Cost-Minimization analysis for cardiac revascularization in 12 healthcare systems based on the EuroCMR/SPINS registries

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): EuroCMR registry (Life Sciences GE Healthcare, Medtronic Inc., Minneapolis MN, USA; Novartis International AG, Basel, Switzerland; Siemens Healthcare, Erlangen, Germany), SPINS registry (Siemens Healthineers, Erlangen, Germany; Bayer AG, Leverkusen, Germany)

Background

Coronary artery disease (CAD) is a major contributor to the public health burden. Stress perfusion cardiac magnetic resonance (CMR) has an excellent accuracy to detect CAD, but data on its cost effectiveness are scarce.

Purpose

To compare the costs of a CMR-guided strategy vs 2 invasive strategies based on 2 large international CMR registries.

Methods

In the EuroCMR registry (n = 3’647, 59 centers, 18 countries) and the US-based SPINS registry (n = 2’349, 13 centers, 11 states) costs were calculated for 12 healthcare systems (8 Europe, US, 2 Latin America, 1 Asia). They included diagnostic examinations (CMR, X-ray coronarography (CXA) with/without FFR), revascularizations, and complications during a 1-year follow-up. Endpoints in both registries were all-cause and cardiovascular (CV) death, sudden cardiac death (SCD), aborted SCD, non-fatal myocardial infarction (nf-MI), and stroke. 7 sub-group analyses covered low to high-risk cohorts. Patients with ischemia-positive CMR underwent CXA and revascularization (percuteneous and surgical intervention) at the treating physician’s discretion (=CMR + CXA-strategy). In the hypothetical invasive CXA + FFR-strategy, costs were calculated for an initial CXA and an FFR in vessels with ≥50% stenoses assuming the same proportion of revascularizations/complications as in the CMR + CXA-strategy and FFR positive rates as given in the literature. In the CXA-only strategy, costs included CXA and revascularizations of ≥50% stenoses.

Results

Revascularizations were performed in 8.0% and 6.2% (p < 0.01) of SPINS and EuroCMR patients, respectively. Consistent cost savings were observed for the CMR + CXA strategy vs CXA + FFR in all 12 healthcare systems ranging from 42 ± 20% and 52 ± 15% in the low-risk EuroCMR and SPINS patients with atypical chest pain (CV-death and nf-MI 0.4-0.7%/y), respectively, to 31 ± 16% in the high-risk SPINS patients (CV-death and nf-MI 3.2%/y) with known CAD (p < 0.0001 vs 0 in all groups, Fig 1/2). Cost savings were even higher vs CXA-only with 63 ± 11%, 73 ± 6%, and 52 ± 9%, respectively (p < 0.0001 vs 0 in all groups, Fig 2).

Conclusions

In 12 healthcare systems, a CMR + CXA-strategy yielded consistent moderate to high cost savings compared to a hypothetical CXA + FFR-strategy over the entire spectrum of risk. Cost savings were consistently high vs a CXA-only strategy for all risk groups.

Figure 1: SPINS refers to the subgroup of patients with suspected CAD (n = 1’530), EuroCMR (= suspected CAD; n = 3’647). EuroCMR vs SPINS ns. Countries per region are listed in alphabetical order.

Figure 2: Top: CMR + CXA vs CXA + FFR: ANOVA: overall p = 0.0017, * vs EuroCMR typ angina: p < 0.005 (Scheffe post-hoc testing). Bottom: CMR + CXA vs CXA-only: ANOVA overall p < 0.0001, * vs SPINS with CAD and vs EuroCMR typ A: p < 0.0001; † vs SPINS with CAD: p < 0.03; ‡ vs EuroCMR typ A: p < 0.0001; § vs SPINS with CAD: p < 0.002; ║ vs EuroCMR typ: p < 0.002 (Scheffe post-hoc tesing)

Myocardial extracellular volume by T1 mapping: a new marker of arrhythmia in mitral valve prolapse

Funding Acknowledgements

Type of funding sources: None.

Background

In MVP, MAD has been associated with myocardial replacement fibrosis and arrhythmia, but the importance of interstitial fibrosis remains unknown. We aimed to evaluate the relationship between mitral annular disjunction (MAD) severity and myocardial interstitial fibrosis at the left ventricular (LV) base in patients with mitral valve prolapse (MVP), and to assess the association between severity of interstitial fibrosis and the occurrence of ventricular arrhythmic events

Methods

Thirty patients with MVP and MAD (MVP-MAD) underwent Cardiac Magnetic Resonance (CMR) with assessment of MAD length, late gadolinium enhancement (LGE), and basal segments myocardial extracellular volume (ECV). The control group included 14 patients with mitral regurgitation but no MAD (MR-NoMAD) and 10 patients with normal CMR (NoMR-NoMAD). Fifteen MVP-MAD patients underwent 24h-Holter monitoring.

Results

LGE was observed in 47% of MVP-MAD patients and absent in controls. ECV was higher in MVP-MAD (30 ± 3% vs 24 ± 3% MR-NoMAD, p < 0.0001 and vs 24 ± 2% NoMR-NoMAD, p < 0.0001), even in MVP-MAD patients without LGE (29 ± 3% vs 24 ± 3%, p < 0.0001 and vs 24 ± 2%, p < 0.0001, respectively), Fig.1. MAD length was correlated with ECV (rho = 0.61, p = 0.0003), but not with LGE extent. Four patients had history of OHCA; LGE and ECV were equally performant to identify those high-risk patients (area under the ROC curve 0.81 vs 0.83, p = 0.84). Among patients with Holter, 87% had complex ventricular arrhythmia. ECV was above the cut-off value in all while only 53% had LGE.

