Comparison of feature tracking, fast-SENC, and myocardial tagging for global and segmental left ventricular strain

Comparative analysis of left ventricle function and deformation imaging in short and long axis plane in cardiac magnetic resonance imaging

Background

Advancements in cardiac imaging have revolutionized our understanding of ventricular contraction. While ejection fraction (EF) is still the gold standard parameter to assess left ventricle (LV) function, strain imaging (SI) has provided valuable insights into ventricular mechanics. The lack of an integrative method including SI parameters in a single, validated formula may limit its use. Our aim was to compare different methods for evaluating global circumferential strain (GCS) and their relationship with global longitudinal strain (GLS) and EF in CMR and how the different evaluations fit in the theoretical relationship between EF and global strain.

Methods

Retrospective monocenter study. Inclusion of every patient who underwent a CMR during a 15 months period with various clinical indication (congenital heart defect, myocarditis, cardiomyopathy). A minimum of three LV long-axis planes and a stack of short-axis slices covering the LV using classical steady-state free precession cine sequences. A single assessment of GLS on long axis (LAX) slices and a double assessment of GCS and EF with both short axis (SAX) and LAX slices were made by a single experienced CMR investigator.

Results

GCS-SAX and GCS-LAX were correlated (r = 0.77, P < 0.001) without being interchangeable with a high reproducibility for GCS, GLS and EF. EF calculated from LAX images showed an overestimation compared to EF derived from SAX images of 7%. The correlation between calculated EF and theoretical EF derived from SI was high (r = 0.88 with EF-SAX, 0.95 with EF-LAX).

Data conclusion

This study highlights the need to integrate strain imaging techniques into clinical by incorporating strain parameters into EF calculations, because it gives a deeper understanding of cardiac mechanics.

Free-Breathing Compressed Sensing Cine Cardiac MRI for Assessment of Left Ventricular Strain by Feature Tracking in Children

BACKGROUND

Cardiac MRI feature-tracking (FT) with breath-holding (BH) cine balanced steady state free precession (bSSFP) imaging is well established. It is unclear whether FT-strain measurements can be reliably derived from free-breathing (FB) compressed sensing (CS) bSSFP imaging.

PURPOSE

To compare left ventricular (LV) strain analysis and image quality of an FB CS bSSFP cine sequence with that of a conventional BH bSSFP sequence in children.

STUDY TYPE

Prospective.

SUBJECTS

40 children able to perform BHs (cohort 1 [12.1 ± 2.2 years]) and 17 children unable to perform BHs (cohort 2 [5.2 ± 1.8 years]).

FIELD STRENGTH/SEQUENCE

3T, bSSFP sequence with and without CS.

ASSESSMENT

Acquisition times and image quality were assessed. LV myocardial deformation parameters were compared between BH cine and FB CS cine studies in cohort 1. Strain indices and image quality of FB CS cine studies were also assessed in cohort 2. Intraobserver and interobserver variability of strain parameters was determined.

STATISTICAL TESTS

Paired t-test, Wilcoxon signed-rank test, intraclass correlation coefficient (ICC), and Bland-Altman analysis. A P-value <0.05 was considered statistically significant.

RESULTS

In cohort 1, the mean acquisition time of the FB CS cine study was significantly lower than for conventional BH cine study (15.6 s vs. 209.4 s). No significant difference were found in global circumferential strain rate (P = 0.089), global longitudinal strain rate (P = 0.366) and EuroCMR image quality scores (P = 0.128) between BH and FB sequences in cohort 1. The overall image quality score of FB CS cine in cohort 2 was 3.5 ± 0.5 with acquisition time of 14.7 ± 2.1 s. Interobserver and intraobserver variabilities were good to excellent (ICC = 0.810 to 0.943).

DATA CONCLUSION

FB CS cine imaging may be a promising alternative technique for strain assessment in pediatric patients with poor BH ability.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 1.

Impact of symptom-to-reperfusion-time on transmural infarct extent and left ventricular strain in patients with ST-segment elevation myocardial infarction: a 3D view on the wavefront phenomenon

AIMS

We examined the association between the symptom-to-reperfusion-time and cardiovascular magnetic resonance (CMR)-derived global strain parameters and transmural infarct extent in ST-segment elevation myocardial infarction (STEMI) patients.

METHODS AND RESULTS

The study included 108 STEMI patients who underwent successful primary percutaneous coronary intervention (PPCI). Patients were categorized according to the median symptom-to-reperfusion-time: shorter (<160 min, n = 54) and longer times (>160 min, n = 54). CMR was performed 2-7 days after PPCI and at 1 month. CMR cine imaging was performed for functional assessment and late gadolinium enhancement to evaluate transmural infarct extent. Myocardial feature-tracking was used for strain analysis. Groups were comparable in relation to incidence of LAD disease and pre- and post-PPCI thrombolysis in myocardial infarction (TIMI) flow grades. The mean transmural extent score at follow-up was lower in patients with shorter reperfusion time (P < 0.01). Both baseline and follow-up maximum transmural extent scores were smaller in patients with shorter reperfusion time (P = 0.03 for both). Patients with shorter reperfusion time had more favourable global left ventricular (LV) circumferential strain (baseline, P = 0.049; follow-up, P = 0.01) and radial strain (baseline, P = 0.047; follow-up, P < 0.01), whilst LV longitudinal strain appeared comparable for both baseline and follow-up (P > 0.05 for both). In multi-variable regression analysis including all three strain directions, baseline LV circumferential strain was independently associated with the mean transmural extent score at follow-up (β=1.89, P < 0.001).

CONCLUSION

In STEMI patients, time-to-reperfusion was significantly associated with smaller transmural extent of infarction and better LV circumferential and radial strain. Moreover, infarct transmurality and residual LV circumferential strain are closely linked.

Impact of temporal and spatial resolution on atrial feature tracking cardiovascular magnetic resonance imaging

BACKGROUND

Myocardial deformation assessment by cardiovascular magnetic resonance-feature tracking (CMR-FT) has incremental prognostic value over volumetric analyses. Recently, atrial functional analyses have come to the fore. However, to date recommendations for optimal resolution parameters for accurate atrial functional analyses are still lacking.

METHODS

CMR-FT was performed in 12 healthy volunteers and 9 ischemic heart failure (HF) patients. Cine sequences were acquired using different temporal (20, 30, 40 and 50 frames/cardiac cycle) and spatial resolution parameters (high 1.5 × 1.5 mm in plane and 5 mm slice thickness, standard 1.8 × 1.8 × 8 mm and low 3.0 × 3.0 × 10 mm). Inter- and intra-observer reproducibility were calculated.

RESULTS

Increasing temporal resolution is associated with higher absolute strain and strain rate (SR) values. Significant changes in strain assessment for left atrial (LA) total strain occurred between 20 and 30 frames/cycle amounting to 2,5-4,4% in absolute changes depending on spatial resolution settings. From 30 frames/cycle onward, absolute strain values remained unchanged. Significant changes of LA strain rate assessment were observed up to the highest temporal resolution of 50 frames/cycle. Effects of spatial resolution on strain assessment were smaller. For LA total strain a general trend emerged for a mild decrease in strain values obtained comparing the lowest to the highest spatial resolution at temporal resolutions of 20, 40 and 50 frames/cycle (p = 0.006-0.046) but not at 30 frames/cycle (p = 0.140).

CONCLUSION

Temporal and to a smaller extent spatial resolution affect atrial functional assessment. Consistent strain assessment requires a standard spatial resolution and a temporal resolution of 30 frames/cycle, whilst SR assessment requires even higher settings of at least 50 frames/cycle.

Comparison of manual and artificial intelligence based quantification of myocardial strain by feature tracking-a cardiovascular MR study in health and disease

OBJECTIVES

The analysis of myocardial deformation using feature tracking in cardiovascular MR allows for the assessment of global and segmental strain values. The aim of this study was to compare strain values derived from artificial intelligence (AI)-based contours with manually derived strain values in healthy volunteers and patients with cardiac pathologies.

MATERIALS AND METHODS

A cohort of 136 subjects (60 healthy volunteers and 76 patients; of those including 46 cases with left ventricular hypertrophy (LVH) of varying etiology and 30 cases with chronic myocardial infarction) was analyzed. Comparisons were based on quantitative strain analysis and on a geometric level by the Dice similarity coefficient (DSC) of the segmentations. Strain quantification was performed in 3 long-axis slices and short-axis (SAX) stack with epi- and endocardial contours in end-diastole. AI contours were checked for plausibility and potential errors in the tracking algorithm.

RESULTS

AI-derived strain values overestimated radial strain (+ 1.8 ± 1.7% (mean difference ± standard deviation); p = 0.03) and underestimated circumferential (- 0.8 ± 0.8%; p = 0.02) and longitudinal strain (- 0.1 ± 0.8%; p = 0.54). Pairwise group comparisons revealed no significant differences for global strain. The DSC showed good agreement for healthy volunteers (85.3 ± 10.3% for SAX) and patients (80.8 ± 9.6% for SAX). In 27 cases (27/76; 35.5%), a tracking error was found, predominantly (24/27; 88.9%) in the LVH group and 22 of those (22/27; 81.5%) at the insertion of the papillary muscle in lateral segments.

CONCLUSIONS

Strain analysis based on AI-segmented images shows good results in healthy volunteers and in most of the patient groups. Hypertrophied ventricles remain a challenge for contouring and feature tracking.

CLINICAL RELEVANCE STATEMENT

AI-based segmentations can help to streamline and standardize strain analysis by feature tracking.

KEY POINTS

• Assessment of strain in cardiovascular magnetic resonance by feature tracking can generate global and segmental strain values. • Commercially available artificial intelligence algorithms provide segmentation for strain analysis comparable to manual segmentation. • Hypertrophied ventricles are challenging in regards of strain analysis by feature tracking.

Inter-study reproducibility of cardiovascular magnetic resonance-derived hemodynamic force assessments

Cardiovascular magnetic resonance (CMR)-derived hemodynamic force (HDF) analyses have been introduced recently enabling more in-depth cardiac function evaluation. Inter-study reproducibility is important for a widespread clinical use but has not been quantified for this novel CMR post-processing tool yet. Serial CMR imaging was performed in 11 healthy participants in a median interval of 63 days (range 49-87). HDF assessment included left ventricular (LV) longitudinal, systolic peak and impulse, systolic/diastolic transition, diastolic deceleration as well as atrial thrust acceleration forces. Inter-study reproducibility and study sample sizes required to demonstrate 10%, 15% or 20% relative changes of HDF measurements were calculated. In addition, intra- and inter-observer analyses were performed. Intra- and inter-observer reproducibility was excellent for all HDF parameters according to intraclass correlation coefficient (ICC) values (> 0.80 for all). Inter-study reproducibility of all HDF parameters was excellent (ICC ≥ 0.80 for all) with systolic parameters showing lower coeffients of variation (CoV) than diastolic measurements (CoV 15.2% for systolic impulse vs. CoV 30.9% for atrial thrust). Calculated sample sizes to detect relative changes ranged from n = 12 for the detection of a 20% relative change in systolic impulse to n = 200 for the detection of 10% relative change in atrial thrust. Overall inter-study reproducibility of CMR-derived HDF assessments was sufficient with systolic HDF measurements showing lower inter-study variation than diastolic HDF analyses.

