Cardiac magnetic resonance imaging pericardial late gadolinium enhancement and elevated inflammatory markers can predict the reversibility of constrictive pericarditis after antiinflammatory medical therapy: a pilot study.

BACKGROUND: Constrictive pericarditis (CP) is a disabling disease, and usually requires pericardiectomy to relieve heart failure. Reversible CP has been described, but there is no known method to predict the reversibility. Pericardial inflammation may be a marker for reversibility. As a pilot study, we assessed whether cardiac magnetic resonance imaging pericardial late gadolinium enhancement (LGE) and inflammatory biomarkers could predict the reversibility of CP after antiinflammatory therapy. METHOD AND RESULTS: Twenty-nine CP patients received antiinflammatory medications after cardiac magnetic resonance imaging. Fourteen patients had resolution of CP, whereas 15 patients had persistent CP after 13 months of follow-up. Baseline LGE pericardial thickness was greater in the group with reversible CP than in the persistent CP group (4 ± 1 versus 2 ± 1 mm, P = 0.001). Qualitative intensity of pericardial LGE was moderate or severe in 93% of the group with reversible CP and in 33% of the persistent CP group (P = 0.002). Cardiac magnetic resonance imaging LGE pericardial thickness ≥ 3 mm had 86% sensitivity and 80% specificity to predict CP reversibility. The group with reversible CP also had higher baseline C-reactive protein and erythrocyte sedimentation rate than the persistent CP group (59 ± 52 versus 12 ± 14 mg/L, P = 0.04 and 49 ± 25 versus 15 ± 16 mm/h, P = 0.04, respectively). Antiinflammatory therapy was associated with a reduction in C-reactive protein, erythrocyte sedimentation rate, and pericardial LGE in the group with reversible CP but not in the persistent CP group. CONCLUSIONS: Reversible CP was associated with pericardial and systemic inflammation. Antiinflammatory therapy was associated with a reduction in pericardial and systemic inflammation and LGE pericardial thickness, with resolution of CP physiology and symptoms. Further studies in a larger number of patients are needed.

Intracardiac thrombosis and anticoagulation therapy in cardiac amyloidosis.

BACKGROUND: Primary amyloidosis has a poor prognosis as a result of frequent cardiac involvement. We recently reported a high prevalence of intracardiac thrombus in cardiac amyloid patients at autopsy. However, neither the prevalence nor the effect of anticoagulation on intracardiac thrombus has been evaluated antemortem. METHODS AND RESULTS: We studied all transthoracic and transesophageal echocardiograms of cardiac amyloid patients at the Mayo Clinic. The prevalence of intracardiac thrombosis, clinical and transthoracic/transesophageal echocardiographic risks for intracardiac thrombosis, and effect of anticoagulation were investigated. We identified 156 patients with cardiac amyloidosis who underwent transesophageal echocardiograms. Amyloidosis was the primary type (AL) in 80; other types occurred in 76 patients, including 56 with the wild transthyretin type, 17 with the mutant transthyretin type, and 3 with the secondary type. Fifth-eight intracardiac thrombi were identified in 42 patients (27%). AL amyloid had more frequent intracardiac thrombus than the other types (35% versus 18%; P=0.02), although the AL patients were younger and had less atrial fibrillation. Multivariate analysis showed that atrial fibrillation, poor left ventricular diastolic function, and lower left atrial appendage emptying velocity were independently associated with increased risk for intracardiac thrombosis, whereas anticoagulation was associated with a significantly decreased risk (odds ratio, 0.09; 95% CI, 0.01 to 0.51; P<0.006). CONCLUSIONS: Intracardiac thrombosis occurs frequently in cardiac amyloid patients, especially in the AL type and in those with atrial fibrillation. Risk for thrombosis increased if left ventricular diastolic dysfunction and atrial mechanical dysfunction were present. Anticoagulation therapy appears protective. Timely screening in high-risk patients may allow early detection of intracardiac thrombus. Anticoagulation should be carefully considered.

Valsalva sinus aneurysms: findings at CT and MR imaging.

