Aortic dilatation: Value of echocardiography in the systematic assessment of elite rugby players in the French National Rugby League (LNR).

The value of echocardiography in the screening of athletes in addition to the electrocardiogram is debated and still unclear. 336 rugby players in French professional divisions (Top 14, Pro D2) were prospectively assessed with electrocardiogram and echocardiography. 75% were Caucasian, 16.4% Pacific Islanders, and 8.6% Afro-Caribbean. Six (1.8%) players had electrocardiogram abnormalities, exclusively negative T waves. Twenty-one (6.25%) of them had abnormal echocardiography findings: one possible early hypertrophic cardiomyopathy, one anomalous origin of coronary artery, two left ventricular dilatations, one isolated bicuspid aortic valve, two aortic regurgitations, and 14 ascending aortic dilatations. The median aortic diameter was modestly correlated with age: 32 mm [23-48] in players aged ≤25 years vs 33.5 mm [24-50] in those aged >25 years (P = 0.02, correlation coefficient -.01). This tendency increased with cumulative hours of weight training: 34 mm [24-50] in forwards vs 32 mm [25-44] in backs (P = 0.01); and ethnicity, with Pacific Islanders having higher values in both raw data and body surface area or height-indexed data than Afro-Caribbeans and Caucasians: 34 [25-50] vs 32 [27-48] and 33 [23-49] mm (P = 0.017); 15 [12.2-21] vs 14.8 [11-19.9] and 14.8 [10-20.9] mm/m2 (P < 0.0001); 18.5 [14-25] mm/m vs 17.4 [14.8-25] mm/m and 17.6 [12.2-25.3] mm/m (P = 0.0125). In a population of professional rugby players, echocardiography was contributive. The main anomaly was aortic dilatation (14/336, 4.2%). While this is proportionally much higher than in other sports, the cutoffs need to be defined more precisely by including the criterion of ethnicity, as is already the case for electrocardiography.

Right ventricular diastolic function in aging: a head-to-head comparison between phase-contrast MRI and Doppler echocardiography.

To evaluate right ventricle (RV) diastolic function from phase-contrast MRI (PC-MRI) in aging. 89 healthy individuals (50 men, 43 ± 15 years) underwent cardiac MRI including 2D PC-MRI (1.5T) and reference Doppler echocardiography of both ventricles on the same day. Conventional echocardiographic parameters were estimated: early (E, cm/s) and atrial (A) peak velocities as well as myocardial early peak longitudinal velocity (E'). PC-MRI images were analyzed using custom software, providing: E', E and A waves along with respective peak flow rates (Ef, Af, mL/s) and filling volume (mL), for both ventricles. Intra- and inter-observer reproducibility was studied in 30 subjects and coefficients of variation (CoV) as well as intra-class correlation coefficients (ICC) were provided. RV diastolic function indices derived from PC-MRI data were reproducible (CoV ≤ 21%, ICC ≥ 0.75) and reliable as reflected by significant associations with left ventricular diastolic function indices assessed using both echocardiography (linear regression Pearson correlation coefficient r ≤ 0.59) and PC-MRI (r ≤ 71). Despite the fair associations between RV echocardiography and PC-MRI (r ≤ 0.25), the highest correlation with age was obtained for MRI Ef/Af ratio (r = - 0.64, p < 0.0001 vs. r = - 0.40, p = 0.0001 for echocardiographic E/A). Among PC-MRI E/A ratios, highest correlations with age were observed for flow rate and mean velocity ratios (r = - 0.61, p < 0.0001) as compared to maximal velocity ratios (r = - 0.56, p < 0.0001). Associations with age for E' were equivalent between PC-MRI (mean velocity: r = - 0.40, p < 0.0001; maximal velocity: r = - 0.36, p = 0.0005) and echocardiography (r = - 0.36, p = 0.0006). Finally, the significant and age-independent associations between RV mass/end-diastolic volume and E' were stronger for PC-MRI (mean velocity: r = - 0.36, p = 0.0006; maximal velocity: r = - 0.28, p = 0.007) than echocardiography (r = - 0.09, p = 0.38). PC-MRI tricuspid inflow and annulus myocardial velocity parameters were reproducible and able to characterize age-related variations in RV diastolic function.

