German Radiological Society and the Professional Association of German Radiologists Position Paper on Coronary computed tomography: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome. / Positionspapier von DRG und BDR zur Computertomografie des Herzens: Klinische Evidenz und Versorgungsqualität beim chronischen Koronarsyndrom.

This position paper is a joint statement of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR), which reflects the current state of knowledge about coronary computed tomography. It is based on preclinical and clinical studies that have investigated the clinical relevance as well as the technical requirements and fundamentals of cardiac computed tomography. CITATION FORMAT: · Langenbach MC, Sandstede J, Sieren M et al. DRG and BDR Position Paper on Coronary CT: Clinical Evidence and Quality of Patient Care in Chronic Coronary Syndrome. Fortschr Röntgenstr 2023; 195: 115 - 133.

Current Status of Cardiovascular Imaging in Germany: Structured Data from the National Certification Program, ESCR Registry, and Survey among Radiologists.

PURPOSE: In the light of the increasing importance of cardiovascular cross-sectional imaging in current guidelines, the goal of this study is to provide a comprehensive overview of cardiovascular imaging (CVI) offered by radiological institutions across Germany. MATERIALS AND METHODS: Data were extracted from the national certification program database of the German Roentgen Society (DRG) from 2015-2021. A nationwide online survey among radiology institutes (university hospitals, non-university hospitals, and private practices) was conducted for 2019, and data was extracted from the European Society of Cardiovascular Radiology (ESCR) registry. The data collection's key points included the number of centers and individuals certified for CVI, the number of cardiac CT and MRI examinations performed, the reporting habits, and the participation in the ESCR registry. RESULTS: 71 centers and 1278 persons, both with a substantial increase since 2015, were registered and certified by the DRG to perform CVI. According to the survey, a total of 69,286 CT and 64,281 MRI examinations were performed annually. Data from the survey and the ESCR registry indicated that reporting was mostly done solely by radiologists or, to a lesser degree, in joint consensus meetings with non-radiologists. The overall participation rate in the ESCR registry was 48 % among the survey's participants. CONCLUSION: This comprehensive analysis demonstrates that high-quality CVI by radiologists is available nationwide. The current challenges are to provide the best medical and technical quality of CVI by radiology for patient care and to ensure economic sustainability in the German health care system to accommodate the predicted substantial need for CVI in the future. KEY POINTS: · High-quality advanced CVI service by radiologists is available nationwide.. · Highly qualified specialist knowledge is widely represented from university to private practices.. · Certification programs successfully contribute to the dissemination & deepening of CVI expertise.. · The ESCR registry is an established international tool for the documentation of CVI.. CITATION FORMAT: · Sieren M, Maintz D, Gutberlet M et al. Current Status of Cardiovascular Imaging in Germany: Structured Data from the National Certification Program, ESCR Registry, and Survey among Radiologists. Fortschr Röntgenstr 2022; 194: 181 - 191.

Statement of the German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists on Requirements for the Performance and Reporting of MR Imaging Examinations Outside of Radiology. / Positionspapier der Deutschen Röntgengesellschaft (DRG), der Deutschen Gesellschaft für Neuroradiologie (DGNR) und der Gesellschaft für Pädiatrische Radiologie (GPR) zu den fachlichen Anforderungen an Durchführung und Befundung von MRT-Untersuchungen außerhalb des Fachgebietes Radiologie.

