Optimization of Fetal Biometry With 3D Ultrasound and Image Recognition (EPICEA): protocol for a prospective cross-sectional study

CONTEXT

Variability in 2D ultrasound (US) is related to the acquisition of planes of reference and the positioning of callipers and could be reduced in combining US volume acquisitions and anatomical structures recognition.

OBJECTIVES

The primary objective is to assess the consistency between 3D measurements (automated and manual) extracted from a fetal US volume with standard 2D US measurements (I). Secondary objectives are to evaluate the feasibility of the use of software to obtain automated measurements of the fetal head, abdomen and femur from US acquisitions (II) and to assess the impact of automation on intraobserver and interobserver reproducibility (III).

METHODS AND ANALYSIS

225 fetuses will be measured at 16-30 weeks of gestation. For each fetus, six volumes (two for head, abdomen and thigh, respectively) will be prospectively acquired after performing standard 2D biometry measurements (head and abdominal circumference, femoral length). Each volume will be processed later by both a software and an operator to extract the reference planes and to perform the corresponding measurements. The different sets of measurements will be compared using Bland-Altman plots to assess the agreement between the different processes (I). The feasibility of using the software in clinical practice will be assessed through the failure rate of processing and the score of quality of measurements (II). Interclass correlation coefficients will be used to evaluate the intraobserver and interobserver reproducibility (III).

ETHICS AND DISSEMINATION

The study and related consent forms were approved by an institutional review board (CPP SUD-EST 3) on 2 October 2018, under reference number 2018-033 B. The study has been registered in https://clinicaltrials.gov registry on 23 January 2019, under the number NCT03812471. This study will enable an improved understanding and dissemination of the potential benefits of 3D automated measurements and is a prerequisite for the design of intention to treat randomised studies assessing their impact.

TRIAL REGISTRATION NUMBER

NCT03812471; Pre-results.

Mediation of the Relationship Between Endovascular Therapy and Functional Outcome by Follow-up Infarct Volume in Patients With Acute Ischemic Stroke

Importance

The positive treatment effect of endovascular therapy (EVT) is assumed to be caused by the preservation of brain tissue. It remains unclear to what extent the treatment-related reduction in follow-up infarct volume (FIV) explains the improved functional outcome after EVT in patients with acute ischemic stroke.

Objective

To study whether FIV mediates the relationship between EVT and functional outcome in patients with acute ischemic stroke.

Design, Setting, and Participants

Patient data from 7 randomized multicenter trials were pooled. These trials were conducted between December 2010 and April 2015 and included 1764 patients randomly assigned to receive either EVT or standard care (control). Follow-up infarct volume was assessed on computed tomography or magnetic resonance imaging after stroke onset. Mediation analysis was performed to examine the potential causal chain in which FIV may mediate the relationship between EVT and functional outcome. A total of 1690 patients met the inclusion criteria. Twenty-five additional patients were excluded, resulting in a total of 1665 patients, including 821 (49.3%) in the EVT group and 844 (50.7%) in the control group. Data were analyzed from January to June 2017.

Main Outcome and Measure

The 90-day functional outcome via the modified Rankin Scale (mRS).

Results

Among 1665 patients, the median (interquartile range [IQR]) age was 68 (57-76) years, and 781 (46.9%) were female. The median (IQR) time to FIV measurement was 30 (24-237) hours. The median (IQR) FIV was 41 (14-120) mL. Patients in the EVT group had significantly smaller FIVs compared with patients in the control group (median [IQR] FIV, 33 [11-99] vs 51 [18-134] mL; P = .007) and lower mRS scores at 90 days (median [IQR] score, 3 [1-4] vs 4 [2-5]). Follow-up infarct volume was a predictor of functional outcome (adjusted common odds ratio, 0.46; 95% CI, 0.39-0.54; P < .001). Follow-up infarct volume partially mediated the relationship between treatment type with mRS score, as EVT was still significantly associated with functional outcome after adjustment for FIV (adjusted common odds ratio, 2.22; 95% CI, 1.52-3.21; P < .001). Treatment-reduced FIV explained 12% (95% CI, 1-19) of the relationship between EVT and functional outcome.