Aneurysms of the Valsalva sinus (aortic sinus) can be congenital or acquired and are rare. They are more common among men than women and among Asians than other ethnic groups. Nonruptured aneurysms may be asymptomatic and incidentally discovered, or they may be symptomatic and manifest acutely with mass effect on adjacent cardiac structures. Ruptured Valsalva sinus aneurysms result in an aortocardiac shunt and may manifest as insidiously progressive congestive heart failure, severe acute chest pain with dyspnea, or, in extreme cases, cardiac arrest. Although both ruptured and nonruptured Valsalva sinus aneurysms may have potentially fatal complications, after treatment the prognosis is excellent. Thus, prompt and accurate diagnosis is critical. Most Valsalva sinus aneurysms are diagnosed on the basis of echocardiography, with or without angiography. However, both electrocardiographically gated computed tomography and magnetic resonance (MR) imaging can provide excellent anatomic depiction, and MR imaging can provide valuable functional information.

Intracardiac thrombosis and embolism in patients with cardiac amyloidosis.

BACKGROUND: Patients with primary amyloidosis (AL type) have a poor prognosis, in part due to frequent cardiac involvement. Although intracardiac thrombus has been reported in anecdotal cases, neither its frequency nor its role in causing mortality is known. Furthermore, the clinical and echocardiographic variables that may be associated with thromboembolism in cardiac amyloidosis have not been defined. METHODS AND RESULTS: A total of 116 autopsy or explanted cases of cardiac amyloidosis (55 AL and 61 other type) were identified in the Mayo Clinic. Forty-six fatal nonamyloid trauma cases served as controls. Each heart was examined for intracardiac thrombus. The cause of death was determined from autopsy and clinical notes. Intracardiac thrombosis was identified in 38 hearts (33%). Twenty-three had 1 thrombus, whereas 15 had 2 to 5 thrombi. Although subjects in the AL group were younger and had less atrial fibrillation than those with other types of amyloidosis, the AL group had significantly more intracardiac thrombus (51% versus 16%, P<0.001) and more fatal embolic events (26% versus 8%, P<0.03). Control hearts had no intracardiac thrombus. The presence of both atrial fibrillation and AL was associated with an extremely high risk for thromboembolism (odds ratio 55.0 [95% confidence interval 8.1 to 1131.4]). By multivariate analysis, AL type (odds ratio 8.4 [95% confidence interval 1.8 to 51.2]) and left ventricular diastolic dysfunction (odds ratio 12.2 [95% confidence interval 2.7 to 72.7]) were independently associated with thromboembolism. CONCLUSIONS: A high frequency of intracardiac thrombosis was present in cardiac amyloidosis. Furthermore, thromboembolism caused significant fatality. Several risk factors for thromboembolism were identified. Early screening, especially in high-risk patients, and early anticoagulation might reduce morbidity and mortality.

Myocardial contrast echocardiography in biopsy-proven primary cardiac amyloidosis.

Cardiac vasculature is affected in 88-90% of patients with primary cardiac amyloidosis (CA). Myocardial contrast echocardiography (MCE) relies on the ultrasound detection of microbubble contrast agents that are solely confined to the intravascular space, and are therefore useful in the evaluation of flow in the microvasculature. This is the first case report describing the use of MCE during vasodilator stress to evaluate coronary flow reserve in a patient with biopsy-proven primary CA and angiographically normal coronaries. Qualitative MCE demonstrated delayed replenishment of microbubbles during peak stress; quantitative analysis was consistent with a reduction in total myocardial blood flow and reserve values. Comparative imaging modalities including strain and strain rate imaging, magnetic resonance imaging, and myocardial scintigraphy were suggestive to the diagnosis of CA. In conclusion, MCE is a method for recognition of microvascular dysfunction, and might be considered as a useful tool to augment echocardiographic assessment in the early diagnosis of CA.

Cardiac MR imaging of nonischemic cardiomyopathies.

