Variation in cardiovascular magnetic resonance myocardial contouring: Insights from an international survey.

LEVEL OF EVIDENCE: 5 Technical Efficacy Stage: 2 J. Magn. Reson. Imaging 2019;50:1336-1338.

Right ventricular systolic dysfunction in young adults born preterm.

BACKGROUND: Young adults born preterm have distinct differences in left ventricular mass, function, and geometry. Animal studies suggest that cardiomyocyte changes are evident in both ventricles after preterm birth; therefore, we investigated whether these young adults also have differences in their right ventricular structure and function. METHODS AND RESULTS: We studied 102 preterm-born young adults followed up prospectively since birth and 132 term-born control subjects born to uncomplicated pregnancies. We quantified right ventricular structure and function by cardiovascular magnetic resonance on a 1.5-T Siemens scanner using Argus and TomTec postprocessing software. Preterm birth was associated with a small right ventricle (end diastolic volume, 79.8±13.2 versus 88.5±11.8 mL/m(2); P<0.001) but greater right ventricular mass (24.5±3.5 versus 20.4±3.4 g/m2; P<0.001) compared with term-born controls, with the severity of differences proportional to gestational age (r=-0.47, P<0.001). Differences in right ventricular mass and function were proportionally greater than previously reported for the left ventricle. This was most apparent for systolic function; young adults born preterm had significantly lower right ventricular ejection fraction (57±8% versus 60±5%; P=0.006). Indeed, 21% had values below the lower limit observed in the term-born adults and 6% had mild systolic dysfunction (<45%). Postnatal ventilation accounted for some of the variation in mass but not function. CONCLUSIONS: Preterm birth is associated with global myocardial structural and functional differences in adult life, including smaller right ventricular size and greater mass. The changes are greater in the right ventricle than previously observed in the left ventricle, with potentially clinically significant impairment in right ventricular systolic function.

Role of cardiovascular magnetic resonance as a gatekeeper to invasive coronary angiography in patients presenting with heart failure of unknown etiology.

BACKGROUND: In patients presenting with new-onset heart failure of uncertain etiology, the role of coronary angiography (CA) is unclear. Although conventionally performed to differentiate underlying coronary artery disease from dilated cardiomyopathy, CA is associated with a risk of complications and may not detect an ischemic cause resulting from arterial recanalization or an embolic episode. In this study, we assessed the diagnostic accuracy of a cardiovascular magnetic resonance (CMR) protocol incorporating late gadolinium enhancement (LGE) and magnetic resonance CA as a noninvasive gatekeeper to CA in determining the etiology of heart failure in this subset of patients. METHODS AND RESULTS: One hundred twenty consecutive patients underwent CMR and CA. The etiology was ascribed by a consensus panel that used the results of the CMR scans. Similarly, a separate consensus group ascribed an underlying cause by using the results of CA. The diagnostic accuracy of both strategies was compared against a gold-standard panel that made a definitive judgment by reviewing all clinical data. The study was powered to show noninferiority between the 2 techniques. The sensitivity of 100%, specificity of 96%, and diagnostic accuracy of 97% for LGE-CMR were equivalent to CA (sensitivity, 93%; specificity, 96%; and diagnostic accuracy, 95%). As a gatekeeper to CA, LGE-CMR was also found to be a cheaper diagnostic strategy in a decision tree model when United Kingdom-based costs were assumed. The economic merits of this model would change, depending on the relative costs of LGE-CMR and CA in any specific healthcare system. CONCLUSION: This study showed that LGE-CMR is a safe, clinically effective, and potentially economical gatekeeper to CA in patients presenting with heart failure of uncertain etiology.

Cardiovascular magnetic resonance in pulmonary hypertension.

Pulmonary hypertension represents a group of conditions characterized by higher than normal pulmonary artery pressures. Despite improved treatments, outcomes in many instances remain poor. In recent years, there has been growing interest in the use of cardiovascular magnetic resonance (CMR) in patients with pulmonary hypertension. This technique offers certain advantages over other imaging modalities since it is well suited to the assessment of the right ventricle and the proximal pulmonary arteries. Reflecting the relatively sparse evidence supporting its use, CMR is not routinely recommended for patients with pulmonary hypertension. However, it is particularly useful in patient with pulmonary arterial hypertension associated with congenital heart disease. Furthermore, it has proven informative in a number of ways; illustrating how right ventricular remodeling is favorably reversed by drug therapies and providing explicit confirmation of the importance of the right ventricle to clinical outcome. This review will discuss these aspects and practical considerations before speculating on future applications.