Conclusion

Increase in ECV, a marker of interstitial fibrosis, occurs in MVP-MAD even in the absence of LGE, and was correlated with MAD length and OHCA. ECV should be part of the CMR examination of MVP patients in an effort to better assess fibrous remodelling as it may provide additional value beyond the assessment of LGE in the arrhythmic risk stratification.

Feasibility and prognostic value of adenosine stress perfusion cardiovascular magnetic resonance in patient with implantable device

Funding Acknowledgements

Type of funding sources: None.

Background

stress CMR has a limited use in patients with implantable device, in order to the possible artefacts due to the metallic component and to the risk of adenosine interaction with cardiac pacing. The aim of the study was to assess the global feasibility and to assess the prognostic value of stress perfusion CMR in patients with implantable device.

Materials and Methods

we conducted a retrospective single-center longitudinal analysis of consecutive patients with an implantable device referred for stress CMR, performed using a 1.5 Tesla unit (Siemens Healthcare,MAGNETOM Aera, Erlangen-Germany). Protocol was adapted according to current guidelines. Cardiac follow-up [6 months to 7 years] was obtained by medical records of direct contact with patient’s cardiologist referral. 

Results

44 patients were enrolled. 34 patients needed a continuous pacing during adenosine stress, that was settled in DOO in 14 (32%) and in VOO in 20 (45%). Device integrity was not compromised by CMR and not competitive atrial or ventricular stimulation was observed during examination. Image quality was good in 95% cases. 26% cases had a perfusion deficit corresponding to a previous scar, while 12% of patients had a positive stress test. All of them needed continuous pacing during stress test and underwent to a coronary angiography who confirmed the coronary stenosis.  In patients without inducible ischemia 2 patients experienced a Non-ST-elevation Myocardial Infarction after 6 and 2 years while no other cardiac symptoms or cardiac hospitalisation was remarkable during follow up.

Conclusion

adenosine stress CMR in patient who are pacemaker dependent during scanner is feasible, with an overall good image quality, proving an excellent diagnostic and prognostic value in a long term follow up even. Adenosine administration is safe and no the magnetic field interference with the correct functioning of the device have been shown in short or long term follow-up.

Overcoming claustrophobia in cardiovascular magnetic resonance with medical hypnosis

Funding Acknowledgements

Type of funding sources: None.

Background

the role of Cardiovascular Magnetic Resonance has gained the more and more importance in the field of cardiovascular disease. Claustrophobia remains a frequent cause of failure to complete a CMR. It is estimated that 2 million scans worldwide cannot be performed annually either due to premature termination or refusal of the patient to be scanned due to claustrophobia. In this setting, medical hypnosis may prove useful to overcome this main limitation.

Methods

we propose an observational study of consecutive patients referred to CMR and known for severe claustrophobia. Patients were proposed to undergo CMR examination with the help of medical hypnosis according to Milton H. Erickson’s method or with administration of mild sedation (lorazepam 2.5 mg).

Results

20 severe claustrophobic patients were considered in the study. 1 patient was excluded due to psychiatric condition, 1 patient undergo to general anesthesia, 5 patients refused the examination. Among the 13 patients, 10 underwent medical hypnosis while 3 patients accepted to undergo to CMR examination with the administration of lorazepam 2.5 mg. All patients treated with medical hypnosis were able to complete the examination with a great tolerance and no sign of stress or anxiety were reported. CMR protocol was performed according to clinical request and was not different form non-claustrophobic patients. None of the patients treated with lorazepam 2.5mg was able to complete the exam.

Conclusion

we prove medical hypnosis to be safe and effective in controlling patients’ anxiety, allowing optimal diagnostic imaging quality without the need to adapt the examination. Further studies in larger populations are needed to confirm our results.

Late gadolinium enhancement predicts adverse clinical outcome in patients with mitral valve prolapse/mitral annulus disjunction

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Mitral vAlve prolapse and disjunction by cardiac maGnetIC resonance (MA-GIC) registry

Backgroung

Mitral valve prolapse (MVP) is 2-3% prevalent in the general population with good prognosis. However, some patients develop complex ventricular arrhythmias (CVAs), sudden cardiac death (SCD), or severe mitral regurgitation (MR). Previous studies suggested that bi-leaflet involvement, mitral annulus disjunction (MAD), and myocardial fibrosis (MF) are associated with adverse outcome. Notwithstanding, these findings were limited to autopsic series or single-centre studies involving highly selected patients. Moreover, MF has been scantly investigated as predictor of clinical outcome.

Purpose

To investigate the prognostic significance of MF in an international multicentre study of MVP patients studied by cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). 

Methods

From October 2007 to June 2020 patients undergoing LGE-CMR were screened in 14 European centres. Inclusion criteria were: i) age > 18 years; ii) full clinical history and cardiac rhythm monitoring at baseline; iii) MVP (leaflet displacement ≥ 2 mm beyond the annulus). Exclusion criteria were: i) ischemic heart disease; ii) primary cardiomyopathy; iii) inflammatory heart disease; iv) congenital heart diseases; v) moderate-to-severe valvular heart disease. CVAs at the study outset was defined as one of the following: i) ventricular ectopic beats >10000/24h; ii) ≥ 1 episode of non-sustained ventricular tachycardia (VT); iii) sustained VT; iv) aborted SCD. Primary end-point was a composite of SCD, unexplained syncope, and mitral valve repair/replacement. Secondary end-point was a composite of SCD and unexplained syncope. 

