Predictors of reduction in mitral regurgitation in patients undergoing cardiac resynchronisation treatment.

BACKGROUND: CRT causes reduction in MR due to left ventricular (LV) remodelling, but determinants of clinically meaningful MR reduction acutely after CRT have not been evaluated. OBJECTIVES: We evaluated echocardiographic predictors of significant reduction in functional mitral regurgitation (MR) by cardiac resynchronisation treatment (CRT). METHODS: 35 patients with >or= moderate to severe MR underwent CRT for presence of electrical and/or mechanical dyssynchrony. Significant reduction in MR post-CRT was defined as reduction to less than moderate MR (MR jet area/left atrial area <25%, group 1) on follow-up echocardiogram at 1.7 (SD 2.8) months post-CRT. RESULTS: Significant MR reduction of 62% (28%) from baseline MR occurred in 18 patients vs 22% (16%) in the remaining patients (group 2), p<0.01). Follow-up left ventricular ejection fraction (LVEF) was 0.43 (0.09) in group 1 patients vs 0.29% (0.1%) in group 2 patients (p<0.001). On multivariate analysis, time to peak strain in the mid inferior segment was the only significant predictor of MR reduction post-CRT (p = 0.008, OR = 1.023 (CI 1.006 to 1.041). The sensitivity and specificity of the combined variable of time to peak strain of >400 ms in the mid inferior segment and peak negative strain of >or=9% and 8% in the basal and mid posterior segments, respectively, to predict follow-up MR was 88% and 93% respectively and positive and negative predictive value was 94% and 87%. CONCLUSION: In patients with cardiomyopathy and significant MR, the presence of delayed longitudinal strain in the mid inferior LV segment along with preserved negative systolic strain in the basal and mid posterior segments predicts substantial reduction in MR post-CRT.

MR imaging of adventitial vasa vasorum in carotid atherosclerosis.

Vasa vasorum in the adventitia of atherosclerotic arteries may play a role in plaque progression. In this investigation, a method for characterizing vasa vasorum in the carotid artery is proposed, in which the perfusion properties of the adventitia are probed via dynamic contrast-enhanced (DCE) MRI. A parametric "vasa vasorum image" is automatically generated that depicts the plasma volume (vp) and transfer constant (K trans). The average K trans within the adventitia is proposed as a quantitative measurement related to the extent of the vasa vasorum. In 25 subjects with lesions meeting the requirements for carotid endarterectomy (CEA) significantly higher adventitial K trans of 0.155 +/- 0.045 min(-1) was observed, compared to 0.122 +/- 0.029 min(-1) in the remaining 20 subjects with moderate disease (P < 0.01). In the 25 subjects with endarterectomy specimens, histological evaluation showed that adventitial K trans was significantly correlated with the amount of neovasculature (R = 0.41; P = 0.04) and macrophages (R = 0.49; P = 0.01) in the excised plaque. In the remaining 20 subjects without histology, elevated adventitial K trans was significantly correlated with the log of C-reactive protein (CRP) levels (R = 0.57; P = 0.01) and was elevated in active smokers compared to nonsmokers (0.141 +/- 0.036 vs. 0.111 +/- 0.017 min(-1); P = 0.02). Because these factors are all associated with higher risk of atherosclerotic complications, these results suggest that adventitial K(trans) may be a marker of risk as well.

Carotid plaque composition differs between ethno-racial groups: an MRI pilot study comparing mainland Chinese and American Caucasian patients.

