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Singh SP, Jagia P, Ojha V, Seth T, Naik N, Ganga KP, Kumar S. Diagnostic Value of T1 Mapping in Detecting Iron Overload in Indian Patients with Thalassemia Major: A Comparison with T2* Mapping. Indian J Radiol Imaging 2024; 34:54-59. [PMID: 38106847 PMCID: PMC10723946 DOI: 10.1055/s-0043-1772467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Abstract
Purpose T2* is the gold standard for iron quantification in liver as well as myocardium. In this study, we evaluated the diagnostic accuracy of myocardial T1 mapping for the assessment of myocardial iron overload (MIO) as compared to the T2* mapping in patients with thalassemia major (TM). Methods Consecutive TM patients attending the thalassemia clinic were prospectively enrolled. Magnetic resonance imaging was performed on a 1.5 T scanner (Siemens Healthineers, Germany) using a gradient echo T2* as well as a T1 mapping (MOLLI) sequence done at a mid-ventricular short-axis single 8 mm slice of the left ventricle. Values were analyzed by manually drawing a region of interest in the mid-septum. T2*less than 20ms was used as the cutoff for significant MIO. Results One-hundred three patients (58 males, mean age: 17 ± 7.8 years, mean ferritin: 2009.5 µg/L) underwent cardiovascular magnetic resonance. Median T2* of myocardium was 33.45ms. Nineteen patients (18.4%) had T2*less than 20ms. T1 value was low (<850ms) in all the patients with T2* less than 20 ms. Receiver operating characteristic curve analysis revealed the best cutoff of native T1 mapping value as 850 ms which had high specificity (95.2%), sensitivity (94.2%) and negative predictive value (98.8%) for T2* less than 20ms. There was excellent agreement between T1 and T2* for diagnosis of MIO (Kappa-0.848, p <0.001). We did not find any patient who had normal T1 mapping values but had MIO on T2*. Conclusion T1 and T2* correlate well and normal T1 values may rule out presence of MIO. T1 mapping can act as additional imaging marker for MIO and may be helpful in centers with nonavailability or limited experience of T2*.
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Affiliation(s)
- Surya Pratap Singh
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Priya Jagia
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Vineeta Ojha
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Tulika Seth
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Nitish Naik
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Kartik P. Ganga
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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Zoller H, Schaefer B, Vanclooster A, Griffiths B, Bardou-Jacquet E, Corradini E, Porto G, Ryan J, Cornberg M. EASL Clinical Practice Guidelines on haemochromatosis. J Hepatol 2022; 77:479-502. [PMID: 35662478 DOI: 10.1016/j.jhep.2022.03.033] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 03/29/2022] [Indexed: 12/15/2022]
Abstract
Haemochromatosis is characterised by elevated transferrin saturation (TSAT) and progressive iron loading that mainly affects the liver. Early diagnosis and treatment by phlebotomy can prevent cirrhosis, hepatocellular carcinoma, diabetes, arthropathy and other complications. In patients homozygous for p.Cys282Tyr in HFE, provisional iron overload based on serum iron parameters (TSAT >45% and ferritin >200 μg/L in females and TSAT >50% and ferritin >300 μg/L in males and postmenopausal women) is sufficient to diagnose haemochromatosis. In patients with high TSAT and elevated ferritin but other HFE genotypes, diagnosis requires the presence of hepatic iron overload on MRI or liver biopsy. The stage of liver fibrosis and other end-organ damage should be carefully assessed at diagnosis because they determine disease management. Patients with advanced fibrosis should be included in a screening programme for hepatocellular carcinoma. Treatment targets for phlebotomy are ferritin <50 μg/L during the induction phase and <100 μg/L during the maintenance phase.
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Joshi PK, Patel SC, Shreya D, Zamora DI, Patel GS, Grossmann I, Rodriguez K, Soni M, Sange I. Hereditary Hemochromatosis: A Cardiac Perspective. Cureus 2021; 13:e20009. [PMID: 34987900 PMCID: PMC8716004 DOI: 10.7759/cureus.20009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/21/2022] Open
Abstract
Hereditary hemochromatosis (HH) is a common genetic metabolic disorder characterized by excessive iron absorption and elevated serum iron levels, which accumulate in various organs, such as the heart, pancreas, gonads, and damage these organs. There are only a few articles and clinical studies describing the characteristics of cardiac involvement in HH along with the significance of early diagnosis and management in preventing complications. In this review article, we have reviewed multiple pieces of literature and gathered available information regarding the subject. We compiled the data to investigate the importance of early detection of symptoms, regular monitoring, and prompt management with strict adherence to reverse or prevent complications. This article has reviewed different aspects of cardiac hemochromatosis, such as pathogenesis, clinical presentation, diagnosis, and management. Recognition of early symptoms, diagnosis of cardiac involvement with various modalities, and implementation of early treatment are essentially the foundation of better outcomes in HH.
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Seferović PM, Tsutsui H, McNamara DM, Ristić AD, Basso C, Bozkurt B, Cooper LT, Filippatos G, Ide T, Inomata T, Klingel K, Linhart A, Lyon AR, Mehra MR, Polovina M, Milinković I, Nakamura K, Anker SD, Veljić I, Ohtani T, Okumura T, Thum T, Tschöpe C, Rosano G, Coats AJS, Starling RC. Heart Failure Association of the ESC, Heart Failure Society of America and Japanese Heart Failure Society Position statement on endomyocardial biopsy. Eur J Heart Fail 2021; 23:854-871. [PMID: 34010472 DOI: 10.1002/ejhf.2190] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/23/2021] [Accepted: 04/08/2021] [Indexed: 12/17/2022] Open
Abstract
Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant (HTx) rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumours. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples have significantly improved diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, the Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (i) an overview of the practical approach to EMB, (ii) an update on indications for EMB, (iii) a revised plan for HTx rejection surveillance, (iv) the impact of multimodality imaging on EMB, and (v) the current clinical practice in the worldwide use of EMB.
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Affiliation(s)
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Dennis M McNamara
- Heart and Vascur Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arsen D Ristić
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Gerasimos Filippatos
- Attikon University Hospital, Department of Cardiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Karin Klingel
- Cardiopathology, Institute for Pathology, University Hospital, Tuebingen, Germany
| | - Aleš Linhart
- Department of Cardiovascular Medicine, Charles University, Prague, Czech Republic
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, UK
| | - Mandeep R Mehra
- Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marija Polovina
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Milinković
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin, Berlin, Germany
| | - Ivana Veljić
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany.,Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Carsten Tschöpe
- Berlin Institute of Health (BIH) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Department of Cardiology, Campus Virchow Klinikum, Charite University, Berlin, Germany
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele, Rome, Italy.,Cardiology Clinical Academic Group, St George's Hospitals NHS Trust, London, UK
| | - Andrew J S Coats
- Monash University, Melbourne, Australia.,University of Warwick, Coventry, UK
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5
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Seferović PM, Tsutsui H, Mcnamara DM, Ristić AD, Basso C, Bozkurt B, Cooper LT, Filippatos G, Ide T, Inomata T, Klingel K, Linhart A, Lyon AR, Mehra MR, Polovina M, Milinković I, Nakamura K, Anker SD, Veljić I, Ohtani T, Okumura T, Thum T, Tschöpe C, Rosano G, Coats AJS, Starling RC. Heart Failure Association, Heart Failure Society of America, and Japanese Heart Failure Society Position Statement on Endomyocardial Biopsy. J Card Fail 2021; 27:727-743. [PMID: 34022400 DOI: 10.1016/j.cardfail.2021.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Endomyocardial biopsy (EMB) is an invasive procedure, globally most often used for the monitoring of heart transplant rejection. In addition, EMB can have an important complementary role to the clinical assessment in establishing the diagnosis of diverse cardiac disorders, including myocarditis, cardiomyopathies, drug-related cardiotoxicity, amyloidosis, other infiltrative and storage disorders, and cardiac tumors. Improvements in EMB equipment and the development of new techniques for the analysis of EMB samples has significantly improved the diagnostic precision of EMB. The present document is the result of the Trilateral Cooperation Project between the Heart Failure Association of the European Society of Cardiology, Heart Failure Society of America, and the Japanese Heart Failure Society. It represents an expert consensus aiming to provide a comprehensive, up-to-date perspective on EMB, with a focus on the following main issues: (1) an overview of the practical approach to EMB, (2) an update on indications for EMB, (3) a revised plan for heart transplant rejection surveillance, (4) the impact of multimodality imaging on EMB, and (5) the current clinical practice in the worldwide use of EMB.