Results

Four-hundred-fifty-eight MVP patients were eventually included (46 ± 16 years old, 51% males) of whom 68% had MAD. LGE was detected in 103 (22%) of subjects with mid-wall pattern (46%) in left ventricular (LV) lateral wall (66%) as the most prevalent feature. At baseline, 37% of LGE-positive patients vs. 18% of LGE-negative individuals had CVAs (P < 0.001). SVT and/or aborted SCD were more prevalent in LGE-positive than in LGE-negative patients (9% vs 2%, P < 0.001). By multivariable Cox-regression analysis, LGE presence or extent were strong independent predictors of the primary (HR = 4.02, P = 0.003 and HR = 4.76 per 10% increase, P = 0.032, respectively) and secondary (HR = 5.39, P = 0.008 and HR = 8.78 per 10% increase, P = 0.012, respectively) endpoints after correction for major confounders including LV volumes, left atrial size and MAD presence.

Conlusion

Myocardial fibrosis by LGE is the strongest independent predictor of clinical outcome in MVP. In contrast, MAD per se does not harbinger worse prognosis.

Impact of manual thrombectomy on microvascular obstruction in STEMI patients

OBJECTIVE

To assess the effect of manual thrombectomy (MT) on microvascular obstruction (MVO) using cardiac magnetic resonance (CMR) in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

Three hundred and eighty-three patients admitted for STEMI and undergoing CMR fulfilled the inclusion criteria and were categorized into two groups (did or did not undergo MT). The two primary endpoints were the occurrence and extent of MVO, analyzed as a categorical variable and as a semicontinuous variable. Among the 383 patients, 49.1% exhibited MVO. Both the incidence of MVO and the median number of segments presenting with MVO were significantly higher in the MT group than in the no-MT group, (59.5 vs. 38.9%, p < .001) and (1.5 [0;4] vs. 0 [0;2], p < .001). Analysis stratified on coronary thrombus grade showed similar results, only in patients with a high thrombus burden (60.7 vs. 43.5%, p = .004, and 2 [0;4] vs. 0 [0;3], p = .001. When adjusting for baseline differences, MT remained a determinant of MVO occurrence and extent (odds ratio, OR 1.802 [95% confidence interval, CI 1.080-3.009], p = .024) and β = .137, p = .024) in patients with a high thrombus grade.

CONCLUSION

In STEMI patients, MT was associated with the occurrence and extent of MVO, on CMR, especially in patients with a high thrombus burden.

Motion compensated whole-heart coronary cardiovascular magnetic resonance angiography using focused navigation (fNAV)

BACKGROUND

Radial self-navigated (RSN) whole-heart coronary cardiovascular magnetic resonance angiography (CCMRA) is a free-breathing technique that estimates and corrects for respiratory motion. However, RSN has been limited to a 1D rigid correction which is often insufficient for patients with complex respiratory patterns. The goal of this work is therefore to improve the robustness and quality of 3D radial CCMRA by incorporating both 3D motion information and nonrigid intra-acquisition correction of the data into a framework called focused navigation (fNAV).

METHODS

We applied fNAV to 500 data sets from a numerical simulation, 22 healthy subjects, and 549 cardiac patients. In each of these cohorts we compared fNAV to RSN and respiratory resolved extradimensional golden-angle radial sparse parallel (XD-GRASP) reconstructions of the same data. Reconstruction times for each method were recorded. Motion estimate accuracy was measured as the correlation between fNAV and ground truth for simulations, and fNAV and image registration for in vivo data. Percent vessel sharpness was measured in all simulated data sets and healthy subjects, and a subset of patients. Finally, subjective image quality analysis was performed by a blinded expert reviewer who chose the best image for each in vivo data set and scored on a Likert scale 0-4 in a subset of patients by two reviewers in consensus.

RESULTS

The reconstruction time for fNAV images was significantly higher than RSN (6.1 ± 2.1 min vs 1.4 ± 0.3, min, p < 0.025) but significantly lower than XD-GRASP (25.6 ± 7.1, min, p < 0.025). Overall, there is high correlation between the fNAV and reference displacement estimates across all data sets (0.73 ± 0.29). For simulated data, healthy subjects, and patients, fNAV lead to significantly sharper coronary arteries than all other reconstruction methods (p < 0.01). Finally, in a blinded evaluation by an expert reviewer fNAV was chosen as the best image in 444 out of 571 data sets (78%; p < 0.001) and consensus grades of fNAV images (2.6 ± 0.6) were significantly higher (p < 0.05) than uncorrected (1.7 ± 0.7), RSN (1.9 ± 0.6), and XD-GRASP (1.8 ± 0.8).

CONCLUSION

fNAV is a promising technique for improving the quality of RSN free-breathing 3D whole-heart CCMRA. This novel approach to respiratory self-navigation can derive 3D nonrigid motion estimations from an acquired 1D signal yielding statistically significant improvement in image sharpness relative to 1D translational correction as well as XD-GRASP reconstructions. Further study of the diagnostic impact of this technique is therefore warranted to evaluate its full clinical utility.