Incremental prognostic value of left atrial and biventricular feature tracking in dilated cardiomyopathy: a long-term study

BACKGROUND

Despite the use of cardiovascular magnetic resonance (CMR) feature tracking (FT) imaging to detect myocardial deformation, the optimal strain index in dilated cardiomyopathy (DCM) is unclear. This study aimed to determine whether atrial and biventricular strains can provide the greatest or joint incremental prognostic value in patients with DCM over a long follow-up period.

METHODS

Four hundred-twelve DCM patients were included retrospectively. Comprehensive clinical evaluation and imaging investigations were obtained, including measurements of CMR-FT derived left atrial (LA) reservoir, conduit, booster strain (εs, εe, εa); left ventricular (LV) and right ventricular (RV) global longitudinal, radial, circumferential strain (GLS, GRS, GCS). All patients were followed up for major adverse cardiac events (MACE) including all-cause mortality, heart transplantation, and implantable cardioverter defibrillator discharge. The predictors of MACE were examined with univariable and multivariable Cox regression analysis. Subsequently, nested Cox regression models were built to evaluate the incremental prognostic value of strain parameters. The incremental predictive power of strain parameters was assessed by Omnibus tests, and the model performance and discrimination were evaluated by Harrell C-index and integrated discrimination improvement (IDI) analysis. Patient survival was illustrated by Kaplan-Meier curves and differences were evaluated by log-rank test.

RESULTS

During a median follow-up of 5.0 years, MACE were identified in 149 (36%) patients. LAεe, LVGLS, and RVGLS were the most predictive strain parameters for MACE (AUC: 0.854, 0.733, 0.733, respectively). Cox regression models showed that the predictive value of LAεe was independent from and incremental to LVGLS, RVGLS, and baseline variables (HR 0.74, 95% CI 0.68-0.81, P < 0.001). In reclassification analysis, the addition of LAεe provided the best discrimination of the model (χ2 223.34, P < 0.001; C-index 0.833; IDI 0.090, P < 0.001) compared with LVGLS and RVGLS models. Moreover, LAεe with a cutoff of 5.3% further discriminated the survival probability in subgroups of patients with positive LGE or reduced LVEF (all log-rank P < 0.001).

CONCLUSION

LAεe provided the best prognostic value over biventricular strains and added incremental value to conventional clinical predictors for patients with DCM.

Quantifying left ventricular myocardial strain in patients with different CAD-RADS levels based on computed tomography feature tracking technology

To evaluate myocardial strain in patients with different coronary artery disease-reporting and data system (CAD-RADS) levels using the computed tomography (CT) feature tracking technology and to investigate the relationship of myocardial strain with coronary artery calcium scores (CACs) and the degree of coronary artery stenosis. We prospectively enrolled 237 consecutive patients to undergo coronary CT angiography. The participants were divided into the following groups: control (n = 87), CAD-RADS 1 (n = 43), CAD-RADS 2 (n = 43), CAD-RADS 3 (n = 38), and CAD-RADS 4 and above (n = 26). Myocardial strains were analyzed by commercial software, and CACs and coronary stenosis were assessed on post-processing stations. Differences between multiple groups were analyzed using one-way analysis of variance or the Kruskal-Wallis test. Logistic regression were used to analyze the effects of dichotomous variables. As the CAD-RADS level increased, the global circumferential strain (GCS), global longitudinal strain (GLS) and global radial strain (GRS) of the left ventricle based on CT gradually decreased. A significant correlation was observed between global myocardial strain and CACs (GRS: r =  - 0.219, GCS: r = 0.189, GLS: r = 0.491; P < 0.05). The independent predictors of obstructive CAD were age (β = 0.065, odds ratio [OR] = 1.067, P = 0.005), left ventricular ejection fraction (β = 0.145, OR = 1.156, P = 0.047), and GLS (β = 0.232, OR = 1.261, P = 0.01). CT-derived GLS of the left ventricle is correlated with CAD-RADS levels and CACs. It may be a better indicator than CACs to reflect the severity of CAD.

WarpPINN: Cine-MR image registration with physics-informed neural networks

The diagnosis of heart failure usually includes a global functional assessment, such as ejection fraction measured by magnetic resonance imaging. However, these metrics have low discriminate power to distinguish different cardiomyopathies, which may not affect the global function of the heart. Quantifying local deformations in the form of cardiac strain can provide helpful information, but it remains a challenge. In this work, we introduce WarpPINN, a physics-informed neural network to perform image registration to obtain local metrics of heart deformation. We apply this method to cine magnetic resonance images to estimate the motion during the cardiac cycle. We inform our neural network of the near-incompressibility of cardiac tissue by penalizing the Jacobian of the deformation field. The loss function has two components: an intensity-based similarity term between the reference and the warped template images, and a regularizer that represents the hyperelastic behavior of the tissue. The architecture of the neural network allows us to easily compute the strain via automatic differentiation to assess cardiac activity. We use Fourier feature mappings to overcome the spectral bias of neural networks, allowing us to capture discontinuities in the strain field. The algorithm is tested on synthetic examples and on a cine SSFP MRI benchmark of 15 healthy volunteers, where it is trained to learn the deformation mapping of each case. We outperform current methodologies in landmark tracking and provide physiological strain estimations in the radial and circumferential directions. WarpPINN provides precise measurements of local cardiac deformations that can be used for a better diagnosis of heart failure and can be used for general image registration tasks. Source code is available at https://github.com/fsahli/WarpPINN.

The predictive value of cardiac MRI strain parameters in hypertrophic cardiomyopathy patients with preserved left ventricular ejection fraction and a low fibrosis burden: a retrospective cohort study

Background

Prompt interventions prevent adverse events (AE) in hypertrophic cardiomyopathy (HCM). We evaluated the pattern and the predictive role of feature tracking (FT)-cardiac magnetic resonance (CMR) imaging parameters in an HCM population with a normal left ventricular ejection fraction (LVEF) and a low fibrosis burden.

Methods

The CMR and clinical data of 170 patients, consisting of 142 HCM (45 ± 15.7 years, 62.7% male) and 28 healthy (42.2 ± 11.26 years, 50% male) subjects, who were enrolled from 2015 to 2020, were evaluated. HCM patients had a normal LVEF with a late gadolinium enhancement (LGE) percentage below 15%. Between-group differences were described, and the potent predictors of AE were determined. A P-value below 0.05 was considered significant.

Results

LV global longitudinal, circumferential, and radial strains (GLS, GCS, and GRS, respectively) and the LV myocardial mass index (MMI) were different between the healthy and HCM cases (all Ps < 0.05). Strains were significantly impaired in the HCM patients with a normal MMI. A progressive decrease in LVGLS and a distinct fall in LVGCS were noted with a rise in MMI. AE were predicted by LVGLS, LVGCS, and the LGE percentage, and LVGCS was the single robust predictor (HR, 1.144; 95% CI, 1.080-1.212; P = 0.001). An LVGCS below 16.2% predicted AE with 77% specificity and 58% sensitivity.

Conclusions

LV strains were impaired in HCM patients with a normal EF and a low fibrosis burden, even in the presence of a normal MMI. CMR parameters, especially FT-CMR values, predicted AE in our HCM patients.

Impact of myocardial deformation on risk prediction in patients following acute myocardial infarction

Background

Strain analyses derived from cardiovascular magnetic resonance-feature tracking (CMR-FT) provide incremental prognostic benefit in patients sufferring from acute myocardial infarction (AMI). This study aims to evaluate and revalidate previously reported prognostic implications of comprehensive strain analyses in a large independent cohort of patients with ST-elevation myocardial infarction (STEMI).

Methods

Overall, 566 STEMI patients enrolled in the CONDITIONING-LIPSIA trial including pre- and/or postconditioning treatment in addition to conventional percutaneous coronary intervention underwent CMR imaging in median 3 days after primary percutaneous coronary intervention. CMR-based left atrial (LA) reservoir (Es), conduit (Ee), and boosterpump (Ea) strain analyses, as well as left ventricular (LV) global longitudinal strain (GLS), circumferential strain (GCS), and radial strain (GRS) analyses were carried out. Previously identified cutoff values were revalidated for risk stratification. Major adverse cardiac events (MACE) comprising death, reinfarction, and new congestive heart failure were assessed within 12 months after the occurrence of the index event.

Results

Both atrial and ventricular strain values were significantly reduced in patients with MACE (p < 0.01 for all). Predetermined LA and LV strain cutoffs enabled accurate risk assessment. All LA and LV strain values were associated with MACE on univariable regression modeling (p < 0.001 for all), with LA Es emerging as an independent predictor of MACE on multivariable regression modeling (HR 0.92, p = 0.033). Furthermore, LA Es provided an incremental prognostic value above LVEF (a c-index increase from 0.7 to 0.74, p = 0.03).

Conclusion

External validation of CMR-FT-derived LA and LV strain evaluations confirmed the prognostic value of cardiac deformation assessment in STEMI patients. In the present study, LA strain parameters especially enabled further risk stratification and prognostic assessment over and above clinically established risk parameters.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT02158468.

Deep Learning Synthetic Strain: Quantitative Assessment of Regional Myocardial Wall Motion at MRI

Purpose

To assess the feasibility of a newly developed algorithm, called deep learning synthetic strain (DLSS), to infer myocardial velocity from cine steady-state free precession (SSFP) images and detect wall motion abnormalities in patients with ischemic heart disease.

Materials and Methods

In this retrospective study, DLSS was developed by using a data set of 223 cardiac MRI examinations including cine SSFP images and four-dimensional flow velocity data (November 2017 to May 2021). To establish normal ranges, segmental strain was measured in 40 individuals (mean age, 41 years ± 17 [SD]; 30 men) without cardiac disease. Then, DLSS performance in the detection of wall motion abnormalities was assessed in a separate group of patients with coronary artery disease, and these findings were compared with consensus results of four independent cardiothoracic radiologists (ground truth). Algorithm performance was evaluated by using receiver operating characteristic curve analysis.

Results

Median peak segmental radial strain in individuals with normal cardiac MRI findings was 38% (IQR: 30%-48%). Among patients with ischemic heart disease (846 segments in 53 patients; mean age, 61 years ± 12; 41 men), the Cohen κ among four cardiothoracic readers for detecting wall motion abnormalities was 0.60-0.78. DLSS achieved an area under the receiver operating characteristic curve of 0.90. Using a fixed 30% threshold for abnormal peak radial strain, the algorithm achieved a sensitivity, specificity, and accuracy of 86%, 85%, and 86%, respectively.

Conclusion

The deep learning algorithm had comparable performance with subspecialty radiologists in inferring myocardial velocity from cine SSFP images and identifying myocardial wall motion abnormalities at rest in patients with ischemic heart disease.Keywords: Neural Networks, Cardiac, MR Imaging, Ischemia/Infarction Supplemental material is available for this article. © RSNA, 2023.

