Association of QRS-T angle and Late Gadolinium Enhancement in patients with a Clinical Suspicion of Myocarditis.

Objective: To investigate the association of a wide QRS-T angle on the surface ECG and late gadolinium enhancement on contrast-enhanced cardiovascular magnetic (CMR) imaging in patients with clinically suspected myocarditis. Background: Diagnosis and risk stratification in patients with suspected myocarditis is particularly challenging due to a great spectrum of clinical presentations. Late gadolinium enhancement (LGE) visualizes myocardial necrosis and fibrosis in patients with biopsy-proven myocarditis. The presence or absence of late gadolinium enhancements in these patients is prognostically meaningful. The QRS-T angle from the surface ECG, on the other hand, may serve as a simple and easily available risk marker in suspected myocarditis. Methods: We enrolled 97 consecutive patients that were referred to CMR imaging for a clinical suspicion of myocarditis. All patients obtained a standardized digital 12-lead ECG for the calculation of the QRS-T angle and underwent contrast-enhanced CMR imaging. Patients were divided into two groups according to the absence or presence of LGE on CMR. Results: 78 of 97 patients with suspected myocarditis had LGE on CMR. Patients with LGE had wider QRS-T angles as compared to the patient group without LGE (53.95-47.5 vs. 26.2-21.2; p<0.001). The sensivity, specificity, negative predictive value and positive predictive value for a QRS-T angle above 90 degrees for LGE positive myocarditis were 16.5%, 100%, 24.7%, and 100%, respectively. Conclusion: A wide QRS-T angle of 90 degrees or more is linked to myocardial fibrosis or necrosis (late gadolinium enhancement) in patients with suspected myocarditis.

QRS-T-angle in Patients with ST-Segment Elevation Myocardial Infarction (STEMI) - a Comparison with Cardiac Magnetic Resonance Imaging.

Background: The QRS-T angle from the surface EKG is a promising prognostic marker in patients with coronary artery disease. Cardiovascular magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) offers high resolution imaging of myocardial damage. We investigated the association of the QRS-T angle and the extent of myocardial damage as assessed by LGE in patients with acute ST-segment myocardial infarction (STEMI) Methods: 169 patients with STEMI obtained a standardized digital 12-lead EKG on admission for the calculation of the QRS-T angle and underwent CMR imaging for analysis of infarct size by LGE within the first week. Patients were divided into groups: (1) abnormal QRS-T angle ≥ 90 degree and (2) QRS-T angle < 90 degree. Results: Patients with a QRS-T angle of 90 degree or more had larger infarcts (36.5±12.4 vs. 13.3±9.5; p<0.001) and lower ejection fraction (42.9±12.1% vs. 50.6±10.6%; p<0.001). Conclusion: The extent of myocardial damage as measured by the gold standard LGE is associated with a larger QRS-T angle calculated from the surface EKG.

2015 Update on Acute Adverse Reactions to Gadolinium based Contrast Agents in Cardiovascular MR. Large Multi-National and Multi-Ethnical Population Experience With 37788 Patients From the EuroCMR Registry.

OBJECTIVES: Specifically we aim to demonstrate that the results of our earlier safety data hold true in this much larger multi-national and multi-ethnical population. BACKGROUND: We sought to re-evaluate the frequency, manifestations, and severity of acute adverse reactions associated with administration of several gadolinium- based contrast agents during routine CMR on a European level. METHODS: Multi-centre, multi-national, and multi-ethnical registry with consecutive enrolment of patients in 57 European centres. RESULTS: During the current observation 37,788 doses of Gadolinium based contrast agent were administered to 37,788 patients. The mean dose was 24.7 ml (range 5-80 ml), which is equivalent to 0.123 mmol/kg (range 0.01 - 0.3 mmol/kg). Forty-five acute adverse reactions due to contrast administration occurred (0.12%). Most reactions were classified as mild (43 of 45) according to the American College of Radiology definition. The most frequent complaints following contrast administration were rashes and hives (15 of 45), followed by nausea (10 of 45) and flushes (10 of 45). The event rate ranged from 0.05% (linear non-ionic agent gadodiamide) to 0.42% (linear ionic agent gadobenate dimeglumine). Interestingly, we also found different event rates between the three main indications for CMR ranging from 0.05% (risk stratification in suspected CAD) to 0.22% (viability in known CAD). CONCLUSIONS: The current data indicate that the results of the earlier safety data hold true in this much larger multi-national and multi-ethnical population. Thus, the "off-label" use of Gadolinium based contrast in cardiovascular MR should be regarded as safe concerning the frequency, manifestation and severity of acute events.