Evolution of biventricular T1 values in patients with right-sided congenital heart disease

Funding Acknowledgements

Type of funding sources: None.

Background

Conflicting reports exist on the prevalence and clinical impact of interstitial fibrosis in right ventricular (RV) congenital heart disease (CHD). This study evaluates the longitudinal evolution of native myocardial T1 relaxation time (T1) in RV CHD.

Methods

On a 1.5T scanner, an ECG-triggered modified Look-Locker inversion recovery sequence (scheme 3(3)3(3)5) was acquired on a short-axis basal slice covering the RV and left ventricle (LV) on two consecutive CMR exams. Global and segmental (LV = 6, RV = 4) RV and LV T1 values  were calculated (Figure).

Results

Mean time between CMR exams for 36 included patients (age 34 ± 2y) was 22 ± 2 months. All LV segments and 81/88% of RV segments of first and second CMR could be analyzed, respectively.  T1 increased mildly but not significantly (table). There was no relationship of T1 to pulmonary regurgitation fraction, pulmonary stenosis or RV enddiastolic volume (p &gt; 0.05). Global RV T1 of the second CMR was related to RV ejection fraction (RVEF): r = 0.353, 3.0 ± 1.4, p = 0.038. T1 of the infero-septal LV segment of first and second CMR, global LV T1 of second CMR and increase of T1 of global LV, anterior, antero-lateral and –septal LV segments, were related to age at CMR: r = 0.333 - 0.463, p &lt; 0.05, respectively.

Conclusions

Native T1 values increased mildly in patients with stable RV CHD, which was not statistically significant probably due to the short to median follow-up. Global RV T1 appears to be related to RVEF which could be sign of increasing interstitial fibrosis whereas the relationship of LV T1 to age might be a physiological finding.

First CMR native T1 (ms) Second CMR native T1 (ms) p LV Global 1007 ± 37 1014 ± 39 0.413 LV Anterior 994 ± 53 999 ± 54 0.710 LV Antero-lateral 965 ± 63 981 ± 58 0.186 LV Infero-lateral 1000 ± 52 1004 ± 63 0.695 LV Inferior 1035 42 1037 ± 50 0.744 LV Infero-septal 1028 ± 35 1036 ± 43 0.282 LV Antero-septal 1016 ± 38 1024 ± 48 0.347 RV Global 1091 ± 90 1096 ± 85 0.410 RV Inferior 1112 ± 104 1115 ± 118 0.696 RV Infero-lateral 1061 ± 130 1077 ± 115 0.425 RV Antero-lateral 1046 ± 127 1080 ± 109 0.088 RV Anterior 1088 ± 156 1108 ± 154 0.410 Abstract Figure. Determination of biventricular T1 values

Myocardial interstitial fibrosis assessed by extracellular volume quantification is a determinant of symptoms in aortic valve regurgitation with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Introduction

According to current guidelines indication for surgery is straightforward with a class I recommendation in case of severe symptomatic aortic regurgitation (AR) and/or left ventricular ejection fraction (LVEF) decrease ≤50%. However, the management of patients with asymptomatic severe AR with preserved LVEF remains debated, with a cruel lack of prognostic factors to identify patients who may benefit from early intervention. An explanation to the absence of such factors is that the determinants of symptoms, a strong prognostic parameter, have been poorly identified. Beyond LV dilation and systolic dysfunction, which are both recognized prognostic factors in chronic AR, we hypothesized that interstitial myocardial fibrosis, as an early indicator of LV remodeling, may also influence the occurrence of symptoms. Cardiovascular magnetic resonance (CMR)-based myocardial extracellular volume (ECV) quantification by T1 mapping has emerged as a valuable tool to quantify diffuse myocardial fibrosis.

Objective

To study the relationship between myocardial interstitial fibrosis quantified by T1 mapping and the symptomatic status of patients with chronic aortic valve regurgitation.

Methods

We retrospectively included 38 consecutive patients with chronic, isolated, mild to severe AR who underwent a CMR at our institution. Exclusion criteria were the presence of any other heart condition that may induce myocardial fibrosis, ≥ mild associated valve disease, AR secondary to endocarditis, genetic, inflammatory or congenital disease except bicuspid aortic valve. T1 mapping of the basal segments was performed before and after contrast administration measuring native and post-contrast T1 relaxation time and ECV.

Results

Mean age was 56 ± 20 years, 30 patients (79%) were males, and symptoms were reported in 11 patients (29%). Mean LVEF was 57 ± 9% and ≥50% in 30 patients (79%). Aortic valve regurgitation fraction (RF) was 25 ± 13%, ECV 0.27 ± 0.04%, indexed LV end-diastolic volume (LVEDVi) 98 ± 32 ml/m2, end-systolic volume (LVESVi) 46 ± 19 ml/m2, and LV mass 79 ± 21 g/m2. LVESVi (r = 0.41,p = 0.01), LVEF (r=-0.59,p = 0.0001), and ECV (r = 0.42,p = 0.008) were correlated with symptoms, whereas age (r = 0.16,p = 0.33), gender (r=-0.24,p = 0.15), LVEDVi (r = 0.28,p = 0.09), LV mass index (r = 0.08,p = 0.62), and RF (r = 0.31,p = 0.06) were not. In the subgroup of patients with preserved LVEF (≥50%), after adjustment for LVESVi and RF, only ECV remained independently associated with symptoms (p = 0.046). Interestingly, when including the patients with a reduced LVEF &lt; 50% in the multivariable analysis only LVESVi was an independent determinant of symptoms (p = 0.04) and ECV was not (p = 0.07)

Conclusion

myocardial fibrosis quantified by ECV calculation is a determinant of symptoms in AR with preserved LVEF. Further studies are warranted to determine the prognostic value of ECV that may justify earlier intervention.