Conclusions and Relevance

In this analysis, follow-up infarct volume predicted functional outcome; however, a reduced infarct volume after treatment with EVT only explained 12% of the treatment benefit. Follow-up infarct volume as measured on computed tomography and magnetic resonance imaging is not a valid proxy for estimating treatment effect in phase II and III trials of acute ischemic stroke.

Validation of overestimation ratio and TL-SVS as imaging biomarker of cardioembolic stroke and time from onset to MRI

OBJECTIVE

We aimed to determine in the "THRACE" trial, the clinical and MRI technical parameters associated with the two-layered susceptibility vessel sign (TL-SVS) and the overestimation ratio (overR).

MATERIALS AND METHODS

Patients with pre-treatment brain gradient echo (GRE) sequence and an etiological work-up were identified. Two readers reviewed TL-SVS, i.e., a SVS with a linear low-intense signal core surrounded by a higher intensity and measured the overR as the width of SVS divided by the width of the artery. Binomial and ordinal logistic regression respectively tested the association between TL-SVS and quartiles of overR with patient characteristics, cardioembolic stroke (CES), time from onset to imaging, and GRE sequence parameters (inter slice gap, slice thickness, echo time, flip angle, voxel size, and field strength).

RESULTS

Among 258 included patients, 102 patients were examined by 3 Tesla MRI and 156 by 1.5 Tesla MRI. Intra- and inter-reader agreements for quartiles of overR and TL-SVS were good to excellent. The median overR was 1.59 (IQR, 1.30 to 1.86). TL-SVS was present in 101 patients (39.2%, 95%CI, 33.1 to 45.1%). In multivariate analysis, only CES was associated with overR quartiles (OR, 1.83; 95%CI, 1.11 to 2.99), and every 60 min increase from onset to MRI time was associated with TL-SVS (OR, 1.72; 95%CI, 1.10 to 2.67). MRI technical parameters were statistically associated with neither overR nor TL-SVS.

CONCLUSION

Independent of GRE sequence parameters, an increased overR was associated to CES, while the TL-SVS is independently related to a longer time from onset to MRI.

KEY POINTS

• An imaging biomarker would be useful to predict the etiology of stroke in order to adapt secondary prevention of stroke. • The two-layered susceptibility vessel sign and the overestimation ratio are paramagnetic effect derived markers that vary according to the MRI machines and sequence parameters. • Independent of sequence parameters, an increased overestimation ratio was associated to cardioembolic stroke, while the two-layered susceptibility vessel sign is independently related to a longer time from onset to MRI.

[Follow-up and evaluation of plans developed during pulmonary rehabilitation]

BACKGROUND

Pulmonary rehabilitation inevitably contains two essential components: therapeutic education and exercise training. The principal aim of this study was to evaluate the evolution over a year of the realization of plans determined during a pulmonary rehabilitation program (PRP).

METHODS

At the end of a PRP the patient made plans in accordance with his health condition. A telephone enquiry was undertaken at 3, 7 and 12 months to evaluate the progress of the plans, the motivation to perform them, dyspnoea and quality of life.

RESULTS

The data of 65 patients were analyzed (87 inclusions). Fifty-seven percent of the plans continued for one year. Walking had an adherence rating of 71%. Loss of motivation appeared to be the main cause for stopping (20%). Quality of life remained stable (p=0.39) and an increase in dyspnoea, though statistically significant (p<0.01), was of no clinical relevance.

CONCLUSION

The majority of plans were maintained but without clinical effect on the quality of life or the level of dyspnoea. Decreased motivation was the major limitation to realization or continuation of the plans. New studies will have to be implemented to analyze the factors which lead to this decrease.

Susceptibility Vessel Sign and Cardioembolic Etiology in the THRACE Trial

PURPOSE

The susceptibility vessel sign (SVS) has been described on gradient echo (GRE) magnetic resonance imaging (MRI) in acute ischemic stroke patients by large vessel occlusion. The presence of SVS (SVS+) was associated with treatment outcome and stroke etiology with conflicting results. Based on multicenter data from the THRombectomie des Artères CErebrales (THRACE) study, we aimed to determine if the association between SVS and cardioembolic etiology (CE) was independent of GRE sequence parameters.