OBJECTIVE: Ethnicity-based research may identify new clues to the pathogenesis of atherosclerotic disease. Therefore, we sought to determine whether carotid lesions differ between 20 Chinese and 20 Caucasian Americans by MRI. METHODS AND RESULTS: Inclusion criteria were >50% stenosis as measured by duplex ultrasound and recent symptoms attributed to carotid artery disease. The patients were imaged in 2 centers (Beijing, China and Seattle, Wash) using a standardized protocol. Both carotid arteries were reviewed quantitatively (lumen, wall, outer wall, tissue components) and morphologically (lesion types, fibrous cap status). Significant differences between the Chinese and Americans were found for the mean size of the lipid/necrotic core (13.6 versus 7.8 mm2; P=0.002), percentage of slices with calcified type VII lesions (1.6 versus 12.4%; P=0.03), and percentage of slices with early type III lesions (19.3 versus 9.3%; P=0.02). Furthermore, the mean outer wall area in the common carotid artery was larger in the Chinese population (P=0.007). CONCLUSIONS: This pilot study suggests that composition and morphology of atherosclerotic lesions in symptomatic carotid disease differ between ethno-racial groups. Quantitative MRI-based review of carotid atherosclerosis comparing plaque morphology and composition between ethno-racial groups is feasible, and future MRI studies may improve our understanding of the pathophysiology of this disease.

Differentiation of intraplaque versus juxtaluminal hemorrhage/thrombus in advanced human carotid atherosclerotic lesions by in vivo magnetic resonance imaging.

BACKGROUND: Intraplaque hemorrhage and juxtaluminal hemorrhage/thrombus may differ in cause and clinical implications. This study tested the hypothesis that MRI can distinguish between intraplaque hemorrhage and juxtaluminal hemorrhage/thrombus and investigated the association between hemorrhage and underlying lesion types. METHODS AND RESULTS: Twenty-six patients scheduled for carotid endarterectomy were imaged with a 1.5-T GE scanner by a multicontrast-weighted MRI technique. Hemorrhages were identified with previously established MRI criteria, and differentiations were made between intraplaque and juxtaluminal hemorrhage/thrombus. Corresponding histology was used to confirm the magnetic resonance findings. Tissues underlying areas of hemorrhage/thrombus were histologically categorized according to modified American Heart Association criteria. Of 190 matched sections, 140 contained areas of hemorrhage by histology, of which MRI correctly detected 134. The sensitivity and specificity for MRI to correctly identify cross sections that contained hemorrhage were 96% and 82%, respectively. Furthermore, MRI was able to distinguish juxtaluminal hemorrhage/thrombus from intraplaque hemorrhage with an accuracy of 96%. The distribution of lesion types underlying hemorrhages differed significantly (P=0.004). Intraplaque hemorrhage had an underlying lipid-rich type IV/V lesion in 55% of histological sections, whereas juxtaluminal hemorrhage/thrombus had an underlying calcified lesion type VII in 70% of sections. CONCLUSIONS: In vivo high-resolution MRI can detect and differentiate intraplaque hemorrhage from juxtaluminal hemorrhage/thrombus with good accuracy. The association of hemorrhage and lesion types suggests potential differences in origin. Noninvasive MRI therefore provides a possible tool for prospectively studying differences in origin of plaque hemorrhage and the association of plaque progression and instability.

High-pass-low-pass (HP-LP) reconstruction of CINE phase-contrast MRI.

A new interpretation of CINE phase-contrast (PC) MRI is presented in which flowing blood is shown to induce separate high- and low-temporal-frequency components in the resulting image sequence. The flow velocities can then be extracted from the ratio of these two components, independently of any unknown phase offset. This interpretation leads to new insights into improving temporal resolution, eliminating noise, and reducing acquisition time in PC imaging. A specific example explored in this article uses a technique related to unaliasing by Fourier-encoding the overlaps using the temporal dimension (UNFOLD) to acquire PC velocity measurements at 54-68 time points in the cardiac cycle, all within a single breath-hold of <20 s. In experimental studies, these techniques were shown to yield improved signal-to-noise ratios (SNRs) in a flow phantom and cerebrospinal fluid (CSF) flow studies, and to resolve the formation of a flow vortex during left ventricular (LV) filling in humans.

Noise and motion correction in dynamic contrast-enhanced MRI for analysis of atherosclerotic lesions.