Characteristics, management modalities and outcome in chronic systolic heart failure patients treated in tertiary care centers: results from the EVIdence based TreAtment in Heart Failure (EVITA-HF) registry.

BACKGROUND: Limited data exist regarding baseline characteristics and management of heart failure with reduced ejection fraction (EF) in tertiary care facilities. METHODS: EVITA-HF comprises web-based case report data on demography, comorbidities, diagnostic and therapy measures, quality of life, adverse events and 1-year follow-up of patients hospitalized for chronic heart failure and an ejection fraction of less than 40%. RESULTS: Between February 2009 and June 2011, a total of 1,853 consecutive, hospitalized patients (pts) were included in 16 centers in Germany. Mean age was 70 years, 76% were male. Median EF was 30%, and 63% were in NYHA III/IV. Ischemic cardiomyopathy was present in 56%, history of hypertension in 76%, diabetes in 39%, impaired renal function in 33%, thyroid dysfunction in 12%, and malignoma in 7%. Sixty-eight percent of pts had a non-elective admission. Rhythm was sinus/atrial fibrillation or flutter/pacemaker in 64, 28 and 11%, respectively. Median heart rate amounted to 80 bpm, median blood pressure to 122/74 mmHg. LBBB was present in 26% of non-pacemaker pts. Eighteen percent had an ICD or CRT-D. Medication (admission vs. discharge) consisted of ACEI or ARB in 73 vs. 88%, ß-blocker in 71 vs. 89%, mineral corticosteroid receptor antagonist (MRA) in 32 vs. 57%, diuretics in 68 vs. 83% (p < 0.001 for each). Forty-two percent of pts received a specific treatment procedure beyond pharmacotherapy, of these 48% revascularization, 39% device therapy, 14% electrical cardioversion, 5% ablation procedures, 9 % valvular procedures, 6% iv inotropes, 1.8% IABP or LVAD implantation. At discharge, 33% of survivors had ICD- or CRT-D implants. One-year mortality amounted to 16.8%, and death or rehospitalization to 56%. NYHA class III/IV was found in 30% (p < 0.001 vs. index admission), general health status was improved in 45% and unchanged in 36% of patients. Eighty-five percent of pts took ACEI or ARB, 86% ß-blockers, 47% MRA, and 78% diuretics (p < 0.001 vs. index discharge for all). CONCLUSION: Patients with chronic heart failure and low ejection fraction represent an elderly and multimorbid population. While hospitalized, they experience a significant optimization of prognosis-relevant medication, revascularization and device therapy. After 1 year, mortality is moderate; drug adherence is high and NYHA status favourable. The EVITA-HF registry is able to reflect coherently the real-world management, efforts and follow-up in heart failure pts managed in tertiary care facilities.

Cardiac MRI: T2-Mapping Versus T2-Weighted Dark-Blood TSE Imaging for Myocardial Edema Visualization in Acute Myocardial Infarction.