Abstract Figure. ECV in AR with preserved LVEF

2D cine vs. 3D free-breathing self-navigated whole heart for aortic root measurements in congenital heart disease

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac magnetic resonance is considered the method of choice for determination of aortic root diameters in congenital heart disease. Usually, a cross-sectional 2D cine stack is acquired perpendicular to the vessel’s axis. However, this method requires a considerable patient collaboration and precise planning of image planes. This study compares a recently introduced free-breathing high-resolution 3D self-navigating whole heart sequence (3D self nav) to the 2D cine technique for determination of aortic root diameters.

Methods

Two observers measured on 2D cine and 3D self nav cross-sectional planes of the aortic root (figure A and B), acquired on a 1.5T scanner, cusp-commissure (CuCo) and cusp-cusp (CuCu) enddiastolic diameters (figure B and C). Asymmetry of the aortic root was evaluated by the ratio of the minimal to maximum CuCu diameter. CuCu diameters were compared to transthoracic echocardiographic (TTE) aortic root diameters.

Results

65 exams in 58 patients (mean age 32 ± 15y) were included. 2D cine and 3D self nav spatial resolution was 1.4x4.5-6mm and 1.1³mm, respectively. 3D self nav and CuCu yielded larger diameters than 2D cine and CuCo, respectively (table). Intra- and interobserver variabilities were excellent for both techniques ( bias -0.5 to 1.0 mm). Intra-observer variability of the experienced observer was better for 3D self nav (F-test p &lt; 0.05). Aortic root asymmetry was more pronounced in patients with bicuspid aortic valve (BAV: 0.73 (0.69; 0.78) vs. 0.93 (0.9; 0.96), p &lt; 0.001), which was associated with a larger difference of maximum CuCu to TTE diameters: 5.5 ± 3.3 vs. 3.3 ± 3.8 mm, p = 0.03.

Conclusion

Both, the 3D self nav and 2D cine techniques allow reliable determination of aortic root diameters. However, the 3D self nav technique and measurement of the CuCu diameters should be privileged to avoid underestimation of the maximum diameter, particularly in patients with asymmetric aortic roots and/or BAV

2D cine vs. 3D self nav CuCo min CuCo mid CuCo max CuCu min CuCu mid CuCu max Mean diameter 2D cine (mm) 33.5 34.8 36.2 33.4 37.6 38.5 Mean diameter 3D self nav (mm) 34.5 35.9 37.2 34.3 38.5 39.7 Mean difference (mm) -1.0 -1.1 -1.0 -0.8 -1.3 -1.2 95% Limits of agreement (mm) -5.1 to 3.2 -5.3 to 3.1 -5.5 to 3.5 -5.5 to 3.8 -4.7 to 2.0 -4.7 to 2.3 Standard deviation (mm) 3.2 2.1 2.3 2.4 1.7 1.8 Variance (mm2) 4.5 4.5 5.2 5.6 2.9 3.2 Pearson’s correlation (r) 0.952 0.954 0.945 0.944 0.972 0.951 P value (t-test) 0.003 0.001 0.006 0.005 &lt;0.001 &lt;0.001 Abstract Figure.

Acute chest pain with ST-segment elevation in lead V1-V3: when you hear hoofbeats, also look for zebras

ST-segment elevation (STE) in the anterior precordial leads is the hallmark of anterior myocardial infarction. In rare cases, this ECG pattern may be due to isolated infarction of the right ventricle since leads V1-V3 directly overlie the right ventricular free wall. Herein, we aimed to provide clues to recognize and understand this diagnostic pitfall through a series of 4 patients presenting with STE in the anterior leads.

[Cardiology]

In 2020, new guidelines have been published by the European Society of Cardiology including those on non-ST-segment elevation acute coronary syndromes, atrial fibrillation and adult congenital heart disease. Regarding interventional cardiology, POPular TAVI opens the possibility of anti-platelet monotherapy after transcutaneous aortic valve replacement. EMPEROR-Reduced confirms the importance of SGLT2 inhibitors in the treatment of heart failure with reduced ejection fraction. Within the field of imaging, stress MRI has now become the first-line technique for the screening of coronary artery disease, demonstrating an excellent cost-benefit ratio. Finally, renin-angiotensin-aldosterone inhibitors do not appear to increase the risk of an infection by COVID-19.

A concealed carcinoid cardiac metastasis uncovered by comprehensive cardiovascular magnetic resonance-based tissue characterization: a case report

Background

Cardiac metastases of carcinoid tumours are extremely rare, and their diagnosis poses a significant challenge. A variety of techniques has been reported in the literature for this purpose, ranging from echocardiogram to the Indium-111 Octreotide, positron emission tomography using specific tracers, and biopsy. Occasionally, the diagnosis is only made post-mortem. Recently, CMR (cardiovascular magnetic resonance) has been added to the diagnostic toolkit. This case report describes the CMR sequences that can be used to characterize cardiac metastases of carcinoid tumours.