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Affiliation(s)
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Dennis M Mcnamara
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arsen D Ristić
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | - Gerasimos Filippatos
- Attikon University Hospital, Department of Cardiology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Tokyo, Japan
| | - Karin Klingel
- Cardiopathology, Institute for Pathology, University Hospital, Tuebingen, Germany
| | - Aleš Linhart
- Department of Cardiovascular Medicine, Charles University, Prague, Czech Republic
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College and Royal Brompton Hospital, London, UK
| | - Mandeep R Mehra
- Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Marija Polovina
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivan Milinković
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Ivana Veljić
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany; Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Carsten Tschöpe
- Berlin Institute of Health (BIH) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Department of Cardiology, Campus Virchow Klinikum, Charite University, Berlin, Germany
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele, Rome, Italy, and Cardiology Clinical Academic Group, St George's Hospitals NHS Trust
| | - Andrew J S Coats
- Monash University, Australia, and University of Warwick, Coventry, UK
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6
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Jensen PD, Nielsen AH, Simonsen CW, Baandrup UT, Jensen SE, Bøgsted M, Magnusdottir SO, Jensen ABH, Kjaergaard B. In vivo calibration of the T2* cardiovascular magnetic resonance method at 1.5 T for estimation of cardiac iron in a minipig model of transfusional iron overload. J Cardiovasc Magn Reson 2021; 23:27. [PMID: 33691716 PMCID: PMC7948337 DOI: 10.1186/s12968-021-00715-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/26/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Non-invasive estimation of the cardiac iron concentration (CIC) by T2* cardiovascular magnetic resonance (CMR) has been validated repeatedly and is in widespread clinical use. However, calibration data are limited, and mostly from post-mortem studies. In the present study, we performed an in vivo calibration in a dextran-iron loaded minipig model. METHODS R2* (= 1/T2*) was assessed in vivo by 1.5 T CMR in the cardiac septum. Chemical CIC was assessed by inductively coupled plasma-optical emission spectroscopy in endomyocardial catheter biopsies (EMBs) from cardiac septum taken during follow up of 11 minipigs on dextran-iron loading, and also in full-wall biopsies from cardiac septum, taken post-mortem in another 16 minipigs, after completed iron loading. RESULTS A strong correlation could be demonstrated between chemical CIC in 55 EMBs and parallel cardiac T2* (Spearman rank correlation coefficient 0.72, P < 0.001). Regression analysis led to [CIC] = (R2* - 17.16)/41.12 for the calibration equation with CIC in mg/g dry weight and R2* in Hz. An even stronger correlation was found, when chemical CIC was measured by full-wall biopsies from cardiac septum, taken immediately after euthanasia, in connection with the last CMR session after finished iron loading (Spearman rank correlation coefficient 0.95 (P < 0.001). Regression analysis led to the calibration equation [CIC] = (R2* - 17.2)/31.8. CONCLUSIONS Calibration of cardiac T2* by EMBs is possible in the minipig model but is less accurate than by full-wall biopsies. Likely explanations are sampling error, variable content of non-iron containing tissue and smaller biopsies, when using catheter biopsies. The results further validate the CMR T2* technique for estimation of cardiac iron in conditions with iron overload and add to the limited calibration data published earlier.
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Affiliation(s)
- Peter Diedrich Jensen
- Department of Hematology, Aalborg University Hospital, PO box 365, 9100, Aalborg, Denmark.
| | | | | | - Ulrik Thorngren Baandrup
- Centre for Clinical Research, North Denmark Regional Hospital, Hjoerring, Aalborg University Hospital, Aalborg, Denmark
| | | | - Martin Bøgsted
- Department of Hematology, Aalborg University Hospital, PO box 365, 9100, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark
| | | | | | - Benedict Kjaergaard
- Biomedical Research Laboratory, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
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Nazarova EE, Tereshchenko GV, Kupriyanov DA, Smetanina NS, Novichkova GA. Free-breathing T2* mapping for MR myocardial iron assessment at 3 T. Eur Radiol Exp 2020; 4:25. [PMID: 32303909 PMCID: PMC7165216 DOI: 10.1186/s41747-020-00156-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/19/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Timely diagnosis of cardiac iron overload is important for children with transfusion-dependent anaemias and requires modern measure methods. Nowadays, myocardial iron quantification is performed by magnetic resonance (MR) breath-hold techniques, sensitive to respiratory motion and unfeasible in patients who are unable to hold their breath. Free-breathing T2* mapping sequences would allow to scan children who cannot hold their breath for a specified duration. Our aim was to test a free-breathing T2* mapping sequence, based on motion correction by multiple signal accumulation technique. METHODS We used an electrocardiographically gated T2* mapping sequence based on multiple gradient echo at 3-T in 37 paediatric patients with haematologic disorders aged from 2 to 16. We compared T2* values of myocardium and signal-to-noise ratio of this new sequence with standard breath-holding T2* mapping sequence. T2* values were measured in the interventricular septum for both methods in studies with adequate image quality. RESULTS All children were scanned without complications. Five patients were excluded from analysis because of the presence of respiratory artefacts on the T2* images with breath-holding technique due to patient's inability to hold their breath. Breath-holding T2* was 19.5 ± 7.7 ms (mean ± standard deviation), free-breathing T2* was 19.4 ± 7.6 ms, with positive correlation (r = 0.99, R2 = 0.98; p < 0.001). The free-breathing sequence had a higher signal-to-noise ratio (median 212.8, interquartile range 148.5-566.5) than the breath-holding sequence (112.6, 71.1-334.1) (p = 0.03). CONCLUSION A free-breathing sequence provided accurate measurement of myocardial T2* values in children.
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Affiliation(s)
- E E Nazarova
- Radiology department, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Samory Mashela st., 1, Moscow, Russia, 117997.
| | - G V Tereshchenko
- Radiology department, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Samory Mashela st., 1, Moscow, Russia, 117997
| | - D A Kupriyanov
- Radiology department, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Samory Mashela st., 1, Moscow, Russia, 117997
- Philips Healthcare, Moscow, Russia
| | - N S Smetanina
- Radiology department, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Samory Mashela st., 1, Moscow, Russia, 117997
- 3Pirogov Russian National Research Medical University, Moscow, Russia
| | - G A Novichkova
- Radiology department, Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Samory Mashela st., 1, Moscow, Russia, 117997
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Meloni A, Maggio A, Positano V, Leto F, Angelini A, Putti MC, Maresi E, Pucci A, Basso C, Marra MP, Pistoia L, De Marchi D, Pepe A. CMR for myocardial iron overload quantification: calibration curve from the MIOT Network. Eur Radiol 2020; 30:3217-3225. [PMID: 32052169 DOI: 10.1007/s00330-020-06668-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/18/2019] [Accepted: 01/22/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVES R2* cardiac magnetic resonance (CMR) allows the non-invasive measurement of myocardial iron. We calibrated cardiac R2* values against myocardial tissue-measured iron concentration by using a segmental approach and we assessed the iron distribution. METHODS Five hearts of thalassemia patients were donated after death/transplantation to the CoreLab of the Myocardial Iron Overload in Thalassemia Network. A multislice multiecho R2* approach was adopted. After CMR, used as guidance, the heart was cut in three short-axis slices and each slice was cut into different equiangular segments according to AHA segmentation and differentiated into endocardial and epicardial layers. Tissue iron concentration was measured by atomic absorption spectrometer technique. RESULTS Fifty-five samples were used since only for two hearts all the 16 samples were analyzed. Mean iron concentration was 4.71 ± 4.67 mg/g dw. Segmental iron levels ranged from 0.24 to 13.78 mg/g dw. The coefficient of variability of iron for myocardial segments ranged from 8.08 to 24.54% (mean 13.49 ± 6.93%). Iron concentration was significantly higher in the epicardial than in the endocardial layer (5.99 ± 6.01 vs 4.84 ± 4.87 mg/g dw; p = 0.042). Four different circumferential regions (anterior, septal, inferior, and lateral) were defined. A circumferential heterogeneity was noted, with more iron in the anterior region, followed by the inferior region. The direct nonlinear fitting of R2* and [Fe] data led to the calibration curve: [Fe] = 0.0022 ∙ (R2*-ROI)1.462 (R-square = 0.956). CONCLUSIONS Our data further validate R2* CMR using a segmental approach as a sensitive and early technique for quantifying iron distribution in the current clinical practice. KEY POINTS • Calibration in humans for cardiovascular magnetic resonance R2* against myocardial iron concentration was provided. • A circumferential heterogeneity in cardiac iron distribution was detected: more iron was observed in the anterior region, followed by the inferior region. This finding corroborates the use of a segmental T2* CMR approach in the clinical practice to detect a heterogeneous iron distribution. • The comparison between the cardiac T2* values obtained with the region-based and the pixel-wise approaches showed a significant correlation and no significant difference but, in presence of significant iron load, the region-based approach resulted in significantly higher T2* values.
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Affiliation(s)
- Antonella Meloni
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Aurelio Maggio
- Ematologia II con Talassemia, Ospedale "V. Cervello", Palermo, Italy
| | - Vincenzo Positano
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Filippo Leto
- Ematologia II con Talassemia, Ospedale "V. Cervello", Palermo, Italy
| | - Annalisa Angelini
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Maria Caterina Putti
- Clinica di Emato-Oncologia Pediatrica, Azienda Ospedaliero-Università di Padova, Padua, Italy
| | - Emiliano Maresi
- Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", Università degli studi di Palermo, Palermo, Italy
| | - Angela Pucci
- Department of Histopathology, Pisa University Hospital, Pisa, Italy
| | - Cristina Basso
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Martina Perazzolo Marra
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Laura Pistoia
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Daniele De Marchi
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi, 1, 56124, Pisa, Italy
| | - Alessia Pepe
- MRI Unit, Fondazione G. Monasterio CNR-Regione Toscana, Area della Ricerca S. Cataldo, Via Moruzzi, 1, 56124, Pisa, Italy.
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9
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Abstract
Iron-overload syndromes may be hereditary or acquired. Patients may be asymptomatic early in the disease. Once heart failure develops, there is rapid deterioration. Cardiac hemochromatosis is characterized by a dilated cardiomyopathy with dilated ventricles, reduced ejection fraction, and reduced fractional shortening. Deposition of iron may occur in the entire cardiac conduction system, especially the atrioventricular node. Cardiac hemochromatosis should be considered in any patient with unexplained heart failure. Screening for systemic iron overload with serum ferritin and transferin saturation should be performed. If these tests are consistent with iron overload, further noninvasive and histologic confirmation is indicated to confirm organ involvement with iron overload. Cardiac magnetic resonance imaging is superior to other diagnostic tests since it can quantitatively assess myocardial iron load. Therapeutic phlebotomy is the therapy of choice in nonanemic patients with cardiac hemochromatosis. Therapeutic phlebotomy should be started in men with serum ferritin levels of 300 μg/l or more and in women with serum ferritin levels of 200 μg/l or more. Therapeutic phlebotomy consists of removing 1 unit of blood (450 to 500 ml) weekly until the serum ferritin level is 10 to 20 μg/l and maintenance of the serum ferritin level at 50 μg/l or lower thereafter by periodic removal of blood. Phlebotomy is not a treatment option in patients with anemia (secondary iron-overload disorders) nor in patients with severe congestive heart failure. In these patients, the treatment of choice is iron chelation therapy.