PURPOSE: To assess the diagnostic accuracy of T2 mapping for the detection of myocardial edema in acute myocardial infarction (AMI), and to compare this diagnostic accuracy with that of the current standard for myocardial edema imaging, which is T2w dark-blood TSE imaging. MATERIALS AND METHODS: 29 patients with AMI were examined at 1.5 T. For the visualization of myocardial edema, T2 maps, calculated from three T2w SSFP images, and T2w dark-blood TSE images were acquired in standard short- and long-axis views. Cine SSFP images were acquired for the analysis of left ventricular (LV) function and late gadolinium enhancement images (LGE) for the visualization of myocardial necrosis. The T2 maps as well as the T2w dark-blood TSE images were evaluated twice independently from the cine SSFP and LGE images. The presence or absence of myocardial edema was rated visually for each LV segment. As the standard of reference, the infarct zone was defined based on the cine SSFP and the LGE images. RESULTS: In this segment-based analysis, T2 mapping showed a sensitivity of 82 % and a specificity of 94 % for the detection of edema in the infarct zone. T2w dark-blood TSE imaging revealed a sensitivity of 50 % and a specificity of 98 %. T2 mapping showed a higher intra-rater agreement compared to T2w dark-blood TSE imaging (κ: 0.87 vs. 0.76). CONCLUSIONS: T2 mapping allows for the visualization of myocardial edema in AMI with a high sensitivity and specificity, and features better diagnostic accuracy in terms of a higher sensitivity compared to T2w dark-blood TSE imaging. Citation Format: • Naßenstein K, Nensa F, Schlosser T et al. Cardiac MRI: T2-Mapping Versus T2-Weighted Dark-Blood TSE Imaging for Myocardial Edema Visualization in Acute Myocardial Infarction. Fortschr Röntgenstr 2014; 186: 166 - 172.

[Extensive left ventricular myocardial fat deposition detected by cardiac MRI]. / Ausgeprägte linksventrikuläre Fettdeposition im Herz-MRT.

Although it is well known from pathological studies that intramyocardial fat deposition frequently occurs after left ventricular myocardial infarction, a left ventricular fat deposition is rarely diagnosed in the clinical routine. We report the case of extensive fat deposition in the left ventricular myocardium which was detected by routine cardiac magnetic resonance imaging.

Echocardiography versus intracardiac electrocardiography-based optimization for cardiac resynchronization therapy : a comparative clinical long-term trial.

BACKGROUND: Optimization of AV and VV delay programming has been shown to be essential for the success of cardiac resynchronization therapy (CRT). Acute hemodynamic improvement can be obtained by intracardiac electrocardiogram (IEGM)-based optimization. The aim of the present study was to evaluate whether this IEGM-based algorithm is comparable to the current gold standard of echocardiography. METHODS: After device implantation patients with standard criteria for CRT, AV and VV delay programming was either optimized by an IEGM-based algorithm (IEGM group, n = 24) or by echocardiography (echo group, n = 24). Cardiopulmonary exercise capacity was assessed after 3 and 12 months on the basis of NYHA class and the 6-min-walk test. Left ventricular ejection fraction was evaluated by echocardiography. RESULTS: In both groups there was a significant decrease in NYHA class and a significant increase in 6-min-walk distance and ejection fraction after 3 and 12 months. After 12 months there was no significant difference in the proportion of responders, NYHA class and 6-min-walk distance between the IEGM the echo group. CONCLUSION: The present data show that a sustained improvement of cardiopulmonary exercise capacity can be obtained by optimizing CRT patients on the basis of an IEGM algorithm. The comparable results for cardiopulmonary exercise parameters suggest that this new method might become an important tool for adjusting CRT programming in daily practice.

Cardiac MRI: estimation of changes in normalized myocardial gadolinium accumulation over time after contrast injection in patients with acute myocarditis and healthy volunteers.

PURPOSE: An increased normalized gadolinium accumulation (NGA) in the myocardium during early washout has been used for the diagnosis of acute myocarditis (AM). Due to the fact that the pharmacokinetics of contrast agents are complex, time-related changes in NGA after contrast injection are likely. Because knowledge about time-related changes of NGA may improve the diagnostic accuracy of MR, our study aimed to estimate the time course of NGA after contrast injection in patients as well as in healthy volunteers. MATERIALS AND METHODS: An ECG-triggered inversion recovery SSFP sequence with incrementally increasing inversion times was repetitively acquired over the 15 minutes after injection of 0.2 Gd-DTPA per kg body weight in a 4-chamber view in 15 patients with AM and 20 volunteers. The T 1relaxation times and the longitudinal relaxation rates (R1) of the myocardium and skeletal musculature were calculated for each point in time after contrast injection. The time course of NGA was estimated based on the linear relationship between R1 and tissue Gd concentration. RESULTS: NGA decreased over time in the form of a negative power function in patients with AM and in healthy controls. NGA in AM tended to be higher than in controls (p > 0.05). CONCLUSION: NGA rapidly changes after contrast injection, which must be considered when measuring NGA. Although we observed a trend towards higher NGA values in patients with AM with a maximum difference one minute after contrast injection, NGA did not allow us to differentiate patients with AM from healthy volunteers, because the observed differences did not reach a level of significance.

