Right Ventricular Volumes and Systolic Function by Cardiac Magnetic Resonance and the Impact of Sex, Age, and Obesity in a Longitudinally Followed Cohort Free of Pulmonary and Cardiovascular Disease: The Framingham Heart Study.

BACKGROUND: Cardiac magnetic resonance is uniquely well suited for noninvasive imaging of the right ventricle. We sought to define normal cardiac magnetic resonance reference values and to identify the main determinants of right ventricular (RV) volumes and systolic function using a modern imaging sequence in a community-dwelling, longitudinally followed cohort free of clinical cardiovascular and pulmonary disease. METHODS AND RESULTS: The Framingham Heart Study Offspring cohort has been followed since 1971. We scanned 1794 Offspring cohort members using steady-state free precession cardiac magnetic resonance and identified a reference group of 1336 adults (64±9 years, 576 men) free of prevalent cardiovascular and pulmonary disease. RV trabeculations and papillary muscles were considered cavity volume. Men had greater RV volumes and cardiac output before and after indexation to body size (all P<0.001). Women had higher RV ejection fraction than men (68±6% versus 64±7%; P<0.0001). RV volumes and cardiac output decreased with advancing age. There was an increase in raw and height-indexed RV measurements with increasing body mass index, but this trend was weakly inverted after indexation of RV volumes to body surface area. Sex, age, height, body mass index, and heart rate account for most of the variability in RV volumes and function in this community-dwelling population. CONCLUSIONS: We report sex-specific normative values for RV measurements among principally middle-aged and older adults. RV ejection fraction is greater in women. RV volumes increase with body size, are greater in men, and are smaller in older people. Body surface area seems to be appropriate for indexation of cardiac magnetic resonance-derived RV volumes.

Prognostic value of pulmonary vein size in prediction of atrial fibrillation recurrence after pulmonary vein isolation: a cardiovascular magnetic resonance study.

BACKGROUND: The relationship between pulmonary vein (PV) anatomy and successful catheter ablation of atrial fibrillation (AF) is poorly understood METHODS: First-pass contrast enhanced PV magnetic resonance angiography was performed in 71 consecutive patients prior to PV isolation. PV diameter and cross-sectional area (CSA) were measured prior to PV isolation. Any symptomatic or asymptomatic AF >10s was considered a recurrence. Early recurrence was defined as recurrent AF ≤30 days after PV isolation, while late recurrence of AF was defined as recurrent AF >30 days after. RESULTS: At 1 year, 57% had any recurrence of AF while 41% had late recurrence of AF. Study subjects with one or more PV diameter in the top 10(th) percentile had trend toward more early recurrent AF (HR 1.99, p = 0.053). Study subjects with one or more PV CSA in the top 10th percentile had more late recurrent AF (HR 2.25, p = 0.039) and a trend toward more early recurrent AF (HR 1.94, p = 0.064). With multivariate analysis, PV size was not associated with early recurrent AF, but late recurrent AF was associated with one or more large PV, increased left atrial size, and non-paroxysmal AF. Study subjects with all three of these risk factors had a 100% rate of late recurrent AF at 1 year, while those with none had a 7% rate of late recurrent AF. CONCLUSIONS: Larger PV size is independently associated with more late recurrent AF after PV isolation. Determination of PV size prior to PV isolation may predict procedural success.

Impact of age, sex, and indexation method on MR left ventricular reference values in the Framingham Heart Study offspring cohort.

PURPOSE: To determine normative values for left ventricular (LV) volumes, mass, concentricity, and ejection fraction (EF) and investigate associations between sex, age, and body size with LV parameters in community-dwelling adults. MATERIALS AND METHODS: In all, 1794 Framingham Heart Study Offspring cohort members underwent LV short-axis oriented, contiguous multislice cine steady-state free precession MR of the left ventricle; from these a healthy referent group (n = 852, 61 ± 9 years, 40% men) free of clinical cardiac disease and hypertension (SBP < 140, DBP < 90 mmHg, never used antihypertensive medication ≥30 years prior to scanning) was identified. Referent participants were stratified by sex and age group (≤55, 56-65, >65 years); LV parameters were indexed to measures of body size. RESULTS: Men have greater LV volumes and mass than women both before and after indexation to height, powers of height, and body surface area (P < 0.01 all), but indexation to fat-free mass yielded greater LV volume and mass in women. In both sexes, LV volumes and mass decrease with advancing age, although indexation attenuates this association. LVEF is greater in women than men (68 ± 5% vs. 66 ± 5%, P < 0.01) and increases with age in both sexes (P < 0.05). CONCLUSION: Among nonhypertensive adults free of cardiac disease, men have greater LV volumes and mass with sex differences generally persisting after indexation to body size. LV volumes and mass tend to decrease with greater age in both sexes. Female sex and advanced age were both associated with greater LVEF. J. Magn. Reson. Imaging 2015;41:1038-1045. © 2014 Wiley Periodicals, Inc.