Dynamic contrast-enhanced MRI of atherosclerotic vessels after contrast agent injection may provide unique information regarding lesion structure and vulnerability. The high-resolution images necessary for viewing lesion substructures, however, are often corrupted by patient motion and low signal-to-noise ratios, making pixel-level analyses difficult. This article presents a postprocessing method that enables pixel-level analysis of dynamic images by eliminating motion and enhancing image quality. Noise and motion correction are performed using optimal statistical methods under the assumption that noise and contrast agent dynamics are random processes. The method is demonstrated and validated on dynamic images of atherosclerotic plaques in human carotid arteries.

In vivo accuracy of multispectral magnetic resonance imaging for identifying lipid-rich necrotic cores and intraplaque hemorrhage in advanced human carotid plaques.

BACKGROUND: High-resolution MRI has been shown to be capable of identifying plaque constituents, such as the necrotic core and intraplaque hemorrhage, in human carotid atherosclerosis. The purpose of this study was to evaluate differential contrast-weighted images, specifically a multispectral MR technique, to improve the accuracy of identifying the lipid-rich necrotic core and acute intraplaque hemorrhage in vivo. METHODS AND RESULTS: Eighteen patients scheduled for carotid endarterectomy underwent a preoperative carotid MRI examination in a 1.5-T GE Signa scanner using a protocol that generated 4 contrast weightings (T1, T2, proton density, and 3D time of flight). MR images of the vessel wall were examined for the presence of a lipid-rich necrotic core and/or intraplaque hemorrhage. Ninety cross sections were compared with matched histological sections of the excised specimen in a double-blinded fashion. Overall accuracy (95% CI) of multispectral MRI was 87% (80% to 94%), sensitivity was 85% (78% to 92%), and specificity was 92% (86% to 98%). There was good agreement between MRI and histological findings, with a value of kappa=0.69 (0.53 to 0.85). CONCLUSIONS: Multispectral MRI can identify the lipid-rich necrotic core in human carotid atherosclerosis in vivo with high sensitivity and specificity. This MRI technique provides a noninvasive tool to study the pathogenesis and natural history of carotid atherosclerosis. Furthermore, it will permit a direct assessment of the effect of pharmacological therapy, such as aggressive lipid lowering, on plaque lipid composition.

Ventricular contraction abnormalities in dilated cardiomyopathy: effect of biventricular pacing to correct interventricular dyssynchrony.

OBJECTIVE: To measure ventricular contractile synchrony in patients with dilated cardiomyopathy (DCM) and to evaluate the effects of biventricular pacing on contractile synchrony and ejection fraction. BACKGROUND: Dilated cardiomyopathy is characterized by abnormal ventricular activation and contraction. Biventricular pacing may promote a more coordinated ventricular contraction pattern in these patients. We hypothesized that biventricular pacing would improve synchrony of right ventricular and left ventricular (RV/LV) contraction, resulting in improved ventricular ejection fraction. METHODS: Thirteen patients with DCM and intraventricular conduction delay underwent multiple gated equilibrium blood pool scintigraphy. Phase image analysis was applied to the scintigraphic data and mean phase angles computed for the RV and LV. Phase measures of interventricular (RV/LV) synchrony were computed in sinus rhythm and during atrial sensed biventricular pacing (BiV). RESULTS: The degree of interventricular dyssynchrony present in normal sinus rhythm correlated with LV ejection fraction (r = -0.69, p < 0.01). During BiV, interventricular contractile synchrony improved overall from 27.5 +/- 23.1 degrees to 14.1 +/- 13 degrees (p = 0.01). The degree of interventricular dyssynchrony present in sinus rhythm correlated with the magnitude of improvement in synchrony during BiV (r = 0.83, p < 0.001). Left ventricular ejection fraction increased in all thirteen patients during BiV, from 17.2 +/- 7.9% to 22.5 +/- 8.3% (p < 0.0001) and correlated significantly with improvement in RV/LV synchrony during BiV (r = 0.86, p < 0.001). CONCLUSIONS: Dilated cardiomyopathy with intraventricular conduction delay is associated with significant interventricular dyssynchrony. Improvements in interventricular synchrony during biventricular pacing correlate with acute improvements in LV ejection fraction.