Coronary artery calcium score: influence of the reconstruction interval on cardiac risk stratification in asymptomatic patients using dual-source computed tomography.

PURPOSE: To evaluate the impact of the reconstruction interval on coronary calcium score and cardiac risk stratification using dual-source computed tomography (DSCT). MATERIALS AND METHODS: DSCT coronary calcium scoring was performed in 61 consecutive patients, and five data sets per patient were reconstructed within diastole (50 - 70 % of the R-R interval). The Agatston score, volumetric score and the relative variability were assessed for all reconstructions. To assess the individual cardiovascular risk, patients were assigned to risk groups based on age and gender-matched percentile ranks. RESULTS: The mean Agatston score was 184.8 ± 377.9 (relative variability 47 % ± 52 %). The mean volumetric score was 164.4 ± 310.1 (relative variability 49 % ± 58 %). There was a negative correlation between the total Agatston score and the relative variability (r = -0.37; p < 0.01). Depending on the reconstruction interval used, 18 predominantly young patients were assigned to more than one risk group. CONCLUSION: Despite the increased temporal resolution of DSCT examinations, the Agatston and volumetric scores depend on the reconstruction time within the cardiac cycle. The fact that the greatest relative variability for both the Agatston score and the volumetric score was found in young patients with small amounts of coronary calcium may result in different treatment strategies for young patients depending on the reconstruction used. Therefore, more accurate risk stratification may require the analysis of multiple reconstruction intervals.

Comparison of a multi-breath-hold and a single breath-hold cine imaging approach for 4D guide-point modeling of the left ventricle.

PURPOSE: Guide-point modeling (GPM) enables reliable and time-efficient assessment of left ventricular (LV) volumes when using sequences that allow acquisition of short- and long-axis scans within a single breath-hold. Slice misalignment may influence GPM analysis of standard multi-breath-hold images due to image acquisition in different breath-holds. Thus, our study aimed to assess if such an approach allows for reliable volumetric calculations in the clinical routine. MATERIALS AND METHODS: 52 patients were examined on a 1.5 T scanner with multi-breath-hold acquisitions on the standard short- and long-axis using an SSFP (TR 3 ms, TE 1.5 ms, FA 60 degrees ) sequence and a TPAT accelerated SSFP (TR 4.6 msec, TE 1.1msec, FA 60 degrees , acceleration factor 3) sequence that covered the LV in 3 short- and 2 long-axis slices within a single breath-hold. For both datasets GPM was used to assess LV volumes. In addition, LV parameters were calculated by applying the summation of slices (SoS) approach (standard of reference) with the short-axis views of the multi-breath-hold dataset. RESULTS: The post-processing times were shorter with both GPM approaches (both, p < 0.001). No significant difference between the 3 methods for the calculation of the ejection fraction was observed. However, end-diastolic, end-systolic and stroke volumes yielded higher results than the standard of reference if the GPM technique was employed. Excellent correlations were observed for all volumetric parameters derived from both GPM evaluations (all r > 0.97). CONCLUSION: Cine short- and long-axis images that had been acquired in different breath-holds can be reliably evaluated by the GPM approach.

Dobutamine stress cardiovascular magnetic resonance imaging in patients after invasive coronary revascularization with stent placement.