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Affiliation(s)
- Wilbert S Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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Mavrogeni S, Kolovou G, Bigalke B, Rigopoulos A, Noutsias M, Adamopoulos S. Transplantation in patients with iron overload: is there a place for magnetic resonance imaging? : Transplantation in iron overload. Heart Fail Rev 2018; 23:173-180. [PMID: 29359261 DOI: 10.1007/s10741-018-9670-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In iron overload diseases (thalassemia, sickle cell, and myelodysplastic syndrome), iron is deposited in all internal organs, leading to functional abnormalities. Hematopoietic stem cell transplantation (HSCT) is the only treatment offering a potential cure in these diseases. Our aim was to describe the experience in the field and the role of magnetic resonance imaging in the evaluation of iron overload before and after HSCT. Magnetic resonance imaging (MRI), using T2*, is the most commonly used tool to diagnose myocardial-liver iron overload and guide tailored treatment. Currently, HSCT offers complete cure in thalassemia major, after overcoming the immunologic barrier, and should be considered for all patients who have a suitable donor. The overall thalassemia-free survival of low-risk, HLA-matched sibling stem cell transplantation patients is 85-90%, with a 95% overall survival. The problems of rejection and engraftment are improving with the use of adequate immunosuppression. However, a detailed iron assessment of both heart and liver is necessary for pre- and post-transplant evaluation. In iron overload diseases, heart and liver iron evaluation is indispensable not only for the patients' survival, but also for evaluation before and after HSCT.
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Affiliation(s)
- Sophie Mavrogeni
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece. .,, Athens, Greece.
| | - Genovefa Kolovou
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece
| | - Boris Bigalke
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin (CBF), Hindenburgdamm 30, 12200, Berlin, Germany
| | - Angelos Rigopoulos
- Department of Cardiology, Leopoldina Hospital, 97422, Schweinfurt, Germany
| | - Michel Noutsias
- Department of Internal Medicine I, Division of Cardiology, Pneumology, Angiology and Intensive Medical Care, University Hospital Jena, Friedrich-Schiller-University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Stamatis Adamopoulos
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece
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Abstract
Trace elements are chemical elements needed in minute amounts for normal physiology. Some of the physiologically relevant trace elements include iodine, copper, iron, manganese, zinc, selenium, cobalt and molybdenum. Of these, some are metals, and in particular, transition metals. The different electron shells of an atom carry different energy levels, with those closest to the nucleus being lowest in energy. The number of electrons in the outermost shell determines the reactivity of such an atom. The electron shells are divided in sub-shells, and in particular the third shell has s, p and d sub-shells. Transition metals are strictly defined as elements whose atom has an incomplete d sub-shell. This incomplete d sub-shell makes them prone to chemical reactions, particularly redox reactions. Transition metals of biologic importance include copper, iron, manganese, cobalt and molybdenum. Zinc is not a transition metal, since it has a complete d sub-shell. Selenium, on the other hand, is strictly speaking a nonmetal, although given its chemical properties between those of metals and nonmetals, it is sometimes considered a metalloid. In this review, we summarize the current knowledge on the inborn errors of metal and metalloid metabolism.
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Affiliation(s)
- Carlos R. Ferreira
- Division of Genetics and Metabolism, Children’s National Health System, Washington, DC, USA
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, MD, USA
| | - William A. Gahl
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, NIH, Bethesda, MD, USA
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Davidsen ES, Liseth K, Omvik P, Hervig T, Gerdts E. Reduced exercise capacity in genetic haemochromatosis. ACTA ACUST UNITED AC 2016; 14:470-5. [PMID: 17568251 DOI: 10.1097/hjr.0b013e3280ac151c] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Many patients with genetic haemochromatosis complain about fatigue and reduced physical capacity. Exercise capacity, however, has not been evaluated in larger series of haemochromatosis patients treated with repeated phlebotomy. DESIGN AND METHODS We performed exercise echocardiography in 152 treated haemochromatosis patients (48+/-13 years, 26% women) and 50 healthy blood donors (49+/-13 years, 30% women), who served as controls. Echocardiography was performed at rest and during exercise in a semiupright position on a chair bicycle, starting from 20 W, increasing by 20 W/min. Transmitral early and atrial velocity and isovolumic relaxation time were measured at each step. Ventilatory gas exchange was measured by the breath-to-breath-technique. RESULTS Compared with healthy controls, haemochromatosis patients were more obese and less trained. More of them smoked, and 17% had a history of cardiovascular or pulmonary disease. Adjusted for training, the left ventricular function and dimensions at rest did not differ between the groups. During exercise the haemochromatosis patients obtained a significantly lower peak oxygen (O2) uptake (28.1 vs. 34.4 ml/kg per min, P<0.001). In a multiple regression analysis haemochromatosis predicted lower peak O2 uptake independently of significant contributions of sex, age, and height, as well as of systolic blood pressure and log-transformed isovolumic relaxation time at peak exercise, whereas no independent association was found with weight or physical activity (multiple R=0.74, P<0.001). Adding genotype, s-ferritin, prevalence of smoking, or history of cardiopulmonary disease among the covariates in subsequent models did not change the results. CONCLUSION Genetic haemochromatosis, even when treated with regular phlebotomy, is associated with lower exercise capacity independently of other covariates of exercise capacity.
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Khater NH, El Shahat HM, Fahmy HS, El Hadidy SS. Comparative study between black blood T2∗ and conventional bright GRE sequences in assessment of myocardial iron concentration. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2016.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Pepe A, Meloni A, Borsellino Z, Cuccia L, Borgna-Pignatti C, Maggio A, Restaino G, Gagliardotto F, Caruso V, Spasiano A, Filosa A, Centra M, D'Ascola D, Quarta A, Peluso A, Midiri M, Rossi G, Positano V, Capra M. Myocardial fibrosis by late gadolinium enhancement cardiac magnetic resonance and hepatitis C virus infection in thalassemia major patients. J Cardiovasc Med (Hagerstown) 2016; 16:689-95. [PMID: 26090920 DOI: 10.2459/jcm.0000000000000278] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Our aim was to evaluate the correlation between myocardial fibrosis detected using the late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) technique and chronic hepatitis C (CHC) in a large, retrospective, multicentre cohort of thalassemia major patients. METHODS LGE images were acquired in 434 thalassemia major patients (233 men, 31 ± 9 years) enrolled in the MIOT (Myocardial Iron Overload in Thalassemia) study. Hepatitis C virus (HCV)-RNA tests were sensitive to detect more than 50 copies/ml. RESULTS No patient manifested moderate/severe adverse events associated with the use of Gadobutrol. Myocardial fibrosis was detected in 90 (21%) patients. Among the 312 patients tested for HCV-RNA, there was a significant correlation between the presence of myocardial fibrosis and CHC (P = 0.011). Among the 62 patients with myocardial fibrosis tested for HCV-RNA, we found a significantly higher prevalence of diabetes mellitus in CHC patients versus the no-CHC patients (P = 0.049). CONCLUSION Our findings support the use of the LGE CMR approach well tolerated in the thalassemia major patients with CHC. HCV infection can be involved in the pathogenesis of myocardial fibrosis through both myocarditis directly and the pancreas and liver damage with the development of diabetes indirectly. These patients could therefore benefit from cardioactive drugs and therapeutic interventions directed towards the eradication of virus.
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Affiliation(s)
- Alessia Pepe
- aCMR Unit, Fondazione 'G. Monasterio' CNR-Regione Toscana, Pisa bEmatologia-Emoglobinopatie, Civico ARNAS Hospital, Palermo cDepartment of Clinical and Experimental Medicine (Pediatrics), University of Ferrara, Ferrara dHaematology II with Thalassemia, 'V. Cervello' Hospital, Palermo eRadiology Department, 'John Paul II' Catholic University, Campobasso fCentro Talassemie, ARNAS Garibaldi, Catania gUOSD Centro per le Microcitemie, AORN Cardarelli, Napoli hDepartment of Microcitemia, 'Casa Sollievo della Sofferenza' Hospital, San Giovanni Rotondo (FG) iU.O. Microcitemie, A.O. 'Bianchi-Melacrino-Morelli', Reggio Calabria jEmatologia, 'A. Perrino' Hospital, Brindisi kMicrocitemia - Azienda Unità Sanitaria Locale TA/1, Presidio Ospedaliero Centrale, Taranto lDepartment of Radiology, University of Palermo, Palermo mEpidemiology and Biostatistics Unit, Institute of Clinical Physiology, CNR, Pisa, Italy
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Constrictive Pericarditis Versus Restrictive Cardiomyopathy? J Am Coll Cardiol 2016; 67:2061-76. [DOI: 10.1016/j.jacc.2016.01.076] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/14/2016] [Accepted: 01/28/2016] [Indexed: 11/24/2022]
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A RETROSPECTIVE STUDY OF THE LESIONS ASSOCIATED WITH IRON STORAGE DISEASE IN CAPTIVE EGYPTIAN FRUIT BATS (ROUSETTUS AEGYPTIACUS). J Zoo Wildl Med 2016; 47:45-55. [DOI: 10.1638/2015-0224.1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bejar D, Colombo PC, Latif F, Yuzefpolskaya M. Infiltrative Cardiomyopathies. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:29-38. [PMID: 26244036 PMCID: PMC4498662 DOI: 10.4137/cmc.s19706] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Revised: 03/05/2015] [Accepted: 03/18/2015] [Indexed: 12/15/2022]
Abstract
Infiltrative cardiomyopathies can result from a wide spectrum of both inherited and acquired conditions with varying systemic manifestations. They portend an adverse prognosis, with only a few exceptions (ie, glycogen storage disease), where early diagnosis can result in potentially curative treatment. The extent of cardiac abnormalities varies based on the degree of infiltration and results in increased ventricular wall thickness, chamber dilatation, and disruption of the conduction system. These changes often lead to the development of heart failure, atrioventricular (AV) block, and ventricular arrhythmia. Because these diseases are relatively rare, a high degree of clinical suspicion is important for diagnosis. Electrocardiography and echocardiography are helpful, but advanced techniques including cardiac magnetic resonance (CMR) and nuclear imaging are increasingly preferred. Treatment is dependent on the etiology and extent of the disease and involves medications, device therapy, and, in some cases, organ transplantation. Cardiac amyloid is the archetype of the infiltrative cardiomyopathies and is discussed in great detail in this review.