Cardiomyopathies, diseases of the myocardium associated with cardiac dysfunction, include hypertrophic, restrictive, and dilated forms and rare entities, such as arrhythmogenic right ventricular dysplasia, ventricular noncompaction, and apical ballooning syndrome. Many have similar presentations, but the underlying condition determines prognoses and treatment. Cardiac MR imaging plays a role in characterizing the range of entities and is crucial for evaluation and management. In addition, delayed enhanced imaging can allow differentiation among the forms of cardiomyopathy and offer prognostic information. As the speed and technical ease of cardiac imaging improve, MR imaging will assume an increasing role in the care of patients who have cardiomyopathy.

MR imaging of the pericardium.

Imaging of the pericardium requires understanding of anatomy and the normal and abnormal physiology of the pericardium. MR imaging is well-suited for answering clinical questions regarding suspected pericardial disease. Pericardial diseases that may be effectively imaged with MR imaging include pericarditis, pericardial effusion, cardiac-pericardial tamponade, constrictive pericarditis, pericardial cysts, absence of the pericardium, and pericardial masses. Although benign and malignant primary tumors of the pericardium may be occasionally encountered, the most common etiology of a pericardial mass is metastatic disease.

MR imaging of cardiac masses.

Cardiac MR imaging is the preferred method for assessment of cardiac masses. A comprehensive cardiac MR imaging examination for a cardiac mass consists of static morphologic images using fast spin-echo sequences, including single-shot techniques, with T1 and T2 weighting and fat suppression pulses as well as dynamic imaging with cine steady-state free precession techniques. Further tissue characterization is provided with perfusion and delayed enhancement imaging. Specific cardiac tumoral characterization is possible in many cases. When specific tumor characterization is not possible, MR imaging often can demonstrate aggressive versus nonaggressive features that help in differentiating malignant from benign tumors.

Lead Extraction Imaging.

Lead extraction procedures have a low but real risk of major complications, such as superior vena cava tear and cardiac tamponade. Complications during lead removal are commonly related to lead binding sites, lead malposition, and lead perforation. Lead extraction imaging may indicate lead vascular binding sites, lead position, and perforation. Several imaging modalities are available, including chest radiograph, cardiac computed tomography, and echocardiography. The information provided by various imaging modalities will help assess the challenges of each lead extraction procedure and allows for better preprocedure planning.

Twelve-Lead ECG Optimization of Cardiac Resynchronization Therapy in Patients With and Without Delayed Enhancement on Cardiac Magnetic Resonance Imaging.

Background Delayed enhancement ( DE ) on magnetic resonance imaging is associated with ventricular arrhythmias, adverse events, and worse left ventricular mechanics. We investigated the impact of DE on cardiac resynchronization therapy ( CRT ) outcomes and the effect of CRT optimization. Methods and Results We studied 130 patients with ejection fraction ( EF ) ≤40% and QRS ≥120 ms, contrast cardiac magnetic resonance imaging, and both pre- and 1-year post- CRT echocardiograms. Sixty-three (48%) patients did not have routine optimization of CRT . The remaining patients were optimized for wavefront fusion by 12-lead ECG . The primary end point in this study was change in EF following CRT . To investigate the association between electrical dyssynchrony and EF outcomes, the standard deviation of activation times from body-surface mapping was calculated during native conduction and selected device settings in 52 of the optimized patients. Patients had no DE (n=45), midwall septal stripe (n=30), or scar (n=55). Patients without DE had better ∆ EF (13±10 versus 4±10 units; P<0.01). Optimized patients had greater ∆ EF in midwall stripe (2±9 versus 12±12 units; P=0.01) and scar (0±7 versus 5±10; P=0.04) groups, but not in the no- DE group. Patients without DE had greater native standard deviation of activation times ( P=0.03) and greater ∆standard deviation of activation times with standard programming ( P=0.01). Device optimization reduced standard deviation of activation times only in patients with DE ( P<0.01). Conclusions DE on magnetic resonance imaging is associated with worse EF outcomes following CRT . Device optimization is associated with improved EF and reduced electrical dyssynchrony in patients with DE .

Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction.