MATERIAL AND METHODS

Patients with a pretreatment brain GRE sequence were identified. Logistic regression tested the association between SVS+, CE, time from onset to imaging and GRE sequence parameters (e.g. echo time, voxel size, field strength). We calculated the sensitivity, specificity, positive and negative predictive values (PPV and NPV) for the SVS to predict a stroke from a CE.

RESULTS

An SVS+ was observed in 237 out of 287 (83%) patients. In the univariate analysis, there was a significant association between SVS+ and a CE with an odds ratio (OR) and 95% confidence interval (95% CI) of 2.10 (1.02-4.29), respectively (p = 0.04) but not with GRE sequence parameters. In multivariate analysis, there was an independent relationship between SVS+ and CE (OR [95% CI]: 2.14 [1.02-4.45], p = 0.04). Sensitivity and specificity of SVS+ to predict CE were 0.89 and 0.21, respectively. The PPV and NPV of SVS+ were 0.44 and 0.78, respectively.

CONCLUSION

The presence of SVS is associated to CE, independent of GRE sequence parameters. While the specificity and the PPV of the sign were low, CE seems less likely in the absence of an SVS.

Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials

Background

Follow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement.

Objective

To examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality.

Methods

Data of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated.

Results

Of 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14–120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15–131) vs 22 mL (IQR 8–71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively).

Conclusions

In patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.

Ex vivo magnetic resonance angiography to explore placental vascular anatomy

INTRODUCTION

A normal placenta development is crucial for a successful pregnancy. In case of major obstetric complications such as intra-uterine growth restriction, the placental vascularization morphological alteration at macroscopic level is less known than that at microscopic scale. Ex vivo MRA has the potential to visualize whole fresh human placental vasculature fast and efficiently but can be hampered by contrast agent extravasation problem. This study aimed to provide an optimized ex vivo MRA protocol to acquire understanding of global human placenta vasculature morphology.

METHODS

Six fresh normal human placentas were imaged with two contrast agents (i.e. Gd-chelate and pump oil) using different imaging parameters on a 3T clinical MR scanner (GE). The contrast to noise ratio, signal to noise ratio and enhancement efficiency were assessed in order to decide which contrast agent and imaging protocol was better. In the end, morphology indices were measured based on the 3D vasculature models reconstructed from the placentas imaged with the optimized protocol.

RESULTS

With the same imaging parameters, the CNR and the enhancement efficiency of images enhanced with pump oil were superior to those using Gd-chelate. Enhanced by pump oil, an optimized ex vivo MRA protocol was determined, leading to a clear 3D visualization and reconstruction of human placenta vascularization.

DISCUSSION

The proposed ex vivo MRA method is easy to manipulate, and can be used to investigate the human placental vasculature morphology. The acquired data are of good quality and can be used for characterization of placenta vascularization morphology.

Impact of denoising on precision and accuracy of saturation-recovery-based myocardial T1 mapping

PURPOSE

To evaluate the impact of a novel postprocessing denoising technique on accuracy and precision in myocardial T₁ mapping.

MATERIALS AND METHODS

This study introduces a fast and robust denoising method developed for magnetic resonance T₁ mapping. The technique imposes edge-preserving regularity and exploits the co-occurence of spatial gradients in the acquired T₁ -weighted images. The proposed approach was assessed in simulations, ex vivo data and in vivo imaging on a cohort of 16 healthy volunteers (12 males, average age 39 ± 8 years, 62 ± 9 bpm) both in pre- and postcontrast injection. The method was evaluated in myocardial T₁ mapping at 3T with a saturation-recovery technique that is accurate but sensitive to noise. ROIs in the myocardium and left-ventricle blood pool were analyzed by an experienced reader. Mean T₁ values and standard deviation were extracted and compared in all studies.