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Affiliation(s)
- David Bejar
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Paolo C Colombo
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Farhana Latif
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA
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Mavrogeni S, Markousis-Mavrogenis G, Kolovou G. The Role of Magnetic Resonance Imaging in the Evaluation of Thalassemic Syndromes: Current Practice and Future Perspectives. THALASSEMIA REPORTS 2014. [DOI: 10.4081/thal.2014.1859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Iron can be deposited in all internal organs, leading to different types of functional abnormalities. However, myocardial iron overload that contributes to heart failure remains one of the main causes of death in thalassemia major. Using magnetic resonance imaging, tissue iron is detected indirectly by the effects on relaxation times of ferritin and hemosiderin iron interacting with hydrogen nuclei. The presence of iron in the human body results in marked alterations of tissue relaxation times. Currently, cardiovascular magnetic resonance using T2* is routinely used in many countries to identify patients with myocardial iron loading and guide chelation therapy, specifically tailored to the heart. Myocardial T2* is the only clinically validated non-invasive measure of myocardial iron loading and is superior to surrogates such as serum ferritin, liver iron, ventricular ejection fraction and tissue Doppler parameters. Finally, the substantial amelioration of patients’ survival, allows the detection of other organs’ abnormalities due to iron overload, apart from the heart, missed in the past. Recent studies revealed that iron deposition has a different pattern in various parenchymal organs, which is independent from serum ferritin and follows an individual way after chelation treatment application. This new upcoming reality orders a closer monitoring of all organs of the body in order to detect preclinical lesions and early apply adequate treatment.
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Carpenter JP, He T, Kirk P, Roughton M, Anderson LJ, de Noronha SV, Baksi AJ, Sheppard MN, Porter JB, Walker JM, Wood JC, Forni G, Catani G, Matta G, Fucharoen S, Fleming A, House M, Black G, Firmin DN, St. Pierre TG, Pennell DJ. Calibration of myocardial T2 and T1 against iron concentration. J Cardiovasc Magn Reson 2014; 16:62. [PMID: 25158620 PMCID: PMC4145261 DOI: 10.1186/s12968-014-0062-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 07/31/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The assessment of myocardial iron using T2* cardiovascular magnetic resonance (CMR) has been validated and calibrated, and is in clinical use. However, there is very limited data assessing the relaxation parameters T1 and T2 for measurement of human myocardial iron. METHODS Twelve hearts were examined from transfusion-dependent patients: 11 with end-stage heart failure, either following death (n=7) or cardiac transplantation (n=4), and 1 heart from a patient who died from a stroke with no cardiac iron loading. Ex-vivo R1 and R2 measurements (R1=1/T1 and R2=1/T2) at 1.5 Tesla were compared with myocardial iron concentration measured using inductively coupled plasma atomic emission spectroscopy. RESULTS From a single myocardial slice in formalin which was repeatedly examined, a modest decrease in T2 was observed with time, from mean (± SD) 23.7 ± 0.93 ms at baseline (13 days after death and formalin fixation) to 18.5 ± 1.41 ms at day 566 (p<0.001). Raw T2 values were therefore adjusted to correct for this fall over time. Myocardial R2 was correlated with iron concentration [Fe] (R2 0.566, p<0.001), but the correlation was stronger between LnR2 and Ln[Fe] (R2 0.790, p<0.001). The relation was [Fe] = 5081•(T2)-2.22 between T2 (ms) and myocardial iron (mg/g dry weight). Analysis of T1 proved challenging with a dichotomous distribution of T1, with very short T1 (mean 72.3 ± 25.8 ms) that was independent of iron concentration in all hearts stored in formalin for greater than 12 months. In the remaining hearts stored for <10 weeks prior to scanning, LnR1 and iron concentration were correlated but with marked scatter (R2 0.517, p<0.001). A linear relationship was present between T1 and T2 in the hearts stored for a short period (R2 0.657, p<0.001). CONCLUSION Myocardial T2 correlates well with myocardial iron concentration, which raises the possibility that T2 may provide additive information to T2* for patients with myocardial siderosis. However, ex-vivo T1 measurements are less reliable due to the severe chemical effects of formalin on T1 shortening, and therefore T1 calibration may only be practical from in-vivo human studies.
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Affiliation(s)
- John-Paul Carpenter
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Taigang He
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Paul Kirk
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael Roughton
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- University College Hospitals NHS Trust, London, UK
| | | | - Sofia V de Noronha
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - A John Baksi
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Mary N Sheppard
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | | | | | - John C Wood
- Children’s Hospital Los Angeles, California, USA
| | | | | | | | | | - Adam Fleming
- The University of Western Australia, Perth, Australia
| | - Mike House
- The University of Western Australia, Perth, Australia
| | - Greg Black
- The University of Western Australia, Perth, Australia
| | - David N Firmin
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | | | - Dudley J Pennell
- NIHR Cardiovascular BRU, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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Said Othman KM, Elshazly SA, Heiba NM. Role of non-invasive assessment in prediction of preclinical cardiac affection in multi-transfused thalassaemia major patients. ACTA ACUST UNITED AC 2013; 19:380-7. [PMID: 24225039 DOI: 10.1179/1607845413y.0000000140] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND The principal cause of mortality and morbidity in β-thalassemia major (β-TM) is the iron overload as these patients receive about 20 times the normal intake of iron, which leads to iron accumulation and damage in the liver, heart, and endocrine organs. Chronically transfused patients used to die from cardiac iron overload in their teens and twenties. Monitoring of iron status through cardiac magnetic resonance imaging (CMRI) has replaced the conventional methods of assessment, yet this modality is not readily available in centers where the disease distribution is maximal. Objectives The aim of this work is to study some simple non-invasive tools and their abilities to predict preclinical cardiac affection reflecting cardiac iron deposition (CID) in multi-transfused β-TM patients taking the T2* CMRI as a gold standard reference test. METHODS One hundred consecutive multi-transfused, clinically stable β-TM patients with age ranging from 16 to 30 years (mean ± SD, 21.1 ± 3.9) were included in this study. Assessment of serum ferritin, serum hepcidin, and high-sensitivity C-reactive protein as well as cardiac assessment by echo-doppler and 24-hour Holter were used to predict CID, and consequently predict preclinical cardiac affection, in reference to CMRI results as the standard method of cardiac iron assessment. RESULTS According to CMRI results, patients were subdivided into a group of 42 patients with detectable myocardial iron (T*≤ 20 ms) and a group of 58 patients with no detectable myocardial iron (T* > 20 ms). No differences in age, gender, or distribution of splenectomized patients were observed between both groups. Patients with detectable myocardial iron received significantly higher number of transfusions per year than those with no detectable myocardial iron (mean ± SD, 14.6 ± 1.7 vs. 12.5 ± 1.7; P < 0.001) yet comparable levels of serum ferritin, serum hepcidin, and hepcidin/ferritin ratio (P > 0.05) were noted. Cardiac iron detection was associated with significantly lower heart rate (mean ± SD, 75 ± 6.1 vs. 80 ± 6.9; P < 0.001), lower left ventricular ejection fraction (LVEF) (mean ± SD 60.1 ± 3.2 vs. 70.1 ± 2.8; P < 0.001), and higher total number of premature ventricular contractions (PVCs) (median 78 vs. 14; P < 0.001). The group with CID comprised significantly more patients with left ventricular diastolic dysfunction (15/42, 35.7% vs. 3/58, 5.2%; P < 0.001); PVCs ≥10/hour (13/42, 31% vs. 2/58, 3.4%; P < 0.001); episodes of sinus pauses (6/42, 14.3% vs. 1/58, 1.7%; P < 0.05); episodes of high-grade atrio-ventricular block (5/42, 11.9% vs. 1/58, 1.7%; P < 0.05) compared to the group with no (CID). In presence of normal LVEF, detection of 10 or more PVCs per hour was the most predictive of cardiac iron loading with a positive predictive value of 86.7% and specificity of 96.6%, and the highest likelihood ratio (9.09). Detection of more than 22 PVCs/24 hours had the best sensitivity (81%) and the best negative predictive value (84%). The positive likelihood ratio of the studied parameters was highest in case of presence of PVCs ≥10/hour and lowest in case of average heart rate with a cut-off level of ≤77.5 bpm (9.09 and 1.46, respectively). CONCLUSION Our results support our hypothesis that monitoring β-TM patients with echo and Holter electrocardiogram can help in the detection of preclinical cardiac affection in centers lacking cardiac MRI; however, due to relatively low sensitivity they can not fully replace CMRI. Further work is needed to identify additional simple parameters that can form a diagnostic model with adequate sensitivity.