Application of Magnetic Resonance Strain Analysis Using Feature Tracking in a Myocardial Infarction Model

This study validates the usefulness of myocardial strain analysis with cardiac cine magnetic resonance imaging (MRI) by evaluating the changes in the cardiac function and myocardial strain values longitudinally in a myocardial disease model. Six eight-week-old male Wistar rats were used as a model of myocardial infarction (MI). Cine images were taken in the short axis, two-chamber view longitudinal axis, and four-chamber view longitudinal axis directions in rats 3 and 9 days after MI and in control rats, with preclinical 7-T MRI. The control images and the images on days 3 and 9 were evaluated by measuring the ventricular ejection fraction (EF) and the strain values in the circumferential (CS), radial (RS), and longitudinal directions (LS). The CS decreased significantly 3 days after MI, but there was no difference between the images on days 3 and 9. The two-chamber view LS was -9.7 ± 2.1% at 3 days and -13.9 ± 1.4% at 9 days after MI. The four-chamber view LS was -9.9 ± 1.5% at 3 days and -11.9 ± 1.3% at 9 days after MI. Both the two- and four-chamber LS values were significantly decreased 3 days after MI. Myocardial strain analysis is, therefore, useful for assessing the pathophysiology of MI.

Cardiovascular magnetic resonance-derived left atrioventricular coupling index and major adverse cardiac events in patients following acute myocardial infarction

BACKGROUND

Recently, a novel left atrioventricular coupling index (LACI) has been introduced providing prognostic value to predict cardiovascular events beyond common risk factors in patients without cardiovascular disease. Since data on cardiovascular magnetic resonance (CMR)-derived LACI in patients following acute myocardial infarction (AMI) are scarce, we aimed to assess the diagnostic and prognostic implications of LACI in a large AMI patient cohort.

METHODS

In total, 1046 patients following AMI were included. After primary percutaneous coronary intervention CMR imaging and subsequent functional analyses were performed. LACI was defined by the ratio of the left atrial end-diastolic volume divided by the left ventricular (LV) end-diastolic volume. Major adverse cardiac events (MACE) including death, reinfarction or heart failure within 12 months after the index event were defined as primary clinical endpoint.

RESULTS

LACI was significantly higher in patients with MACE compared to those without MACE (p < 0.001). Youden Index identified an optimal LACI cut-off at 34.7% to classify patients at high-risk (p < 0.001 on log-rank testing). Greater LACI was associated with MACE on univariate regression modeling (HR 8.1, 95% CI 3.4-14.9, p < 0.001) and after adjusting for baseline confounders and LV ejection fraction (LVEF) on multivariate regression analyses (HR 3.1 95% CI 1.0-9, p = 0.049). Furthermore, LACI assessment enabled further risk stratification in high-risk patients with impaired LV systolic function (LVEF ≤ 35%; p < 0.001 on log-rank testing).

CONCLUSION

Atrial-ventricular interaction using CMR-derived LACI is a superior measure of outcome beyond LVEF especially in high-risk patients following AMI. Trial registration ClinicalTrials.gov, NCT00712101 and NCT01612312.

3-Dimensional Strain Analysis of Hypertrophic Cardiomyopathy: Insights From the NHLBI International HCM Registry

BACKGROUND

Abnormal global longitudinal strain (GLS) has been independently associated with adverse cardiac outcomes in both obstructive and nonobstructive hypertrophic cardiomyopathy.

OBJECTIVES

The goal of this study was to understand predictors of abnormal GLS from baseline data from the National Heart, Lung, and Blood Institute (NHLBI) Hypertrophic Cardiomyopathy Registry (HCMR).

METHODS

The study evaluated comprehensive 3-dimensional left ventricular myocardial strain from cine cardiac magnetic resonance in 2,311 patients from HCMR using in-house validated feature-tracking software. These data were correlated with other imaging markers, serum biomarkers, and demographic variables.

RESULTS

Abnormal median GLS (> -11.0%) was associated with higher left ventricular (LV) mass index (93.8 ± 29.2 g/m2 vs 75.1 ± 19.7 g/m2; P < 0.0001) and maximal wall thickness (21.7 ± 5.2 mm vs 19.3 ± 4.1 mm; P < 0.0001), lower left (62% ± 9% vs 66% ± 7%; P < 0.0001) and right (68% ± 11% vs 69% ± 10%; P < 0.01) ventricular ejection fractions, lower left atrial emptying functions (P < 0.0001 for all), and higher presence and myocardial extent of late gadolinium enhancement (6 SD and visual quantification; P < 0.0001 for both). Elastic net regression showed that adjusted predictors of GLS included female sex, Black race, history of syncope, presence of systolic anterior motion of the mitral valve, reverse curvature and apical morphologies, LV ejection fraction, LV mass index, and both presence/extent of late gadolinium enhancement and baseline N-terminal pro-B-type natriuretic peptide and troponin levels.

CONCLUSIONS

Abnormal strain in hypertrophic cardiomyopathy is associated with other imaging and serum biomarkers of increased risk. Further follow-up of the HCMR cohort is needed to understand the independent relationship between LV strain and adverse cardiac outcomes in hypertrophic cardiomyopathy.

Reduced functional capacity is associated with the proportion of impaired myocardial deformation assessed in heart failure patients by CMR

Aims

Heart failure (HF) does not only reduce the life expectancy in patients, but their life is also often limited by HF symptoms leading to a reduced quality of life (QoL) and a diminished exercise capacity. Novel parameters in cardiac imaging, including both global and regional myocardial strain imaging, promise to contribute to better patient characterization and ultimately to better patient management. However, many of these methods are not part of clinical routine yet, their associations with clinical parameters have been poorly studied. An imaging parameters that also indicate the clinical symptom burden of HF patients would make cardiac imaging more robust toward incomplete clinical information and support the clinical decision process.

Methods and results

This prospective study conducted at two centers in Germany between 2017 and 2018 enrolled stable outpatient subjects with HF [n = 56, including HF with reduced ejection fraction (HFrEF), HF with mid-range ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF)] and a control cohort (n = 19). Parameters assessed included measures for external myocardial function, for example, cardiac index and myocardial deformation measurements by cardiovascular magnetic resonance imaging, left ventricular global longitudinal strain (GLS), the global circumferential strain (GCS), and the regional distribution of segment deformation within the LV myocardium, as well as basic phenotypical characteristics including the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the 6-minute walk test (6MWT). If less than 80% of the LV segments are preserved in their deformation capacity the functional capacity by 6MWT (6 minutes walking distance: MyoHealth ≥ 80%: 579.8 ± 177.6 m; MyoHealth 60-<80%: 401.3 ± 121.7 m; MyoHealth 40-<60%: 456.4 ± 68.9 m; MyoHealth < 40%: 397.6 ± 125.9 m, overall p-value: 0.03) as well as the symptom burden are significantly impaired (NYHA class: MyoHealth ≥ 80%: 0.6 ± 1.1 m; MyoHealth 60-<80%: 1.7 ± 1.2 m; MyoHealth 40-<60%: 1.8 ± 0.7 m; MyoHealth < 40%: 2.4 ± 0.5 m; overall p-value < 0.01). Differences were also observed in the perceived exertion assessed by on the Borg scale (MyoHealth ≥ 80%: 8.2 ± 2.3 m; MyoHealth 60-<80%: 10.4 ± 3.2 m; MyoHealth 40-<60%: 9.8 ± 2.1 m; MyoHealth < 40%: 11.0 ± 2.9 m; overall p-value: 0.20) as well as quality of life measures (MLHFQ; MyoHealth ≥ 80%: 7.5 ± 12.4 m; MyoHealth 60-<80%: 23.4 ± 23.4 m; MyoHealth 40-<60%: 20.5 ± 21.2 m; MyoHealth < 40%: 27.4 ± 24.4 m; overall p-value: 0.15)-while these differences were not significant.

Conclusion

The share of LV segments with preserved myocardial contraction promises to discriminate between symptomatic and asymptomatic subjects based on the imaging findings, even when the LV ejection fraction is preserved. This finding is promising to make imaging studies more robust toward incomplete clinical information.

Cardiac Magnetic Resonance Imaging in Appraising Myocardial Strain and Biomechanics: A Current Overview

Subclinical alterations in myocardial structure and function occur early during the natural disease course. In contrast, clinically overt signs and symptoms occur during late phases, being associated with worse outcomes. Identification of such subclinical changes is critical for timely diagnosis and accurate management. Hence, implementing cost-effective imaging techniques with accuracy and reproducibility may improve long-term prognosis. A growing body of evidence supports using cardiac magnetic resonance (CMR) to quantify deformation parameters. Tissue-tagging (TT-CMR) and feature-tracking CMR (FT-CMR) can measure longitudinal, circumferential, and radial strains and recent research emphasize their diagnostic and prognostic roles in ischemic heart disease and primary myocardial illnesses. Additionally, these methods can accurately determine LV wringing and functional dynamic geometry parameters, such as LV torsion, twist/untwist, LV sphericity index, and long-axis strain, and several studies have proved their utility in prognostic prediction in various cardiovascular patients. More recently, few yet important studies have suggested the superiority of fast strain-encoded imaging CMR-derived myocardial strain in terms of accuracy and significantly reduced acquisition time, however, more studies need to be carried out to establish its clinical impact. Herein, the current review aims to provide an overview of currently available data regarding the role of CMR in evaluating myocardial strain and biomechanics.

Radial and Circumferential CMR-Based RV Strain Predicts Low R Wave Amplitude after ICD Implantation in Patients with Arrhythmogenic Cardiomyopathy

Inadequate R wave amplitude (RWA) after implantable cardiac defibrillator (ICD) implantation in patients with arrhythmogenic cardiomyopathy (ACM) was suspected to relate to right ventricle impairment. However, little data-based evidence was provided to quantify the association. We retrospectively enrolled ACM patients receiving CMR examinations before transvenous ICD implantation from Fuwai Hospital. The RWA was obtained within 24 h and at 2-6-month follow-up after the operation. Structural, functional, as well as tissue characterization of the left ventricle (LV) and right ventricle (RV), were analyzed in relation to RWA. Among the 87 ACM patients (median RWA: 8.0 mV), 19 (21.8%) patients were found with low initial RWA (<5 mV) despite attempts in multiple positions. RV end diastolic diameter (RVEDD), (r = -0.44), RV ejection fraction (RVEF, r = 0.43), RV end diastolic volume index (RVEDVi, r = -0.49), RV end systolic volume index (RVESVi, r = -0.53), RV global circumferential (RVGCS, r = -0.64), and radial strain (RVGRS, r = 0.61, all p < 0.001) rather than LV metrics correlated strongly with initial RWA. RVGCS, RVESVi, and RVGRS were decent predictors of low RWA (areas under the curve AUC: 0.814, 0.769, 0.757, respectively) early after implantation and during 2-6-month follow-up. To summarize, low RWA of ICD lead in ACM patients was associated with RV abnormalities. The RVGCS, RVGRS, and RVESVi can be valuable predictors for identifying low RWA prior to ICD implantation.

