpose of this study was to determine the clinical and echocardiographic predictors of success in converting AF of > or = 24 h duration. METHODS: Demographic and clinical and echocardiographic parameters of 101 patients with recent onset AF (> 24 h) who received ibutilide were studied. RESULTS: Of 101 patients, 56 (55%) converted to sinus rhythm. Age, gender, hypertension, diabetes mellitus, left ventricular ejection fraction (< or = 35%), congestive heart failure, and previous medication for rate control had no significant effect on the conversion rate. Conversion rate was only 30% (9/30 patients) in the presence of an enlarged left atrium (LA > or = 5 cm) and 37.7% (23/61 patients) in the presence of mitral valve disease (MVD), whereas the conversion rate was 82.5% (33/40 patients) in the absence of MVD and 85% (29/34 patients) in the absence of both enlarged LA and MVD (p = <0.001). Patients with coronary artery disease (CAD) also exhibited a significantly greater response to ibutilide than patients without CAD (77 vs. 46%, p-value 0.005). CONCLUSION: As a therapy for cardioversion of AF, ibutilide is most effective in a selected subgroup patients, such as in patients with CAD and in patients without MVD and/or markedly enlarged left atrium.

New-onset congestive heart failure secondary to a "huge" right atrial mass--a case report.

Transesophageal echocardiography is a useful adjunct to other diagnostic modalities in uncovering the etiology of congestive heart failure. The authors describe the case of a 75-year-old woman with a 4-week history of progressive congestive heart failure, in whom transesophageal echocardiography played a critical role in the diagnosis of a right atrial mass, accounting for this patient's constellation of symptoms.

[Rational use of noninvasive cardiac stress testing in the diagnosis of coronary artery disease]. / Perspectivas sobre la utilización de las modalidades de imagen de estrés en la valoración inicial de la cardiopatía isquémica.

A variety of noninvasive tests are available to clinicians for the evaluation of patients in whom ischemic heart disease is suspected because of chest pain, clinical antecedents, or a combination of the two. Although all tests in general help to varying degrees to refine (by inclusion or exclusion) the diagnosis in a given patient, there are undoubtedly important differences between tests regarding their scope and diagnostic accuracy in general, and with respect to certain groups of patients in particular. Because of this, and in view of the obvious economic implications, the topic merits critical review before the information obtained from these tests is used in patient management. This review is not intended to cover all features that argue for or against all currently available noninvasive tests for ischemic heart disease, but to place into perspective the importance of the clinical assessment of the patient in the light of the results of testing, and to obtain a more rational idea of their usefulness. Despite the risk of excluding certain material of interest, excellent techniques such as magnetic resonance imaging will not be covered in the review, only because they have not yet been included in meta-analyses. Emphasis on the Bayesian rationale or paradigm, together with discussion of recent meta-analyses, offers a balanced perspective of the use and possible misuse of these diagnostic tests, and of their clinical and economic implications.

Inverted Takotsubo cardiomyopathy and the fundamental diagnostic role of echocardiography.

Takotsubo cardiomyopathy is characterized by the development of transient focal wall-motion abnormalities that involve the apical and midventricular segments, in the absence of obstructive coronary artery disease. A variant, inverted takotsubo cardiomyopathy, was described in 2010. We report 3 cases in which each patient's transthoracic echocardiogram revealed the characteristic basal and midventricular segmental akinesis of this variant. This pattern is not associated with coronary artery distribution, and it therefore can be differentiated from coronary artery disease with the use of echocardiography, by evaluating the distribution and temporal changes of akinetic areas.

Transthoracic echocardiographic assessment of continuous-flow left ventricular assist devices.

An increasing number of patients are implanted with continuous-flow left ventricular assist devices (LVAD) for the treatment of severe congestive heart failure. In parallel with this growing experience has been an increase in knowledge of how these devices alter cardiac physiology and the important implications this has for cardiac function. Echocardiography offers the ability to provide serial noninvasive evaluation before and after LVAD implantation to document these changes, guide management decisions, and identify LVAD dysfunction. The authors detail a comprehensive assessment of LVAD function by transthoracic echocardiography.

Worsening of nose bleeding heralds high cardiac output state in hereditary hemorrhagic telangiectasia.