BACKGROUND: Magnetic Resonance Imaging (MRI) is a very innovative, but at the same time complex and technically demanding diagnostic method in radiology. It plays an increasing role in high-quality and efficient patient management. Quality assurance in MRI is of utmost importance to avoid patient risks due to errors before and during the examination and when reporting the results. Therefore, MRI requires higher physician qualification and expertise than any other diagnostic imaging technique in medicine. This holds true for indication, performance of the examination itself, and in particular for image evaluation and writing of the report. In Germany, the radiologist is the only specialist who is systematically educated in all aspects of MRI during medical specialty training and who must document a specified, high number of examinations during this training. However, also non-radiologist physicians are increasingly endeavoring to conduct and bill MRI examinations on their own. METHOD: In this position statement, the following aspects of quality assurance for MRI examinations and billing by radiologists and non-radiologist physician specialists are examined scientifically: Requirements for specialist physician training, MRI risks and contraindications, radiation protection in the case of non-ionizing radiation, application of MR contrast agents, requirements regarding image quality, significance of image artifacts and incidental findings, image evaluation and reporting, interdisciplinary communication and multiple-eyes principle, and impact on healthcare system costs. CONCLUSION: The German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists are critical with regard to MRI performance by non-radiologists in the interest of quality standards, patient welfare, and healthcare payers. The 24-month additional qualification in MRI as defined by the physician specialization regulations (Weiterbildungsordnung) through the German state medical associations (Landesärztekammern) is the only competence-based and quality-assured training program for board-certified specialist physicians outside radiology. This has to be required as the minimum standard for performance and reporting of MRI exams. Exclusively unstructured MRI training outside the physician specialization regulations has to be strictly rejected for reasons of patient safety. The performance and reporting of MRI examinations must be reserved for adequately trained and continuously educated specialist physicians. KEY POINTS: · MR imaging plays an increasing role due to its high diagnostic value and serves as the reference standard in many indications.. · MRI is a complex technique that implies patient risks in case of inappropriare application or lack of expertise.. · In Germany, the radiologist is the only specialist physician that has been systematically trained in all aspects of MRI such as indication, performance, and reporting of examinations in specified, high numbers.. · The only competence-based and quality-assured MRI training program for specialist physicians outside radiology is the 24-month additional qualification as defined by the regulations through the German state medical associations.. · In view of quality-assurance and patient safety, a finalized training program following the physician specialization regulations has to be required for the performance and reporting of MRI examinations.. CITATION FORMAT: · Hunold P, Bucher AM, Sandstede J et al. Statement of the German Roentgen Society, German Society of Neuroradiology, and Society of German-speaking Pediatric Radiologists on Requirements for the Performance and Reporting of MR Imaging Examinations Outside of Radiology. Fortschr Röntgenstr 2021; 193: 1050 - 1060.

Impact of enzyme replacement therapy on cardiac morphology and function and late enhancement in Fabry's cardiomyopathy.

The present study evaluated the evolution of cardiac morphology, function, and late enhancement as a noninvasive marker of myocardial fibrosis, and their inter-relation during enzyme replacement therapy in patients with Fabry's disease using magnetic resonance imaging and color Doppler myocardial imaging. Late enhancement, which was present in up to 50% of patients, was associated with increased left ventricular mass, the failure of a significant regression of hypertrophy during enzyme replacement therapy, and worse segmental myocardial function. Late enhancement may predict the effect of enzyme replacement therapy on left ventricular mass and cardiac function.

Absolute concentrations of high-energy phosphate metabolites in normal, hypertrophied, and failing human myocardium measured noninvasively with (31)P-SLOOP magnetic resonance spectroscopy.

OBJECTIVE: The purpose of the present study was to measure absolute concentrations of phosphocreatine (PCr) and adenosine triphosphate (ATP) in normal, hypertrophied, and failing human heart. BACKGROUND: Conflicting evidence exists on the extent of changes of high-energy phosphate metabolites in hypertrophied and failing human heart. Previous reports using phosphorus-31 magnetic resonance spectroscopy ((31)P-MRS) have quantified metabolites in relative terms only. However, this analysis cannot detect simultaneous reductions. METHODS: Four groups of subjects (n = 10 each), were studied: volunteers and patients with hypertensive heart disease (HHD), aortic stenosis, and dilated cardiomyopathy (DCM). Left ventricular (LV) function and mass were measured by cine magnetic resonance imaging. Absolute and relative concentrations of PCr and ATP were determined by (31)P-MRS with spatial localization with optimum point spread function. RESULTS: Left ventricular ejection fraction remained normal in HHD and aortic stenosis, but was severely reduced to 18% in DCM; LV mass was increased by 55%, 79%, and 68% respectively. In volunteers, PCr and ATP concentrations were 8.82 +/- 1.30 mmol/kg wet weight and 5.69 +/- 1.02 mmol/kg wet weight, and the PCr/ATP ratio was 1.59 +/- 0.33. High-energy phosphate levels were unaltered in HHD. In aortic stenosis, PCr was decreased by 28%, whereas ATP remained constant. In DCM, PCr was reduced by 51%, ATP by 35%, and reduction of the PCr/ATP ratio by 25% was of borderline significance (p = 0.06). Significant correlations were observed among energetic and functional variables, with the closest relations for PCr. CONCLUSIONS: In human heart failure due to DCM, both PCr and ATP are significantly reduced. Ratios of PCr to ATP underestimate changes of high-energy phosphate levels.