Clinical Utility of Strain Imaging in Assessment of Myocardial Fibrosis

Myocardial fibrosis (MF) is a non-reversible process that occurs following acute or chronic myocardial damage. MF worsens myocardial deformation, remodels the heart and raises myocardial stiffness, and is a crucial pathological manifestation in patients with end-stage cardiovascular diseases and closely related to cardiac adverse events. Therefore, early quantitative analysis of MF plays an important role in risk stratification, clinical decision, and improvement in prognosis. With the advent and development of strain imaging modalities in recent years, MF may be detected early in cardiovascular diseases. This review summarizes the clinical usefulness of strain imaging techniques in the non-invasive assessment of MF.

Comparison of left ventricular global and segmental strain parameters by cardiovascular magnetic resonance tissue tracking in light-chain cardiac amyloidosis and hypertrophic cardiomyopathy

Background

Apical sparing of left ventricular (LV) strain can occur in light-chain cardiac amyloidosis (AL-CA). We employed indicators of the strain ratio of the apex to base (RAB) and the relative apical sparing of strain (RAS) on the basis of LV global and segmental strain to distinguish AL-CA from hypertrophic cardiomyopathy (HCM).

Methods

In all, 36 AL-CA patients, 37 HCM patients, and 36 healthy controls underwent 3.0 T cardiac magnetic resonance (CMR) examination. We compared LV strain parameters from CMR tissue tracking (CMR-TT), including global and segmental peak radial strain (PRS), peak circumferential strain (PCS), and peak longitudinal strain (PLS); the peak systolic strain rate in radial, circumferential, and longitudinal directions (PSSR_R, PSSR_C, PSSR_L); and the peak diastolic strain rate in radial, circumferential, and longitudinal directions (PDSR_R, PDSR_C, PDSR_L). We also assessed the values of RAB and RAS. Differences in all groups were compared using an independent t-test and a nonparametric rank sum test.

Results

In the comparison of global strain parameters, all the peak strain, systolic, and diastolic peak strain rates of the AL-CA group significantly decreased compared with those of the HCM and healthy control groups (all P<0.001). The values of PSSR in all directions were lower in the AL-CA than in the HCM patients (PSSR_R, P<0.001; PSSR_C, P=0.004; PSSR_L, P=0.010) . In the analysis of segmental strain parameters, all peak strains in the basal segment showed significant differences between the AL-CA and HCM groups (all P<0.001). Some strain rate parameters in the basal segment were also noted to be significantly different (PSSR_R, P<0.001; PSSR_L, P<0.001; PDSR_R, P=0.015; PDSR_C, P=0.020). Both the RAB and RAS of peak strain in all directions showed significant differences between the AL-CA and HCM groups (all P<0.001). The RAB of the radial and circumferential PSSR showed statistical differences between the 2 groups (P<0.001 and P=0.001). The RAS in the radial direction of both the PSSR and PDSR was statistically different (P=0.003 and P=0.012).

Conclusions

The CMR-TT technique can be used to quantitatively compare global and segmental strain differences between AL-CA and HCM. In addition, RAB and RAS are reliable parameters for assessing the apical sparing pattern and thus, for distinguishing AL-CA from HCM.

CMR left ventricular strains beyond global longitudinal strain in differentiating light-chain cardiac amyloidosis from hypertrophic cardiomyopathy

Background

The clinical value of left ventricular (LV) global longitudinal strain (GLS) in the differential diagnosis of light-chain cardiac amyloidosis (AL-CA) and hypertrophic cardiomyopathy (HCM) has been previously reported. In this study, we analyzed the potential clinical value of the LV long-axis strain (LAS) to discriminate AL-CA from HCM. Furthermore, we analyzed the association between all the LV global strain parameters derived from cardiac magnetic resonance (CMR) feature tracking and LAS in both the AL-CA and HCM patients to assess the differential diagnostic efficacies of these global peak systolic strains.

Materials and methods

Thus, this study enrolled 89 participants who underwent cardiac MRI (CMRI), consisting of 30 AL-CA patients, 30 HCM patients, and 29 healthy controls. The intra- and inter-observer reproducibility of the LV strain parameters including GLS, global circumferential strain (GCS), global radial strain (GRS), and LAS were assessed in all the groups and compared. Receiver operating characteristic (ROC) curve analysis was performed to determine the diagnostic performances of the CMR strain parameters in discriminating AL-CA from HCM.

Results

The intra- and inter-observer reproducibility of the LV global strains and LAS were excellent (range of interclass correlation coefficients: 0.907-0.965). ROC curve analyses showed that the differential diagnostic performances of the global strains in discriminating AL-CA from HCM were good to excellent (GRS, AUC = 0.921; GCS, AUC = 0.914; GLS, AUC = 0.832). Furthermore, among all the strain parameters analyzed, LAS showed the highest diagnostic efficacy in differentiating between AL-CA and HCM (AUC = 0.962).

Conclusion

CMRI-derived strain parameters such as GLS, LAS, GRS, and GCS are promising diagnostic indicators that distinguish AL-CA from HCM with high accuracy. LAS showed the highest diagnostic accuracy among all the strain parameters.

Emerging MRI techniques for molecular and functional phenotyping of the diseased heart

Recent advances in cardiac MRI (CMR) capabilities have truly transformed its potential for deep phenotyping of the diseased heart. Long known for its unparalleled soft tissue contrast and excellent depiction of three-dimensional (3D) structure, CMR now boasts a range of unique capabilities for probing disease at the tissue and molecular level. We can look beyond coronary vessel blockages and detect vessel disease not visible on a structural level. We can assess if early fibrotic tissue is being laid down in between viable cardiac muscle cells. We can measure deformation of the heart wall to determine early presentation of stiffening. We can even assess how cardiomyocytes are utilizing energy, where abnormalities are often precursors to overt structural and functional deficits. Finally, with artificial intelligence gaining traction due to the high computing power available today, deep learning has proven itself a viable contender with traditional acceleration techniques for real-time CMR. In this review, we will survey five key emerging MRI techniques that have the potential to transform the CMR clinic and permit early detection and intervention. The emerging areas are: (1) imaging microvascular dysfunction, (2) imaging fibrosis, (3) imaging strain, (4) imaging early metabolic changes, and (5) deep learning for acceleration. Through a concerted effort to develop and translate these areas into the CMR clinic, we are committing ourselves to actualizing early diagnostics for the most intractable heart disease phenotypes.

A head-to-head comparison of fast-SENC and feature tracking to LV long axis strain for assessment of myocardial deformation in chest pain patients

BACKGROUND

Myocardial strain imaging has gained importance in cardiac magnetic resonance (CMR) imaging in recent years as an even more sensitive marker of early left ventricular dysfunction than left-ventricular ejection fraction (LVEF). fSENC (fast strain encoded imaging) and FT (feature tracking) both allow for reproducible assessment of myocardial strain. However, left-ventricular long axis strain (LVLAS) might enable an equally sensitive measurement of myocardial deformation as global longitudinal or circumferential strain in a more rapid and simple fashion.

METHODS

In this study we compared the diagnostic performance of fSENC, FT and LVLAS for identification of cardiac pathology (ACS, cardiac-non-ACS) in patients presenting with chest pain (initial hscTnT 5-52 ng/l). Patients were prospectively recruited from the chest pain unit in Heidelberg. The CMR scan was performed within 1 h after patient presentation. Analysis of LVLAS was compared to the GLS and GCS as measured by fSENC and FT.

RESULTS

In total 40 patients were recruited (ACS n = 6, cardiac-non-ACS n = 6, non-cardiac n = 28). LVLAS was comparable to fSENC for differentiation between healthy myocardium and myocardial dysfunction (GLS-fSENC AUC: 0.882; GCS-fSENC AUC: 0.899; LVLAS AUC: 0.771; GLS-FT AUC: 0.740; GCS-FT: 0.688), while FT-derived strain did not allow for differentiation between ACS and non-cardiac patients. There was significant variability between the three techniques. Intra- and inter-observer variability (OV) was excellent for fSENC and FT, while for LVLAS the agreement was lower and levels of variability higher (intra-OV: Pearson > 0.7, ICC > 0.8; inter-OV: Pearson > 0.65, ICC > 0.8; CoV > 25%).

CONCLUSIONS

While reproducibility was excellent for both FT and fSENC, it was only fSENC and the LVLAS which allowed for significant identification of myocardial dysfunction, even before LVEF, and therefore might be used as rapid supporting parameters for assessment of left-ventricular function.

Cardiovascular magnetic resonance imaging patterns of acute COVID-19 mRNA vaccine-associated myocarditis in young male patients: A first single-center experience

Background

The risk of myocarditis after mRNA vaccination against COVID-19 has emerged recently. Current evidence suggests that young male patients are predominantly affected. In the majority of the cases, only mild symptoms were observed. However, little is known about cardiac magnetic resonance (CMR) imaging patterns in mRNA-related myocarditis and their differences when compared to classical viral myocarditis in the acute phase of inflammation.

Methods and results

In total, 10 mRNA vaccination-associated patients with myocarditis were retrospectively enrolled in this study and compared to 10 patients suffering from viral myocarditis, who were matched for age, sex, comorbidities, and laboratory markers. All patients (n = 20) were hospitalized and underwent a standardized clinical examination, as well as an echocardiography and a CMR. Both, clinical and imaging findings and, in particular, functional and volumetric CMR assessments, as well as detailed tissue characterization using late gadolinium enhancement and T1 + T2-weighted sequences, were compared between both groups. The median age of the overall cohort was 26 years (group 1: 25.5; group 2: 27.5; p = 0.57). All patients described chest pain as the leading reason for their initial presentation. CMR volumetric and functional parameters did not differ significantly between both groups. In all cases, the lateral left ventricular wall showed late gadolinium enhancement without significant differences in terms of the localization or in-depth tissue characterization (late gadolinium enhancement [LGE] enlargement: group 1: 5.4%; group 2: 6.5%; p = 0.14; T2 global/maximum value: group 1: 38.9/52 ms; group 2: 37.8/54.5 ms; p = 0.79 and p = 0.80).

Conclusion

This study yielded the first evidence that COVID-19 mRNA vaccine-associated myocarditis does not show specific CMR patterns during the very acute stage in the most affected patient group of young male patients. The observed imaging markers were closely related to regular viral myocarditis in our cohort. Additionally, we could not find any markers implying adverse outcomes in this relatively little number of patients; however, this has to be confirmed by future studies that will include larger sample sizes.

Comparison of Strain-Encoding and Feature-Tracking Derived Myocardial Deformation Assessment of Left Ventricular Function in a Pediatric and Adult Congenital Heart Disease Cohort

BACKGROUND

Cardiac magnetic resonance (CMR) strain can be assessed with feature-tracking (FT), which utilizes a post-processing algorithm to quantify myocardial deformation on routine cine images, and strain-encoding magnetic resonance imaging (SENC), which uses parallel magnetization tags combined with out-of-plane phase-encoding gradients to quantify deformation. Assessing agreement is critical to determine whether results can be translated between methods. We compared SENC to FT in the assessment of left ventricle (LV) global longitudinal strain (GLS) and global circumferential strain (GCS) in a cohort of pediatric and adult congenital heart disease (ACHD) patients.