OBJECTIVE: The presentation and electrocardiographic (ECG) characteristics of transient left ventricular apical ballooning syndrome (TLVABS) can be similar to that of anterior ST-segment elevation myocardial infarction (STEMI). We tested the hypothesis that the ECG on presentation could reliably differentiate these syndromes. SUBJECTS AND METHODS: Between January 1, 2002 and July 31, 2004, we identified 18 consecutive patients with TLVABS who were matched with 36 subjects presenting with acute anterior STEMI due to atherothrombotic left anterior descending coronary artery occlusion. RESULTS: All patients with TLVABS were women (mean age, 72.0 +/- 13.1 years). The heart rate, PR interval, QRS duration, and corrected QT interval were similar between groups. Distribution of ST elevation was similar, but patients with anterior STEMI exhibited greater ST elevation. Regressive partitioning analysis indicated that the combination of ST elevation in lead V2 of less than 1.75 mm and ST-segment elevation in lead V3 of less than 2.5 mm was a suggestive predictor of TLVABS (sensitivity, 67%; specificity, 94%). Conditional logistic regression indicated that the formula: (3 x ST-elevation lead V2) + (ST-elevation V3) + (2 x ST-elevation V5) allowed possible discrimination between TLVABS and anterior STEMI with an optimal cutoff level of less than 11.5 mm for TLVABS (sensitivity, 94%; specificity, 72%). Patients with TLVABS were less likely to have concurrent ST-segment depression (6% vs 44%; P = .003). CONCLUSIONS: Women presenting with TLVABS have similar ECG findings to patients with anterior infarct but with less-prominent ST-segment elevation in the anterior precordial ECG leads. These ECG findings are relatively subtle and do not have sufficient predictive value to allow reliable emergency differentiation of these syndromes.

LGE Provides Incremental Prognostic Information Over Serum Biomarkers in AL Cardiac Amyloidosis.

OBJECTIVES: This study sought to determine the prognostic value of cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) in amyloid light chain (AL) cardiac amyloidosis. BACKGROUND: Cardiac involvement is the major determinant of mortality in AL amyloidosis. CMR LGE is a marker of amyloid infiltration of the myocardium. The purpose of this study was to evaluate retrospectively the prognostic value of CMR LGE for determining all-cause mortality in AL amyloidosis and to compare the prognostic power with the biomarker stage. METHODS: Seventy-six patients with histologically proven AL amyloidosis underwent CMR LGE imaging. LGE was categorized as global, focal patchy, or none. Global LGE was considered present if it was visualized on LGE images or if the myocardium nulled before the blood pool on a cine multiple inversion time (TI) sequence. CMR morphologic and functional evaluation, echocardiographic diastolic evaluation, and cardiac biomarker staging were also performed. Subjects' charts were reviewed for all-cause mortality. Cox proportional hazards analysis was used to evaluate survival in univariate and multivariate analysis. RESULTS: There were 40 deaths, and the median study follow-up period was 34.4 months. Global LGE was associated with all-cause mortality in univariate analysis (hazard ratio = 2.93; p < 0.001). In multivariate modeling with biomarker stage, global LGE remained prognostic (hazard ratio = 2.43; p = 0.01). CONCLUSIONS: Diffuse LGE provides incremental prognosis over cardiac biomarker stage in patients with AL cardiac amyloidosis.

Utility of transthoracic echocardiography to estimate severity of right ventricular dysfunction: an MRI comparison study.

Prognostic implications of severe right ventricular (RV) dysfunction are difficult to assess because of limitations in functional characterization using standard echocardiography (TTE) and the cost and availability of options such as MRI. We sought to determine how assessments of RV dysfunction via TTE correlate with RV ejection fraction (EF) by MRI. Patients undergoing MRI and TTE within 21 days of one another were included. Left ventricular (LV) and RV EF were recorded from MRI and subjective assessment of RV function (normal, mild, moderate, or severe dysfunction), right ventricular index of myocardial performance (RIMP), and right ventricular systolic pressure (RVSP) were recorded from TTE. Patients were considered to have significant RV dysfunction if EF ≤ 35% on MRI and normal function if EF ≥ 45%. A total of 474 patients were included (age 50 ± 12, 57% male). Of these, 363 (76.6%) had normal function, 54 (11.4%) had mild dysfunction, 41 (8.6%) had moderate dysfunction, and 16 (3.4%) had severe dysfunction on TTE. Moderate or severe dysfunction had good sensitivity (80%) and specificity (97%) for RV EF ≤ 35%. Furthermore, RIMP > 0.70 and RVSP > 70 mm Hg were very specific for RV EF ≤ 35% (sensitivity = 29%, 22%, respectively; specificity = 98%, 99%, respectively). Specificity and sensitivity of TTE assessments did not change if LV function or disease indication was considered. A subjective assessment of moderate to severe RV dysfunction on TTE compares favorably with quantitative MRI assessment of the RV EF. Further study is needed to evaluate whether this comparability is true across institutions.