BACKGROUND: High-dose dobutamine stress magnetic resonance (DSMR) is a well-established imaging technique for the detection of coronary artery disease (CAD). PURPOSE: To investigate the value of DSMR for the detection of in-stent restenoses (ISR) in patients with prior coronary stenting, using invasive coronary angiography (ICA) as the standard of reference. MATERIAL AND METHODS: 50 patients with 74 stents and without wall motion abnormalities at rest were examined on a 1.5T MR scanner and underwent ICA for clinical reasons within 14 days after DSMR examination. A dobutamine/atropine stress protocol was employed until age-predicted heart rate was achieved, and imaging was performed in at least three long- and three short-axis views using a segmented steady-state free precession sequence (repetition/echo time [TR/TE] 3/1.5 ms, flip angle 60 degrees). All examinations were read by an experienced cardiologist and radiologist in consensus, with myocardial ischemia being defined as a new stress-induced wall motion abnormality in at least one myocardial segment. Statistical analysis was performed on a per-vessel (left circumflex artery [LCX], left anterior descending artery [LAD], and right coronary artery [RCA]) basis and with regard to the number of affected vessels (one-, two- or three-vessel disease). RESULTS: ICA yielded seven ISR, of which one was missed by DSMR (sensitivity 86%, 95% confidence interval [CI] 0.42-0.99). Sixty-seven coronary arteries showed no ISR in ICA; however, due to new wall motion abnormalities, seven ISR were suspected in DSMR (2xRCA, 3xLCX, and 2xLAD; sensitivity 86%, specificity 90%, positive predictive value 46%, negative predictive value 98%, and diagnostic accuracy 89%). The per-vessel analysis of the three main coronary arteries revealed highest sensitivity (100%), specificity (93%), and diagnostic accuracy (94%) for the LAD. CONCLUSION: High-dose DSMR is an accurate, noninvasive technique for the detection of ISR and reliably allows identification of patients who need to undergo control ICA.

Myocardial scars are an underestimated cardiovascular burden in patients with internal carotid artery stenosis.

BACKGROUND: Patients with internal carotid artery (ICA) stenosis have an increased incidence of coronary heart disease. Evidence about the incidence of clinically silent myocardial infarction (MI) in these patients is limited. Contrast-enhanced cardiac magnetic resonance (CMR) imaging allows for the detection of minor myocardial damage. OBJECTIVE: We tested whether patients with ICA stenosis exhibit a relevant incidence of silent MI when assessed by CMR. METHODS: In a single-center study, 77 consecutive patients (age 68 +/- 7 years) with suspected ICA stenosis were imaged prospectively with a combined MRI protocol including T(1), T(2), diffusion-weighted imaging, fluid-attenuated inversion recovery, and contrast-enhanced MR angiography (CEMRA) imaging of the brain and a short (11 min) CMR protocol with left ventricular function and late gadolinium enhancement imaging. Blinded to any clinical information, two readers evaluated the cardiac and neuroradiologic examinations. RESULTS: Of 154 imaged ICA, 85 presented with stenosis and 17 were occluded. In 7 patients, the suspected ICA stenosis could not be confirmed by CEMRA. In the remaining 70 patients with ICA stenosis, 34.3% had cerebral lesions (15.7% with a homodynamic pattern,18.6% with territorial infarction). CMR detected MI in 29 (41%) patients, whereas ECG and medical history enabled diagnosis in only 7 (10%) patients. CONCLUSIONS: ICA stenosis patients have a higher incidence of myocardial scars proving silent MI when detected by contrast-enhanced CMR than clinically expected. Whether the presence and extent of silent MIs detected by CMR affect peri-interventional risk and prognosis of ICA stenosis patients remains to be evaluated in a large patient cohort with long-term follow-up.

Comparison of aortic valve area measured by magnetic resonance imaging and dual-source computed tomography.

