Incremental Utility of First-Pass Perfusion CMR for Prognostic Risk Stratification of Cancer-Associated Cardiac Masses.

BACKGROUND: Cardiac magnetic resonance (CMR) differentiates cardiac metastasis (CMET) and cardiac thrombus (CTHR) based on tissue characteristics stemming from vascularity on late gadolinium enhancement (LGE). Perfusion CMR can assess magnitude of vascularity; utility for cardiac masses (CMASS) is unknown. OBJECTIVES: This study sought to determine if perfusion CMR provides diagnostic and prognostic utility for CMASS beyond binary differentiation of CMET and CTHR. METHODS: The population comprised adult cancer patients with CMASS on CMR; CMET and CTHR were defined using LGE-CMR: CMASS+ patients were matched to CMASS- control subjects for cancer type/stage. First-pass perfusion CMR was interpreted visually and semiquantitatively for CMASS vascularity, including contrast enhancement ratio (CER) (plateau vs baseline) and contrast uptake rate (CUR) (slope). Follow-up was performed for all-cause mortality. RESULTS: A total of 462 cancer patients were studied, including patients with (CMET = 173, CTHR = 69) and without CMASS on LGE-CMR. On perfusion CMR, CER and CUR were higher within CMET vs CTHR (P < 0.001); CUR yielded better performance (AUC: 0.89-0.93) than CER (AUC: 0.66-0.72) (both P < 0.001) to differentiate LGE-CMR-evidenced CMET and CTHR, although both CUR (P = 0.10) and CER (P = 0.01) typically misclassified CMET with minimal enhancement. During follow-up, mortality among CMET patients was high but variable; 47% of patients were alive 1 year post-CMR. Patients with semiquantitative perfusion CMR-evidenced CMET had higher mortality than control subjects (HR: 1.42 [95% CI: 1.06-1.90]; P = 0.02), paralleling visual perfusion CMR (HR: 1.47 [95% CI: 1.12-1.94]; P = 0.006) and LGE-CMR (HR: 1.52 [95% CI: 1.16-2.00]; P = 0.003). Among patients with CMET on LGE-CMR, mortality was highest among patients (P = 0.002) with lesions in the bottom perfusion (CER) tertile, corresponding to low vascularity. Among CMET and cancer-matched control subjects, mortality was equivalent (P = NS) among patients with lesions in the upper CER tertile (corresponding to higher lesion vascularity). Conversely, patients with CMET in the middle (P = 0.03) and lowest (lowest vascularity) (P = 0.001) CER tertiles had increased mortality. CONCLUSIONS: Perfusion CMR yields prognostic utility that complements LGE-CMR: Among cancer patients with LGE-CMR defined CMET, mortality increases in proportion to magnitude of lesion hypoperfusion.

Impact of acute TTE-evidenced cardiac dysfunction on in-hospital and outpatient mortality: A multicenter NYC COVID-19 registry study.

BACKGROUND: COVID-19 is associated with cardiac dysfunction. This study tested the relative prognostic role of left (LV), right and bi- (BiV) ventricular dysfunction on mortality in a large multicenter cohort of patients during and after acute COVID-19 hospitalization. METHODS/RESULTS: All hospitalized COVID-19 patients who underwent clinically indicated transthoracic echocardiography within 30 days of admission at four NYC hospitals between March 2020 and January 2021 were studied. Images were re-analyzed by a central core lab blinded to clinical data. Nine hundred patients were studied (28% Hispanic, 16% African-American), and LV, RV and BiV dysfunction were observed in 50%, 38% and 17%, respectively. Within the overall cohort, 194 patients had TTEs prior to COVID-19 diagnosis, among whom LV, RV, BiV dysfunction prevalence increased following acute infection (p<0.001). Cardiac dysfunction was linked to biomarker-evidenced myocardial injury, with higher prevalence of troponin elevation in patients with LV (14%), RV (16%) and BiV (21%) dysfunction compared to those with normal BiV function (8%, all p<0.05). During in- and out-patient follow-up, 290 patients died (32%), among whom 230 died in the hospital and 60 post-discharge. Unadjusted mortality risk was greatest among patients with BiV (41%), followed by RV (39%) and LV dysfunction (37%), compared to patients without dysfunction (27%, all p<0.01). In multivariable analysis, any RV dysfunction, but not LV dysfunction, was independently associated with increased mortality risk (p<0.01). CONCLUSIONS: LV, RV and BiV function declines during acute COVID-19 infection with each contributing to increased in- and out-patient mortality risk. RV dysfunction independently increases mortality risk.