Atherosclerotic biomarkers and aortic atherosclerosis by cardiovascular magnetic resonance imaging in the Framingham Heart Study.

BACKGROUND: The relations between subclinical atherosclerosis and inflammatory biomarkers have generated intense interest but their significance remains unclear. We sought to determine the association between a panel of biomarkers and subclinical aortic atherosclerosis in a community-based cohort. METHODS AND RESULTS: We evaluated 1547 participants of the Framingham Heart Study Offspring cohort who attended the 7th examination cycle and underwent both cardiovascular magnetic resonance imaging (CMR) and assays for 10 biomarkers associated with atherosclerosis: high-sensitivity C-reactive protein, fibrinogen, intercellular adhesion molecule-1, interleukin-6, interleukin-18, lipoprotein-associated phospholipase-A2 activity and mass, monocyte chemoattractant protein-1, P-selectin, and tumor necrosis factor receptor-2. In logistic regression analysis, we found no significant association between the biomarker panel and the presence of aortic plaque (global P=0.53). Using Tobit regression with aortic plaque as a continuous variable, we noted a modest association between biomarker panel and aortic plaque volume in age- and sex-adjusted analyses (P=0.003). However, this association was attenuated after further adjustment for clinical covariates (P=0.09). CONCLUSIONS: In our community-based cohort, we found no significant association between our multibiomarker panel and aortic plaque. Our results underscore the strengths and limitations of the use of biomarkers for the identification of subclinical atherosclerosis and the importance of traditional risk factors.

Correlation of trabeculae and papillary muscles with clinical and cardiac characteristics and impact on CMR measures of LV anatomy and function.

OBJECTIVES: The goal of this study was to assess the relationship of left ventricular (LV) trabeculae and papillary muscles (TPM) with clinical characteristics in a community-based, free-living adult cohort and to determine the effect of TPM on quantitative measures of LV volume, mass, and ejection fraction (EF). BACKGROUND: Hypertrabeculation has been associated with adverse cardiovascular events, but the distribution and clinical correlates of the volume and mass of the TPM in a normal left ventricle have not been well characterized. METHODS: Short-axis cine cardiac magnetic resonance images, obtained using a steady-state free precession sequence from 1,494 members of the Framingham Heart Study Offspring cohort, were analyzed with software that automatically segments TPM. Absolute TPM volume, TPM as a fraction of end-diastolic volume (EDV) (TPM/EDV), and TPM mass as a fraction of LV mass were determined in all offspring and in a referent group of offspring free of clinical cardiovascular disease and hypertension. RESULTS: In the referent group (mean age 61 ± 9 years; 262 men and 423 women), mean TPM was 23 ± 3% of LV EDV in both sexes (p = 0.9). TPM/EDV decreased with age (p < 0.02) but was not associated with body mass index. TPM mass as a fraction of LV mass was inversely correlated with age (p < 0.0001), body mass index (p < 0.018), and systolic blood pressure (p < 0.0001). Among all 1,494 participants (699 men), LV volumes decreased 23%, LV mass increased 28%, and EF increased by 7.5 EF units (p < 0.0001) when TPM were considered myocardial mass rather than part of the LV blood pool. CONCLUSIONS: Global cardiac magnetic resonance LV parameters were significantly affected by whether TPM was considered as part of the LV blood pool or as part of LV mass. Our cross-sectional data from a healthy referent group of adults free of clinical cardiovascular disease demonstrated that TPM/EDV decreases with increasing age in both sexes but is not related to hypertension or obesity.

Usefulness of the left ventricular myocardial contraction fraction in healthy men and women to predict cardiovascular morbidity and mortality.