BACKGROUND: Aortic valve stenosis is the most common type of valve lesion in Europe and North America. Patient treatment is based on disease severity, which is classified by determining the aortic valve area (AVA). PURPOSE: To compare dual-source computed tomography (DSCT) with magnetic resonance (MR) imaging for quantifying AVA. MATERIAL AND METHODS: Thirty-two patients, 28 with normal aortic valve function and four with aortic valve stenosis, who underwent DSCT coronary angiography (Somatom Definition; Siemens, Erlangen, Germany), were included in this study. Retrospective ECG-gated contrast-enhanced DSCT scans with dose-reducing tube current modulation were performed, and data sets were reconstructed in 3% steps of the R-R interval (slice thickness 0.75 mm, increment 0.6 mm). Planimetry of the AVA in systole was assessed on cross-sectional images by multiplanar reformations. Within 48 hours, MR was performed with a 1.5T scanner (Magnetom Sonata; Siemens, Erlangen, Germany) using a balanced steady-state free-precession cine sequence (repetition/echo time 3/1.5 ms, flip angle 60 degrees, spatial resolution 1.4 x 1.4 mm(2)). Cine sequences of the left ventricular outflow tract (LVOT) were obtained in two orthogonal planes, and MR planimetry was performed on cross-sectional images of the aortic valve perpendicular to the LVOT images. RESULTS: AVA assessment by DSCT and MR was feasible in all 32 patients. Mean AVA values determined by DSCT and MR were 4.73+/-1.5 cm(2) and 4.69+/-1.4 cm(2), respectively. A strong positive correlation was found between both imaging modalities (R=0.98, P<0.001). Bland-Altman analysis demonstrated an excellent intermodality agreement, with a slight underestimation of AVA by DSCT. The mean difference was -0.04 cm(2), with a standard deviation of 0.32 cm(2). CONCLUSION: Retrospective ECG-gated contrast-enhanced DSCT with tube current modulation provides an accurate imaging technique for the assessment of the AVA. Further studies are required to determine whether DSCT also allows for AVA quantification in patients with aortic valve stenosis.

[Quantification of microvascular obstruction in acute myocardial infarction using cardiac MRI]. / Kardiale MRT zur Quantifizierung der mikrovaskulären Obstruktion beim akuten Myokardinfarkt.

PURPOSE: Microvascular obstruction (MO) and the extent of infarction are important prognostic factors in acute myocardial infarction. Our study aimed to investigate the effect of the time interval between contrast administration and image acquisition on the quantification of microvascular obstruction and myocardial infarction. MATERIALS AND METHODS: 50 consecutive patients with acute myocardial infarction (40 male, mean age 58.1 +/- 11.7 years) treated by percutaneous coronary revascularization resulting in a grade 3 flow according to the thrombolysis in myocardial infarction flow classification were examined on a 1.5 T MR scanner within the first 5 days after infarction. 2, 5, 10, and 20 minutes after I.V. administration of 0.2 mmol/kg per kg body weight of Gadodiamid (Omniscan), GE Healthcare Buchler, Germany), a single shot IR-SSFP sequence (TR 2.4 ms, TE 1.08 ms, TI 180 - 280 ms, FA 50 degrees) covering the entire left ventricle was acquired. Areas of MO and myocardial infarction were measured for all times after contrast injection (p. i.). RESULTS: MO was detected in 32 of 50 patients two minutes p. i., while 23 patients showed evidence of MO (p = 0.002) 20 min. p. i. In all patients with MO, the extent of MO decreased over time (7.4 +/- 9.0 % of the LV myocardium 2 min. p. i. vs. 2.4 +/- 4.6 % 20 min. p. i. p < 0.0001). The area of myocardial infarction increased from 13.9 +/- 13.5 % 2 min. p. i. to 18.6 +/- 14.2 % 10 min. p. i. (p < 0.0001), and then remained unchanged (18.7 +/- 14.3 % at 20 min. p = 0.57). CONCLUSION: Our study shows that the time delay between contrast media injection and image acquisition has a significant impact on the delimitable extent of MO and infarct size.

Prevalence, pattern, and functional impact of late gadolinium enhancement in left ventricular hypertrophy due to aortic valve stenosis.