ECG-gated dual-source CT for detection of left atrial appendage thrombus in patients undergoing catheter ablation for atrial fibrillation.

PURPOSE: Left atrial ablation is increasingly used to treat patients with symptomatic atrial fibrillation (AF). Prior to ablation, exclusion of left atrial appendage (LAA) thrombus is important. Whether ECG-gated dual-source computed tomography (DSCT) provides a sensitive means of detecting LAA thrombus in patients undergoing percutaneous AF ablation is unknown. Thus, we sought to determine the utility of ECG-gated DSCT in detecting LAA thrombus in patients with AF. METHODS: A total of 255 patients (age 58 ± 11 years, 78% male, ejection fraction 58 ± 9%) who underwent ECG-gated DSCT and transesophageal echocardiography (TEE) prior to AF ablation between February 2006 and October 2007 were included. CHADS2 score and demographic data were obtained prospectively. Gated DSCT images were independently reviewed by two cardiac imagers blinded to TEE findings. The LAA was either defined as normal (fully opacified) or abnormal (under-filled) by DSCT. RESULTS: An under-filled LAA was identified in 33 patients (12.9%), of whom four had thrombus confirmed by TEE. All patients diagnosed with LAA thrombus using TEE also had an abnormal LAA by gated DSCT. Thus, sensitivity and specificity for gated DSCT were 100% and 88%, respectively. No cases of LAA filling defects were observed in patients <51 years old with a CHADS2 of 0. CONCLUSION: In patients referred for AF ablation, thrombus is uncommon in the absence of additional risk factors. Gated DSCT provides excellent sensitivity for the detection of thrombus. Thus, in AF patients with a CHADS2 of 0, gated DSCT may provide a useful stand-alone imaging modality.

Role of cardiac magnetic resonance imaging in the detection of cardiac amyloidosis.

OBJECTIVES: Our aim was to evaluate the role and mechanism of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) in identifying cardiac amyloidosis (CA) and to investigate associations between LGE and clinical, morphologic, functional, and biochemical features. BACKGROUND: CA can be challenging to diagnose by echocardiography. Recent studies have demonstrated an emerging role for LGE-CMR. METHODS: LGE-CMR was performed in 120 patients with amyloidosis. Cardiac histology was available in 35 patients. The remaining 85 patients were divided into those with and without echocardiographic evidence of CA. RESULTS: Of the 35 patients with histologically verified CA, abnormal LGE was present in 34 (97%) patients and increased echocardiographic left ventricular wall thickness in 32 (91%) patients. Global transmural or subendocardial LGE (83%) was most common and was associated with greater interstitial amyloid deposition (p = 0.03). Suboptimal myocardial nulling (8%) and patchy focal LGE (6%) were also observed. LGE distribution matched the deposition pattern of interstitial amyloid. Among patients without cardiac histology, LGE was present in 86% of those with evidence of CA by echocardiography and in 47% of those without evidence of CA by echocardiography. In patients without echocardiographic evidence of CA, the presence of LGE was associated with worse clinical, electrocardiographic (ECG), and cardiac biomarker profiles. In all patients, LGE presence and pattern was associated with New York Heart Association functional class, ECG voltage, left ventricular mass index, right ventricular wall thickness, troponin-T, and B-type natriuretic peptide levels. CONCLUSIONS: LGE is common in CA and detects interstitial expansion from amyloid deposition. Global transmural or subendocardial LGE is most common, but suboptimal myocardial nulling and focal patchy LGE are also observed. LGE-CMR may detect early cardiac abnormalities in patients with amyloidosis with normal left ventricular thickness. The presence and pattern of LGE is strongly associated with clinical, morphologic, functional, and biochemical markers of prognosis.