We sought to determine whether depressed myocardial contraction fraction (MCF; ratio of left ventricular [LV] stroke volume to myocardial volume) predicts cardiovascular disease (CVD) events in initially healthy adults. A subset (n = 318, 60 ± 9 years old, 158 men) of the Framingham Heart Study Offspring cohort free of clinical CVD underwent volumetric cardiovascular magnetic resonance imaging in 1998 through 1999. LV ejection fraction (EF), mass, and MCF were determined. "Hard" CVD events consisted of cardiovascular death, myocardial infarction, stroke, or new heart failure. A Cox proportional hazards model adjusting for Framingham Coronary Risk Score was used to estimate hazard ratios for incident hard CVD events for gender-specific quartiles of MCF, LV mass, and LVEF. The lowest quartile of LV mass and highest quartiles of MCF and EF served as referents. Kaplan-Meier survival plots and log-rank test were used to compare event-free survival. MCF was greater in women (0.58 ± 0.13) than in men (0.52 ± 0.11, p <0.01). Nearly all participants (99%) had EF ≥0.55. During an up to 9-year follow-up (median 5.2), 31 participants (10%) developed an incident hard CVD event. Lowest-quartile MCF was 7 times more likely to develop a hard CVD (hazard ratio 7.11, p = 0.010) compared to the remaining quartiles, and increased hazards persisted even after adjustment for LV mass (hazard ratio 6.09, p = 0.020). The highest-quartile LV mass/height 2.7 had a nearly fivefold risk (hazard ratio 4.68, p = 0.016). Event-free survival was shorter in lowest-quartile MCF (p = 0.0006) but not in lowest-quartile LVEF. In conclusion, in a cohort of adults initially without clinical CVD, lowest-quartile MCF conferred an increased hazard for hard CVD events after adjustment for traditional CVD risk factors and LV mass.

Relationship between central and peripheral atherosclerosis and left ventricular dysfunction in a community population.

We aimed to determine the relationships between resting left ventricular (LV) wall motion abnormalities (WMAs), aortic plaque, and peripheral artery disease (PAD) in a community cohort. A total of 1726 Framingham Heart Study Offspring Cohort participants (806 males, 65 ± 9 years) underwent cardiovascular magnetic resonance with quantification of aortic plaque volume and assessment of regional left ventricular systolic function. Claudication, lower extremity revascularization, and ankle-brachial index (ABI) were recorded at the most contemporaneous examination visit. WMAs were associated with greater aortic plaque burden, decreased ABI, and claudication in age- and sex-adjusted analyses (all p < 0.001), which were not significant after adjustment for cardiovascular risk factors. In age- and sex-adjusted analyses, both the presence (p < 0.001) and volume of aortic plaque were associated with decreased ABI (p < 0.001). After multivariable adjustment, an ABI ≤ 0.9 or prior revascularization was associated with a threefold odds of aortic plaque (p = 0.0083). Plaque volume significantly increased with decreasing ABI in multivariable-adjusted analyses (p < 0.0001). In this free-living population, associations of WMAs with aortic plaque burden and clinical measures of PAD were attenuated after adjustment for coronary heart disease risk factors. Aortic plaque volume and ABI remained strongly negatively correlated after multivariable adjustment. Our findings suggest that the association between coronary heart disease and non-coronary atherosclerosis is explained by cardiovascular risk factors. Aortic atherosclerosis and PAD remain strongly associated after multivariable adjustment, suggesting shared mechanisms beyond those captured by traditional risk factors.

Subclinical and clinical correlates of left ventricular wall motion abnormalities in the community.