High-Resolution Late Gadolinium Enhancement Magnetic Resonance for the Diagnosis of Myocardial Infarction With Nonobstructed Coronary Arteries.

OBJECTIVES: The aim of this study was to assess the diagnostic yield of cardiac magnetic resonance (CMR) including high-resolution (HR) late gadolinium enhancement (LGE) imaging using a 3-dimensional respiratory-navigated method in patients with myocardial infarction with nonobstructed coronary arteries (MINOCA). BACKGROUND: CMR plays a pivotal role for the diagnosis of patients with MINOCA. However, the diagnosis remains inconclusive in a significant number of patients, the results of CMR being either negative or uncertain (i.e., compatible with multiple diagnoses). METHODS: Consecutive patients categorized as having MINOCA after blood testing, electrocardiography, coronary angiography, and echocardiography underwent conventional CMR, including cine, T2-weighted, first-pass perfusion, and conventional breath-held LGE imaging. HR LGE imaging using a free-breathing method allowing improved spatial resolution (voxel size 1.25 × 1.25 × 2.5 mm) was added to the protocol when the results of conventional CMR were inconclusive and was optional otherwise. Diagnoses retained after reviewing conventional CMR were compared with those retained after the addition of HR LGE imaging. RESULTS: From 2013 to 2016, 229 patients were included (mean age 56 ± 17 years, 45% women). HR LGE imaging was performed in 172 patients (75%). In this subpopulation, definite diagnoses were retained after conventional CMR in 86 patients (50%): infarction in 39 (23%), myocarditis in 32 (19%), takotsubo cardiomyopathy in 13 (8%), and other diagnoses in 2 (1%). In the remaining 86 patients (50%), results of CMR were inconclusive: negative in 54 (31%) and consistent with multiple diagnoses in 32 (19%). HR LGE imaging led to changes in final diagnosis in 45 patients (26%) and to a lower rate of inconclusive final diagnosis (29%) (p < 0.001). In particular, HR LGE imaging could reveal or ascertain the diagnosis of infarction in 14% and rule out the diagnosis of infarction in 12%. HR LGE imaging was particularly useful when the results of transthoracic echocardiography, ventriculography, and conventional CMR were negative, with a 48% rate of modified diagnosis in this subpopulation. CONCLUSIONS: HR LGE imaging has high diagnostic value in patients with MINOCA and inconclusive findings on conventional CMR. This has major diagnostic, prognostic, and therapeutic implications.

Relationship Between Fibrosis Detected on Late Gadolinium-Enhanced Cardiac Magnetic Resonance and Re-Entrant Activity Assessed With Electrocardiographic Imaging in Human Persistent Atrial Fibrillation.

OBJECTIVES: This study sought to assess the relationship between fibrosis and re-entrant activity in persistent atrial fibrillation (AF). BACKGROUND: The mechanisms involved in sustaining re-entrant activity during AF are poorly understood. METHODS: Forty-one patients with persistent AF (age 56 ± 12 years; 6 women) were evaluated. High-resolution electrocardiographic imaging (ECGI) was performed during AF by using a 252-chest electrode array, and phase mapping was applied to locate re-entrant activity. Sites of high re-entrant activity were defined as re-entrant regions. Late gadolinium-enhanced (LGE) cardiac magnetic resonance (CMR) was performed at 1.25 × 1.25 × 2.5 mm resolution to characterize atrial fibrosis and measure atrial volumes. The relationship between LGE burden and the number of re-entrant regions was analyzed. Local LGE density was computed and characterized at re-entrant sites. All patients underwent catheter ablation targeting re-entrant regions, the procedural endpoint being AF termination. Clinical, CMR, and ECGI predictors of acute procedural success were then analyzed. RESULTS: Left atrial (LA) LGE burden was 22.1 ± 5.9% of the wall, and LA volume was 74 ± 21 ml/m2. The number of re-entrant regions was 4.3 ± 1.7 per patient. LA LGE imaging was significantly associated with the number of re-entrant regions (R = 0.52, p = 0.001), LA volume (R = 0.62, p < 0.0001), and AF duration (R = 0.54, p = 0.0007). Regional analysis demonstrated a clustering of re-entrant activity at LGE borders. Areas with high re-entrant activity showed higher local LGE density as compared with the remaining atrial areas (p < 0.0001). Failure to achieve AF termination during ablation was associated with higher LA LGE burden (p < 0.001), higher number of re-entrant regions (p < 0.001), and longer AF duration (p = 0.008). CONCLUSIONS: The number of re-entrant regions during AF relates to the extent of LGE on CMR, with the location of these regions clustering to LGE areas. These characteristics affect procedural outcomes of ablation.