A k-space analysis of MR tagging.

We present a k-space approximation that directly relates a pulse sequence to its residual pattern of z-directed magnetization M(z), in a manner akin to the k-space approximation for small tip-angle excitation. Our approximation is particularly useful for the analysis and design of tagging sequences, in which M(z) is the important quantity-as opposed to the transverse magnetization components M(x) and M(y) considered in selective excitation. We demonstrate that our approximation provides new insights into tagging, can be used to design novel tag patterns, and, more generally, may be applied to selective presaturation sequences for purposes other than tagging.

Cardiac motion tracking using CINE harmonic phase (HARP) magnetic resonance imaging.

This article introduces a new image processing technique for rapid analysis of tagged cardiac magnetic resonance image sequences. The method uses isolated spectral peaks in SPAMM-tagged magnetic resonance images, which contain information about cardiac motion. The inverse Fourier transform of a spectral peak is a complex image whose calculated angle is called a harmonic phase (HARP) image. It is shown how two HARP image sequences can be used to automatically and accurately track material points through time. A rapid, semiautomated procedure to calculate circumferential and radial Lagrangian strain from tracked points is described. This new computational approach permits rapid analysis and visualization of myocardial strain within 5-10 min after the scan is complete. Its performance is demonstrated on MR image sequences reflecting both normal and abnormal cardiac motion. Results from the new method are shown to compare very well with a previously validated tracking algorithm. Magn Reson Med 42:1048-1060, 1999.

Acute effects of intraoperative multisite ventricular pacing on left ventricular function and activation/contraction sequence in patients with depressed ventricular function.

INTRODUCTION: We hypothesized that simultaneous right and left ventricular apical pacing would result in improvement in left ventricular function due to improved coordination of segmental ventricular contraction. Structural changes in ventricular muscle present in dilated cardiomyopathy compromise ventricular excitation and mechanical contraction. METHODS AND RESULTS: Eleven patients with depressed left ventricular function having cardiac surgery underwent epicardial multisite pacing with continuous transesophageal echocardiographic imaging. Quantitative measurement of percent fractional area change was performed, and segmental changes in contraction sequence resulting from simultaneous right and left ventricular pacing were assessed by application of phase analysis to recorded transesophageal images. There was no statistically significant difference between the paced QRS duration achieved with simultaneous right and left ventricular apical pacing and the native QRS duration (139+/-39 msec vs 106+/-18 msec, P = NS), but all other paced modes resulted in longer QRS durations. Percent fractional area change improved with simultaneous right and left ventricular apical pacing but not with other paced modes (41.5+/-11.9 vs 34.3+/-9.7, P < 0.01). Phase analysis demonstrated a resequencing of segmental left ventricular activation/contraction when compared to baseline ventricular activation. CONCLUSION: Simultaneous right and left ventricular apical pacing results in acute improvements in global ventricular performance in patients with depressed ventricular function. Improvements may result from pacing-induced global coordination through recruitment of left and right ventricular apical and septal segments critical to effective ventricular contraction.

Cardiac material markers from tagged MR images.

Tagged magnetic resonance imaging (MRI) has shown great promise in non-invasive analysis of heart motion. To replace implanted markers as a gold standard, however, tagged MRI must be able to track a sparse set of material points, so-called material markers, with high accuracy. This paper presents a new method for generating accurate motion estimates over a sparse set of material points using standard, parallel-tagged MR images. Each tracked point is located at the intersection of three tag surfaces, each of which is estimated using a thin-plate spline. The intersections are determined by an iterative alternating projections algorithm for which a proof of convergence is provided. The resulting data sets are compatible with applications developed to exploit implanted marker data. One set of these material markers from a normal human volunteer is examined in detail using several methods to visualize the markers. Numerical results that include additional studies are also discussed. Finally, an error analysis is presented using a computer-simulated left ventricle for which material markers are tracked with an RMS error of approximately 0.2 mm for typical imaging parameters and noise levels.