The prevalence and clinical correlates of left ventricular (LV) wall motion abnormalities (WMAs), associated with morbidity and mortality, have not been well-characterized in the population. Framingham Heart Study Offspring Cohort participants (n = 1,794, 844 men, age 65 ± 9 years) underwent cine cardiovascular magnetic resonance for evaluation of LV function. A subset (n = 1,009, 460 men) underwent cardiac multidetector computed tomography for analysis of coronary artery calcium. The presence of coronary heart disease and heart failure (CHD-HF) were assessed in relation to the presence of WMAs. WMAs were present in 117 participants (6.5%) and were associated with male gender, elevated hemoglobin A1c, LV mass, LV end-diastolic volume, and lower LV ejection fraction. Of the 1,637 participants without CHD-HF, 68 (4.2%) had WMAs. In this group, WMAs were associated with obesity, hypertension, and Framingham coronary heart disease risk score in the age- and gender-adjusted analyses and were associated with male gender and hypertension on multivariate analysis. Most subjects with WMAs were in the greatest coronary artery calcium groups. The presence of coronary artery calcium greater than the seventy-fifth percentile and Agatston score >100 were associated with a greater than twofold risk of WMAs in the age- and gender-adjusted analysis but were no longer significant when additionally adjusted for CHD-HF. Previous Q-wave myocardial infarction was present in 29% of the 117 participants with WMAs. In conclusion, in the present longitudinally followed free-living population, 4.2% of the participants without CHD-HF had WMAs. WMAs were associated with the clinical parameters associated with cardiovascular disease risk. Aggressive risk factor modification may be prudent for subjects with WMAs, particularly those free of clinical CHD-HF.

CMR predictors of mitral regurgitation in mitral valve prolapse.

OBJECTIVES: We sought to assess the correlation between mitral valve characteristics and severity of mitral regurgitation (MR) in subjects with mitral valve prolapse (MVP) undergoing cardiac magnetic resonance (CMR) imaging. BACKGROUND: Compared with extensive echocardiographic studies, CMR predictors of MVP-related MR are unknown. The severity of MR at the time of diagnosis has prognostic implication for patients; therefore, the identification of determinants of MR and its progression may be important for risk stratification, follow-up recommendations, and surgical decision making. METHODS: Seventy-one MVP patients (age 54 ± 11 years, 58% males, left ventricular [LV] ejection fraction 65 ± 5%) underwent cine CMR to assess annular dimensions, maximum systolic anterior and posterior leaflet displacement, papillary muscle (PM) distance to coaptation point and prolapsed leaflets, as well as diastolic anterior and posterior leaflet thickness and length, and LV volumes and mass. Velocity-encoded CMR was used to obtain aortic outflow and to quantify MR volume. RESULTS: Using multiple linear regression analysis including all variables, LV mass (p < 0.001), anterior leaflet length (p = 0.006), and posterior displacement (p = 0.01) were the best determinants of MR volume with a model-adjusted R(2) = 0.6. When the analysis was restricted to valvular characteristics, MR volume correlated with anterior mitral leaflet length (p < 0.001), posterior mitral leaflet displacement (p = 0.003), posterior leaflet thickness (p = 0.008), and the presence of flail (p = 0.005) with a model-adjusted R(2) = 0.5. We also demonstrated acceptable intraobserver and interobserver variability in these measurements. CONCLUSIONS: Anterior leaflet length, posterior leaflet displacement, posterior leaflet thickness, and the presence of flail are the best CMR valvular determinants of MVP-related MR. The acceptable intraobserver and interobserver variability of our measurements confirms the role of CMR as an imaging modality for assessment of MVP patients with significant MR.

Evaluation of papillary muscle function using cardiovascular magnetic resonance imaging in mitral valve prolapse.

Abnormal traction and excursion of the papillary muscle (PM) can be observed in patients with mitral valve prolapse (MVP) and can adversely affect the electrophysiologic stability of the underlying myocardium. Cardiovascular magnetic resonance (CMR) techniques can directly measure the excursion and velocity of PM tips during ventricular systole. In addition, high-resolution late gadolinium enhancement (LGE) CMR imaging allows for visualization of the underlying potentially arrhythmogenic PM fibrosis substrate. We prospectively studied 16 patients with MVP and 9 healthy adult subjects using phase-contrast CMR and cine CMR to assess the PM velocity and excursion. LGE CMR was performed in 13 patients with MVP (81%). The peak PM systolic velocity and maximum PM excursion were significantly increased in those with MVP (12 +/- 5 vs 5 +/- 2 cm/s and 15 +/- 5 vs 2 +/- 3 mm, both p <0.001). Definite PM LGE was found in 6 patients (46%) but the finding did not correlate with PM velocity or excursion. In conclusion, functional CMR imaging demonstrated increased peak PM systolic velocity and excursion distance in patients with MVP. These parameters, however, did not relate to underlying PM fibrosis.

Relations of insulin resistance and glycemic abnormalities to cardiovascular magnetic resonance measures of cardiac structure and function: the Framingham Heart Study.