METHODS

Pediatric subjects and ACHD patients underwent CMR on 1.5 T Siemens scanners, including balanced steady-state-free precession (bSSFP) cine imaging and SENC acquisitions in apical two and four chamber, left ventricular outflow tract, and short axis views. bSSFP cine imaging FT analysis was completed with Medis QStrain. Myocardial Solutions MyoStrain was used to analyze SENC. Correlation was assessed by Spearman's rank correlation coefficient. Agreement between techniques was assessed with concordance correlation coefficient (CCC) and Bland-Altman.

RESULTS

The cohort included 134 patients, 75 with congenital heart disease (56%). The median age was 16.3 years (IQR 13.7, 19.5). Median LV ejection fraction was 57% (IQR 54.4, 61.6). SENC and FT were in poor agreement for GLS (Spearman's ρ = 0.58, p < 0.001; CCC 0.24) and GCS (Spearman's ρ = 0.29, p < 0.001; CCC 0.03).

CONCLUSION

There was poor agreement between SENC and FT derived GLS and GCS in a cohort of pediatric and ACHD patients, suggesting that SENC and FT cannot be used interchangeably.

A head-to-head comparison of myocardial strain by fast-strain encoding and feature tracking imaging in acute myocardial infarction

Background

Myocardial infarction (MI) is a major cause of heart failure. Left ventricular adverse remodeling is common post-MI. Several studies have demonstrated a correlation between reduced myocardial strain and the development of adverse remodeling. Cardiac magnetic resonance (CMR) with fast-strain encoding (fast-SENC) or feature tracking (FT) enables rapid assessment of myocardial deformation. The aim of this study was to establish a head-to-head comparison of fast-SENC and FT in post-ST-elevated myocardial infarction (STEMI) patients, with clinical 2D speckle tracking echocardiography (2DEcho) as a reference.

Methods

Thirty patients treated with primary percutaneous coronary intervention for STEMI were investigated. All participants underwent CMR examination with late gadolinium enhancement, cine-loop steady-state free precession, and fast-SENC imaging using a 1.5T scanner as well as a 2DEcho. Global longitudinal strain (GLS), segmental longitudinal strain (SLS), global circumferential strain (GCS), and segmental circumferential strain (SCS) were assessed along with the MI scar extent.

Results

The GCS measurements from fast-SENC and FT were nearly identical: the mean difference was 0.01 (2.5)% (95% CI - 0.92 to 0.95). For GLS, fast-SENC values were higher than FT, with a mean difference of 1.8 (1.4)% (95% CI 1.31-2.35). Tests of significance for GLS did not show any differences between the MR methods and 2DEcho. Average strain in the infarct-related artery (IRA) segments compared to the remote myocardium was significantly lower for the left anterior descending artery and right coronary artery culprits but not for the left circumflex artery culprits. Fast-SENC displayed a higher area under the curve for detecting infarcted segments than FT for both SCS and SLS.

Conclusion

GLS and GCS did not significantly differ between fast-SENC and FT. Both showed acceptable agreement with 2DEcho for longitudinal strain. Segments perfused by the IRA showed significantly reduced strain values compared to the remote myocardium. Fast-SENC presented a higher sensitivity and specificity for detecting infarcted segments than FT.

Artificial intelligence fully automated myocardial strain quantification for risk stratification following acute myocardial infarction

Feasibility of automated volume-derived cardiac functional evaluation has successfully been demonstrated using cardiovascular magnetic resonance (CMR) imaging. Notwithstanding, strain assessment has proven incremental value for cardiovascular risk stratification. Since introduction of deformation imaging to clinical practice has been complicated by time-consuming post-processing, we sought to investigate automation respectively. CMR data (n = 1095 patients) from two prospectively recruited acute myocardial infarction (AMI) populations with ST-elevation (STEMI) (AIDA STEMI n = 759) and non-STEMI (TATORT-NSTEMI n = 336) were analysed fully automated and manually on conventional cine sequences. LV function assessment included global longitudinal, circumferential, and radial strains (GLS/GCS/GRS). Agreements were assessed between automated and manual strain assessments. The former were assessed for major adverse cardiac event (MACE) prediction within 12 months following AMI. Manually and automated derived GLS showed the best and excellent agreement with an intraclass correlation coefficient (ICC) of 0.81. Agreement was good for GCS and poor for GRS. Amongst automated analyses, GLS (HR 1.12, 95% CI 1.08-1.16, p < 0.001) and GCS (HR 1.07, 95% CI 1.05-1.10, p < 0.001) best predicted MACE with similar diagnostic accuracy compared to manual analyses; area under the curve (AUC) for GLS (auto 0.691 vs. manual 0.693, p = 0.801) and GCS (auto 0.668 vs. manual 0.686, p = 0.425). Amongst automated functional analyses, GLS was the only independent predictor of MACE in multivariate analyses (HR 1.10, 95% CI 1.04-1.15, p < 0.001). Considering high agreement of automated GLS and equally high accuracy for risk prediction compared to the reference standard of manual analyses, automation may improve efficiency and aid in clinical routine implementation.Trial registration: ClinicalTrials.gov, NCT00712101 and NCT01612312.

Diagnostic performance of cardiac magnetic resonance segmental myocardial strain for detecting microvascular obstruction and late gadolinium enhancement in patients presenting after a ST-elevation myocardial infarction

Background

Microvascular obstruction (MVO) and Late Gadolinium Enhancement (LGE) assessed in cardiac magnetic resonance (CMR) are associated with adverse outcome in patients with ST-elevation myocardial infarction (STEMI). Our aim was to analyze the diagnostic performance of segmental strain for the detection of MVO and LGE.

Methods

Patients with anterior STEMI, who underwent additional CMR were enrolled in this sub-study of the CARE-AMI trial. Using CMR feature tracking (FT) segmental circumferential peak strain (SCS) was measured and the diagnostic performance of SCS to discriminate MVO and LGE was assessed in a derivation and validation cohort.

Results

Forty-eight STEMI patients (62 ± 12 years old), 39 (81%) males, who underwent CMR (i.e., mean 3.0 ± 1.5 days) after primary percutaneous coronary intervention (PCI) were included. All patients presented with LGE and in 40 (83%) patients, MVO was additionally present. Segments in all patients were visually classified and 146 (19%) segments showed MVO (i.e., LGE+/MVO+), 308 (40%) segments showed LGE and no MVO (i.e., LGE+/MVO–), and 314 (41%) segments showed no LGE (i.e., LGE–). Diagnostic performance of SCS for detecting MVO segments (i.e., LGE+/MVO+ vs. LGE+/MVO–, and LGE–) showed an AUC = 0.764 and SCS cut-off value was –11.2%, resulting in a sensitivity of 78% and a specificity of 67% with a positive predictive value (PPV) of 30% and a negative predictive value (NPV) of 94% when tested in the validation group. For LGE segments (i.e., LGE+/MVO+ and LGE+/MVO– vs. LGE–) AUC = 0.848 and SCS with a cut-off value of –13.8% yielded to a sensitivity of 76%, specificity of 74%, PPV of 81%, and NPV of 70%.

Conclusion

Segmental strain in STEMI patients was associated with good diagnostic performance for detection of MVO+ segments and very good diagnostic performance of LGE+ segments. Segmental strain may be useful as a potential contrast-free surrogate marker to improve early risk stratification in patients after primary PCI.

Different Impacts on the Heart After COVID-19 Infection and Vaccination: Insights From Cardiovascular Magnetic Resonance

Introduction

Myocarditis-like findings after COVID-19 (coronavirus disease 2019) infection and vaccination were reported by applying cardiovascular magnetic resonance (CMR). These results are very heterogenous and dependent on several factors such as hospital admission or outpatient treatment, timing of CMR, and symptomatic load. This retrospective study aimed to identify differences in myocardial damage in patients with persistent symptoms both after COVID-19 infection and vaccine by applying CMR.

Materials and Methods

This study entails a retrospective analysis of consecutive patients referred for CMR between August 2020 and November 2021 with persistent symptoms after COVID-19 infection or vaccination. Patients were compared to healthy controls (HC). All patients underwent a CMR examination in a 1.5-T scanner with a scan protocol including: cine imaging for biventricular function and strain assessment using feature tracking, T2 mapping for the quantification of edema, and T1 mapping for diffuse fibrosis and late gadolinium enhancement (LGE) for the detection and quantification of focal fibrosis. Patients were divided into a subacute COVID-19 (sCov) group with symptoms lasting < 12 weeks, post-COVID-19 (pCov) group with symptoms > 12 weeks, and patients after COVID-19 vaccination (CovVac).

Results

A total of 162 patients were recruited of whom 141 were included for analysis. The median age in years (interquartile range (IQR)) of the entire cohort was 45 (37–56) which included 83 women and 58 men. Subgroups were as follows (total patients per subgroup, median age in years (IQR), main gender): 34 sCov, 43 (37–52), 19 women; 63 pCov, 52 (39–58), 43 women; 44 CovVac, 43 (32–56), 23 men; 44 HC (41 (28–52), 24 women). The biventricular function was preserved and revealed no differences between the groups. No active inflammation was detected by T2 mapping. Global T1 values were higher in pCov in comparison with HC (median (IQR) in ms: pCov 1002ms (981–1023) vs. HC 987ms (963–1009; p = 0.005) with other parings revealing no differences. In 49/141 (34.6%) of patients, focal fibrosis was detectable with the majority having a non-ischemic pattern (43/141; 30.4%; patients) with the subgroups after infection having more often a subepicardial pattern compared with CovVac (total (% of group): sCov: 7/34(21%); pCov 13/63(21%); CovVac 2/44(5%); p = 0.04).

Conclusion

Patients after COVID-19 infection showed more focal fibrosis in comparison with patients after COVID-19 vaccination without alterations in the biventricular function.

Left ventricular remodelling post-myocardial infarction: pathophysiology, imaging, and novel therapies

Most patients survive acute myocardial infarction (MI). Yet this encouraging development has certain drawbacks: heart failure (HF) prevalence is increasing and patients affected tend to have more comorbidities worsening economic strain on healthcare systems and impeding effective medical management. The heart’s pathological changes in structure and/or function, termed myocardial remodelling, significantly impact on patient outcomes. Risk factors like diabetes, chronic obstructive pulmonary disease, female sex, and others distinctly shape disease progression on the ‘road to HF’. Despite the availability of HF drugs that interact with general pathways involved in myocardial remodelling, targeted drugs remain absent, and patient risk stratification is poor. Hence, in this review, we highlight the pathophysiological basis, current diagnostic methods and available treatments for cardiac remodelling following MI. We further aim to provide a roadmap for developing improved risk stratification and novel medical and interventional therapies.