Impact of Right Ventricular Dysfunction on Mortality in Patients Hospitalized With COVID-19, According to Race.

BACKGROUND: Epidemiologic studies suggest that Black, Asian, and minority ethnic (BAME) patients may be at risk of worse outcomes from coronavirus disease-2019 (COVID-19), but the pathophysiological drivers for this association are unknown. This study sought to investigate the relationship between findings on echocardiography, mortality, and race in COVID-19 pneumonia. METHODS: This was a multicentre, retrospective, observational study including 164 adults (aged 61 ± 13 years; 78% male; 36% BAME) hospitalized with COVID-19 undergoing echocardiography between March 16 and May 9, 2020 at 3 days (interquartile range 2-5) from admission. The primary outcome was all-cause mortality. RESULTS: After a median follow-up of 31 days (interquartile range 14-42 days), 66 (40%) patients had died. The right ventricle was dilated in 62 (38%) patients, and 58 (35%) patients had right ventricular (RV) systolic dysfunction. Only 2 (1%) patients had left ventricular (LV) dilatation, and 133 (81%) had normal or hyperdynamic LV systolic function. Reduced tricuspid annulus planar systolic excursion was associated with elevated D-dimer (ρ = -0.18, P = 0.025) and high-sensitivity cardiac Troponin (ρ = -0.30, P < 0.0001). Reduced RV systolic function (hazard ratio 1.80; 95% confidence interval, 1.05-3.09; P = 0.032) was an independent predictor of all-cause mortality after adjustment for demographic and clinical risk factors. Comparing white and BAME individuals, there were no differences in echocardiography findings, biomarkers, or mortality. CONCLUSIONS: In patients hospitalized with COVID-19 pneumonia, reduced RV systolic function is prevalent and associated with all-cause mortality. There is, however, no racial variation in the early findings on echocardiography, biomarkers, or mortality.

CONTEXTE: Des études épidémiologiques suggèrent que les patients noirs, asiatiques et appartenant à des minorités ethniques (BAME) auraient un risque accru d'aggravation de la maladie à coronavirus 2019 (COVID-19), mais les facteurs physiopathologiques de cette association sont inconnus. Cette étude a cherché à étudier la relation entre les données d'échocardiographie, de mortalité, de l'origine ethnique avec la pneumonie associée à la COVID-19. MÉTHODES: Il s'agit d'une étude observationnelle rétrospective multicentrique portant sur 164 adultes (âgés de 61 ± 13 ans; 78 % d'hommes; 36 % de BAME) hospitalisés pour la COVID-19 et soumis à une échocardiographie entre le 16 mars et le 9 mai 2020, trois jours (écart interquartile 2-5) après leur admission. Le critère principal d'évaluation était la mortalité, toutes causes confondues. RÉSULTATS: Après un suivi médian de 31 jours (intervalle interquartile 14-42 jours), 66 (40 %) patients sont décédés. Le ventricule droit était dilaté chez 62 (38 %) des patients, et 58 (35 %) patients présentaient une dysfonction systolique du ventricule droit (VD). Seuls deux (1 %) patients présentaient une dilatation du ventricule gauche (VG), et 133 (81 %) avaient une fonction systolique VG normale ou en état hyperdynamique. Une réduction du déplacement systolique de l'anneau tricuspide a été associée à un taux de D-dimère élevé (ρ = -0,18, P = 0,025) et à une Troponine cardiaque de haute sensibilité (ρ = -0,30, P < 0,0001). Une fonction systolique VD réduite (rapport de risque de 1,80; intervalle de confiance à 95 %, 1,05-3,09 ; P = 0,032) était un facteur prédicteur indépendant pour la mortalité, toutes causes confondues, après ajustement pour les facteurs de risque démographiques et cliniques. En comparant les individus blancs et BAME, aucune différence n'a été constatée concernant les résultats d'échocardiographie, les biomarqueurs ou la mortalité. CONCLUSIONS: Chez les patients hospitalisés pour une pneumonie liée à la COVID-19, une réduction de la fonction systolique VD est apparue comme prévalente et associée à la mortalité, toutes causes confondues. Il n'y a cependant aucune influence de l'ethnicité en rapport avec les premiers résultats d'échocardiographie, des biomarqueurs ou de la mortalité.

Measuring the heart in pulmonary arterial hypertension (PAH): implications for trial study size.