Prediction of response to cardiac resynchronization therapy using left ventricular pacing lead position and cardiovascular magnetic resonance derived wall motion patterns: a prospective cohort study.

BACKGROUND: Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Recently, a "U-shaped" (type II) wall motion pattern identified by cardiovascular magnetic resonance (CMR) has been associated with improved CRT response compared to a homogenous (type I) wall motion pattern. There is also evidence that a left ventricular (LV) lead localized to the latest contracting LV site predicts superior response, compared to an LV lead localized remotely from the latest contracting LV site. METHODS: We prospectively evaluated patients undergoing CRT with pre-procedural CMR to determine the presence of type I and type II wall motion patterns and pre-procedural echocardiography to determine end systolic volume (ESV). We assessed the final LV lead position on post-procedural fluoroscopic images to determine whether the lead was positioned concordant to or remote from the latest contracting LV site. CRT response was defined as a ≥ 15% reduction in ESV on a 6 month follow-up echocardiogram. RESULTS: The study included 33 patients meeting conventional indications for CRT with a mean New York Heart Association class of 2.8 ± 0.4 and mean LV ejection fraction of 28 ± 9%. Overall, 55% of patients were echocardiographic responders by ESV criteria. Patients with both a type II pattern and an LV lead concordant to the latest contracting site (T2CL) had a response rate of 92%, compared to a response rate of 33% for those without T2CL (p = 0.003). T2CL was the only independent predictor of response on multivariate analysis (odds ratio 18, 95% confidence interval 1.6-206; p = 0.018). T2CL resulted in significant incremental improvement in prediction of echocardiographic response (increase in the area under the receiver operator curve from 0.69 to 0.84; p = 0.038). CONCLUSIONS: The presence of a type II wall motion pattern on CMR and a concordant LV lead predicts superior CRT response. Improving patient selection by evaluating wall motion pattern and targeting LV lead placement may ultimately improve the response rate to CRT.

Postsurgical hemodynamics of the aortic valve bypass operation evaluated with phase contrast magnetic resonance.

PURPOSE: To characterize the postsurgical hemodynamics in aortic valve bypass (AVB) patients, and to determine the relationship between presurgical native aortic valve pressure gradient and postsurgical hemodynamics. MATERIALS AND METHODS: Twenty patients scheduled for AVB surgery underwent presurgical transthoracic Doppler echocardiography to assess the degree of aortic stenosis and postsurgical cardiac magnetic resonance imaging (MRI) to acquire phase contrast magnetic resonance (PCMR) flow values along the ascending and descending aorta, and in the conduit. Net flow values were calculated from the PCMR images and compared to presurgical aortic valve pressure gradient measurements. RESULTS: PCMR showed that: 1) The blood flow split between the aorta and the conduit was 35%:65% of cardiac output and 2) 60% of patients had net retrograde blood flow in the superior thoracic aorta over the cardiac cycle. Patients with presurgical pressure gradient (ΔP) > 45 mmHg had significantly less blood flow out of the native aorta than patients with ΔP < 45 mmHg, and had significantly more retrograde flow in the superior thoracic aorta postsurgery. CONCLUSION: In patients undergoing AVB, presurgical aortic valve pressure gradient is associated with the volume of blood flow out the aorta and the direction of blood flow in the superior thoracic aorta after conduit addition as measured by PCMR.