Fabry disease: diagnosis and treatment.

Fabry disease is an X-linked lysosomal storage disorder that results from a deficiency of the enzyme alpha-galactosidase A (alpha-Gal A). The lack of alpha-Gal A causes an intracellular accumulation of glycosphingolipids, mainly globotriaosyceramide (GL3). Affected organs include, among others, the vascular endothelium, heart, brain, and kidneys, leading to end-stage renal disease (ESRD). Since Fabry disease cannot be cured at present, clinical management is symptomatic. Enzyme replacement therapy (ERT) with recombinant alpha-Gal A has been introduced as a new therapeutic option for the treatment of Fabry patients. Short-term (one year) clinical studies have positively correlated ERT with improvement of clinical symptoms and microvascular endothelial cell clearance. Treatment outcome concerning severe organ manifestations such as proteinuria and renal function impairment, left ventricular hypertrophy, and heart failure in the long run has yet to be shown. In our studies we used sensitive and noninvasive techniques such as ultrasound-based strain rate imaging and magnetic resonance imaging (MRI), combined with MR-spectroscopy (MR-S), for the quantification of functional abnormalities at an early stage of the disease and during long-term follow-up. Future issues should determine the appropriate timing to start therapy and how children and heterozygous females should be managed. Given the diagnostic and therapeutic potential today, it is of importance to identify patients at an early stage and to start therapeutic intervention before progression of organ damage is inevitable.

MR-based analysis of regional cardiac function in relation to cellular integrity in Fabry disease.

BACKGROUND: Fabry cardiomyopathy is characterized by left ventricular (LV) hypertrophy and regional fibrosis. Recent high-end echocardiography studies of selected LV sections suggest an interrelation between regional fibrosis, impaired function, and hypertrophy possibly changing under specific enzyme replacement therapy (ERT). METHODS: Magnetic resonance imaging (MRI) was used for a region dependent study of cardiac function, morphology and late enhancement (LE) in 25 Fabry patients before and after 12 months of ERT in comparison to 43 healthy volunteers. RESULTS: Fabry patients presented with LV increased wall thickness (EDWT) and reduced wall thickening (WT) with a focus on basal and midventricular regions corresponding to areas of LE. The degree of hypertrophy and hypokinesia were the highest if LE was detectable. A significant decrease of the EDWT under ERT was observed in LE negative patients accompanied by a decline of hypokinesia with regional differences. CONCLUSIONS: Regional differences of LV hypertrophy and wall motion were detected corresponding to the distribution of myocardial fibrosis (LE). Functional impairment was closely restricted to fibrotic regions while morphologic changes slightly exceeded the areas of fibrosis. ERT resulted in regional improvements whereby absence of fibrosis was connected to a better outcome.

Cardiac energy metabolism is disturbed in Fabry disease and improves with enzyme replacement therapy using recombinant human galactosidase A.