Serial Assessment of Right Ventricular Deformation in Patients With Hypoplastic Left Heart Syndrome: A Cardiovascular Magnetic Resonance Feature Tracking Study

Background As right ventricular dysfunction is a major cause of adverse outcome in patients with hypoplastic left heart syndrome, the aim was to assess right ventricular function and deformation after Fontan completion by performing 2-dimensional cardiovascular magnetic resonance feature tracking in serial cardiovascular magnetic resonance studies. Methods and Results Cardiovascular magnetic resonance examinations of 108 patients with hypoplastic left heart syndrome (female: 31) were analyzed. Short-axis cine images were used for right ventricular volumetry. Two-dimensional cardiovascular magnetic resonance feature tracking was performed using long-axis and short-axis cine images to measure myocardial global longitudinal, circumferential, and radial strain. All patients had at least 2 cardiovascular magnetic resonance examinations after Fontan completion and 41 patients had 3 examinations. Global strain values and right ventricular ejection fraction decreased from the first to the third examination with a significant decline in global longitudinal strain from the first examination to the second examination (median, first, and third quartile: -18.8%, [-20.5;-16.5] versus -16.9%, [-19.3;-14.7]) and from the first to the third examination in 41 patients (-18.6%, [-20.9;-15.7] versus -15.8%, [-18.7;-12.6]; P-values <0.004). Right ventricular ejection fraction decreased significantly from the first to the third examination (55.4%, [49.8;59.3] versus 50.2%, [45.0;55.9]; P<0.002) and from the second to the third examination (53.8%, [47.2;58.7] versus 50.2%, [45.0;55.9]; P<0.0002). Conclusions Serial assessment of cardiovascular magnetic resonance studies in patients with hypoplastic left heart syndrome after Fontan completion demonstrates a significant reduction in global strain values and right ventricular ejection fraction at follow-up. The significant reduction in global longitudinal strain between the first 2 examinations with non-significant changes in right ventricular ejection fraction suggest that global longitudinal strain measured by 2-dimensional cardiovascular magnetic resonance feature tracking might be a superior technique for the detection of changes in myocardial function.

Impact of Right Ventricular Trabeculation on Right Ventricular Function in Patients With Left Ventricular Non-compaction Phenotype

Right ventricular (RV) involvement in left ventricular (LV) non-compaction (LVNC) remains unknown. We aimed to describe the RV volumetric, functional, and strain characteristics and clinical features of patients with LVNC phenotype and good LV ejection fraction (EF) using cardiac magnetic resonance to characterize RV trabeculation in LVNC and to study the relationships of RV and LV trabeculation with RV volume and function. This retrospective study included 100 Caucasian patients with LVNC phenotype and good LV-EF and 100 age- and sex-matched healthy controls. Patients were further divided into two subgroups according to RV indexed trabecular mass [RV-TMi; patients with RV hypertrabeculation (RV-HT) vs. patients with normal RV trabeculation (RV-NT)]. We measured the LV and RV volumetric, functional, and TMi values using threshold-based postprocessing software and the RV and LV strain values using feature tracking and collected the patients' LVNC-related clinical features. Patients had higher RV volumes, lower RV-EF, and worse RV strain values than controls. A total of 22% of patients had RV-TMi values above the reference range; furthermore, RV-HT patients had higher RV and LV volumes, lower RV- and LV-EF, and worse RV strain values than RV-NT patients. We identified a strong positive correlation between RV- and LV-TMi and between RV-TMi and RV volumes and a significant inverse relationship of both RV- and LV-TMi with RV function. The prevalence of LVNC-related clinical features was similar in the RV-HT and RV-NT groups. These results suggest that some patients with LVNC phenotype might have RV non-compaction with subclinical RV dysfunction and without more severe clinical features.

Ventricular longitudinal function by cardiovascular magnetic resonance predicts cardiovascular morbidity in HFrEF patients

Aims

Ventricular longitudinal function measured as basal‐apical atrioventricular plane displacement (AVPD) or global longitudinal strain (GLS) is a potent predictor of mortality and could potentially be a predictor of heart failure‐associated morbidity. We hypothesized that low AVPD and GLS are associated with the combined endpoint of cardiovascular mortality and heart failure‐associated morbidity.

Methods and results

Two hundred eighty‐seven patients (age 62 ± 12 years, 78% male) with heart failure with reduced (≤40%) ejection fraction (HFrEF) referred to a cardiovascular magnetic resonance exam were included. Ventricular longitudinal function, ventricular volume, and myocardial fibrosis or infarction were analysed from cine and late gadolinium enhancement images. National registries provided data on causes of cardiovascular hospitalizations and cardiovascular mortality for the combined endpoint. Time‐to‐event analysis capable of including reoccurring events was employed with a 5‐year follow‐up. HFrEF patients had EF 26.5 ± 8.0%, AVPD 7.8 ± 2.4 mm, and GLS −7.5 ± 3.0%. In contrast, ventricular longitudinal function was approximately twice as large in an age‐matched control group (AVPD 15.3 ± 1.6 mm; GLS −20.6 ± 2.0%; P < 0.001 for both). There were 578 events in total, and the majority were HF hospitalizations (n = 418). Other major events were revascularizations (n = 64), cardiovascular deaths (n = 40), and myocardial infarctions (n = 21). One hundred fifty‐five (54%) patients experienced at least one event (mean 2.0, range 0–64). Of these patients, 119 (71%) had three events or fewer, and the first three events comprised 51% of all events (295 events). Patients in the bottom AVPD or GLS tertile (<6.8 mm or >−6.1%) overall experienced more than 3 times as many events as the top tertile (>8.8 mm or <−8.4%; P < 0.001). Patients in this tertile also faced more cardiovascular deaths (P < 0.05), HF hospitalizations (P = 0.001), myocardial infarctions (only GLS: P = 0.032), and accumulated longer in‐hospital length‐of‐stay overall (AVPD 20.9 vs. 9.1 days; GLS 22.4 vs. 6.5 days; P = 0.001 for both), and from HF hospitalizations (AVPD 19.3 vs. 8.3 days; GLS 19.3 vs. 5.4 days; P = 0.001 for both). In multivariate analysis adjusted for significant covariates, AVPD and GLS remained independent predictors of events (hazard ratio 1.12 per‐mm‐decrease and 1.13 per‐%‐increase) alongside hyponatremia (<135 mmol/L), aetiology of HF, and LV end‐diastolic volume index.

Conclusions

Low ventricular longitudinal function is associated with an increase in number of events as well as longer in‐hospital stay from cardiovascular causes. In addition, AVPD and GLS have independent prognostic value for cardiovascular mortality and morbidity in HFrEF patients.

Reproducibility of global and segmental myocardial strain using cine DENSE at 3 T: a multicenter cardiovascular magnetic resonance study in healthy subjects and patients with heart disease

BACKGROUND

While multiple cardiovascular magnetic resonance (CMR) methods provide excellent reproducibility of global circumferential and global longitudinal strain, achieving highly reproducible segmental strain is more challenging. Previous single-center studies have demonstrated excellent reproducibility of displacement encoding with stimulated echoes (DENSE) segmental circumferential strain. The present study evaluated the reproducibility of DENSE for measurement of whole-slice or global circumferential (E_cc), longitudinal (E_ll) and radial (E_rr) strain, torsion, and segmental E_cc at multiple centers.

METHODS

Six centers participated and a total of 81 subjects were studied, including 60 healthy subjects and 21 patients with various types of heart disease. CMR utilized 3 T scanners, and cine DENSE images were acquired in three short-axis planes and in the four-chamber long-axis view. During one imaging session, each subject underwent two separate DENSE scans to assess inter-scan reproducibility. Each subject was taken out of the scanner and repositioned between the scans. Intra-user, inter-user-same-site, inter-user-different-site, and inter-user-Human-Deep-Learning (DL) comparisons assessed the reproducibility of different users analyzing the same data. Inter-scan comparisons assessed the reproducibility of DENSE from scan to scan. The reproducibility of whole-slice or global E_cc, E_ll and E_rr, torsion, and segmental E_cc were quantified using Bland-Altman analysis, the coefficient of variation (CV), and the intraclass correlation coefficient (ICC). CV was considered excellent for CV ≤ 10%, good for 10% < CV ≤ 20%, fair for 20% < CV ≤ 40%, and poor for CV > 40. ICC values were considered excellent for ICC > 0.74, good for ICC 0.6 < ICC ≤ 0.74, fair for ICC 0.4 < ICC ≤ 0.59, poor for ICC < 0.4.

RESULTS

Based on CV and ICC, segmental E_cc provided excellent intra-user, inter-user-same-site, inter-user-different-site, inter-user-Human-DL reproducibility and good-excellent inter-scan reproducibility. Whole-slice E_cc and global E_ll provided excellent intra-user, inter-user-same-site, inter-user-different-site, inter-user-Human-DL and inter-scan reproducibility. The reproducibility of torsion was good-excellent for all comparisons. For whole-slice E_rr, CV was in the fair-good range, and ICC was in the good-excellent range.

CONCLUSIONS

Multicenter data show that 3 T CMR DENSE provides highly reproducible whole-slice and segmental E_cc, global E_ll, and torsion measurements in healthy subjects and heart disease patients.

Reproducibility of global and segmental myocardial strain using cine DENSE at 3 T: a multicenter cardiovascular magnetic resonance study in healthy subjects and patients with heart disease

BACKGROUND

While multiple cardiovascular magnetic resonance (CMR) methods provide excellent reproducibility of global circumferential and global longitudinal strain, achieving highly reproducible segmental strain is more challenging. Previous single-center studies have demonstrated excellent reproducibility of displacement encoding with stimulated echoes (DENSE) segmental circumferential strain. The present study evaluated the reproducibility of DENSE for measurement of whole-slice or global circumferential (Ecc), longitudinal (Ell) and radial (Err) strain, torsion, and segmental Ecc at multiple centers.

METHODS

Six centers participated and a total of 81 subjects were studied, including 60 healthy subjects and 21 patients with various types of heart disease. CMR utilized 3 T scanners, and cine DENSE images were acquired in three short-axis planes and in the four-chamber long-axis view. During one imaging session, each subject underwent two separate DENSE scans to assess inter-scan reproducibility. Each subject was taken out of the scanner and repositioned between the scans. Intra-user, inter-user-same-site, inter-user-different-site, and inter-user-Human-Deep-Learning (DL) comparisons assessed the reproducibility of different users analyzing the same data. Inter-scan comparisons assessed the reproducibility of DENSE from scan to scan. The reproducibility of whole-slice or global Ecc, Ell and Err, torsion, and segmental Ecc were quantified using Bland-Altman analysis, the coefficient of variation (CV), and the intraclass correlation coefficient (ICC). CV was considered excellent for CV ≤ 10%, good for 10% < CV ≤ 20%, fair for 20% < CV ≤ 40%, and poor for CV > 40. ICC values were considered excellent for ICC > 0.74, good for ICC 0.6 < ICC ≤ 0.74, fair for ICC 0.4 < ICC ≤ 0.59, poor for ICC < 0.4.

RESULTS

Based on CV and ICC, segmental Ecc provided excellent intra-user, inter-user-same-site, inter-user-different-site, inter-user-Human-DL reproducibility and good-excellent inter-scan reproducibility. Whole-slice Ecc and global Ell provided excellent intra-user, inter-user-same-site, inter-user-different-site, inter-user-Human-DL and inter-scan reproducibility. The reproducibility of torsion was good-excellent for all comparisons. For whole-slice Err, CV was in the fair-good range, and ICC was in the good-excellent range.

CONCLUSIONS

Multicenter data show that 3 T CMR DENSE provides highly reproducible whole-slice and segmental Ecc, global Ell, and torsion measurements in healthy subjects and heart disease patients.