Case summary

A 55-year-old woman with an antecedent history of resected carcinoid tumour of the ileocecal junction underwent whole-body In-111 Octreoscan single-photon emission computed tomography in the context of her follow-up. This raised the suspicion of pericardial involvement, which prompted a CMR study. Comprehensive CMR findings were consistent with isolated carcinoid tumour metastasis embedded within the anterior papillary muscle. We describe the CMR sequences that were used to characterize the metastasis.

Discussion

The rarity of cardiac metastasis of carcinoid tumour makes its diagnosis challenging and warrants a high level of clinical suspicion. Cardiovascular magnetic resonance imaging proves to be an indispensable tool in the tissue characterization of such tumours.

Left Ventricular Hypertrabeculation Is Not Associated With Cardiovascular Morbity or Mortality: Insights From the Eurocmr Registry

Aim: Left ventricular non-compaction (LVNC) is perceived as a rare high-risk cardiomyopathy characterized by excess left ventricular (LV) trabeculation. However, there is increasing evidence contesting the clinical significance of LV hyper-trabeculation and the existence of LVNC as a distinct cardiomyopathy. The aim of this study is to assess the association of LV trabeculation extent with cardiovascular morbidity and all-cause mortality in patients undergoing clinical cardiac magnetic resonance (CMR) scans across 57 European centers from the EuroCMR registry.

Methods and Results: We studied 822 randomly selected cases from the EuroCMR registry. Image acquisition was according to international guidelines. We manually segmented images for LV chamber quantification and measurement of LV trabeculation (as per Petersen criteria). We report the association between LV trabeculation extent and important cardiovascular morbidities (stroke, atrial fibrillation, heart failure) and all-cause mortality prospectively recorded over 404 ± 82 days of follow-up. Maximal non-compaction to compaction ratio (NC/C) was mean (standard deviation) 1.81 ± 0.67, from these, 17% were above the threshold for hyper-trabeculation (NC/C > 2.3). LV trabeculation extent was not associated with increased risk of the defined outcomes (morbidities, mortality, LV CMR indices) in the whole cohort, or in sub-analyses of individuals without ischaemic heart disease, or those with NC/C > 2.3.

Conclusion: Among 882 patients undergoing clinical CMR, excess LV trabeculation was not associated with a range of important cardiovascular morbidities or all-cause mortality over ~12 months of prospective follow-up. These findings suggest that LV hyper-trabeculation alone is not an indicator for worse cardiovascular prognosis.

Head-to-head comparison of multiple cardiovascular magnetic resonance techniques for the detection and quantification of intramyocardial haemorrhage in patients with ST-elevation myocardial infarction

Objectives

T2*-weighted (T2*w) is deemed as a reference standard for post-infarction intramyocardial haemorrhage (IMH). However, high proportion of T2* images is affected by off-resonance artefacts hampering image interpretation. Diagnostic accuracy and precision of alternative techniques for IMH diagnosis and quantification have been seldomly investigated.

Methods and results

Between April 2016 and May 2017, 50 ST-segment elevation myocardial infarction patients (66% male, 57 ± 17 years) and 15 healthy controls (60% male, 58 ± 13) were consecutively enrolled. Subjects underwent head-to-head comparison of single mid-infarct slice acquired on black-blood T2-weighted short-TI-inversion recovery (T2w-STIR), bright-blood T2prep-steady-state-free precession (T2prep-SSFP), and T2/T1 maps for IMH diagnosis and quantification against T2*w. All images were graded for quality (grade 1: very poor; grade 4: excellent) and diagnostic confidence (Likert scale, 1: very unsure and 5: highly confident). Reduced relaxation time/hypointense region (hypocore) embedded in infarct-related oedema on T2 map, T1 map, and T2w-STIR had the best overall diagnostic accuracy (per-subject: 91%, 86%, and 86%, respectively; per segment: 95%, 93%, and 93%, respectively). By mixed-effects analysis, image quality, and diagnostic confidence were higher for T2 map and T1 maps than T2*w (p < 0.05 for both scores). For IMH quantification, hypocore on T2 map and T1 map strongly correlated (Spearman’s r > 0.7, p < 0.001 for both) with IMH extent on T2*w and presented an overall excellent agreement on Bland-Altman analysis. By linear mixed model analysis, absolute hypocore size did not differ among T1-, T2 map, and T2*w. T2/T1 maps had the best intra- and inter-observer reproducibility among CMR techniques.

Conclusion

Hypocore on T2/T1 map is the best alternative technique to T2*w for diagnosing and quantifying IMH in post-STEMI patients.

Key Point

• Mapping techniques are the best alternatives for diagnosing post-infarction intramyocardial haemorrhage.

• Mapping techniques are valuable tools for imaging intramyocardial haemorrhage.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-07254-1) contains supplementary material, which is available to authorized users.

MRI perfusion in patients with stable chest-pain

Perfusion-cardiovascular MR (CMR) imaging has been shown to reliably identify patients with suspected or known coronary artery disease (CAD), who are at risk for future cardiac events and thus, allows for guiding therapy including revascularizations. Accordingly, it is an ideal test to exclude prognostically relevant coronary artery disease. Several guidelines, such as the ESC guidelines, currently recommend CMR as non-invasive testing in patients with stable chest pain. CMR has as an advantage over the more conventional pathways as it lacks radiation and it potentially reduces costs.