RESULTS

Simulations on synthetic phantom showed signal-to-noise ratio and sharpness improvement with the proposed method in comparison with conventional denoising. In vivo results demonstrated that our method preserves accuracy, as no difference in mean T₁ values was observed in the myocardium (precontrast: 1433/1426 msec, 95%CI: [-40.7, 55.9], p = 0.75, postcontrast: 766/759 msec, 95%CI: [-60.7, 77.2], p = 0.8). Meanwhile, precision was improved with standard deviations of T₁ values being significantly decreased (precontrast: 223/151 msec, 95%CI: [27.3, 116.5], p = 0.003, postcontrast: 176/135 msec, 95%CI: [5.5, 77.1], p = 0.03).

CONCLUSION

The proposed denoising method preserves accuracy and improves precision in myocardial T₁ mapping, with the potential to offer better map visualization and analysis.

LEVEL OF EVIDENCE

3 Technical Efficacy: Stage 1 J. Magn. Reson. Imaging 2017;46:1377-1388.

Untangling the relationship between diet and visceral fat mass through blood metabolomics and gut microbiome profiling

BACKGROUND/OBJECTIVES

Higher visceral fat mass (VFM) is associated with an increased risk for developing cardio-metabolic diseases. The mechanisms by which an unhealthy diet pattern may influence visceral fat (VF) development has yet to be examined through cutting-edge multi-omic methods. Therefore, our objective was to examine the dietary influences on VFM and identify gut microbiome and metabolite profiles that link food intakes to VFM.

SUBJECTS/METHODS

In 2218 twins with VFM, food intake and metabolomics data available we identified food intakes most strongly associated with VFM in 50% of the sample, then constructed and tested the 'VFM diet score' in the remainder of the sample. Using linear regression (adjusted for covariates, including body mass index and total fat mass), we investigated associations between the VFM diet score, the blood metabolomics profile and the fecal microbiome (n=889), and confirmed these associations with VFM. We replicated top findings in monozygotic (MZ) twins discordant (⩾1 s.d. apart) for VFM, matched for age, sex and the baseline genetic sequence.

RESULTS

Four metabolites were associated with the VFM diet score and VFM: hippurate, alpha-hydroxyisovalerate, bilirubin (Z,Z) and butyrylcarnitine. We replicated associations between VFM and the diet score (beta (s.e.): 0.281 (0.091); P=0.002), butyrylcarnitine (0.199 (0.087); P=0.023) and hippurate (-0.297 (0.095); P=0.002) in VFM-discordant MZ twins. We identified a single species, Eubacterium dolichum to be associated with the VFM diet score (0.042 (0.011), P=8.47 × 10^-5), VFM (0.057 (0.019), P=2.73 × 10^-3) and hippurate (-0.075 (0.032), P=0.021). Moreover, higher blood hippurate was associated with elevated adipose tissue expression neuroglobin, with roles in cellular oxygen homeostasis (0.016 (0.004), P=9.82x10^-6).

CONCLUSIONS

We linked a dietary VFM score and VFM to E. dolichum and four metabolites in the blood. In particular, the relationship between hippurate, a metabolite derived from microbial metabolism of dietary polyphenols, and reduced VFM, the microbiome and increased adipose tissue expression of neuroglobin provides potential mechanistic insight into the influence of diet on VFM.

Cardiac remodeling following reperfused acute myocardial infarction is linked to the concomitant evolution of vascular function as assessed by cardiovascular magnetic resonance

BACKGROUND

Left ventricular (LV) remodeling following acute myocardial infarction (MI) is difficult to predict at an individual level although a possible interfering role of vascular function has yet to be considered to date. This study aimed to determine the extent to which this LV remodeling is influenced by the concomitant evolution of vascular function and LV loading conditions, as assessed by phase-contrast Cardiovascular Magnetic Resonance (CMR) of the ascending aorta.

METHODS

CMR was performed in 121 patients, 2-4 days after reperfusion of a first ST-segment elevation myocardial infarction and 6 months thereafter. LV remodeling was: (i) assessed by the 6-month increase in end-diastolic volume (EDV) and/or ejection fraction (EF) and (ii) correlated with the indexed aortic stroke volume (mL.m-2), determined by a CMR phase-contrast sequence, along with derived functional vascular parameters (total peripheral vascular resistance (TPVR), total arterial compliance index, effective arterial elastance).