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Carpenter JP, Roughton M, Pennell DJ. International survey of T2* cardiovascular magnetic resonance in β-thalassemia major. Haematologica 2013; 98:1368-74. [PMID: 23812939 PMCID: PMC3762092 DOI: 10.3324/haematol.2013.083634] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 06/20/2013] [Indexed: 12/18/2022] Open
Abstract
Accumulation of myocardial iron is the cause of heart failure and early death in most transfused thalassemia major patients. T2* cardiovascular magnetic resonance provides calibrated, reproducible measurements of myocardial iron. However, there are few data regarding myocardial iron loading and its relation to outcome across the world. A survey is reported of 3,095 patients in 27 worldwide centers using T2* cardiovascular magnetic resonance. Data on baseline T2* and numbers of patients with symptoms of heart failure at first scan (defined as symptoms and signs of heart failure with objective evidence of left ventricular dysfunction) were requested together with more detailed information about patients who subsequently developed heart failure or died. At first scan, 20.6% had severe myocardial iron (T2*≤ 10 ms), 22.8% had moderate myocardial iron (T2* 10-20 ms) and 56.6% of patients had no iron loading (T2*>20 ms). There was significant geographical variation in myocardial iron loading (24.8-52.6%; P<0.001). At first scan, 85 (2.9%) of 2,915 patients were reported to have heart failure (81.2% had T2* <10 ms; 98.8% had T2* <20 ms). During follow up, 108 (3.8%) of 2,830 patients developed new heart failure. Of these, T2* at first scan had been less than 10 ms in 96.3% and less than 20 ms in 100%. There were 35 (1.1%) cardiac deaths. Of these patients, myocardial T2* at first scan had been less than 10 ms in 85.7% and less than 20 ms in 97.1%. Therefore, in this worldwide cohort of thalassemia major patients, over 43% had moderate/severe myocardial iron loading with significant geographical differences, and myocardial T2* values less than 10 ms were strongly associated with heart failure and death.
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Affiliation(s)
- John-Paul Carpenter
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, UK
| | | | - Dudley J. Pennell
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, UK
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Diffuse diseases of the myocardium: MRI-pathologic review of cardiomyopathies with dilatation. AJR Am J Roentgenol 2013; 200:W274-82. [PMID: 23436872 DOI: 10.2214/ajr.12.9634] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In this radiologic-pathologic review of the cardiomyopathies, we present the pertinent imaging findings of diffuse myocardial diseases that are associated with ventricular dilatation, including ischemic cardiomyopathy, nonischemic dilated cardiomyopathy, cardiac sarcoidosis, and iron overload cardiomyopathy. CONCLUSION Correlation of the key radiologic findings with gross and microscopic pathologic features is presented, to provide the reader with a focused and in-depth review of the pathophysiology underlying each entity and the basis for the corresponding imaging characteristics.
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Abstract
Transfusion therapy has greatly improved the survival of transfusion dependent thalassemia major (TM) patients; however, the resultant iron load damages tissues including the heart, liver and endocrine organs. Among these, heart complication still remains the leading cause of mortality. Myocardial iron deposition can occur independently of other solid organ involvement; conversely, the heart may be spared despite heavy siderosis in other tissues. Iron chelation treatment diminishes the risk of hemosiderosis; however, the chelation treatment has its own toxicities and might not be available to all patients due to costs. Close monitoring of individual organ iron concentration and function is thus important for optimization of individual patient care. This review outlines the importance and clinical significance of recently available MRI techniques for monitoring cardiac iron load.
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Affiliation(s)
- Winnie C W Chu
- Department of Imaging & Interventional Radiology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR
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Abstract
T2* is a magnetic relaxation property of any tissue and is inversely related to intracellular iron stores. Measurement is simple, quick, and robust and has high reproducibility. The ability to measure ventricular function plus T2* in the heart and liver during the same scan has revolutionized the understanding of iron storage disease and the management of the iron-loaded patient. The early findings using T2* challenged conventional teachings, and both the technique and the findings were initially viewed with scepticism. However, after a decade of work in validating, calibrating, and expanding access to this method, it is now accepted as the method of choice for tissue iron assessment. In the UK, where T2* measurement was first used in the clinical care of patients with thalassemia major, a large and significant fall in mortality has been seen in this patient group.
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Affiliation(s)
- Lisa J Anderson
- Department of Cardiology, St George's University of London, Tooting, London, UK.
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Meloni A, Luciani A, Positano V, De Marchi D, Valeri G, Restaino G, Cracolici E, Caruso V, Dell'amico MC, Favilli B, Lombardi M, Pepe A. Single region of interest versus multislice T2* MRI approach for the quantification of hepatic iron overload. J Magn Reson Imaging 2011; 33:348-55. [PMID: 21274976 DOI: 10.1002/jmri.22417] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To evaluate the effectiveness of the single ROI approach for the detection of hepatic iron burden in thalassemia major (TM) patients in respect to a whole liver measurement. MATERIALS AND METHODS Five transverse hepatic slices were acquired by a T2* gradient-echo sequence in 101 TM patients and 20 healthy subjects. The T2* value was calculated in a single region of interest (ROI) defined in the medium-hepatic slice. Moreover, the T2* value was extracted on each of the eight ROIs defined in the functionally independent segments. The mean hepatic T2* value was calculated. RESULTS For patients, the mean T2* values over segments VII and VIII were significantly lower. This pattern was substantially preserved in the two groups identified considering the T2* normal cutoff. All segmental T2* values were correlated with the single ROI T2* value. After the application of a correction map based on T2* fluctuations in the healthy subjects, no significant differences were found in the segmental T2* values. CONCLUSION Hepatic T2* variations are low and due to artifacts and measurement variability. The single ROI approach can be adopted in the clinical arena, taking care to avoid the susceptibility artifacts, occurring mainly in segments VII and VIII.
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Affiliation(s)
- Antonella Meloni
- Fondazione G.Monasterio CNR-Regione Toscana and Institute of Clinical Physiology, Pisa, Italy.
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Carpenter JP, He T, Kirk P, Roughton M, Anderson LJ, de Noronha SV, Sheppard MN, Porter JB, Walker JM, Wood JC, Galanello R, Forni G, Catani G, Matta G, Fucharoen S, Fleming A, House MJ, Black G, Firmin DN, St Pierre TG, Pennell DJ. On T2* magnetic resonance and cardiac iron. Circulation 2011; 123:1519-28. [PMID: 21444881 DOI: 10.1161/circulationaha.110.007641] [Citation(s) in RCA: 333] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Measurement of myocardial iron is key to the clinical management of patients at risk of siderotic cardiomyopathy. The cardiovascular magnetic resonance relaxation parameter R2* (assessed clinically via its reciprocal, T2*) measured in the ventricular septum is used to assess cardiac iron, but iron calibration and distribution data in humans are limited. METHODS AND RESULTS Twelve human hearts were studied from transfusion-dependent patients after either death (heart failure, n=7; stroke, n=1) or transplantation for end-stage heart failure (n=4). After cardiovascular magnetic resonance R2* measurement, tissue iron concentration was measured in multiple samples of each heart with inductively coupled plasma atomic emission spectroscopy. Iron distribution throughout the heart showed no systematic variation between segments, but epicardial iron concentration was higher than in the endocardium. The mean ± SD global myocardial iron causing severe heart failure in 10 patients was 5.98 ± 2.42 mg/g dry weight (range, 3.19 to 9.50 mg/g), but in 1 outlier case of heart failure was 25.9 mg/g dry weight. Myocardial ln[R2*] was strongly linearly correlated with ln[Fe] (R²=0.910, P<0.001), leading to [Fe]=45.0×(T2*)⁻¹·²² for the clinical calibration equation with [Fe] in milligrams per gram dry weight and T2* in milliseconds. Midventricular septal iron concentration and R2* were both highly representative of mean global myocardial iron. CONCLUSIONS These data detail the iron distribution throughout the heart in iron overload and provide calibration in humans for cardiovascular magnetic resonance R2* against myocardial iron concentration. The iron values are of considerable interest in terms of the level of cardiac iron associated with iron-related death and indicate that the heart is more sensitive to iron loading than the liver. The results also validate the current clinical practice of monitoring cardiac iron in vivo by cardiovascular magnetic resonance of the midseptum.
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Kirk P, Carpenter JP, Tanner MA, Pennell DJ. Low prevalence of fibrosis in thalassemia major assessed by late gadolinium enhancement cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2011; 13:8. [PMID: 21241474 PMCID: PMC3025880 DOI: 10.1186/1532-429x-13-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Accepted: 01/17/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heart failure remains a major cause of mortality in thalassaemia major. The possible role of cardiac fibrosis in thalassemia major in the genesis of heart failure is not clear. It is also unclear whether cardiac fibrosis might arise as a result of heart failure. METHODS We studied 45 patients with thalassaemia major who had a wide range of current cardiac iron loading and included patients with prior and current heart failure. Myocardial iron was measured using T2* cardiovascular magnetic resonance (CMR), and following this, late gadolinium enhancement (LGE) was used to determine the presence of macroscopic myocardial fibrosis. RESULTS The median myocardial T2* in all patients was 22.6 ms (range 5.3-58.8 ms). Fibrosis was detected in only one patient, whose myocardial T2* was 20.1 ms and left ventricular ejection fraction 57%. No fibrosis was identified in 5 patients with a history of heart failure with full recovery, in 3 patients with current left ventricular dysfunction undergoing treatment, or in 18 patients with myocardial iron loading with cardiacT2* < 20 ms at the time of scan. CONCLUSION This study shows that macroscopic myocardial fibrosis is uncommon in thalassemia major across a broad spectrum of myocardial iron loading. Importantly, there was no macroscopic fibrosis in patients with current or prior heart failure, or in patients with myocardial iron loading without heart failure. Therefore if myocardial fibrosis indeed contributes to myocardial dysfunction in thalassemia, our data combined with the knowledge that the myocardial dysfunction of iron overload can be reversed, indicates that any such fibrosis would need to be both microscopic and reversible.