Comparison of magnetic resonance imaging versus Doppler echocardiography for the evaluation of left ventricular diastolic function in patients with cardiac amyloidosis.

To assess the role of magnetic resonance imaging (MRI) in the assessment of diastolic function, diastolic mitral inflow parameters using MRI and transthoracic Doppler echocardiography (echocardiography) were compared in patients with cardiac amyloidosis. Thirty-eight patients (age 60 +/- 12 years; 32% women) in sinus rhythm with cardiac amyloidosis (biopsy-proven systemic amyloidosis and positive echocardiographic and contrast-enhanced cardiac MRI findings) were evaluated. Cine phase-contrast MRI images of mitral inflow were obtained in the left ventricle to quantify diastolic blood flow. MRI measurements of diastolic parameters were compared (Spearman's rank correlation) with echocardiographic diastolic mitral inflow velocity parameters. Additional analysis was performed comparing MRI findings in patients with a restrictive echocardiographic diastolic filling pattern (n = 23) versus those without (n = 15). For the 38 patients, early diastolic (E) peak velocity was 61 +/- 26 cm/s using MRI versus 79 +/- 21 using echocardiography (Spearman's rank correlation 0.55, p = 0.0004), and late diastolic (A) peak velocity was 46 +/- 22 cm/s using MRI versus 47 +/- 22 cm/s using echocardiography (Spearman's rank correlation 0.54, p = 0.0005). E/A ratio was 1.55 +/- 0.9 using MRI and 2.25 +/- 1.4 using echocardiography (Spearman's rank correlation 0.75, p <0.0001). Deceleration times in both modalities showed good correlation (MRI, 180 +/- 44 ms vs echocardiography, 179 +/- 49; Spearman's rank correlation 0.61, p = 0.0001). MRI E/A ratio for peak velocities was significantly higher in patients with restrictive echocardiographic patterns (1.95 +/- 1.0) versus those without (0.93 +/- 0.3; p = 0.0003). Two of 23 patients with a restrictive echocardiographic pattern had an MRI E/A ratio <1. In conclusion, mitral inflow peak velocities, deceleration times, and E/A ratios detected using phase-contrast MRI in patients with cardiac amyloidosis showed moderately good correlation with echocardiography and identified most patients with restrictive echocardiographic patterns.

Echocardiographic features of cardiac amyloidosis presenting as endomyocardial disease in a 54-year-old male.

Although primary cardiac amyloidosis is a rare affliction of the heart, its clinical and pathology features have been well described. Patients generally present with exertional dyspnea, chest discomfort, or congestive heart failure. Cardiac imaging typically reveals ventricular wall thickening, systolic and diastolic dysfunction, valvular thickening, and pericardial effusion. In the case reported herein, a patient with suspected cardiac amyloid demonstrated electrocardiographic and echocardiographic findings that were not only inconsistent with typical depositional patterns, but also potentially suggestive of endomyocardial disease.

Utility of nongated multidetector computed tomography for detection of left atrial thrombus in patients undergoing catheter ablation of atrial fibrillation.