BACKGROUND: Data regarding the relationships of diabetes, insulin resistance, and subclinical hyperinsulinemia/hyperglycemia with cardiac structure and function are conflicting. We sought to apply volumetric cardiovascular magnetic resonance (CMR) in a free-living cohort to potentially clarify these associations. METHODS AND RESULTS: A total of 1603 Framingham Heart Study Offspring participants (age, 64+/-9 years; 55% women) underwent CMR to determine left ventricular mass (LVM), LVM to end-diastolic volume ratio (LVM/LVEDV), relative wall thickness (RWT), ejection fraction, cardiac output, and left atrial size. Data regarding insulin resistance (homeostasis model, HOMA-IR) and glycemia categories (normal, impaired insulinemia or glycemia, prediabetes, and diabetes) were determined. In a subgroup (253 men, 290 women) that underwent oral glucose tolerance testing, we related 2-hour insulin and glucose with CMR measures. In both men and women, all age-adjusted CMR measures increased across HOMA-IR quartiles, but multivariable-adjusted trends were significant only for LVM/ht(2.7) and LVM/LVEDV. LVM/LVEDV and RWT were higher in participants with prediabetes and diabetes (in both sexes) in age-adjusted models, but these associations remained significant after multivariable adjustment only in men. LVM/LVEDV was significantly associated with 2-hour insulin in men only, and RWT was significantly associated with 2-hour glucose in women only. In multivariable stepwise selection analyses, the inclusion of body mass index led to a loss in statistical significance. CONCLUSIONS: Although insulin and glucose indices are associated with abnormalities in cardiac structure, insulin resistance and worsening glycemia are consistently and independently associated with LVM/LVEDV. These data implicate hyperglycemia and insulin resistance in concentric LV remodeling.

Predictors of preserved left ventricular systolic function after surgery for chronic organic mitral regurgitation: a prospective study.

BACKGROUND AND AIM OF THE STUDY: For patients with chronic severe mitral regurgitation (MR), one consideration for the timing of mitral valve surgery is the desire to have a preserved postoperative left ventricular ejection fraction (LVEF). It was hypothesized that the preoperative left ventricular (LV) volume and effective forward LVEF (defined as the ratio of forward aortic stroke volume and LV end-diastolic volume (LVEDV)) would accurately predict the intermediate (three-month) LVEF following surgery. It was also hypothesized that at years after successful surgical correction, there would be ongoing positive ventricular remodeling with improvements in systolic function. A quantitative volumetric cardiovascular magnetic resonance (CMR) system was used prospectively to study these relationships, and to define predictors of postoperative LV systolic function after surgery for chronic severe MR. METHODS: Twenty patients (eight females, 12 males; mean age 52 +/-12 years) with chronic severe MR, who had been referred for elective mitral valve repair or replacement with chordal preservation, were prospectively enrolled. All patients underwent quantitative CMR with assessment of LV volume, LVEF, and effective forward LVEF prior to, and at three months after, surgery. Fourteen of the patients returned at a median of 27 months after valve surgery for repeat CMR. RESULTS: The preoperative LVEF was normal in 90% of patients (0.62 +/- 0.09), but the effective forward LVEF was depressed in all subjects (0.36 +/- 0.09). Compared to preoperative values, at three months after surgery the LVEF had declined by 0.16 +/- 0.08 (p < 0.001), whereas the effective forward LVEF was increased by 0.09 +/- 0.10 (p < 0.001) and the LV end-diastolic volume index (LVEDVI) had declined by 32% (p < 0.001). Multivariate analysis demonstrated a significant correlation between postoperative LVEF and both preoperative LV end-systolic volume index (LVESVI) (p = 0.003) and the preoperative effective forward LVEF (p = 0.05). A depressed postoperative LVEF (< 0.50) during the early period was best predicted by a preoperative effective forward LVEF < 0.40 (sensitivity 100%, specificity 75%). At the 27-month follow up, 12 of the 14 patients (86%) had a normal LVEF, and there was a continuing normalization of other LV parameters, including the LVEDVI and LV mass index. CONCLUSION: Among patients with chronic severe MR, the preoperative LVESVI best correlated with the three-month postoperative LVEF. A preoperative effective forward LVEF < 0.40 accurately predicted a depressed postoperative LVEE. Over the succeeding two years, there will be ongoing positive LV remodeling. If confirmed in a larger series, the effective forward LVEF may serve as a useful clinical guide for the timing of corrective surgery in this population.