Automated left ventricular diastolic function evaluation from phase-contrast cardiovascular magnetic resonance and comparison with Doppler echocardiography.

BACKGROUND: Early detection of diastolic dysfunction is crucial for patients with incipient heart failure. Although this evaluation could be performed from phase-contrast (PC) cardiovascular magnetic resonance (CMR) data, its usefulness in clinical routine is not yet established, mainly because the interpretation of such data remains mostly based on manual post-processing. Accordingly, our goal was to develop a robust process to automatically estimate velocity and flow rate-related diastolic parameters from PC-CMR data and to test the consistency of these parameters against echocardiography as well as their ability to characterize left ventricular (LV) diastolic dysfunction. RESULTS: We studied 35 controls and 18 patients with severe aortic valve stenosis and preserved LV ejection fraction who had PC-CMR and Doppler echocardiography exams on the same day. PC-CMR mitral flow and myocardial velocity data were analyzed using custom software for semi-automated extraction of diastolic parameters. Inter-operator reproducibility of flow pattern segmentation and functional parameters was assessed on a sub-group of 30 subjects. The mean percentage of overlap between the transmitral flow segmentations performed by two independent operators was 99.7 ± 1.6%, resulting in a small variability (<1.96 ± 2.95%) in functional parameter measurement. For maximal myocardial longitudinal velocities, the inter-operator variability was 4.25 ± 5.89%. The MR diastolic parameters varied significantly in patients as opposed to controls (p < 0.0002). Both velocity and flow rate diastolic parameters were consistent with echocardiographic values (r > 0.71) and receiver operating characteristic (ROC) analysis revealed their ability to separate patients from controls, with sensitivity > 0.80, specificity > 0.80 and accuracy > 0.85. Slight superiority in terms of correlation with echocardiography (r = 0.81) and accuracy to detect LV abnormalities (sensitivity > 0.83, specificity > 0.91 and accuracy > 0.89) was found for the PC-CMR flow-rate related parameters. CONCLUSIONS: A fast and reproducible technique for flow and myocardial PC-CMR data analysis was successfully used on controls and patients to extract consistent velocity-related diastolic parameters, as well as flow rate-related parameters. This technique provides a valuable addition to established CMR tools in the evaluation and the management of patients with diastolic dysfunction.

Early thoracic aorta enlargement in asymptomatic individuals at risk for cardiovascular disease: determinant factors and clinical implication.

OBJECTIVES: We analyzed, in above-average risk asymptomatic individuals, the factors determining early thoracic aorta enlargement. METHODS: Ascending aortic diameter (AAD) was measured with noncontrast multidetector computed tomography in 345 participants (mean age 56 years; 78% men) without cardiovascular disease. We analyzed the associations of AAD with risk factors and Framingham risk score (FRS), multidetector computed tomography-assessed coronary artery calcium (CAC), and ultrasound interrogation of plaque presence at five sites (right and left carotid arteries, right and left femoral arteries, and abdominal aorta), the number of diseased sites with presence of plaque being counted from 0 to 5. RESULTS: AAD was positively associated with age (P < 0.001), male sex (P < 0.01), body surface area (BSA; P < 0.001), hypertension (P < 0.001), systolic and diastolic blood pressures in individuals without antihypertensive medication (P < 0.05, P < 0.01), and FRS (P < 0.001). AAD was positively associated with CAC score after adjusting for age, sex, and BSA (P < 0001) or for FRS and BSA (P < 0.001). AAD was higher in the presence of three, four, or five than in the presence of no, one, or two diseased sites with plaque, after adjusting for age, sex, and BSA (P < 0.05) or for FRS and BSA (P < 0.001). When participants were divided into subsets by AAD tertiles and by number of sites with plaque, FRS and CAC score were greatest in individuals with AAD top tertile and 3-5 sites with plaque and lowest in those with AAD bottom tertile and 0-2 sites with plaque (P < 0.001). CONCLUSION: These findings suggest that thoracic ascending aorta dilatation is related to hypertension and represents a part of a generalized atherosclerotic process of the entire vasculature.