PURPOSE: To assess the prevalence and pattern of myocardial late gadolinium enhancement (LGE) and its functional impact on patients with left ventricular hypertrophy caused by aortic valve stenosis. MATERIALS AND METHODS: Cardiac magnetic resonance imaging of 40 patients (17 female, 23 male, mean age: 76.6 +/- 22.5 years) with known aortic valve stenosis (mean aortic valve area: 89.8 +/- 19.2 mm(2)) and without coronary artery disease was performed at 1.5 T using steady-state free precession sequences for aortic valve planimetry and for the assessment of left ventricular (LV) volumes and mass. Ten to 15 minutes after injection of 0.2 mmol Gd-DTPA per kilogram body weight, inversion-recovery prepared spoiled gradient echo images were acquired in standard long and short axis views to detect areas of LGE. RESULTS: LGE was observed in 32.5 % (13/40) of our patients. LGE was mainly located in the basal septal and inferior LV segments, and showed a non-ischemic pattern with sparing of the subendocardial region. Patients with LGE showed lower LV ejection fractions (55.5 +/- 13.8 % vs. 69.1 +/- 10.7 %, p = 0.0014), higher LV end-systolic volumes (59.8 +/- 33.3 ml vs. 36.6 +/- 16.0 ml, p = 0.0048), and LV masses (211.0 +/- 13.8 vs. 157.9 +/- 37.5 g, p = 0.0002) compared to patients without LGE. CONCLUSION: LGE is frequent in patients with hypertrophic left ventricles due to aortic valve stenosis and is associated with worse LV function.

[Detection and characterization of left ventricular thrombi by MRI compared to transthoracic echocardiography]. / Detektion und Charakterisierung linksventrikulärer Thromben mittels MRT im Vergleich zur transthorakalen Echokardiographie.

PURPOSE: Transthoracic echocardiography is the routine diagnostic procedure in assessing patients with left ventricular thrombi, but is limited by the acoustic window and poor contrast between thrombus and adjacent myocardium. This study evaluates the role of cardiac MRI in the detection of left ventricular thrombi in patients with chronic myocardial infarction compared to standard transthoracic echocardiography. MATERIALS AND METHODS: In 82 patients (55 men and 27 women, age 36 to 79 years, median 59 +/- 11 years) who suffered a myocardial infarction more than 6 months earlier, transthoracic echocardiography and MRI were performed. The MRI protocol included steady state cine imaging (true FISP: TR 3.0 ms, TE 1.5 ms, FA 65 degrees ) in standard long and short axis orientation and contrast-enhanced imaging using a 3D IR-FLASH sequence with long inversion time (TR 4 ms, TE 1.43 ms, FA 10 degrees , TI 300 ms) early, and a 2D IR-FLASH sequence with optimized inversion time (TR 8 ms, TE 4.3 ms, FA 20 degrees , TI 180 - 280 ms) late after administration of gadolinium. RESULTS: Transthoracic echocardiography depicted 12 thrombi. Contrast-enhanced MRI confirmed these 12 thrombi and detected 23 additional thrombi. With the exception of 2 very small apical thrombi only visible on contrast-enhanced MR images, spherical thrombi were diagnosed by both techniques, whereas only contrast-enhanced MRI was able to visualize mural thrombi. Left ventricular thrombi were more frequently diagnosed in patients with moderate to severe impairment of the left ventricular systolic function, 32/42 (76 %), or in patients with left ventricular aneurysms, 21/24 (84 %). CONCLUSION: Contrast-enhanced MRI is mostly superior to transthoracic echocardiography in diagnosing mural left ventricular thrombi in patients who had suffered a myocardial infarction. Intracavitary thrombi are more frequently found in patients with impaired regional and global left ventricular function.

["Integrated care"--the Essen concept: organizational strategies in the treatment of acute myocardial infarction]. / Integrierte Versorgung am Beispiel des Herzinfarktverbundes Essen.

The German "GKV-Modernisierungsgesetz" offers new opportunities for patient care. The concept of "integrated care" provides organizational structures for an standardized treatment of myocardial infarction by bridging the different sectors of the German health care system. Apart from guideline-based therapy, innovative diagnostic (cardiac MRI) and therapeutic (drug-eluting stents) techniques are implemented in the "integrated care" model as well. The "Herzinfarktverbund Essen" is the first national real world experience of the integrated care concept in the treatment of myocardial infarction.