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Affiliation(s)
- Paul Kirk
- Royal Brompton Hospital and Imperial College, London, UK
| | | | - Mark A Tanner
- Royal Brompton Hospital and Imperial College, London, UK
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Evaluation of cardiac iron load by cardiac magnetic resonance in thalassemia. Indian Pediatr 2010; 48:697-701. [PMID: 21169646 DOI: 10.1007/s13312-011-0115-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2010] [Accepted: 08/23/2010] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To quantify myocardial iron stores by Cardiac Magnetic Resonance (CMR). DESIGN Prospective cohort study. SETTING Thalassemia center in a teaching hospital. PARTICIPANTS 60 transfusion dependant thalassemia major patients and 10 controls during 2008-2009. METHODS MRI T2* for cardiac iron load and cardiac functions was performed on a 1.5 Tesla Siemens Sonata machine using the thalassemia tools software. Ejection fraction (EF) was measured using standard CMR sequence and EF <56% considered as cardiac dysfunction. Quantification of iron deposition was categorized as T2* <10 milliseconds (ms) as high risk, 10-20 ms as intermediate risk and >20 ms as low risk. Simultaneous liver iron T2* values were categorized into normal i.e. >6.3 ms, mild iron overload 6.3-2.7 ms , moderate iron overload 2.7- 1.4 ms and severe iron overload <1.4 ms. Pretransfusion serum ferritin levels were simultaneously determined. Data was analyzed by paired and unpaired t test of mean. RESULTS Of 60 patients, 50% had no cardiac siderosis; 33.3% had mild to moderate and while 16.7% had severe cardiac siderosis . In contrast, only 8.3% had normal liver iron values, 55.7% had mild to moderate and 36% had severe iron stores. The mean serum ferritin of all 60 cases was 3528.6 ± 1958.6 ng/mL. There was a statistically significant difference in the mean cardiac T2* of patients (23.45 ± 13.4 ms) as compared to controls (32.67 ± 2.68 ms) (P<0.01). CONCLUSIONS Thalassemia patients had significantly higher cardiac iron stores as compared to controls. Serum ferritin and liver iron values did not correlate with cardiac iron values. Three of 10 patients <10 years showed evidence of myocardial siderosis.
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Murphy CJ, Oudit GY. Iron-Overload Cardiomyopathy: Pathophysiology, Diagnosis, and Treatment. J Card Fail 2010; 16:888-900. [DOI: 10.1016/j.cardfail.2010.05.009] [Citation(s) in RCA: 147] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 05/11/2010] [Accepted: 05/11/2010] [Indexed: 01/31/2023]
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Meloni A, Positano V, Pepe A, Rossi G, Dell'Amico M, Salvatori C, Keilberg P, Filosa A, Sallustio G, Midiri M, D'Ascola D, Santarelli MF, Lombardi M. Preferential patterns of myocardial iron overload by multislice multiecho T*2 CMR in thalassemia major patients. Magn Reson Med 2010; 64:211-9. [PMID: 20572148 DOI: 10.1002/mrm.22410] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
T*(2) multislice multiecho cardiac MR allows quantification of the segmental distribution of myocardial iron overload. This study aimed to determine if there were preferential patterns of myocardial iron overload in thalassemia major. Five hundred twenty-three thalassemia major patients underwent cardiac MR. Three short-axis views of the left ventricle were acquired and analyzed using a 16-segment standardized model. The T*(2) value on each segment was calculated, as well as the global value. Four main circumferential regions (anterior, septal, inferior, and lateral) were defined. Significant segmental variability was found in the 229 patients with significant myocardial iron overload (global T*(2) <26 ms), subsequently divided into two groups: severe (global T*(2) <10 ms) and mild to moderate (global T*(2) between 10 and 26 ms) myocardial iron overload. A preferential pattern of iron store in anterior and inferior regions was detected in both groups. This pattern was preserved among the slices. The pattern could not be explained by additive susceptibility artifacts, negligible in heavily iron-loaded patients. A significantly higher T*(2) value in the basal slice was found in patients with severe iron overload. In conclusion, a segmental T*(2) cardiac MR approach could identify early iron deposit, useful for tailoring chelation therapy and preventing myocardial dysfunction in the clinical setting.
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Affiliation(s)
- Antonella Meloni
- G. Monasterio Foundation and Institute of Clinical Physiology, CNR, Pisa, Italy.
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Abstract
Endomyocardial biopsy is a commonly performed useful procedure utilized for the evaluation of cardiac tissue. Biopsy may be used to monitor transplant rejection, but it has many other applications including the evaluation of myocarditis, cardiomyopathy, chest pain, arrhythmia, and secondary involvement by systemic diseases. Drug toxicity may be evaluated and neoplasms may be biopsied. Recent developments include advances in myocardial and viral molecular biology and advances in image or electrophysiology guided biopsy. The utility of endomyocardial biopsy is reviewed with consideration of these advances.
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Affiliation(s)
- John P Veinot
- Division of Anatomical Pathology, University of Ottawa Heart Institute, Department of Pathology and Laboratory Medicine at the Ottawa Hospital,Civic Campus and the University of Ottawa, Ottawa, Ontario, Canada.
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Gujja P, Rosing DR, Tripodi DJ, Shizukuda Y. Iron overload cardiomyopathy: better understanding of an increasing disorder. J Am Coll Cardiol 2010; 56:1001-12. [PMID: 20846597 PMCID: PMC2947953 DOI: 10.1016/j.jacc.2010.03.083] [Citation(s) in RCA: 228] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 02/26/2010] [Accepted: 03/18/2010] [Indexed: 11/20/2022]
Abstract
The prevalence of iron overload cardiomyopathy (IOC) is increasing. The spectrum of symptoms of IOC is varied. Early in the disease process, patients may be asymptomatic, whereas severely overloaded patients can have terminal heart failure complaints that are refractory to treatment. It has been shown that early recognition and intervention may alter outcomes. Biochemical markers and tissue biopsy, which have traditionally been used to diagnose and guide therapy, are not sensitive enough to detect early cardiac iron deposition. Newer diagnostic modalities such as magnetic resonance imaging are noninvasive and can assess quantitative cardiac iron load. Phlebotomy and chelating drugs are suboptimal means of treating IOC; hence, the roles of gene therapy, hepcidin, and calcium channel blockers are being actively investigated. There is a need for the development of clinical guidelines in order to improve the management of this emerging complex disease.
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Affiliation(s)
- Pradeep Gujja
- Division of Cardiovascular Diseases, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio 45267-0542, USA.
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Ramazzotti A, Pepe A, Positano V, Rossi G, De Marchi D, Brizi MG, Luciani A, Midiri M, Sallustio G, Valeri G, Caruso V, Centra M, Cianciulli P, De Sanctis V, Maggio A, Lombardi M. Multicenter validation of the magnetic resonance T2* technique for segmental and global quantification of myocardial iron. J Magn Reson Imaging 2009; 30:62-8. [PMID: 19557847 DOI: 10.1002/jmri.21781] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To assess the transferability of the magnetic resonance imaging (MRI) multislice multiecho T2(*) technique for global and segmental measurement of iron overload in thalassemia patients. MATERIALS AND METHODS Multiecho T2(*) sequences were installed on six MRI scanners. Five healthy subjects (n = 30) were scanned at each site; five thalassemia major (TM) patients were scanned at the reference site and were rescanned locally (n = 25) within 1 month. T2(*) images were analyzed using previously validated software. RESULTS T2(*) values of healthy subjects showed intersite homogeneity. On TM patients, for global heart T2(*) values the correlation coefficient was 0.97, coefficients of variation (CoV(s)) ranged from 0.04-0.12, and intraclass coefficients (ICC(s)) ranged from 0.94-0.99. The mean CoV and ICC for segmental T2(*) distribution were 0.198 and 88, respectively. CONCLUSION The multislice multiecho T2(*) technique is transferable among scanners with good reproducibility.
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Affiliation(s)
- Anna Ramazzotti
- MRI Laboratory, G Monasterio Foundation and Institute of Clinical Physiology, Pisa, Italy
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Positano V, Pepe A, Santarelli MF, Ramazzotti A, Meloni A, De Marchi D, Favilli B, Cracolici E, Midiri M, Spasiano A, Lombardi M, Landini L. Multislice multiecho T2* cardiac magnetic resonance for the detection of heterogeneous myocardial iron distribution in thalassaemia patients. NMR IN BIOMEDICINE 2009; 22:707-715. [PMID: 19322807 DOI: 10.1002/nbm.1382] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The present study investigated myocardial T2* heterogeneity in thalassaemia major (TM) patients by cardiac magnetic resonance (CMR), to determine whether is related to inhomogeneous iron overload distribution. A total of 230 TM patients consecutively referred to our laboratory were studied retrospectively. Three short-axis views (basal, medium and apical) of the left ventricle (LV) were obtained by multislice multiecho T2* CMR. T2* segmental distribution was mapped on a 16-segment LV model. The level of heterogeneity of the T2* segmental distribution, evaluated by the coefficient of variation (CoV), was compared with that of a surrogate data set, to determine whether the inhomogeneous segmental distribution of T2* could be generated by susceptibility artefacts. Susceptibility artefacts offer an explanation for the T2* heterogeneity observed in patients without iron overload. In subjects with global T2* below the lower limit of the normal, T2* heterogeneity increased abruptly which could not be explained by artefactual effects. Some segmental T2* values were below and others above the limit of normal threshold (20 ms) in 104 (45%) TM patients. Among these patients, 74% showed a normal T2* global value. In conclusion, a true heterogeneity in the iron overload distribution may be present in TM patients. Heterogeneity seemingly appears in the borderline myocardial iron and stabilizes at moderate to severe iron burden.
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Affiliation(s)
- Vincenzo Positano
- G. Monasterio Foundation and CNR Institute of Clinical Physiology, Pisa, Italy.
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Meloni A, Pepe A, Positano V, Favilli B, Maggio A, Capra M, Lo Pinto C, Gerardi C, Santarelli MF, Midiri M, Landini L, Lombardi M. Influence of myocardial fibrosis and blood oxygenation on heart T2* values in thalassemia patients. J Magn Reson Imaging 2009; 29:832-7. [DOI: 10.1002/jmri.21704] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Antonella Meloni
- MRI Laboratory, Institute of Clinical Physiology, G. Monasterio Foundation, Pisa, Italy.
