[Benefits of cardiac magnetic resonance diagnostics in patients with heart rhythm disorders : From risk stratification to interventional procedures]. / Nutzen der kardialen Magnetresonanzdiagnostik für Patienten mit Herzrhythmusstörungen : Von der Risikostratifizierung bis zur Intervention.

Cardiac magnetic resonance imaging (cMRI) now rates among the established diagnostic procedures for the clarification of cardiac disease patterns. In modern clinical electrophysiology, apart from providing basic cardiac diagnostics of patients prior to interventional procedures, the imaging method enables the three-dimensional reconstruction of cardiac target structures of the planned ablation procedure, which can significantly improve the safety and efficacy of the intervention. Furthermore, cMRI has a high significance with respect to risk stratification during implantable cardioverter defibrillator (ICD) evaluation. In addition to an exact determination of ventricular function, its capability for detailed tissue characterization enables the visualization and quantification of fibrotic lesions and scar tissue as potential arrhythmogenic triggers. This anatomic assignment also enables an increased accuracy of the ablation of substrate-based arrhythmia. In comparison to this the interventional cMRI as a direct interface between cMRI and invasive electrophysiology represents a comparably new field of application. Initial clinical experiences in the field of ablation of typical atrial fibrillation could not only confirm the feasibility of the concept but also enabled recognition of the clear advantages of an imaging-guided electrophysiological procedure.

Evaluation of the right heart using cardiovascular magnetic resonance imaging in patients with cardiac devices.

BACKGROUND: Patients with cardiac implantable electronic devices (CIED) necessitate comprehensive cardiovascular magnetic resonance (CMR) examinations. The aim of this study was to provide data on CMR image quality and feasibility of functional assessment of the right heart in patients with CIED depending on the device type and imaging sequence used. METHODS: 120 CIED carriers (Insertable cardiac monitoring system, n = 13; implantable loop-recorder, n = 22; pacemaker, n = 30; implantable cardioverter-defibrillator (ICD), n = 43; and cardiac resynchronization therapy defibrillator (CRT-D), n = 12) underwent clinically indicated CMR imaging using a 1.5 T. CMR protocols consisted of cine imaging and myocardial tissue characterization including T1-and T2-weighted blackblood imaging and late gadolinium enhancement (LGE) imaging. Image quality was evaluated with regard to device-related imaging artifacts per right-ventricular (RV) segment. RESULTS: RV segmental evaluability was influenced by the device type and CMR imaging sequence: Cine steady-state-free-precision (SSFP) imaging was found to be non-diagnostic in patients with ICD/CRT-D and implantable loop recorders; a significant improvement of image quality was achieved when using cine turbo-field-echo (TFE) sequences with a further improvement on post-contrast TFE imaging. LGE scans were artifact-free in at least 91% of RV segments with best results in patients with a pacemaker or an insertable cardiac monitoring system. CONCLUSIONS: In patients with CIED, artifact-free CMR imaging of the right ventricle was performed in the majority of patients and resulted in highly reproducible evaluability of RV functional parameters. This finding is of particular importance for the diagnosis and follow-up of right-ventricular diseases.

[Management of syncope in clinical practice : What has changed according to the new ESC guidelines 2018?] / Synkopenmanagement in der Praxis : Was ändert sich gemäß den neuen ESC-Leitlinien 2018?

Syncope is a common problem in clinical practice, which affects approximately 1% of patients admitted to European emergency departments. The clinical practice guidelines for the diagnosis and management of syncope published by the European Society of Cardiology (ESC) are based on the newest scientific data in the field and have provided clinical cardiologists with a structured therapeutic approach for affected patients over many years. The previous ESC guidelines on syncope were published in 2009 and are compared to the most recent edition, which was published in 2018. This review summarizes the most important innovations with respect to the diagnostic principles and treatment of syncope. The initial assessment of the patient and the risk stratification in the emergency department are the focus of the review. Another important topic that is adequately covered in the current guidelines is the rising significance of implantable loop recorders for the evaluation of unexplained syncope and the assessment of potential indications for a definitive treatment with a pacemaker or implantable cardioverter defibrillator (ICD). Additional changes involve the evidence level with respect to the use of other diagnostic (ECG monitoring, tilt testing) and therapeutic measures (indications for pacemaker implantation, catheter ablation of tachycardiac rhythm disorders).

Comprehensive morphologic and functional imaging of heart transplant patients: first experience with dynamic perfusion CT.

OBJECTIVES: We aimed to assess the diagnostic performance of a combined protocol with coronary computed tomography angiography (CCTA) and stress CT perfusion imaging (CTP) in heart transplant patients for comprehensive morphological and functional imaging. METHODS: In this prospective study, 13 patients undergoing routine follow-up 8±6 years after heart transplantation underwent CCTA and dynamic adenosine stress CTP using a third-generation dual-source CT scanner, cardiac magnetic resonance (MR) adenosine stress perfusion imaging at 1.5 T, and catheter coronary angiography. In CCTA stenoses >50% luminal diameter narrowing were noted. Myocardial perfusion deficits were documented in CTP and MR. Quantitative myocardial blood flow (MBF) was calculated with CTP. Left ventricular ejection fraction was determined on cardiac MR cine images. Radiation doses of CT were determined. RESULTS: One of the 13 patients had to be excluded because of severe motion artifacts. CCTA identified three patients with stenosis >50%, which were confirmed with catheter coronary angiography. CTP showed four patients with stress-induced myocardial hypoperfusion, which were confirmed by MR stress perfusion imaging. Quantitative analysis of global MBF showed lower mean values as compared to known reference values (MBF under stress 125.5 ± 34.5 ml/100 ml/min). Average left ventricular ejection fraction was preserved (56 ± 5%). CONCLUSIONS: In heart transplant patients, a comprehensive CT protocol for the assessment of morphology and function including CCTA and CTP showed good concordance to results from MR perfusion imaging and catheter coronary angiography. KEY POINTS: • Stress CT perfusion imaging enables the detection of myocardial ischemia • CT myocardial perfusion imaging can be combined with coronary computed tomography angiography • Combining perfusion and coronary CT imaging is accurate in heart transplant patients • CT myocardial perfusion imaging can be performed at a reasonable radiation dose.