AIMS: In vitro studies have shown impairment of energy metabolism in cardiac fibroblasts from Fabry patients. A recent in vivo study reported an association between cardiac energy metabolism and increased myocardial mass in Fabry patients. We therefore assessed possible disturbances of cardiac energy metabolism in Fabry patients by in vivo (31)P-MR-spectroscopy. Additionally, the effect of enzyme replacement therapy (ERT) on cardiac energetics was tested. METHODS AND RESULTS: Twenty-three patients (41 ± 9 years; 10 females) with genetically proven Fabry disease were examined with a 1.5 T Scanner, and compared with an age-matched healthy control group. Eight patients underwent ERT and had follow-up examinations after 3 and 14 months. The high-energy phosphate molecules phosphocreatine (PCr) and adenosine triphosphate (ATP) were quantified in localized 31P-spectra by SLOOP (spectral localization with optimum point spread function). Cine- and late gadolinium enhancement (LGE) studies were also performed. When compared with healthy controls, Fabry patients demonstrated reduced PCr- (6.1 ± 1.9 vs. 8.8 ± 2.6 mmol/kg; P = 0.003) and ATP concentrations (3.9 ± 1.5 vs. 4.6 ± 1.0 mmol/kg; P = 0.048). During ERT, PCr concentrations increased (7.1 ± 1.5 mmol/kg vs. 6.1 ± 1.9; P < 0.05) and left ventricular mass decreased (215 ± 55 vs. 185 ± 45 g; P = 0.012). Disturbances in cardiac energetics were not correlated to the presence or absence of cardiac fibrosis on LGE. CONCLUSION: Cardiac energy metabolism is disturbed in Fabry disease; this may play an important role in the pathogenesis of Fabry cardiomyopathy. Enzyme replacement therapy ameliorates energetic depression.

Endovascular reconstruction of the aortic bifurcation in patients with Leriche syndrome.

BACKGROUND: The Leriche syndrome with contiguous total occlusions of the infrarenal aorta and the iliac arteries is a variant of Trans-Atlantic Inter-Society Consensus (TASC) type D aortoiliac disease, for which surgery is the recommended treatment of choice. We sought to prospectively assess the feasibility and safety of an endovascular therapeutic approach. METHODS: Eleven consecutive patients with Leriche syndrome (eight men; 64 +/- 12 years) constituted the study cohort. The treatment strategy consisted of recanalization by transbrachial access of the occluded segments and subsequent transfemoral angioplasty with selective stent placement in the distal aorta and primary nitinol stent placement in the iliac arteries. RESULTS: Bilateral endovascular success was achieved in eight patients (73%), unilateral success in the other three patients. Seven patients received aortic stents; the total stented segment length in 19 iliac arteries successfully recanalized amounted to a median of 18 cm (range 12-26 cm). There was one periprocedural complication, an acute thrombotic aortoiliac occlusion managed by thrombolysis. One patient with unilateral endovascular success had to undergo femorofemoral crossover bypass grafting. At a median of 14 months, significant hemodynamic improvement was observed in successfully revascularized legs (ankle-brachial index, 0.79 +/- 0.20 vs. 0.48 +/- 0.08 at baseline; P = 0.0004); walking capacity as well as Rutherford category of peripheral arterial disease had improved in all patients. CONCLUSIONS: In this small series of patients with Leriche syndrome, the reconstruction of the totally occluded aortoiliac bifurcation by endoluminal means was shown to be feasible and safe and associated with excellent mid-term clinical outcomes.

Late cerebral embolization after emboli-protected carotid artery stenting assessed by sequential diffusion-weighted magnetic resonance imaging.

OBJECTIVES: This study sought to assess the timing of cerebral ischemia after emboli-protected carotid artery stenting (CAS). BACKGROUND: Predominantly clinically silent cerebral ischemia has been observed in up to 50% of patients undergoing emboli-protected CAS. The timing and location of cerebral ischemia has not been sufficiently elucidated. METHODS: In 58 patients (69.6 +/- 8.3 years) who underwent 59 procedures, diffusion-weighted magnetic resonance imaging (DWMRI) was performed before the intervention and at 2 time points (t(1) and t(2)) after the intervention. RESULTS: No patient showed recent cerebral injury before CAS. At t(1) = 3.5 +/- 1.8 h, new ischemic foci, all located in the ipsilateral hemisphere, were observed in 12 of 59 DWMRI studies (20.3%, 95% confidence interval: 11.0% to 32.8%). At t(2) = 18.0 +/- 3.1 h, 7 more DWMRI scans showed recent ischemic foci, and 3 scans in patients with positive scans at t(1) showed additional foci, for a total of 10 scans (17.0%, 95% confidence interval: 8.4% to 29.0%) documenting late cerebral ischemia. In 4 of these (40%), ischemic foci were located contralaterally. Cerebral ischemia was not associated with overt neurological sequelae out to 30 days in any patient. CONCLUSIONS: The incidence of late cerebral ischemia occurring between 3.5 and 18 h after emboli-protected CAS was 17%. It may occur with equal likelihood in either hemisphere. Preventive measures to possibly reduce the incidence of cerebral embolization should focus not only on the target lesion, but also on the access vasculature. Patients should be monitored and DWMRI delayed for at least 18 h after the intervention.