Stereotactic Radiotherapy for the Management of Refractory Ventricular Tachycardia: Promise and Future Directions

Ventricular tachycardia (VT) caused by myocardial scaring bears a significant risk of mortality and morbidity. Antiarrhythmic drug therapy (AAD) and catheter ablation remain the cornerstone of VT management, but both treatments have limited efficacy and potential adverse effects. Stereotactic body radiotherapy (SBRT) is routinely used in oncology to treat non-invasively solid tumors with high precision and efficacy. Recently, this technology has been evaluated for the treatment of VT. This review presents the basic underlying principles, proof of concept, and main results of trials and case series that used SBRT for the treatment of VT refractory to AAD and catheter ablation.

First Documentation of Persistent SARS-Cov-2 Infection Presenting With Late Acute Severe Myocarditis

A 64-year-old man presented with severe myocarditis 6 weeks after an initial almost asymptomatic severe acute respiratory syndrome coronavirus-2 (SARS-CoV2) infection. He was found to have a persistent positive swab. Mechanisms explaining myocardial injury in patients with COVID-19 remains unclear, but this case suggests that severe acute myocarditis can develop in the late phase of COVID-19 infection, even after a symptom-free interval.

Deep Learning to Automate Reference-Free Image Quality Assessment of Whole-Heart MR Images

Purpose

To develop and characterize an algorithm that mimics human expert visual assessment to quantitatively determine the quality of three-dimensional (3D) whole-heart MR images.

Materials and Methods

In this study, 3D whole-heart cardiac MRI scans from 424 participants (average age, 57 years ± 18 [standard deviation]; 66.5% men) were used to generate an image quality assessment algorithm. A deep convolutional neural network for image quality assessment (IQ-DCNN) was designed, trained, optimized, and cross-validated on a clinical database of 324 (training set) scans. On a separate test set (100 scans), two hypotheses were tested: (a) that the algorithm can assess image quality in concordance with human expert assessment as assessed by human-machine correlation and intra- and interobserver agreement and (b) that the IQ-DCNN algorithm may be used to monitor a compressed sensing reconstruction process where image quality progressively improves. Weighted κ values, agreement and disagreement counts, and Krippendorff α reliability coefficients were reported.

Results

Regression performance of the IQ-DCNN was within the range of human intra- and interobserver agreement and in very good agreement with the human expert (R ² = 0.78, κ = 0.67). The image quality assessment during compressed sensing reconstruction correlated with the cost function at each iteration and was successfully applied to rank the results in very good agreement with the human expert.

Conclusion

The proposed IQ-DCNN was trained to mimic expert visual image quality assessment of 3D whole-heart MR images. The results from the IQ-DCNN were in good agreement with human expert reading, and the network was capable of automatically comparing different reconstructed volumes.Supplemental material is available for this article.© RSNA, 2020.

Detection of myocardial medium-chain fatty acid oxidation and tricarboxylic acid cycle activity with hyperpolarized [1-13 C]octanoate

Under normal conditions, the heart mainly relies on fatty acid oxidation to meet its energy needs. Changes in myocardial fuel preference are noted in the diseased and failing heart. The magnetic resonance signal enhancement provided by spin hyperpolarization allows the metabolism of substrates labeled with carbon-13 to be followed in real time in vivo. Although the low water solubility of long-chain fatty acids abrogates their hyperpolarization by dissolution dynamic nuclear polarization, medium-chain fatty acids have sufficient solubility to be efficiently polarized and dissolved. In this study, we investigated the applicability of hyperpolarized [1-¹³ C]octanoate to measure myocardial medium-chain fatty acid metabolism in vivo. Scanning rats infused with a bolus of hyperpolarized [1-¹³ C]octanoate, the primary metabolite observed in the heart was identified as [1-¹³ C]acetylcarnitine. Additionally, [5-¹³ C]glutamate and [5-¹³ C]citrate could be respectively resolved in seven and five of 31 experiments, demonstrating the incorporation of oxidation products of octanoate into the tricarboxylic acid cycle. A variable drop in blood pressure was observed immediately following the bolus injection, and this drop correlated with a decrease in normalized acetylcarnitine signal (acetylcarnitine/octanoate). Increasing the delay before infusion moderated the decrease in blood pressure, which was attributed to the presence of residual gas bubbles in the octanoate solution. No significant difference in normalized acetylcarnitine signal was apparent between fed and 12-hour fasted rats. Compared with a solution in buffer, the longitudinal relaxation of [1-¹³ C]octanoate was accelerated ~3-fold in blood and by the addition of serum albumin. These results demonstrate the potential of hyperpolarized [1-¹³ C]octanoate to probe myocardial medium-chain fatty acid metabolism as well as some of the limitations that may accompany its use.

[Cardiology]

In 2019, the guidelines on the new entity « chronic coronary syndrome » have been published. They influence importantly the work-up and treatment of patients with stable coronary artery disease. We will also report on publications showing the benefit of percutaneous aortic valve implantation (TAVI) in patients with aortic stenosis and low risk surgical risk. With regard to infectious endocarditis, we elucidate the importance of the vegetation's size for predicting mortality and the prognostic value of the positron emission tomography in predicting septic embolism. We highlight the spectacular results of the DAPA-HF study in patients with heart failure and review publications showing the important role of the detection of myocardial fibrosis and scar by cardiac MRI for risk stratification of sudden cardiac death.