Circumferential myocardial strain in cardiomyopathy with and without left bundle branch block.

BACKGROUND: Cardiac resynchronization therapy (CRT) has been shown to decrease mortality in 60-70% of advanced heart failure patients with left bundle branch block (LBBB) and QRS duration > 120 ms. There have been intense efforts to find reproducible non-invasive parameters to predict CRT response. We hypothesized that different left ventricular contraction patterns may exist in LBBB patients with depressed systolic function and applied tagged cardiovascular magnetic resonance (CMR) to assess circumferential strain in this population. METHODS: We determined myocardial circumferential strain at the basal, mid, and apical ventricular level in 35 subjects (10 with ischemic cardiomyopathy, 15 with non-ischemic cardiomyopathy, and 10 healthy controls). Patterns of circumferential strain were analyzed. Time to peak systolic circumferential strain in each of the 6 segments in all three ventricular slices and the standard deviation of time to peak strain in the basal and mid ventricular slices were determined. RESULTS: Dyskinesis of the anterior septum and the inferior septum in at least two ventricular levels was seen in 50% (5 out of 10) of LBBB patients while 30% had isolated dyskinesis of the anteroseptum, and 20% had no dyskinesis in any segments, similar to all of the non-LBBB patients and healthy controls. Peak circumferential strain shortening was significantly reduced in all cardiomyopathy patients at the mid-ventricular level (LBBB 9 +/- 6%, non-LBBB 10 +/- 4% vs. healthy 19 +/- 4%; both p < 0.0001 compared to healthy), but was similar among the LBBB and non-LBBB groups (p = 0.20). The LBBB group had significantly greater dyssynchrony compared to the non-LBBB group and healthy controls assessed by opposing wall delays and 12-segment standard deviation (LBBB 164 +/- 30 ms vs. non-LBBB 70 +/- 17 ms (p < 0.0001), non-LBBB vs. healthy 65 +/- 17 ms (p = 0.47)). CONCLUSIONS: Septal dyskinesis exists in some patients with LBBB. Myocardial circumferential strain analysis enables detailed characterization of contraction patterns, strengths, and timing in cardiomyopathy patients with and without LBBB.

Impact of papillary and trabecular muscles on quantitative analyses of cardiac function in hypertrophic cardiomyopathy.

PURPOSE: To examine the impact of cardiovascular magnetic resonance (CMR) partitioning methods on volumetric analysis in hypertrophic cardiomyopathy (HCM) patients. The standard CMR method for partitioning ventricular myocardium from ventricular cavity includes the myocardial papillary and trabecular muscles in the cavity volume. This approach may misrepresent ventricular mass and volume in patients with HCM due to large papillary muscles and extensive trabeculations. MATERIALS AND METHODS: Ventricular volume and mass analyses were performed in 30 patients with HCM using the standard method and a detailed method that excluded papillary and trabecular muscles from the left ventricular (LV) volume while including them in LV mass. We also analyzed the degree of mitral regurgitation and compared the results with Doppler echocardiography in a subgroup of 12 patients. Interobserver variability was assessed. RESULTS: The detailed method yielded 17% higher indexed LV mass, 20% lower indexed LV diastolic volume, 13% higher LV ejection fraction (EF) (all P < 0.0001). The resultant mitral regurgitant volumes using the detailed method had less discrepancy with Doppler echocardiography results compared with the results from the standard methods. Interobserver variability was similar by both methods. CONCLUSION: For patients with HCM, a detailed analysis in which the ventricular papillary and trabecular muscles are excluded from LV volume is preferred.

Noncardiac pathology on clinical cardiac magnetic resonance imaging.