Direct comparison of echocardiography speckle tracking and cardiac magnetic resonance feature tracking for quantification of right ventricular strain: a prospective intermodality study in functional mitral regurgitation.

BACKGROUND: Functional mitral regurgitation (FMR) is a known risk factor for right ventricular dysfunction (RVDYS). RV global longitudinal strain (GLS) is an emerging index of RV function; however, the magnitude of agreement between RV GLS by echocardiography (echo) and cardiac magnetic resonance (CMR) and the relative utility of each modality for both the diagnosis of RVDYS and prognostication of all-cause mortality and heart failure hospitalization remain unknown. RESULTS: 32% of patients had RVDYS (EF < 50%) on CMR, among whom there was more advanced NYHA class and lower LV and RV ejection fraction (all p < 0.05). RV GLS was impaired in patients with RVDYS whether quantified via STE or FT-CMR, with strong correlation between modalities (r = 0.81). Both STE and FT-CMR derived GLS yielded excellent detection of RVDYS (AUC 0.94 for both), paralleling similar performance for free wall strain by both modalities (FT-CMR AUC 0.94, STE AUC 0.92) with lower accuracy demonstrated by STE derived septal strain (STE AUC 0.78 and FT-CMR AUC 0.92). RV S' and TAPSE showed lower diagnostic accuracy (RV S' AUC 0.77 and TAPSE AUC 0.81). During median follow up of 51 months (IQR 42, 60 months), all-cause mortality or HF hospitalization occurred in 25% (n = 25). Both STE and FT-CMR derived RV GLS stratified risk for adverse prognosis (STE p = 0.007, FT-CMR p = 0.005) whereas conventional RV indices, TAPSE and RV S', did not (TAPSE p = 0.30, S' p = 0.69). CONCLUSION: RV GLS is a robust marker of RVDYS irrespective of modality which provides incremental diagnostic value and improves risk stratification for event free survival beyond conventional RV indices.

Myocardial Contractile Mechanics in Ischemic Mitral Regurgitation: Multicenter Data Using Stress Perfusion Cardiovascular Magnetic Resonance.

BACKGROUND: Left ventricular (LV) ischemia has been variably associated with functional mitral regurgitation (FMR). Determinants of FMR in patients with ischemia are poorly understood. OBJECTIVES: This study sought to test whether contractile mechanics in ischemic myocardium underlying the mitral valve have an impact on likelihood of FMR. METHODS: Vasodilator stress perfusion cardiac magnetic resonance was performed in patients with coronary artery disease (CAD) at multiple centers. FMR severity was confirmed quantitatively via core lab analysis. To test relationship of contractile mechanics with ischemic FMR, regional wall motion and strain were assessed in patients with inducible ischemia and minimal (≤5% LV myocardium, nontransmural) infarction. RESULTS: A total of 2,647 patients with CAD were studied; 34% had FMR (7% moderate or greater). FMR severity increased with presence (P < 0.001) and extent (P = 0.01) of subpapillary ischemia: patients with moderate or greater FMR had more subpapillary ischemia (odds ratio [OR]: 1.13 per 10% LV; 95% CI: 1.05-1.21; P = 0.001) independent of ischemia in remote regions (P = NS); moderate or greater FMR prevalence increased stepwise with extent of ischemia and infarction in subpapillary myocardium (P < 0.001); stronger associations between FMR and infarction paralleled greater wall motion scores in infarct-affected territories. Among patients with inducible ischemia and minimal infarction (n = 532), wall motion and radial strain analysis showed impaired subpapillary contractile mechanics to associate with moderate or greater FMR (P < 0.05) independent of remote regions (P = NS). Conversely, subpapillary ischemia without contractile dysfunction did not augment FMR likelihood. Mitral and interpapillary dimensions increased with subpapillary radial strain impairment; each remodeling parameter associated with impaired subpapillary strain (P < 0.05) independent of remote strain (P = NS). Subpapillary radial strain (OR: 1.13 per 5% [95% CI: 1.02-1.25]; P = 0.02) and mitral tenting area (OR: 1.05 per 10 mm2 [95% CI: 1.00-1.10]; P = 0.04) were associated with moderate or greater FMR controlling for global remodeling represented by LV end-systolic volume (P = NS): when substituting sphericity for LV volume, moderate or greater FMR remained independently associated with subpapillary radial strain impairment (OR: 1.22 per 5% [95% CI: 1.02-1.47]; P = 0.03). CONCLUSIONS: Among patients with CAD and ischemia, FMR severity and adverse mitral apparatus remodeling increase in proportion to contractile dysfunction underlying the mitral valve.