Combined Analysis of Myocardial Deformation and Oxygenation Detects Inducible Ischemia Unmasked by Breathing Maneuvers in Chronic Coronary Syndrome

Introduction

In patients with chronic coronary syndromes, hyperventilation followed by apnea has been shown to unmask myocardium susceptible to inducible deoxygenation. The aim of this study was to assess whether such a provoked response is co-localized with myocardial dysfunction.

Methods

A group of twenty-six CAD patients with a defined stenosis (quantitative coronary angiography > 50%) underwent a cardiovascular magnetic resonance (CMR) exam prior to revascularization. Healthy volunteers older than 50 years served as controls (n = 12). Participants hyperventilated for 60s followed by brief apnea. Oxygenation-sensitive images were analyzed for changes in myocardial oxygenation and strain.

Results

In healthy subjects, hyperventilation resulted in global myocardial deoxygenation (-10.2 ± 8.2%, p < 0.001) and augmented peak circumferential systolic strain (-3.3 ± 1.6%, p < 0.001). At the end of apnea, myocardial signal intensity had increased (+9.1 ± 5.3%, p < 0.001) and strain had normalized to baseline. CAD patients had a similar global oxygenation response to hyperventilation (−5.8 ± 9.6%, p = 0.085) but showed no change in peak strain from their resting state (-1.3 ± 1.6%), which was significantly attenuated in comparison the strain response observed in controls (p = 0.008). With apnea, the CAD patients showed an attenuated global oxygenation response to apnea compared to controls (+2.7 ± 6.2%, p < 0.001). This was accompanied by a significant depression of peak strain (3.0 ± 1.7%, p < 0.001), which also differed from the control response (p = 0.025). Regional analysis demonstrated that post-stenotic myocardium was most susceptible to de-oxygenation and systolic strain abnormalities during respiratory maneuvers. CMR measures at rest were unable to discriminate post-stenotic territory (p > 0.05), yet this was significant for both myocardial oxygenation [area under the curve (AUC): 0.88, p > 0.001] and peak strain (AUC: 0.73, p = 0.023) measured with apnea. A combined analysis of myocardial oxygenation and peak strain resulted in an incrementally higher AUC of 0.91, p < 0.001 than strain alone.

Conclusion

In myocardium of patients with chronic coronary syndromes and primarily intermediate coronary stenoses, cine oxygenation-sensitive CMR can identify an impaired vascular and functional response to a vasoactive breathing maneuver stimulus indicative of inducible ischemia.

State-of-the-art myocardial strain by CMR feature tracking: clinical applications and future perspectives

Based on conventional cine sequences of cardiac magnetic resonance (CMR), feature tracking (FT) is an emerging tissue tracking technique that evaluates myocardial motion and deformation quantitatively by strain, strain rate, torsion, and dyssynchrony. It has been widely accepted in modern literature that strain analysis can offer incremental information in addition to classic global and segmental functional analysis. Furthermore, CMR-FT facilitates measurement of all cardiac chambers, including the relatively thin-walled atria and the right ventricle, which has been a difficult measurement to obtain with the reference standard technique of myocardial tagging. CMR-FT objectively quantifies cardiovascular impairment and characterizes myocardial function in a novel way through direct assessment of myocardial fiber deformation. The purpose of this review is to discuss the current status of clinical applications of myocardial strain by CMR-FT in a variety of cardiovascular diseases. KEY POINTS: • CMR-FT is of great value for differential diagnosis and provides incremental value for evaluating the progression and severity of diseases. • CMR-FT guides the early diagnosis of various cardiovascular diseases and provides the possibility for the early detection of myocardial impairment and additional information regarding subclinical cardiac abnormalities. • Direct assessment of myocardial fiber deformation using CMR-FT has the potential to provide prognostic information incremental to common clinical and CMR risk factors.

Prognostic value of strain by feature-tracking cardiac magnetic resonance in arrhythmogenic right ventricular cardiomyopathy

AIMS

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is characterized by ventricular dysfunction and ventricular arrhythmias (VA). Adequate arrhythmic risk assessment is important to prevent sudden cardiac death. We aimed to study the incremental value of strain by feature-tracking cardiac magnetic resonance imaging (FT-CMR) in predicting sustained VA in ARVC patients.

METHODS AND RESULTS

CMR images of 132 ARVC patients (43% male, 40.6 ± 16.0 years) without prior VA were analysed for global and regional right and left ventricular (RV, LV) strain. Primary outcome was sustained VA during follow-up. We performed multivariable regression assessing strain, in combination with (i) RV ejection fraction (EF); (ii) LVEF; and (iii) the ARVC risk calculator. False discovery rate adjusted P-values were given to correct for multiple comparisons and c-statistics were calculated for each model. During 4.3 (2.0-7.9) years of follow-up, 19% of patients experienced sustained VA. Compared to patients without VA, those with VA had significantly reduced RV longitudinal (P ≤ 0.03) and LV circumferential (P ≤ 0.04) strain. In addition, patients with VA had significantly reduced biventricular EF (P ≤ 0.02). After correcting for RVEF, LVEF, and the ARVC risk calculator separately in multivariable analysis, both RV and LV strain lost their significance [hazard ratio 1.03-1.18, P > 0.05]. Likewise, while strain improved the c-statistic in combination with RVEF, LVEF, and the ARVC risk calculator separately, this did not reach statistical significance (P ≥ 0.18).

CONCLUSION

Both RV longitudinal and LV circumferential strain are reduced in ARVC patients with sustained VA during follow-up. However, strain does not have incremental value over RVEF, LVEF, and the ARVC VA risk calculator.

Quantifying Myocardial Strain of the Left Ventricle in Normal People Using Feature-Tracking Based on Computed Tomography Imaging

Objective: The objective was to evaluate the normal value of left ventricular myocardial strain using the computed tomography feature-tracking technique and to explore the correlation between myocardial strains and cardiac function parameters. Methods: Participants suspected of coronary heart disease were selected from 17 August 2020 to 5 November 2020 to undergo coronary computed tomography angiography using a third-generation dual-source CT scanner. Data were imported into a commercial software (Medis) after multiphase reconstruction. The cardiac function parameters, radial (Err), circumferential (Ecc), and longitudinal strain (Ell) of the left ventricle were recorded. Results: A total of 87 normal subjects were enrolled, including 41 males and 46 females. For healthy subjects, the global radial strain (GRS), circumferential strain (GCS), and longitudinal strain (GLS) of the left ventricle were 74.5 ± 15.2%, −22.7 ± 3.0%, and −26.6 ± 3.2%, respectively. The Err and Ecc absolute values (|Ecc|) were the largest at the apex, and the |Ell| gradually increased from the base to the apex. The Err and |Ecc| were the largest in the lateral and inferior wall, respectively. |Ell| showed a clockwise decrease from the lateral wall in the short axis. Meanwhile, the GRS and |GLS| in females were higher than that in males. Multiple linear regression analysis showed that both SV and LVEF were the independent determinants of GRS, GCS, and GLS. BMI and CO were the independent determined factors of GCS. Conclusions: At a reasonable radiation dose, CT feature-tracking is a feasible and reproducible method to analyze left ventricular myocardial strain. Left ventricular myocardial strain in normal subjects varies in gender, segments, levels, and regions.

Left Ventricular Strain Measurements Derived from MR Feature Tracking: A Head-to-Head Comparison of a Higher Temporal Resolution Method With a Conventional Method

BACKGROUND

Magnetic resonance feature tracking (MR-FT) is an imaging technique that quantifies both global and regional myocardial strain. Currently, conventional MR-FT provides a superior signal and contrast-to-noise ratio but has a relatively low temporal resolution. A higher temporal resolution MR-FT technique may provide improved results.

PURPOSE

To explore the impact of higher temporal resolution on left ventricular (LV) myocardial strain measurements using MR-FT.

STUDY TYPE

Prospective.

POPULATION

One hundred and fifty-three participants including five healthy subjects and patients with various cardiac diseases referred to MR for cardiac assessment.

FIELD STRENGTH

3 T, balanced steady-state free precession sequence with and without compressed sensing (temporal resolution: 10 msec and 40 msec, respectively).

ASSESSMENT

Conventional (40 msec) and higher (10 msec) temporal resolution data were acquired in all subjects during the same scanning session. Global circumferential strain (GCS), global longitudinal strain (GLS), and global radial strain (GRS) as well as peak systolic and diastolic strain rates (SRs) were measured by MR-FT and compared between the two temporal resolutions. We also performed subgroup analyses according to heart rates (HRs) and LV ejection fraction (LVEF).

STATISTICAL TESTS

Paired t-test, Wilcoxon signed-rank test, linear regression analyses, Bland-Altman plots. A P value <0.05 was considered to be statistically significant.

RESULTS

GCS and GRS were significantly higher in the 10-msec temporal resolution studies compared to the 40-msec temporal resolution studies (GCS: -13.00 ± 6.58% vs. -12.51 ± 5.76%; GRS: 21.97 ± 14.54% vs. 20.62 ± 12.52%). In the subgroup analyses, significantly higher GLS, GCS, and GRS values were obtained in subjects with LVEF ≥50%, and significantly higher GCS and GRS values were obtained in subjects with HRs <70 bpm when assessed with the 10-msec vs. the 40-msec temporal resolutions. All the peak systolic and diastolic SRs were significantly higher in the higher temporal resolution acquisitions. This was also true for all subgroups.

DATA CONCLUSIONS

Higher temporal resolution resulted in significantly higher cardiac strain and SR values using MR-FT and could be beneficial, particularly in patients with LVEF ≥50% and HR <70 bpm.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 1.

Fast-Strain Encoded Cardiac Magnetic Resonance During Vasodilator Perfusion Stress Testing

Background: Cardiac magnetic resonance perfusion imaging during vasodilator stress is an established modality in patients with suspected and known coronary artery disease (CAD). Aim: This study aimed to evaluate the performance of fast-Strain-Encoded-MRI (fast-SENC) for the diagnostic classification and risk stratification of patients with ischemic heart disease. Methods: Perfusion and fast-SENC cardiac magnetic resonance (CMR) images were retrospectively analyzed in 111 patients who underwent stress CMR. The average myocardial perfusion score index, global and segmental longitudinal and circumferential strain (GLS and GCS and SLS and SCS, respectively), were measured at rest and during stress. The combination of SLS and SCS was referred to as segmental aggregate strain (SAS). Segments exhibiting perfusion defects or SAS impairment during stress were defined as "ischemic." All-cause mortality, non-fatal infarction, and urgent revascularization were deemed as our combined clinical endpoint. Results: During adenosine stress testing, 44 of 111 (39.6%) patients exhibited inducible perfusion abnormalities. During a mean follow-up of 1.94 ± 0.65 years, 25 (22.5%) patients reached the combined endpoint (death in n = 2, infarction in n = 3 and urgent revascularization in n = 20). Inducible perfusion defects were associated with higher number of segments with inducible SAS reduction ≥6.5% (χ² = 37.8, AUC = 0.79, 95% CI = 0.71-0.87, p < 0.001). In addition, patients with inducible perfusion defects or SAS impairment exhibited poorer outcomes (AUC_Perf = 0.81 vs. AUC_SAS = 0.74, p = NS vs. each other, and χ² = 30.8, HR = 10.3 and χ² = 9.5, HR = 3.5, respectively, p < 0.01 for both). Conclusion: Purely quantitative strain analysis by fast-SENC during vasodilator stress was related to the diagnosis of ischemia by first-pass perfusion and is non-inferior for the risk stratification of patients with ischemic heart disease. This may bear clinical implications, especially in patients with contraindications for contrast agent administration.