OBJECTIVES: We sought to determine the prevalence of noncardiac pathology in a large consecutive series of patients referred for clinical cardiac magnetic resonance (CMR) studies. BACKGROUND: The imaging field for many CMR sequences extends outside of the heart border. As a result, noncardiac pathology may be identified. These noncardiac findings have clinical significance because they often lead to subsequent imaging/testing and intervention. The prevalence of noncardiac findings on clinical CMR studies has not been well described. METHODS: The reports of all 1,534 (62% male, age 50 +/- 15 years) clinical CMR studies performed at an academic medical center during calendar years 2002 to 2006 were reviewed. All studies had been interpreted by both a staff cardiologist (level III trained in CMR) and a board-certified radiologist (with fellowship training in CMR). For each study, sex, age, indication for CMR study, and reported noncardiac pathology were extracted. Follow-up for each major noncardiac pathology was evaluated by reviewing the patient's medical center electronic medical record. These noncardiac pathologies were then categorized as significant if an intervention or change in the patient's management ensued. RESULTS: A total of 116 (7.6%) studies had at least one noncardiac finding. These findings included 55 major findings (e.g., lymphadenopathy, lung abnormalities, mediastinal masses) in 48 distinct reports (prevalence of 3.1%) and 74 minor findings (e.g., small pleural effusions, liver cysts, renal cysts) in 70 distinct reports (prevalence of 4.6%). The majority (62%) of major findings were previously known, with only 8 findings in 6 (0.4%) of 1,534 reports ultimately deemed to be new and clinically important/significant. The age of those with noncardiac pathology was greater (54 +/- 16 years vs. 49 +/- 16 years, p < 0.001). CONCLUSIONS: In this large series of consecutive clinical CMR studies interpreted by both staff cardiologists and radiologists, noncardiac pathology is uncommonly reported. When reported, the majority of major findings are previously known. New major findings were detected in <0.5% of reports.

A systematic approach to performing a comprehensive transesophageal echocardiogram. A call to order.

BACKGROUND: While the order for a clinical transthoracic examination is fairly standardized, there is considerable variability between laboratories and even among physicians in the same laboratory with regard to the order for transesophageal echocardiograms (TEE). A systematic approach is desirable for more efficient use of physician and patient time, avoidance of inadvertent omission of important views, and to facilitate study review. METHODS: We propose a standardized approach to TEE data acquisition in which cardiac structures are systematically identified and characterized at sequential positions and imaging planes to facilitate organized, efficient and comprehensive assessment. RESULTS: Our approach to TEE study begins in the mid-esophagus with the imaging plane at 0 degrees. Based on the specific indication for the TEE, a cardiac structure (e.g., mitral valve, left atrial appendage, or interatrial septum) is chosen as the primary focal point for a comprehensive, multiplane analysis. This structure is assessed in 20 degrees-30 degrees increments as the imaging plane is advanced from 0 degrees to 165 degrees . Using the aortic valve as a reference point, pertinent cardiac structures are then assessed as the imaging plane is reduced to 135 degrees, to 90 degrees, to 40 - 60 degrees and then back to 0 degrees. The probe is then advanced into the stomach to obtain transgastric images at 0 degrees, 90 degrees, and 120 degrees. Finally, the thoracic aorta and pulmonary artery are assessed as the probe is withdrawn from the body. Using this method, an organized and comprehensive TEE can be performed in 10-15 minutes. CONCLUSION: A standardized and systematic TEE approach is described for efficient and comprehensive TEE study.

Whole heart magnetization-prepared steady-state free precession coronary vein MRI.

PURPOSE: To compare two coronary vein imaging techniques using whole-heart balanced steady-state free precession (SSFP) and a targeted double-oblique spoiled gradient-echo (GRE) sequences in combination with magnetization transfer (MT) preparation sequence for tissue contrast improvement. MATERIALS AND METHODS: Nine healthy subjects were imaged with the proposed technique. The results are compared with optimized targeted MT prepared GRE acquisitions. Both quantitative and qualitative analyses were performed to evaluate each imaging method. RESULTS: Whole-heart images were successfully acquired with no visible image artifact in the vicinity of the coronary veins. The anatomical features and visual grading of both techniques were comparable. However, the targeted small slab acquisition of the left ventricular lateral wall was superior to whole-heart acquisition for visualization of relevant information for cardiac resynchronization therapy (CRT) lead implantation. CONCLUSION: We demonstrated the feasibility of whole-heart coronary vein MRI using a 3D MT-SSFP imaging sequence. A targeted acquisition along the lateral left ventricular wall is preferred for visualization of branches commonly used in CRT lead implantation.

Accuracy of electrocardiographic criteria for atrial enlargement: validation with cardiovascular magnetic resonance.