Left Atrial Strain Quantification by Intraoperative Transesophageal Echocardiography: Validation With Transthoracic Echocardiography.

OBJECTIVE: Whereas left atrial (LA) strain has been well-validated using transthoracic echocardiography (TTE), its detection using transesophageal echocardiography (TEE) has not been studied. Conventional transesophageal views are known to be limited due to the posterior location of the LA. Here, the feasibility and accuracy of the deep transgastric long-axis LA focused view for peak atrial longitudinal strain (PALS) quantification was tested. DESIGN: This was a retrospective study of patients who underwent elective cardiac surgery between 2018 and 2020. TEE deep transgastric long-axis view was compared to TTE 4-chamber atrial focused view as the reference standard. LA area, volume, and PALS were quantified independently. SETTING: At Weill Cornell Medicine, a single, large academic medical center. PARTICIPANTS: The population comprised 42 patients undergoing cardiac surgery who had a TTE and TEE within 14.9 ± 20.8 days. INTERVENTIONS: TTE, TEE, and cardiac surgery. MEASUREMENTS AND MAIN RESULTS: TEE-derived PALS strongly correlated with TTE- derived PALS (r = 0.92, p < 0.001), though absolute PALS were lower (20.7 ± 6.0% v 25.7 ± 6.8%; p < 0.001). Mean TEE-derived atrial length was similar to TTE-derived length (5.18 ± 0.61 cm v 5.24 ± 0.61 cm; p = 0.38), but mean LA area was significantly smaller (16.7 ± 3.5 cm2v 18.9 ± 3.7 cm2; p < 0.001), with significant correlations between the 2 modalities for both (r = 0.74, 0.74, respectively; all p < 0.001). CONCLUSION: This exploratory study supported the feasibility of TEE for assessing LA longitudinal strain. There was an excellent correlation between atrial strain derived via TEE versus TTE, although values tended to be smaller on TEE, and bias between values was highly variable, suggesting that the values were not interchangeable.

Impact of ascending aortic prosthetic grafts on early postoperative descending aortic biomechanics on cardiac magnetic resonance imaging.

OBJECTIVES: Among patients with ascending thoracic aortic aneurysms, prosthetic graft replacement yields major benefits but risk for recurrent aortic events persists for which mechanism is poorly understood. This pilot study employed cardiac magnetic resonance to test the impact of proximal prosthetic grafts on downstream aortic flow and vascular biomechanics. METHODS: Cardiac magnetic resonance imaging was prospectively performed in patients with thoracic aortic aneurysms undergoing surgical (Dacron) prosthetic graft implantation. Imaging included time resolved (4-dimensional) phase velocity encoded cardiac magnetic resonance for flow quantification and cine-cardiac magnetic resonance for aortic wall distensibility/strain. RESULTS: Twenty-nine patients with thoracic aortic aneurysms undergoing proximal aortic graft replacement were studied; cardiac magnetic resonance was performed pre- [12 (4, 21) days] and postoperatively [6.4 (6.2, 7.2) months]. Postoperatively, flow velocity and wall shear stress increased in the arch and descending aorta (P < 0.05); increases were greatest in hereditary aneurysm patients. Global circumferential strain correlated with wall shear stress (r = 0.60-0.72, P < 0.001); strain increased postoperatively in the native descending and thoraco-abdominal aorta (P < 0.001). Graft-induced changes in biomechanical properties of the distal native ascending aorta were associated with post-surgical changes in descending aortic wall shear stress, as evidenced by correlations (r = -0.39-0.52; P ≤ 0.05) between graft-induced reduction of ascending aortic distensibility and increased distal native aortic wall shear stress following grafting. CONCLUSIONS: Prosthetic graft replacement of the ascending aorta increases downstream aortic wall shear stress and strain. Postoperative increments in descending aortic wall shear stress correlate with reduced ascending aortic distensibility, suggesting that grafts provide a nidus for high energy flow and adverse distal aortic remodelling.