OBJECTIVES: The aim of this study was to determine whether multidetector computed tomography (MDCT) is able to exclude left atrial appendage (LAA) thrombus in patients referred for catheter ablation of atrial fibrillation (CAAF). BACKGROUND: MDCT is commonly used to render pulmonary vein and left atrial anatomy before CAAF. Transesophageal echocardiography (TEE) is also often performed before the ablation to exclude LAA thrombus. Whether MDCT alone is sufficient to exclude LAA thrombus is unknown. METHODS: Patients referred for CAAF at the Mayo Clinic between March 2004 and October 2006 were included. Clinical data, 64-slice MDCT (nonelectrocardiography-gated), and TEE were all analyzed. Image data were independently reviewed by 2 cardiac radiologists blinded to the TEE findings. The appearance of the LAA was defined as normal (fully opacified) or abnormal (underfilled). RESULTS: Four hundred two patients (mean age 56 +/- 10 years; 76% male; ejection fraction 56 +/- 10%) were included. Three hundred sixty-two had no evidence of a filling defect by ungated MDCT or left atrial spontaneous echo contrast or thrombus by TEE. In 40 patients, the LAA was "underfilled" with 9 definite thrombi confirmed by TEE. Sensitivity and specificity was 100% and 92%, respectively, with a negative predictive value of 100% and positive predictive value of 23%. In patients with LAA underfilling, Doppler-derived LAA emptying velocities were substantially reduced (mean 19 cm/s; range 6 to 61 cm/s) below the normal range. A higher CHADS(2) (congestive heart failure, hypertension, age older than 75 years, and diabetes) score (1.6 vs. 1.1) was observed in patients with LAA filling defects. No cases of LAA thrombus were observed in patients age <52 years with CHADS(2) score <1. CONCLUSIONS: In patients referred for CAAF, MDCT is a sensitive (100% sensitivity) imaging modality that could be used alone especially in patients age <52 years with a CHADS(2) score <1. Incorporation of these findings could decrease the need for multiple imaging modalities and thereby reduce cost of the procedure.

Cardiac magnetic resonance imaging of eosinophilic endomyocardial disease.

Idiopathic hypereosinophilic syndrome (HES) is rare and frequently involves the heart with development of endomyocardial fibrosis, a characteristic restrictive cardiomyopathy. Non-invasive diagnosis is frequently challenging. Recent developments in cardiac magnetic resonance (CMR) imaging techniques offer potential for improved detection and characterization of this entity. We describe the use of contrast-enhanced CMR to demonstrate thrombus, endomyocardial fibrosis and inflammation in eosinophilic endomyocardial disease. A three-layered appearance consisting of normal myocardium, thickened fibrotic endocardium with inflammatory exudate, and overlying thrombus was seen on cine-images. Post-contrast perfusion and delayed enhancement images confirmed the presence and location of endomyocardial fibrosis and thrombus. CMR is an important and powerful addition to current non-invasive diagnostic tools for the clinical diagnosis of eosinophilic endomyocardial disease, and may potentially obviate the need for cardiac biopsy in the future.

Apical ballooning syndrome or aborted acute myocardial infarction? Insights from cardiovascular magnetic resonance imaging.

INTRODUCTION: Apical Ballooning Syndrome (ABS) is a novel acute cardiac syndrome that mimics acute myocardial infarction (AMI). This study evaluates the diagnostic utility of cardiac magnetic resonance imaging (CMR) in patients with suspected ABS. METHODS AND MATERIALS: Contrast-enhanced CMR was performed in 13 consecutive patients with suspected ABS on the basis of their initial clinical presentation and cardiac catheterization results. RESULTS: Ten patients (all female, mean age 71 +/- 8 years) had an eventual diagnosis of ABS. CMR demonstrated left ventricle regional wall motion abnormalities (RWMA) involving the apex and mid-ventricle. Six also had right ventricular apical akinesis. There was no myocardial delayed enhancement (MDE) in these patients. The remaining three patients had initial features suggestive of ABS but were eventually determined to have AMI. Left ventriculography showed typical apical ballooning that was not explained by coronary angiography results. Two had MDE and persistent RWMA consistent with anterior AMI. One had RWMA on CMR consistent with a single vascular territory, and subsequent intravascular ultrasound showed obstructive plaque in the left anterior descending (LAD) artery. The final diagnosis in these patients was AMI with clot lysis prior to coronary angiography. CONCLUSION: While ABS mimics AMI, AMI with spontaneous clot lysis may also mimic ABS, and at least in some patients, be mistaken for ABS. ABS is characterized by the absence of MDE and complete myocardial viability on CMR. The diagnosis of ABS can be excluded if CMR demonstrates MDE consistent with myocardial necrosis in a pattern and distribution consistent with AMI.