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Nagayoshi Y, Nakayama M, Suzuki S, Hokamaki J, Shimomura H, Tsujita K, Fukuda M, Yamashita T, Nakamura Y, Sugiyama S, Ogawa H. A Q312X mutation in the hemojuvelin gene is associated with cardiomyopathy due to juvenile haemochromatosis. Eur J Heart Fail 2008; 10:1001-6. [PMID: 18725184 DOI: 10.1016/j.ejheart.2008.07.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2007] [Revised: 04/16/2008] [Accepted: 07/14/2008] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND AND AIMS Juvenile haemochromatosis (JH) is an autosomal recessive iron disorder characterized by the early onset of secondary cardiomyopathy. The candidate modifier genes are hemojuvelin (HJV) and hepcidin antimicrobial peptide (HAMP). In the Japanese population, the prevalence of JH is quite low. The influence of HJV mutation on the JH phenotype is still unclear. METHODS AND RESULTS We searched for possible mutations in a Japanese family with 2 members who were JH patients with severe heart failure. To search for possible variants in the HJV and HAMP genes, we performed direct sequencing in the family members. A homozygous nonsense mutation in exon 4 of HJV (Q312X) was identified in the JH patients and their mother. Three individuals in the family were heterozygous for this mutation. Subsequently, we evaluated the frequency of Q312X mutation in a large population (n=361) without heart failure, using allele-specific real-time PCR assay. No Q312X mutation was detected in this population. In the patients with the homozygous HJV mutation, iron loading revealed high serum ferritin concentration with accompanying elevated transferrin iron saturation. In contrast, ferritin levels were within the normal range in individuals with the heterozygous mutation. CONCLUSIONS We found a nonsense mutation in the HJV gene. This mutation elevates ferritin levels and leads to JH associated with severe cardiomyopathy.
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Affiliation(s)
- Yasuhiro Nagayoshi
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto City, Japan.
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Positano V, Pepe A, Santarelli MF, Scattini B, De Marchi D, Ramazzotti A, Forni G, Borgna-Pignatti C, Lai ME, Midiri M, Maggio A, Lombardi M, Landini L. Standardized T2* map of normal human heart in vivo to correct T2* segmental artefacts. NMR IN BIOMEDICINE 2007; 20:578-90. [PMID: 17205488 DOI: 10.1002/nbm.1121] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
A segmental, multislice, multi-echo T2* MRI approach could be useful in heart iron-overloaded patients to account for heterogeneous iron distribution, demonstrated by histological studies. However, segmental T2* assessment in heart can be affected by the presence of geometrical and susceptibility artefacts, which can act on different segments in different ways. The aim of this study was to assess T2* value distribution in the left ventricle and to develop a correction procedure to compensate for artefactual variations in segmental analysis. MRI was performed in four groups of 22 subjects each: healthy subjects (I), controls (II) (thalassemia intermedia patients without iron overload), thalassemia major patients with mild (III) and heavy (IV) iron overload. Three short-axis views (basal, median, and apical) of the left ventricle were obtained and analyzed using custom-written, previously validated software. The myocardium was automatically segmented into a 16-segment standardized heart model, and the mean T2* value for each segment was calculated. Punctual distribution of T2* over the myocardium was assessed, and T2* inhomogeneity maps for the three slices were obtained. In group I, no significant variation in the mean T2* among slices was found. T2* showed a characteristic circumferential variation in all three slices. The effect of susceptibility differences induced by cardiac veins was evident, together with low-scale variations induced by geometrical artefacts. Using the mean segmental deviations as correction factors, an artefact correction map was developed and used to normalize segmental data. The correction procedure was validated on group II. Group IV showed no significant presence of segmental artefacts, confirming the hypothesis that susceptibility artefacts are additive in nature and become negligible for high levels of iron overload. Group III showed a greater variability with respect to normal subjects. The correction map failed to compensate for these variations if both additive and percentage-based corrections were applied. This may reinforce the hypothesis that true inhomogeneity in iron deposition exists.
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Janower S, Rosmorduc O, Cohen A. [Cardiac involvement in hemochromatosis]. Presse Med 2007; 36:1301-12. [PMID: 17574380 DOI: 10.1016/j.lpm.2006.12.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 12/31/2006] [Indexed: 10/22/2022] Open
Abstract
Cardiac involvement in hemochromatosis affects mainly the myocardium: iron overload of the myocytes reduces left ventricular distensibility. Heart failure is the most frequent manifestation of cardiac involvement. Diagnosis of cardiac involvement depends essentially on Doppler echocardiography showing abnormal left ventricular filling and, later, ventricular dilatation with left ventricular systolic dysfunction. Magnetic resonance imaging can quantify intrahepatic and intramyocardial iron levels. Age at onset of symptoms and specific organ involvement in hemochromatosis depend on the type of mutation. The two principal means of treatment by iron depletion are phlebotomy in primary hemochromatosis and excretion of iron by chemical chelation in secondary hemochromatosis. Early diagnosis and iron depletion improve survival by reducing organ iron overload, especially in the liver and the myocardium. Recent guidelines issued by Anaes (national agency for health evaluation) make it possible to identify risk factors for complications early, to determine disease stage, and to provide appropriate management as a function of disease severity.
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Affiliation(s)
- Sandra Janower
- Service de cardiologie, Hôpital Saint-Antoine, AP-HP, et Université Pierre et Marie Curie, Paris VI
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Pepe A, Positano V, Santarelli MF, Sorrentino F, Cracolici E, De Marchi D, Maggio A, Midiri M, Landini L, Lombardi M. Multislice multiecho T2* cardiovascular magnetic resonance for detection of the heterogeneous distribution of myocardial iron overload. J Magn Reson Imaging 2006; 23:662-8. [PMID: 16568436 DOI: 10.1002/jmri.20566] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To assess the tissue iron concentration of the left ventricle (LV) using a multislice, multiecho T2* MR technique and a segmental analysis. MATERIALS AND METHODS T2* multiecho MRI was performed in 53 thalassemia major patients. Three short-axis views of the LV were obtained and analyzed with custom-written software. The myocardium was automatically segmented into 12 segments. The T2* value on each segment as well as the global T2* value were calculated. Cine dynamic images were also obtained to evaluate biventricular function parameters by quantitative analysis. RESULTS For the T2* global value, the coefficient of variation (CoV) for intra-/interobserver and interstudy reproducibility was 3.9% (r = 0.98), 5.5% (r = 0.98), and 4.7% (r = 0.99) respectively. Three groups were identified based on analysis of myocardial T2*: homogeneous (21%), heterogeneous (38%), and no myocardial iron overload (41%). The mean serum ferritin, liver iron concentration, and urinary iron excretion were significantly different among the groups. We did not find significant differences among groups in biventricular function. There was a correlation between the global T2* value and the T2* value in the mid-ventricular septum (r = 0.95, P < 0.0001). CONCLUSION Multislice multiecho T2* MRI provides a noninvasive, fast, reproducible means of assessing myocardial iron distribution. The single measurement of mid-septal T2* correlated well with the global T2* value.
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Affiliation(s)
- Alessia Pepe
- MRI Laboratory, Institute of Clinical Physiology, Consiglio Nazionale delle Ricerche, Pisa, Italy.
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Pepe A, Lombardi M, Positano V, Cracolici E, Capra M, Malizia R, Prossomariti L, De Marchi D, Midiri M, Maggio A. Evaluation of the efficacy of oral deferiprone in beta-thalassemia major by multislice multiecho T2*. Eur J Haematol 2006; 76:183-92. [PMID: 16451393 DOI: 10.1111/j.1600-0609.2005.00587.x] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Oral deferiprone (L1) appears to be promising in the treatment of beta-thalassemia major (TM) patients. T2* magnetic resonance imaging (MRI) with a single measurement in the mid-ventricular septum was validated as a quantitative evaluation of myocardial iron overload. Previous studies suggested a marked heterogeneity of iron distribution in the myocardium. We set up a multislice multiecho T2* MRI for the detection of this heterogeneity. The aim of our study was to investigate differences between the L1 vs. the subcutaneous desferrioxamine (DF)-treated patients using this new approach. METHODS Thirty-six beta-TM patients (age 29 +/- 8 yr) underwent MRI. Eighteen patients received long-term L1, and 18 other patients matched for age and sex received DF. T2* multiecho sequences on three short axis views of the left ventricle were obtained and analyzed by custom-made software. In each slice, the myocardium was automatically segmented into four segments. Cine-dynamic images were also obtained to evaluate biventricular function. RESULTS For multislice T2* technique, the coefficient of variation for intra- and inter-observer, and inter-study reproducibility was 3.9%, 4.7%, and 5.5%, respectively. The global heart T2* value was significantly higher in the L1 vs. DF group (35 +/- 7 vs. 27 +/- 2 ms; P = 0.02). The number of segments with normal T2* value (>20 ms) was significantly higher in the L1 vs. the DF group (11 +/- 1 vs. 8 +/- 5 segments; P = 0.03). We did not detect significant differences in biventricular function parameters. CONCLUSIONS This new approach confirms that L1 could be more effective than DF in removal of myocardial iron.
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Affiliation(s)
- Alessia Pepe
- MRI Laboratory, Institute of Clinical Physiology, CNR, Pisa, Italy.
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Ghugre NR, Enriquez CM, Coates TD, Nelson MD, Wood JC. Improved R2* measurements in myocardial iron overload. J Magn Reson Imaging 2006; 23:9-16. [PMID: 16329085 PMCID: PMC2892961 DOI: 10.1002/jmri.20467] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To optimize R2*(1/T2*) measurements for cardiac iron detection in sickle cell and thalassemia patients. MATERIALS AND METHODS We studied 31 patients with transfusion-dependent sickle cell disease and 48 patients with thalassemia major; myocardial R2* was assessed in a single midpapillary slice using a gated gradient-echo pulse sequence. Pixel-wise maps were coregistered among the patients to determine systematic spatial fluctuations in R2*. The contributions of minimum TE, echo spacing, signal-decay model, and region-of-interest (ROI) choice were compared in synthetic and acquired images. RESULTS Cardiac relaxivity demonstrated characteristic circumferential variations regardless of the degree of iron overload. Within the interventricular septum, a gradient in R2* from right to left ventricle was noted at high values. Pixel-wise and ROI techniques yielded nearly identical values. Signal decay was exponential but a constant offset or second exponential term was necessary to avoid underestimation at high iron concentration. Systematic underestimation of R2* was observed for higher minimum TE, limiting the range of iron concentrations that can be profiled. Fat-water oscillations, although detectable, represented only 1% of the total signal. CONCLUSION Clinical cardiac R2* measurements should be restricted to the interventricular septum and should have a minimum TE < or = 2 msec. ROI analysis techniques are accurate; however, offset-correction is essential.