BACKGROUND: Anatomic atrial enlargement is associated with significant morbidity and mortality. However, atrial enlargement may not correlate with clinical measures such as electrocardiographic (ECG) criteria. Past studies correlating ECG criteria with anatomic measures mainly used inferior M-mode or two-dimensional echocardiographic data. We sought to determine the accuracy of the ECG to predict anatomic atrial enlargement as determined by volumetric cardiovascular magnetic resonance (CMR). METHODS: ECG criteria for left (LAE) and right atrial enlargement (RAE) were compared to CMR atrial volume index measurements for 275 consecutive subjects referred for CMR (67% males, 51 +/- 14 years). ECG criteria for LAE and RAE were assessed by an expert observer blinded to CMR data. Atrial volume index was computed using the biplane area-length method. RESULTS: The prevalence of CMR LAE and RAE was 28% and 11%, respectively, and by any ECG criteria was 82% and 5%, respectively. Though nonspecific, the presence of at least one ECG criteria for LAE was 90% sensitive for CMR LAE. The individual criteria P mitrale, P wave axis < 30 degrees , and negative P terminal force in V1 (NPTF-V1) > 0.04s.mm were 88-99% specific although not sensitive for CMR LAE. ECG was insensitive but 96-100% specific for CMR RAE. CONCLUSION: The presence of at least one ECG criteria for LAE is sensitive but not specific for anatomic LAE. Individual criteria for LAE, including P mitrale, P wave axis < 30 degrees , or NPTF-V1 > 0.04s.mm are highly specific, though not sensitive. ECG is highly specific but insensitive for RAE. Individual ECG P wave changes do not reliably both detect and predict anatomic atrial enlargement.

Cardiovascular magnetic resonance characterization of mitral valve prolapse.

OBJECTIVES: This study sought to develop cardiovascular magnetic resonance (CMR) diagnostic criteria for mitral valve prolapse (MVP) using echocardiography as the gold standard and to characterize MVP using cine CMR and late gadolinium enhancement (LGE)-CMR. BACKGROUND: Mitral valve prolapse is a common valvular heart disease with significant complications. Cardiovascular magnetic resonance is a valuable imaging tool for assessing ventricular function, quantifying regurgitant lesions, and identifying fibrosis, but its potential role in evaluating MVP has not been defined. METHODS: To develop CMR diagnostic criteria for MVP, characterize mitral valve morphology, we analyzed transthoracic echocardiography and cine CMR images from 25 MVP patients and 25 control subjects. Leaflet thickness, length, mitral annular diameters, and prolapsed distance were measured. Two- and three-dimensional LGE-CMR images were obtained in 16 MVP and 10 control patients to identify myocardial regions of fibrosis in MVP. RESULTS: We found that a 2-mm threshold for leaflet excursion into the left atrium in the left ventricular outflow tract long-axis view yielded 100% sensitivity and 100% specificity for CMR using transthoracic echocardiography as the clinical gold standard. Compared with control subjects, CMR identified MVP patients as having thicker (3.2 +/- 0.1 mm vs. 2.3 +/- 0.1 mm) and longer (10.5 +/- 0.5 mm/m(2) vs. 7.1 +/- 0.3 mm/m(2)) indexed posterior leaflets and larger indexed mitral annular diameters (27.8 +/- 0.7 mm/m(2) vs. 21.5 +/- 0.5 mm/m(2) for long axis and 22.9 +/-0.7 mm/m(2) vs. 17.8 +/- 0.6 mm/m(2) for short axis). In addition, we identified focal regions of LGE in the papillary muscles suggestive of fibrosis in 10 (63%) of 16 MVP patients and in 0 of 10 control subjects. Papillary muscle LGE was associated with the presence of complex ventricular arrhythmias in MVP patients. CONCLUSIONS: Cardiovascular magnetic resonance image can identify MVP by the same echocardiographic criteria and can identify myocardial fibrosis involving the papillary muscle in MVP patients. Hyperenhancement of papillary muscles on LGE is often present in a subgroup of patients with complex ventricular arrhythmias.

Coronary magnetic resonance imaging.

This article highlights the technical challenges and general imaging strategies for coronary MRI. This is followed by a review of the clinical results for the assessment of anomalous CAD, coronary artery aneurysms, native vessel integrity, and coronary artery bypass graft disease using the more commonly applied MRI methods. It concludes with a brief discussion of the advantages/disadvantages and clinical results comparing coronary MRI with multidetector CT (MDCT) coronary angiography.