BACKGROUND: Hereditary hemorrhagic telangiectasia is characterized by arteriovenous malformations or telangiectasias in multiple organs. Nose bleeding is the most common manifestation of hereditary hemorrhagic telangiectasia and can be debilitating. Cardiac involvement in the form of high-output cardiac failure is a poorly studied complication of hereditary hemorrhagic telangiectasia. The objective of this study is to describe the natural history of high-output cardiac failure in hereditary hemorrhagic telangiectasia and define the relation between bleeding complications and high-output cardiac failure. METHODS: In this case-control study at the Washington University hereditary hemorrhagic telangiectasia center, all patients evaluated for hereditary hemorrhagic telangiectasia and found to have high cardiac output between 1999 and 2006 were enrolled as cases (n = 17) and compared with 17 hereditary hemorrhagic telangiectasia controls without high-output cardiac failure. RESULTS: During lifetime, cases needed more transfusions, emergency department visits, and hospital admission for nose bleeding. Cases experienced significant worsening of nose bleeding immediately before heart failure diagnosis. During the 2 years before study-related evaluation, 16 (94%) cases needed transfusions every month as compared with 2 (12%) controls (P <.001). The number of transfusions required during these 2 years also was higher in cases (median 3, range 0-12) as compared with controls (median 0, range 0-1.5, P <.001). CONCLUSIONS: Hereditary hemorrhagic telangiectasia patients with high-output cardiac failure have significantly greater nose bleeding as compared with patients without high-output cardiac failure. In addition, nose bleeding worsens around the time of development of high-output cardiac failure. Early recognition of the relationship between severe nose bleeding and high-output cardiac failure can lead to earlier diagnosis and provide an opportunity for earlier institution of therapy for high-output cardiac failure.

Strain rate imaging differentiates hypertensive cardiac hypertrophy from physiologic cardiac hypertrophy (athlete's heart).

BACKGROUND: This study sought to determine whether strain rate imaging could distinguish between individuals with hypertensive left ventricular hypertrophy (LVH) and those with strength-training athletic LVH. METHODS: In all, 108 participants (30 hypertensive LVH, 30 strength-training LVH, 48 control) were enrolled. In addition to a baseline echocardiogram, strain, peak systolic strain rate (SR(S)), peak early diastolic strain rate (SR(E)), and peak late diastolic strain rate values were compared in the apical 4-chamber view. RESULTS: Athletes had no significant differences in strain, SR(S), SR(E), or peak late diastolic strain rate compared with control subjects (P = .11, .99, .85, and .09, respectively). Individuals with hypertensive LVH had significantly decreased strain, SR(S), and SR(E) (-16.8 +/- 3.2%, -0.99 +/- 0.15 s(-1), and 1.54 +/- 0.40 s(-1), respectively) compared with control subjects (-21.7 +/- 3.5%, -1.31 +/- 0.27 s(-1), and 2.35 +/- 0.57 s(-1), respectively; all P < .0001). CONCLUSION: Hypertensive LVH has significant longitudinal strain, SR(S), and SR(E) reductions versus control. The lack of these reductions in athletes suggests that strain rate imaging may have clinical use in discerning the physiologic LVH state.

Fragmented left sided QRS in absence of bundle branch block: sign of left ventricular aneurysm.

BACKGROUND: A left ventricular aneurysm (LVA) occurs between 3.5% and 9.4% of all cases of acute myocardial infarction. A fragmented left sided QRS (RSR; pattern or its variant RSr;, rSR;, or rSr;) without evidence of bundle branch block (QRS duration

Perspectivas sobre la utilización de las modalidades de imagen de estrés en la valoración inicial de la cardiopatía isquémica / Rational use of noninvasive cardiac stress testing in the diagnosis of coronary artery disease

Existe una variedad de pruebas no invasivas a disposición de los clínicos para ser utilizadas en la valoración del enfermo con sospecha de cardiopatía isquémica, ya sea por presentar dolor torácico, por otros antecedentes clínicos o por una combinación de éstos. A pesar de que, en general, todas las pruebas contribuyen de forma variada a refinar (afirmar o rechazar) el diagnóstico de un enfermo en particular, no hay duda de que existen diferencias importantes entre las diversas pruebas con respecto a su alcance y su certeza diagnóstica en general, y más aún en algunos grupos de enfermos en particular. Por esto, y por las obvias implicaciones económicas, el tema merece un repaso crítico antes de utilizar, en el manejo clínico del enfermo, la información que se obtenga de estas pruebas. Esta revisión no pretende abarcar todos los aspectos a favor y en contra de todas las pruebas no invasivas de la cardiopatía isquémica que están disponibles en el momento, sino quizá poner en perspectiva la importancia de la valoración clínica del enfermo a la luz de los resultados de las pruebas, para así obtener una idea más lógica de su valor. A riesgo de pecar por exclusión, técnicas excelentes como la resonancia magnética no van a ser objeto de repaso en esta ocasión sólo porque no han sido inlcuidas hasta ahora en metaanálisis para este propósito. El énfasis en el razonamiento o paradigma bayesiano y la discusión de ensayos recientes de metaanálisis al respecto ofrecen una perspectiva equilibrada sobre el uso y posible uso indebido de estas pruebas diagnósticas, con implicaciones clínicas y económicas (AU)