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Affiliation(s)
- Nilesh R. Ghugre
- Division of Cardiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Cathleen M. Enriquez
- Division of Cardiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Thomas D. Coates
- Department of Hematology-Oncology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Marvin D. Nelson
- Department of Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - John C. Wood
- Division of Cardiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
- Department of Radiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Kilo J, Laufer G, Antretter H. Endomyocardial biopsy - jugular/subclavian vein approach. Multimed Man Cardiothorac Surg 2006; 2006:mmcts.2005.001149. [PMID: 24413457 DOI: 10.1510/mmcts.2005.001149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endomyocardial biopsy (EMB) is a diagnostic procedure mainly to survey the sufficiency of immunosuppressive therapy after cardiac transplantation. Other indications for EMB remain controversial. After insertion of an introducer sheet in Seldinger's technique, four to six biopsies are taken from the right ventricle by fluoroscopic guidance. EMB is a very safe operation with a low complication rate which can be rapidly performed with little inconvenience for the patient if performed by a skilled surgeon.
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Affiliation(s)
- Juliane Kilo
- Department of Cardiac Surgery, Medical University Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
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Wood JC, Otto-Duessel M, Aguilar M, Nick H, Nelson MD, Coates TD, Pollack H, Moats R. Cardiac iron determines cardiac T2*, T2, and T1 in the gerbil model of iron cardiomyopathy. Circulation 2005; 112:535-43. [PMID: 16027257 PMCID: PMC2896311 DOI: 10.1161/circulationaha.104.504415] [Citation(s) in RCA: 186] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transfusional therapy for thalassemia major and sickle cell disease can lead to iron deposition and damage to the heart, liver, and endocrine organs. Iron causes the MRI parameters T1, T2, and T2* to shorten in these organs, which creates a potential mechanism for iron quantification. However, because of the danger and variability of cardiac biopsy, tissue validation of cardiac iron estimates by MRI has not been performed. In this study, we demonstrate that iron produces similar T1, T2, and T2* changes in the heart and liver using a gerbil iron-overload model. METHODS AND RESULTS Twelve gerbils underwent iron dextran loading (200 mg . kg(-1) . wk(-1)) from 2 to 14 weeks; 5 age-matched controls were studied as well. Animals had in vivo assessment of cardiac T2* and hepatic T2 and T2* and postmortem assessment of cardiac and hepatic T1 and T2. Relaxation measurements were performed in a clinical 1.5-T magnet and a 60-MHz nuclear magnetic resonance relaxometer. Cardiac and liver iron concentrations rose linearly with administered dose. Cardiac 1/T2*, 1/T2, and 1/T1 rose linearly with cardiac iron concentration. Liver 1/T2*, 1/T2, and 1/T1 also rose linearly, proportional to hepatic iron concentration. Liver and heart calibrations were similar on a dry-weight basis. CONCLUSIONS MRI measurements of cardiac T2 and T2* can be used to quantify cardiac iron. The similarity of liver and cardiac iron calibration curves in the gerbil suggests that extrapolation of human liver calibration curves to heart may be a rational approximation in humans.
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Affiliation(s)
- John C Wood
- Division of Pediatric Cardiology, Department of Pediatrics and Radiology, Children's Hospital of Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027, USA.
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Abstract
The pericardium envelopes the cardiac chambers and under physiological conditions exerts subtle functions, including mechanical effects that enhance normal ventricular interactions that contribute to balancing left and right cardiac outputs. Because the pericardium is non-compliant, conditions that cause intrapericardial crowding elevate intrapericardial pressure, which may be the mediator of adverse cardiac compressive effects. Elevated intrapericardial pressure may result from primary disease of the pericardium itself (tamponade or constriction) or from abrupt chamber dilatation (eg, right ventricular infarction). Regardless of the mechanism leading to increased intrapericardial pressure, the resultant pericardial constraint exerts adverse effects on cardiac filling and output. Constriction and restrictive cardiomyopathy share common pathophysiological and clinical features; their differentiation can be quite challenging. This review will consider the physiology of the normal pericardium and its dynamic interactions with the heart and review in detail the pathophysiology and clinical manifestations of cardiac tamponade, constrictive pericarditis, and restrictive cardiomyopathy.
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Affiliation(s)
- James A Goldstein
- Division of Cardiology, William Beaumont Hospital,3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA,
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Seth S, Thatai D, Sharma S, Chopra P, Talwar KK. Clinico-pathological evaluation of restrictive cardiomyopathy (endomyocardial fibrosis and idiopathic restrictive cardiomyopathy) in India. Eur J Heart Fail 2004; 6:723-9. [PMID: 15542407 DOI: 10.1016/j.ejheart.2003.11.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2003] [Revised: 06/19/2003] [Accepted: 11/25/2003] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Restrictive heart disease is characterized by impairment of ventricular filling during diastole with preserved systolic function. The clinical and histopathological profile on endomyocardial biopsy of a cohort of patients with restrictive cardiomyopathy (RCM) is presented. METHODOLOGY The medical records of patients presenting with heart failure with systemic congestion, subsequently diagnosed as restrictive heart disease after evaluation including cardiac catheterisation, were studied retrospectively to determine the clinical spectrum of restrictive cardiomyopathy. The diagnosis of RCM was made, based on systemic congestion with dilated atria and near normal ventricular size and function. Only patients who had an endomyocardial biopsy were included in the study. Patients with chronic constrictive pericarditis and secondary restrictive heart disease mainly amyloidosis were excluded from the study. RESULTS All 52 patients had heart failure with normal or near normal left ventricular size and function. Based on right and left ventricle angiography, patients were classified into two groups. Group I with findings suggestive of EMF (n=30) and Group II no evidence of EMF on angiography i.e. 'idiopathic RCM' (IRCM) (n=22). Baseline characteristics were similar in the two groups. Echocardiography revealed typical features of endomyocardial fibrosis in Group I patients, with apical obliteration of right and left ventricular apices. Group II patients had no apex obliteration (except in four patients, who were misclassified and in whom angiography did not show apex obliteration). The Group II patients had features of IRCM in the form of normal left and right ventricular size and function with restrictive features of doppler filling along with dilated left and right atria. Angiocardiography in EMF patients showed isolated RV involvement in only two patients. In the remaining 28 patients, the obliterative changes were biventricular with RV involvement more severe than LV involvement. Angiographic findings in Group II (IRCM) patients were unremarkable with preservation of normal trabecular pattern and absence of obliterative changes. Mild atrioventricular regurgitation was present in 10/22 patients. Histopathological examination revealed that endocardial thickening was more common (77% vs. 23%) in EMF patients. The presence of myocyte hypertrophy (70-80%), myocytolysis (40-50%) and interstitial fibrosis (46-56%) were similar in both groups. CONCLUSIONS The majority of our patients had biventricular EMF. A significant number of patients had clinical hemodynamic features of restrictive heart disease but no evidence of EMF on angiography. These IRCM patients had similar clinical profiles to EMF but on endomyocardial biopsy the endocardial thickening was minimal and seen in few patients (5/22).
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Affiliation(s)
- Sandeep Seth
- Department of Cardiology, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India
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Ocel JJ, Edwards WD, Tazelaar HD, Petrovic LM, Edwards BS, Kamath PS. Heart and liver disease in 32 patients undergoing biopsy of both organs, with implications for heart or liver transplantation. Mayo Clin Proc 2004; 79:492-501. [PMID: 15065614 DOI: 10.4065/79.4.492] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine underlying conditions in patients undergoing both heart and liver biopsies. PATIENTS AND METHODS Our study group consisted of 32 patients at the Mayo Clinic in Rochester, Minn, who underwent both endomyocardial and nonsurgical liver biopsies and who underwent at least one of these procedures between January 1,1981, and December 31,2000. Patients were categorized as having (1) heart disease affecting the liver, (2) liver disease affecting the heart, (3) the same disease affecting both organs, or (4) different diseases affecting each organ independently. RESULTS Among 32 patients, cardiac dysfunction was present in 28 (19 systolic, 9 diastolic), and hepatic dysfunction was present in 31. In group 1, 3 of 4 patients had cardiac amyloidosis with secondary hepatic congestion. In group 2, all 3 patients had cirrhosis with cirrhotic cardiomyopathy. Group 3 included 5 patients with hemochromatosis, 3 with alcoholism, and 1 with amyloidosis. In group 4, 8 of 16 patients had idiopathic cardiomyopathy, and 8 had hepatitis. Overall, of 8 patients with hemochromatosis, 3 without cardiac iron had improved cardiac function after phlebotomy, and 1 with cardiac iron had no cardiac dysfunction. Among 7 patients with alcoholism, 3 had alcoholic liver and heart disease. Of 5 patients with cardiac amyloidosis, 1 had hepatic amyloid. Ten patients underwent transplantation (6 liver, 3 heart, and 1 heart and liver). CONCLUSIONS In one half of the patients in the study group, heart and liver diseases had independent causes. In patients with hemochromatosis, there was little correlation between cardiac iron and systolic dysfunction. In patients with chronic alcoholism, liver and heart disorders often had nonalcoholic causes. With cardiac amyloidosis, hepatic dysfunction was generally due to congestion. Specific disease in one organ did not necessarily imply similar involvement in the other. Thus, heart or liver biopsy may be useful in patients being evaluated for liver or heart transplantation, respectively.
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Affiliation(s)
- Joseph J Ocel
- Mayo Medical School, Division of Anatomic Pathology, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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