CMR-derived myocardial strain analysis differentiates ischemic and dilated cardiomyopathy-a propensity score-matched study

Left ventricular (LV) longitudinal, circumferential, and radial motion can be measured using feature tracking of cardiac magnetic resonance (CMR) images. The aim of our study was to detect differences in LV mechanics between patients with dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM) who were matched using a propensity score-based model. Between April 2017 and October 2019, 1224 patients were included in our CMR registry, among them 141 with ICM and 77 with DCM. Propensity score matching was used to pair patients based on their indexed end-diastolic volume (EDVi), ejection fraction (EF), and septal T1 relaxation time (psmatch2 module L Feature tracking provided six parameters for global longitudinal, circumferential, and radial strain with corresponding strain rates in each group. Strain parameters were compared between matched pairs of ICM and DCM patients using paired t tests. Propensity score matching yielded 72 patients in each group (DCM mean age 58.6 ± 11.6 years, 15 females; ICM mean age 62.6 ± 13.2 years, 11 females, p = 0.084 and 0.44 respectively; LV-EF 32.2 ± 13.5% vs. 33.8 ± 12.1%, p = 0.356; EDVi 127.2 ± 30.7 ml/m2 vs. 121.1 ± 41.8 ml/m2, p = 0.251; native T1 values 1165 ± 58 ms vs. 1167 ± 70 ms, p = 0.862). There was no difference in global longitudinal strain between DCM and ICM patients (- 10.9 ± 5.5% vs. - 11.2 ± 4.7%, p = 0.72), whereas in DCM patients there was a significant reduction in global circumferential strain (- 10.0 ± 4.5% vs. - 12.2 ± 4.7%, p = 0.002) and radial strain (17.1 ± 8.51 vs. 21.2 ± 9.7%, p = 0.039). Our data suggest that ICM and DCM patients have inherently different myocardial mechanics, even if phenotypes are similar. Our data show that GCS is significantly more impaired in DCM patients. This feature may help in more thoroughly characterizing cardiomyopathy patients.

Cardiovascular magnetic resonance virtual tagging with B-spline-based free-form deformation

PURPOSE

We developed a virtual tagging technique that reconstructs tagging images using the displacement field obtained by applying B-spline free-form deformation (FFD) between diastolic images and images of other cardiac phases in cardiac cine MRI. The purpose of this study was to validate its characteristics and usefulness in phantom and patient studies.

METHODS

Digital phantoms simulating uniform and non-uniform wall motion models were created, and virtual tagging images were reconstructed with various matrix sizes and tag resolutions to evaluate the accuracy of FFD and the characteristics of the tags. In the patient study, FFD's accuracy was assessed at three levels (base, middle, and apex) in healthy patients. In patients with heart failure, virtual tagging images were compared with strain maps obtained by feature tracking and virtual tagging.

RESULTS

In the phantom study, blurring of tags was observed when tags were reconstructed with high resolution using a small matrix size. In the patient study, the accuracy of FFD was lower in the base than in the apex. Patients with heart failure had decreased distortion of the displacement field vector and virtual tags, indicating decreased local wall motion, consistent with areas of abnormalities found in strain maps.

CONCLUSION

The virtual tagging technique does not require additional imaging and can visualize regional LV motion abnormalities via deformation of the tag as well as conventional cardiovascular magnetic resonance tagging.

An off-resonance insensitive orthogonal CSPAMM sequence (ORI-O-CSPAMM) for the acquisition of CSPAMM and MICSR grids in half scan time

PURPOSE

To develop an Off-Resonance Insensitive Orthogonal CSPAMM sequence (ORI-O-CSPAMM) for the acquisition of CSPAMM and MICSR grids in half of the acquisition time.

METHODS

Phantom and mid-level left ventricle short-axis tagged images were acquired using CSPAMM, ORI-CSPAMM, O-CSPAMM, and the proposed ORI-O-CPAMM sequences to interrogate and compare its behavior under off-resonance effects produced by vegetable oil and subcutaneous and epicardial fat. The images were compared in terms of signal and the capacity to obtain complex difference and MICSR images.

RESULTS

Like ORI-CSPAMM, the proposed ORI-O-CSPAMM sequence removed almost completely the off-resonance artifacts produced during the tagging preparation. Tagging grids without DC components were obtained with ORI-O-CSPAMM using complex difference and MICSR from only two complementary images, which reduced the scan time to a half compared to CSPAMM and ORI-CSPAMM. The removal of off-resonance effects and the capacity to obtain MICSR images are advantages of ORI-O-CSPAMM over the O-CSPAMM sequence.

CONCLUSION

We developed a novel and fast tagging sequence designed to remove off-resonance effects during the tagging preparation, and to obtain complex difference and MICSR grids in half of the scan time compared to CSPAMM and ORI-CSPAMM sequences, which could allow its application to clinical protocols.

Correlation of Myocardial Strain and Late Gadolinium Enhancement by Cardiac Magnetic Resonance After a First Anterior ST-Segment Elevation Myocardial Infarction

Objectives: To investigate the correlation of cardiac magnetic resonance (CMR) feature-tracking with conventional CMR parameters in patients with a first anterior ST-segment elevation myocardial infarction (STEMI).

Methods: This sub-analysis of OCTAMI (Optical Coherence Tomography Examination in Acute Myocardial Infarction) registry included 129 patients who finished a CMR examination 1 month after a first anterior STEMI. Cine images were applied to calculate both global and segmental left ventricular peak strain parameters. The patients were divided into two groups by left ventricular ejection fraction (LVEF) and compared with 42 healthy controls. Segmental late gadolinium enhancement (LGE) was graded according to LGE transmurality as follows: (1) >0 to ≤ 25%; (2) >25 to ≤ 50%; (3) >50 to ≤ 75%; (4) >75%. Left ventricle was divided into infarcted, adjacent, and remote regions to assess regional function.

Results: Compared with controls, global radial (28.39 ± 5.08% vs. 38.54 ± 9.27%, p < 0.05), circumferential (−16.91 ± 2.11% vs. −20.77 ± 2.78%, p < 0.05), and longitudinal (−13.06 ± 2.15 vs. −15.52 ± 2.69, p < 0.05) strains were impaired in STEMI patients with normal LVEF (≥55%). Strain parameters were strongly associated with LGE (radial: r = 0.65; circumferential: r = 0.69; longitudinal: r = 0.61; all p < 0.05). A significant and stepwise impairment of global strains was observed in groups divided by LGE tertiles. Furthermore, segmental strain was different in various degrees of LGE transmurality especially for radial and circumferential strain. Strains of adjacent region were better than infarcted region in radial and circumferential directions and worse than remote region in all three directions.

Conclusion: Global and regional strain could stratify different extent and transmurality of LGE, respectively. Although without LGE, adjacent region had impaired strains comparing with remote region.

Multiparametric Early Detection and Prediction of Cardiotoxicity Using Myocardial Strain, T1 and T2 Mapping, and Biochemical Markers: A Longitudinal Cardiac Resonance Imaging Study During 2 Years of Follow-Up

BACKGROUND

Our goal was to evaluate the ability of cardiovascular magnetic resonance for detecting and predicting cardiac dysfunction in patients receiving cancer therapy. Left ventricular ejection fraction, global and regional strain utilizing fast-strain-encoded, T1 and T2 mapping, and cardiac biomarkers (troponin and BNP [brain natriuretic peptide]) were analyzed.

METHODS

Sixty-one patients (47 with breast cancer, 11 with non-Hodgkin lymphoma, and 3 with Hodgkin lymphoma) underwent cardiovascular magnetic resonance scans at baseline and at regular intervals during 2 years of follow-up. The percentage of all left ventricular myocardial segments with strain ≤-17% (normal myocardium [%]) was analyzed. Clinical cardiotoxicity (CTX) and sub-CTX were defined according to standard measures.

RESULTS

Nine (15%) patients developed CTX, 26 (43%) had sub-CTX. Of the 35 patients with CTX or sub-CTX, 24 (69%) were treated with cardioprotective medications and showed recovery of cardiac function. The amount of normal myocardium (%) exhibited markedly higher accuracy for the detection of CTX and sub-CTX compared with left ventricular ejection fraction, T1, and T2 mapping as well as troponin I (Δareas under the curve=0.20, 0.24, and 0.46 for normal myocardium (%) versus left ventricular ejection fraction, troponin I, and T1 mapping, P<0.001 for all). In addition, normal myocardium (%) at baseline accurately identified patients with subsequent CTX (P<0.001), which was not achieved by any other markers.

CONCLUSIONS

Normal myocardium (%) derived by fast-strain-encoded cardiovascular magnetic resonance, is an accurate and sensitive tool that can establish cardiac safety in patients with cancer undergoing cardiotoxic chemotherapy not only for the early detection but also for the prediction of those at risk of developing CTX. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03543228.

Defining the optimal temporal and spatial resolution for cardiovascular magnetic resonance imaging feature tracking

BACKGROUND

Myocardial deformation analyses using cardiovascular magnetic resonance (CMR) feature tracking (CMR-FT) have incremental value in the assessment of cardiac function beyond volumetric analyses. Since guidelines do not recommend specific imaging parameters, we aimed to define optimal spatial and temporal resolutions for CMR cine images to enable reliable post-processing.

METHODS

Intra- and inter-observer reproducibility was assessed in 12 healthy subjects and 9 heart failure (HF) patients. Cine images were acquired with different temporal (20, 30, 40 and 50 frames/cardiac cycle) and spatial resolutions (high in-plane 1.5 × 1.5 mm through-plane 5 mm, standard 1.8 × 1.8 x 8mm and low 3.0 × 3.0 x 10mm). CMR-FT comprised left ventricular (LV) global and segmental longitudinal/circumferential strain (GLS/GCS) and associated systolic strain rates (SR), and right ventricular (RV) GLS.

RESULTS

Temporal but not spatial resolution did impact absolute strain and SR. Maximum absolute changes between lowest and highest temporal resolution were as follows: 1.8% and 0.3%/s for LV GLS and SR, 2.5% and 0.6%/s for GCS and SR as well as 1.4% for RV GLS. Changes of strain values occurred comparing 20 and 30 frames/cardiac cycle including LV and RV GLS and GCS (p < 0.001-0.046). In contrast, SR values (LV GLS/GCS SR) changed significantly comparing all successive temporal resolutions (p < 0.001-0.013). LV strain and SR reproducibility was not affected by either temporal or spatial resolution, whilst RV strain variability decreased with augmentation of temporal resolution.

CONCLUSION

Temporal but not spatial resolution significantly affects strain and SR in CMR-FT deformation analyses. Strain analyses require lower temporal resolution and 30 frames/cardiac cycle offer consistent strain assessments, whilst SR measurements gain from further increases in temporal resolution.