Comparison of different contrast agents and doses for quantitative MR myocardial perfusion imaging.

PURPOSE: To investigate three different contrast agents at different injection volumes for repetitive quantitative multislice myocardial perfusion imaging using the prebolus technique. MATERIALS AND METHODS: Two consecutive prebolus perfusion measurements were performed on a 1.5 T scanner using identical injection volumes for the first and second examination to test the reproducibility for possible rest and stress examination in normal volunteers. Either 1-8 mL, 1-12 mL Gd-DTPA, 1-4 mL, 1-6 mL, 1-9 mL Gd-BOPTA, or 1-4 mL, 1-6 mL gadobutrol were applied. RESULTS: In cases where injection volumes were sufficiently small, there was no indication of significant differences in quantitative perfusion values with respect to the different contrast agents. Increasing the bolus volume improved the contrast-to-noise ratio (CNR) but led to saturation effects and underestimation of the true perfusion. The highest CNR was measured for gadobutrol (6 mL, p < 0.0005 compared to 8 mL Gd-DTPA). The smallest difference of perfusion values between the first and the second prebolus examination was found for Gd-BOPTA (p < or = 0.006 compared Gd-DTPA). CONCLUSION: Prebolus examinations for quantitative myocardial perfusion imaging are possible with all three contrast agents for sufficient small injection volumes. Gd-BOPTA was found to be advantageous for a combined quantitative rest and stress examination.

Effects of exercise training on myocardial energy metabolism and ventricular function assessed by quantitative phosphorus-31 magnetic resonance spectroscopy and magnetic resonance imaging in dilated cardiomyopathy.

OBJECTIVES: The present study investigated changes in cardiac energy metabolism and function in patients with dilated cardiomyopathy (DCM) before and after exercise training (ET) with phosphorus-31 magnetic resonance spectroscopy (MRS) in combination with magnetic resonance imaging (MRI). BACKGROUND: Exercise training might have a beneficial role on myocardial function and oxidative metabolism in DCM, but it is unclear whether the additional load on the failing heart leads to deterioration of cardiac energy metabolism. METHODS: Twenty-four patients were randomized to an exercise (age 53 +/- 12 years) or a control (age 56 +/- 6 years) group. Supervised ET was performed for 2 months, followed by 6 months of self-regulated training. At baseline and 2 and 8 months, maximal exercise testing along with quantitative MRS and MRI studies were performed. RESULTS: The effectiveness of ET was demonstrated by a 17% increase in peak oxygen uptake (p < 0.05). Exercise training improved left ventricular (LV) end-systolic volume (p < 0.05) and LV ejection fraction (30 +/- 15% vs. 37 +/- 15%; p < 0.01) but not right ventricular parameters. The improvement in cardiac function was not accompanied by changes in cardiac high-energy phosphate concentrations; phosphocreatine, adenosine triphosphate, and the phosphocreatine/adenosine triphosphate ratio were all unchanged after training. CONCLUSIONS: The observation that LV function improved and LV energy metabolism remained unchanged suggests that the beneficial effect of ET on LV function is achieved without adversely affecting metabolism. These findings lend further support for the use of ET as an adjunct therapy in DCM.

Energetic differences between viable and non-viable myocardium in patients with recent myocardial infarction are not an effect of differences in wall thinning- a multivoxel (31)P-MR-spectroscopy and MRI study.