RESULTS

At 6 months, most patients were under angiotensin enzyme converting inhibitors (86%) and beta-blockers (84%) and, on average, all functional vascular parameters were improved whereas blood pressure levels were not. An increase in EDV only (EDV+/EF-) was documented in 17% of patients at 6 months, in EF only (EDV-/EF+) in 31%, in both EDV and EF (EDV+/EF+) in 12% and neither EDV nor EF (EDV-/EF-) in 40%. The increase in EF was mainly and independently linked to a concomitant decline in TPVR (6-month change in mmHg.min.m2.L-1, EDV-/EF-: +1 ± 8, EDV+/EF-: +3 ± 9, EDV-/EF+: -7 ± 6, EDV+/EF+: -15 ± 20, p < 0.001) while the absence of any EF improvement was associated with high persisting rates of abnormally high TPVR at 6 months (EDV-/EF-: 31%, EDV+/EF-: 38%, EDV-/EF+: 5%, EDV+/EF+: 13%, p = 0.007). By contrast, the 6-month increase in EDV was mainly dependent on cardiac as opposed to vascular parameters and particularly on the presence of microvascular obstruction at baseline (EDV-/EF-: 37%, EDV+/EF-: 76%, EDV-/EF+: 38%, EDV+/EF+: 73%, p = 0.003).

CONCLUSION

LV remodeling following reperfused MI is strongly influenced by the variable decrease in systemic vascular resistance under standard care vasodilating medication. The CMR monitoring of vascular resistance may help to tailor these medications for improving vascular resistance and consequently, LV ejection fraction.

TRIAL REGISTRATION

NCT01109225 on ClinicalTrials.gov site (April, 2010).

Non-invasive evaluation of placental blood flow: lessons from animal models

In human obstetrics, placental vascularisation impairment is frequent as well as linked to severe pathological events (preeclampsia and intrauterine growth restriction), and there is a need for reliable methods allowing non-invasive evaluation of placental blood flow. Uteroplacental vascularisation is complex, and animal models are essential for the technical development and safety assessment of these imaging tools for human clinical use; however, these techniques can also be applied in the veterinary context. This paper reviews how ultrasound-based imaging methods such as 2D and 3D Doppler can provide valuable insight for the exploration of placental blood flow both in humans and animals and how new approaches such as the use of ultrasound contrast agents or ultrafast Doppler may allow to discriminate between maternal (non-pulsatile) and foetal (pulsatile) blood flow in the placenta. Finally, functional magnetic resonance imaging could also be used to evaluate placental blood flow, as indicated by studies in animal models, but its safety in human pregnancy still requires to be confirmed.

Myocardial infarct sizing by late gadolinium-enhanced MRI: Comparison of manual, full-width at half-maximum, and n-standard deviation methods

PURPOSE

To compare three widely used methods for myocardial infarct (MI) sizing on late gadolinium-enhanced (LGE) magnetic resonance (MR) images: manual delineation and two semiautomated techniques (full-width at half-maximum [FWHM] and n-standard deviation [SD]).

MATERIALS AND METHODS

3T phase-sensitive inversion-recovery (PSIR) LGE images of 114 patients after an acute MI (2-4 days and 6 months) were analyzed by two independent observers to determine both total and core infarct sizes (TIS/CIS). Manual delineation served as the reference for determination of optimal thresholds for semiautomated methods after thresholding at multiple values. Reproducibility and accuracy were expressed as overall bias ± 95% limits of agreement.

RESULTS

Mean infarct sizes by manual methods were 39.0%/24.4% for the acute MI group (TIS/CIS) and 29.7%/17.3% for the chronic MI group. The optimal thresholds (ie, providing the closest mean value to the manual method) were FWHM30% and 3SD for the TIS measurement and FWHM45% and 6SD for the CIS measurement (paired t-test; all P > 0.05). The best reproducibility was obtained using FWHM. For TIS measurement in the acute MI group, intra-/interobserver agreements, from Bland-Altman analysis, with FWHM30%, 3SD, and manual were -0.02 ± 7.74%/-0.74 ± 5.52%, 0.31 ± 9.78%/2.96 ± 16.62% and -2.12 ± 8.86%/0.18 ± 16.12, respectively; in the chronic MI group, the corresponding values were 0.23 ± 3.5%/-2.28 ± 15.06, -0.29 ± 10.46%/3.12 ± 13.06% and 1.68 ± 6.52%/-2.88 ± 9.62%, respectively. A similar trend for reproducibility was obtained for CIS measurement. However, semiautomated methods produced inconsistent results (variabilities of 24-46%) compared to manual delineation.