PURPOSE: To calculate the sample size for a theoretical pulmonary arterial hypertension (PAH) randomized controlled trial (RCT) by using cardiovascular magnetic resonance (CMR) imaging to determine the repeatability of measures between two scans. MATERIALS AND METHODS: Two same-day examinations from 10 PAH patients were analyzed manually and semiautomatically. Study size was calculated from the standard deviation (SD) of repeatability. Different approaches to right-ventricle (RV) mass were investigated, agreement between methods tested and interobserver reproducibility measured by Bland-Altman analysis to explore how the PAH heart might be best measured. RESULTS: Repeatability was good for almost all manually-measured indices but poor for semiautomated measurement of RV mass and left-ventricle (LV) end-diastolic volume (EDV). Thus, for an RCT (power, 80%; significance level, 5%) analyzing "outcome" indices (RVEDV, LVEDV, RV ejection fraction, and RV mass; anticipated change: 10 mL, 10 mL, 3%, and 10 g, respectively) manually, 34 patients are required compared to 78 if analysis is semiautomated. RV mass was repeatable if the interventricular septum was divided between ventricles or if wholly apportioned to the LV. Limits of agreement between manual and semiautomated analyses were unsatisfactory for RV measures and interobserver reproducibility was worse for semiautomated than manual analysis. CONCLUSION: Manual is more robust than semiautomated analysis and at present should be favored in RCTs in PAH as it leads to lower sample size requirements.

Echocardiographic Findings in Patients With COVID-19 Pneumonia.

The aim of this study was to characterize the echocardiographic phenotype of patients with COVID-19 pneumonia and its relation to biomarkers. Seventy-four patients (59 ± 13 years old, 78% male) admitted with COVID-19 were included after referral for transthoracic echocardiography as part of routine care. A level 1 British Society of Echocardiography transthoracic echocardiography was used to assess chamber size and function, valvular disease, and likelihood of pulmonary hypertension. The chief abnormalities were right ventricle (RV) dilatation (41%) and RV dysfunction (27%). RV impairment was associated with increased D-dimer and C-reactive protein levels. In contrast, left ventricular function was hyperdynamic or normal in most (89%) patients.

Endovascular stent-associated infection with Staphylococcus lugdunensis.

An elderly woman presented febrile 5 days after stenting of multiple coronary arteries. Echocardiography showed a thickening of the aortic root, raising the possibility of stent infection. Four  of four blood culture bottles grew Staphylococcus lugdunensis and repeat echo showed an aortic root abscess. Despite appropriate antibiotic treatment, the patient died. A 24-year-old man with a ventricular septal defect presented febrile 4 weeks after stenting of an aortic coarctation. Initial transoesophageal echo found no vegetations around the stent or elsewhere. Four of six blood culture bottles grew S lugdunensis. Following an episode of hypoxia, the imaging was repeated and a new large vegetation was seen on the pulmonary valve with two thin-walled cavities in the lungs on a CT pulmonary angiogram. The patient was treated with a long course of appropriate antibiotic therapy and discharged from hospital 6 weeks later.

Assessing normal pulse wave velocity in the proximal pulmonary arteries using transit time: a feasibility, repeatability, and observer reproducibility study by cardiovascular magnetic resonance.

PURPOSE: To calculate pulse wave velocity (PWV) in the proximal pulmonary arteries (PAs) by cardiovascular magnetic resonance (CMR) using the transit-time method, and address respiratory variation, repeatability, and observer reproducibility. MATERIALS AND METHODS: A 1.9-msec interleaved phase velocity sequence was repeated three times consecutively in 10 normal subjects. Pulse wave (PW) arrival times (ATs) were determined for the main and branch PAs. The PWV was calculated by dividing the path length traveled by the difference in ATs. Respiratory variation was considered by comparing acquisitions with and without respiratory gating. RESULTS: For navigated data the mean PWVs for the left PA (LPA) and right PA (RPA) were 2.09 +/- 0.64 m/second and 2.33 +/- 0.44 m/second, respectively. For non-navigated data the mean PWVs for the LPA and RPA were 2.14 +/- 0.41 m/second and 2.31 +/- 0.49 m/second, respectively. No statistically significant difference was found between respiratory non-navigated data and navigated data. Repeated on-table measurements were consistent (LPA non-navigated P = 0.95, RPA non-navigated P = 0.91, LPA navigated P = 0.96, RPA navigated P = 0.51). The coefficients of variation (CVs) were 12.2% and 12.5% for intra- and interobserver assessments, respectively. CONCLUSION: One can measure PWV in the proximal PAs using transit-time in a reproducible manner without respiratory gating.