To evaluate multivoxel (31)P-MR spectroscopy (MRS) for assessment of energy metabolism in patients with myocardial infarction (MI) in correlation to left ventricular (LV) wall thickness and the outcome of revascularization. Thirty patients with subacute anterior myocardial infarction and planned revascularization were enrolled. 3D-chemical shift imaging was applied to determine PCr/ATP ratios in two areas: infarcted/anterior and noninfarcted/septal myocardium. MRI was used to evaluate LV function and wall thickness, and was repeated 6 months after revascularization to assess myocardial viability. Fifteen volunteers were controls. Fifteen patients showed normalization of wall motion abnormalities after revascularization (Group 1; viable), 15 not (Group 2; non-viable). Regarding infarcted/anterior myocardium, Group 2 had lower PCr/ATP ratios (0.81 +/- 0.60 vs 1.17 +/- 0.25), and PCr/ATP ratios were reduced in both groups compared to controls (1.45 +/- 0.29). Regarding noninfarcted/septal myocardium, again Group 2 had lower ratios (0.93 +/- 0.53 vs 1.31 +/- 0.38); however, compared to controls (1.51 +/- 0.32) a reduction of PCr/ATP ratios was only found in Group 2. For both myocardial regions, no correlations between PCr/ATP ratios and LV wall thickness were detected. The more severe energetic alteration in irreversibly damaged myocardium is not an effect of differences of wall thinning. Additional alterations of noninfarcted, adjacent myocardium can be detected.

Absolute quantification of myocardial perfusion under adenosine stress.

The prebolus technique allows one to quantify perfusion in the human heart with a low variability by means of MRI. In this study the prebolus technique was used to determine quantitative perfusion values in the human heart under adenosine stress and to measure the myocardial perfusion reserve (MPR). Twelve healthy volunteers were examined using the multislice prebolus technique with 1/4 cc Gd-BOPTA. Signal intensity (SI) time courses were evaluated in 288 manually segmented sectors at rest and stress. Myocardial perfusion was determined by deconvolution of the SI time courses with the arterial input function (AIF) from the prebolus scan. The mean stress perfusion value was 1.78 +/- 0.53 cc/g/min, and the mean rest perfusion was 0.52 +/- 0.11 cc/g/min, resulting in a mean MPR of 3.59 +/- 1.26. The measured values correlate well with data from animal models and human positron emission tomography (PET) studies.

Age and gender dependence of human cardiac phosphorus metabolites determined by SLOOP 31P MR spectroscopy.

The aim of this study was to apply (31)P magnetic resonance spectroscopy (MRS) using spatial localization with optimal point spread function (SLOOP) to investigate possible age and gender dependencies of the energy metabolite concentrations in the human heart. Thirty healthy volunteers (18 males and 12 females, 21-67 years old, mean = 40.7 years) were examined with the use of (31)P-MRS on a 1.5 T scanner. Intra- and interobserver variability measures (determined in eight of the volunteers) were both 3.8% for phosphocreatine (PCr), and 4.7% and 8.3%, respectively, for adenosine triphosphate (ATP). High-energy phosphate (HEP) concentrations in mmol/kg wet weight were 9.7 +/- 2.4 (age < 40 years, N = 16) and 7.7 +/- 2.5 (age >or= 40 years, N = 14) for PCr, and 5.1 +/- 1.0 (age < 40 years) and 4.1 +/- 0.8 (age >or= 40 years) for ATP, respectively. Separated by gender, PCr concentrations of 9.2 +/- 2.4 (men, N = 18) and 8.0 +/- 2.8 (women, N = 12) and ATP concentrations of 4.9 +/- 1.0 (men) and 4.2 +/- 0.9 (women) were measured. A significant decrease of PCr and ATP was found for volunteers older than 40 years (P < 0.05), but the differences in metabolic concentrations between both sexes were not significant. In conclusion, age has a minor but still significant impact on cardiac energy metabolism, and no significant gender differences were detected.

Functional and metabolic recovery of the right ventricle during Bosentan therapy in idiopathic pulmonary arterial hypertension.

An impaired high-energy phosphate metabolism might play a critical role in the pathogenesis of right ventricular (RV) failure due to chronic pulmonary arterial hypertension (PAH). 31P-NMR spectroscopy is well established for measurements of high-energy phosphate metabolites in various left ventricular heart diseases, however, mainly for technical and sensitivity reasons, its successful transfer for measurements in the RV is currently missing. In the present study, the usefulness of this non-invasive approach is not only shown in RV failure due to PAH but also tested during subsequent therapy.