CONCLUSION

The FWHM technique was the most reproducible method for infarct sizing both in acute and chronic MI. However, both FWHM and n-SD methods showed limited accuracy compared to manual delineation. J. Magn. Reson. Imaging 2016;44:1206-1217.

Joint Reconstruction of Multiple Images and Motion in MRI: Application to Free-Breathing Myocardial T₂Quantification

Exploiting redundancies between multiple images of an MRI examination can be formalized as the joint reconstruction of these images. The anatomy is preserved indeed so that specific constraints can be implemented (e.g. most of the features or spatial gradients should be in the same place in all these images) and only the contrast changes from one image to another need to be encoded. The application of this concept is particularly challenging in cardiovascular and body imaging due to the complex organ deformations, especially with the patient breathing. In this study a joint optimization framework is proposed for reconstructing multiple MR images together with a nonrigid motion model. The motion model takes into account both intra-image and inter-image motion and therefore can correct for most ghosting/blurring artifacts and misregistration between images. The framework was validated with free-breathing myocardial T2 mapping experiments from nine heart transplant patients at 1.5 T. Results showed improved image quality and excellent image alignment with the multi-image reconstruction compared to the independent reconstruction of each image. Segment-wise myocardial T2 values were in good agreement with the reference values obtained from multiple breath-holds (62.5 ± 11.1 ms against 62.2 ± 11.2 ms which was not significant with p=0.49).

Assessment of Left Ventricular Ejection Fraction Calculation on Long-axis Views From Cardiac Magnetic Resonance Imaging in Patients With Acute Myocardial Infarction

To assess left ventricular ejection fraction (LVEF) accurately, cardiac magnetic resonance (CMR) can be indicated and lays on the evaluation of multiple slices of the left ventricle in short axis (CMRSAX). The objective of this study was to assess another method consisting of the evaluation of 2 long-axis slices (CMRLAX) for LVEF determination in acute myocardial infarction.One hundred patients underwent CMR 2 to 4 days after acute myocardial infarction. LVEF was computed by the area-length method on horizontal and vertical CMRLAX images. Those results were compared to reference values obtained on contiguous CMRSAX images in one hand, and to values obtained from transthoracic echocardiography (TTE) in the other hand. For CMRSAX and TTE, LVEF was computed with Simpson method. Reproducibility of LVEF measurements was additionally determined. The accuracy of volume measurements was assessed against reference aortic stroke volumes obtained by phase-contrast MR imaging.LVEF from CMRLAX had a mean value of 47 ± 8% and were on average 5% higher than reference LVEF from CMRSAX (42 ± 8%), closer to routine values from TTELAX (49 ± 8%), much better correlated with the reference LVEF from CMRSAX (R = 0.88) than that from TTE (R = 0.58), obtained with a higher reproducibility than with the 2 other techniques (% of interobserver variability: CMRLAX 5%, CMRSAX 11%, and TTE 13%), and obtained with 4-fold lower recording and calculation times than for CMRSAX. Apart from this, CMRLAX stroke volume was well correlated with phase-contrast values (R = 0.81).In patients with predominantly regional contractility abnormalities, the determination of LVEF by CMRLAX is twice more reproducible than the reference CMRSAX method, even though the LVEF is consistently overestimated compared with CMRSAX. However, the CMRLAX LVEF determination provides values closer to TTE measurements, the most available and commonly used method in clinical practice, clinical trials, and guidelines in ischemic cardiomyopathy. Moreover, LVEF determination by CMRLAX allows a 63% gain of acquisition/reading time compared with CMRSAX. Thus, despite the fact that LVEF obtained from CMRSAX remains the gold standard, CMRLAX should be considered to shorten the overall imaging acquisition and reading time as a putative replacement.