1047 Increased interstitial fibrosis in patients with mitral valve prolapse and mitro-annular dysjunction

Background

in patients with myxomatous mitral valve prolapse (MVP), mitral annular disjunction (MAD) has been associated with the presence of late gadolinium enhancement (LGE) at papillary muscle level and the risk of sudden cardiac death. However, patients with MAD but no detectable LGE still may have arrhythmia. We investigated the relation between MAD and the presence of interstitial fibrosis in the basal inferior left ventricular myocardium.

Methods

28 patient with MVP and associated MAD underwent Cardiovascular Magnetic Resonance imaging (CMR) at 1.5 T scanner (Aera, Siemens Medical Solutions, Erlangen, Germany). Exclusion criteria were ischemic heart disease, infiltrative cardiomyopathy and contraindication to CMR. 12 patients with mitral valve regurgitation but no MAD and 10 patients without mitral disease served as the control group. MAD severity was measured from LA wall-posterior MV leaflet junction to the top of the LV infero-basal wall during end systole. Insterstitial fibrosis was assessed by calculating the extracellular volume (ECV) from T1 mapping of the left ventricular basal slice acquired before and after Gadolinium injection.

Results

Mean age was 47,5+\-23,3 years and 60% were male. ECV was higher in patients with MVP compared with controls (basal septum: 0.27 ± 0.04 vs 0.23 ± 0.03 p = 0.006; basal inferoposterior wall 0.28 ± 0.03 vs 0.23 ± 0.02 p = 0.003) and there was a significant correlation between MAD severity and ECV of the basal inferior wall (spearman rho 0.68, p &lt; 0.0001) (Figure 1). Among MVP patients, ECV of the basal inferoposterior wall was higher in patients positive for LGE in the papillary muscles (ECV 0.31 ± 0.03 vs 0.27 ± 0.03 p 0,004).

Conclusion

In MVP patients, MAD severity was associated with a higher amount of interstitial fibrosis even in the absence of detectable macroscopic fibrosis in the papillary muscle region.

Abstract 1047 Figure 1

Curative management of a cardiac metastasis from lung cancer revealed by an electrical storm

Although cardiac metastases (CM) are more common than primary cardiac malignant tumors, they remain a rare localization of metastatic cancer. Until recently, CM were surgically treated as a palliative approach because of a lack of ablative solutions even for oligometastatic patients. Technological advances in radiation therapy (RT) in thoracic oncology have led to high precision delivery that enlarged the indications for stereotactic body radiotherapy (SBRT). To date, there are limited reports of cardiac SBRT for CM. Herein, we report a cardiac SBRT performed in curative intent for a lung cancer patient metastatic to the heart.

4327Results of the DERIVATE study in non-ischemic dilated cardiomyopathy (NICM)

Background

Standard of care (SOC) suggests implanted cardioverter defibrillator (ICD) therapy based on the left ventricular ejection fraction (LVEF) cut-off value as detected by transthoracic echocardiography (TTE-LVEF)

Purpose

The aim of this study was to evaluate the additional prognostic value of a cardiac magnetic resonance (CMR) based score over SOC in a large cohort of non-ischemic cardiomyopathy (NICM) patients evaluated for primary ICD therapy

Methods

DERIVATE is an international, multicenter, prospective, observational registry including consecutive patients with chronic heart failure (HF) who undergo clinical evaluation. We included 1000 patients (derivation cohort) and 509 patients (validation cohort) with chronic heart failure (HF) with LVEF<50% affected by NICM enrolled in the period between January 2007 and October 2017. All-cause mortality and arrhythmic major adverse cardiac events (MACE) were the primary and the secondary endpoint, respectively.

Results

During a median follow-up of 959 days, all-cause mortality and combined MACE occurred in 72 (7%) and 93 (9%) patients respectively. Regarding to primary endpoint, age and number of myocardial segments with late gadolinium enhancement (LGE) midwall>3 were the only independent predictors of mortality (HR: 1.037, 95% CI: 1.018–1.057, p<0.001 and HR: 1.78, 95% CI: 1.062–3.005, p=0.029, respectively). Regarding to the secondary endpoint, gender, left ventricle end-diastolic volume indexed as detected by CMR (CMR-LVEDVi)>120.5 ml/m2, and number of myocardial segments with LGE midwall>2 were independent predictors of MACE (HR: 2.13, 95% CI: 1.231–3.690, p=0.007; HR: 3.16, 95% CI: 1.750–5.709, p<0.001 and HR: 1.69, 95% CI: 1.084–2.644, p<0.02 respectively). Accordingly, a weighted CMR score, including these three variables with a maximum of 7 points was calculated and when added to the model based on SOC provided a net reclassification improvement (NRI) of 63.7% (p<0.001). Finally, when the CMR-score was applied to validation cohort showed a NRI of 31.3% (p: 0.022) with a good prognostic stratification (p: 0.001) as compared to the SOC.

Conclusions

CMR provides additional prognostic stratification as compared to the SOC, which may have direct impact on the indication of ICD implantation. Further, prospective randomized trial should be addressed to test the cost-effectiveness of a CMR strategy as compared to SOC in patients undergoing ICD implantation.

Acknowledgement/Funding

funded by the Italian Ministry of Health, Rome, Italy (RC 2017 R659/17-CCM698