Assessment of myocardial viability by MR imaging.

Diagnosis of myocardial viability after infarction focuses on the prediction of functional improvement of dysfunctional myocardium after revascularization therapy. Magnetic resonance imaging provides different approaches for the detection of myocardial viability. Measurement of end-diastolic wall thickness is easy to perform and has a high sensitivity, but a low specificity, and can only be used 4 months after myocardial infarction due to infarct healing processes. Low-dose dobutamine stress has a good sensitivity with a high specificity for the prediction of wall motion improvement, but this is only true for patients with a singular dysfunctional area and only slightly depressed cardiac function. Late enhancement allows for direct visualization of necrotic or scarred tissue. By measuring the transmural extent of late enhancement, the probability of mechanical improvement can precisely be given. Imaging of microvascular obstruction by first-pass perfusion or late enhancement gives additional information on viability and patient prognosis. Metabolic imaging techniques, such as (31)P-MR spectroscopy and (23)Na-MR imaging, provide further insights into the mechanisms of myocardial infarction and viability. In conclusion, cardiac MRI offers several clinically usable approaches for the assessment of myocardial viability and will probably become the method of choice in the near future.

Quantitative dynamic contrast-enhanced sonography of hepatic tumors.

Liver tumors are defined using quantitative dynamic contrast-enhanced ultrasound compared to histological diagnosis, respectively, long-term follow-ups. Forty-two focal liver lesions in 39 patients were examined by contrast harmonic imaging over a period of 2 min after bolus injection of 10-ml galactose-based contrast agent. Vascular enhancement was quantified by using a dedicated software that allowed us to place representative regions of interest (ROI) in the center of the lesion, in the complete lesion, in regular liver parenchyma and in representative liver vessels (artery, vein and portal vein). Peak enhancement was judged to be either in the arterial, portal venous or in the late phase of liver perfusion. The lesion was described as hypovascular, isovascular and hypervascular compared to liver parenchyma. Contrast uptake was described as centrifugal or centripetal and peripheral or homogenous, respectively. Characterization of the lesions was performed unenhanced and after contrast by four independent specialists unaware of histology. Diagnosis of malignancy was evaluated by using a receiver operating characteristic (ROC) analysis, also overall accuracy, average sensitivity, specificity and negative and positive predictive values were calculated. Interobserver agreement was defined by the Kappa statistics. Histologic examination revealed 29 malignant [hepatocellular carcinoma (HCC), n=11; cholangiocellular carcinoma (CCC), n=1; lymphoma, n=1; metastases, n=16)] and 7 benign [hemangioma, n=1; focal nodular hyperplasia (FNH), n=4, adenoma, n=2)] lesions. Six benign lesions (hemangioma n=1; FNH n=5) were proved by long-term follow-up. ROC analysis regarding the diagnosis of malignancy showed values from 0.43 to 0.62 (mean 0.57) before and from 0.70 to 0.80 (mean 0.75) after contrast agent, respectively. The average values for sensitivity, specificity, accuracy and negative and positive predictive values were 66, 26, 62, 45 and 73% unenhanced and 83, 49, 73, 65 and 82% after contrast, respectively. The interobserver agreement was 0.54 and 0.65 for unenhanced and enhanced examinations, respectively. Quantitative dynamic contrast-enhanced sonography improves the diagnosis of malignancy in liver lesions.

Correction for partial volume errors in MR heart perfusion imaging.

Myocardial MR first-pass perfusion time courses are contaminated by signals from the ventricles (spillover) as a consequence of partial volume effects and motion. An early increase in the signal intensity from the myocardium is an indicator of contamination. This contamination leads to under- or overestimation of perfusion, depending on the amount of contamination. In this work a simple method for contamination correction is proposed: curves proportional to the signal intensity time courses in the ventricles are subtracted from the signal intensity time courses in the myocardium to minimize the variance of signal before the arrival of the contrast medium in the myocardium. The proposed correction is easy to apply, removes the contamination, and leads to more precise perfusion values.