Association of Myocardial Deformation With Mortality Independent of Myocardial Ischemia and Left Ventricular Hypertrophy

Risk and Management of Patients with Cancer and Heart Disease

Cancer and cardiovascular disease are two of the leading causes of global mortality and morbidity. Medical research has generated powerful lifesaving treatments for patients with cancer; however, such treatments may sometimes be at the expense of the patient's myocardium, leading to heart failure. Anti-cancer drugs, including anthracyclines, can result in deleterious cardiac effects, significantly impacting patients' functional capacity, mental well-being, and quality of life. Recognizing this, recent international guidelines and expert papers published recommendations on risk stratification and care delivery, including that of cardio-oncology services. This review will summarize key evidence with a focus on anthracycline therapy, providing clinical guidance for the non-oncology professional caring for a patient with cancer and heart failure.

Cardiac magnetic resonance imaging parameters show association between myocardial abnormalities and severity of chronic kidney disease

BACKGROUND

Chronic kidney disease patients have increased risk of cardiovascular abnormalities. This study investigated the relationship between cardiovascular abnormalities and the severity of chronic kidney disease using cardiac magnetic resonance imaging.

METHODS

We enrolled 84 participants with various stages of chronic kidney disease (group I: stages 1-3, n = 23; group II: stages 4-5, n = 20; group III: hemodialysis patients, n = 41) and 32 healthy subjects. The demographics and biochemical parameters of the study subjects were evaluated. All subjects underwent non-contrast cardiac magnetic resonance scans. Myocardial strain, native T1, and T2 values were calculated from the scanning results. Analysis of covariance was used to compare the imaging parameters between group I-III and the controls.

RESULTS

The left ventricular ejection fraction (49 vs. 56%, p = 0.021), global radial strain (29 vs. 37, p = 0.019) and global circumferential strain (-17.4 vs. -20.6, p < 0.001) were significantly worse in group III patients compared with the controls. Furthermore, the global longitudinal strain had a significant decline in group II and III patients compared with the controls (-13.7 and -12.9 vs. -16.2, p < 0.05). Compared with the controls, the native T1 values were significantly higher in group II and III patients (1,041 ± 7 and 1,053 ± 6 vs. 1,009 ± 6, p < 0.05), and T2 values were obviously higher in group I-III patients (49.9 ± 0.6 and 53.2 ± 0.7 and 50.1 ± 0.5 vs. 46.6 ± 0.5, p < 0.001). The advanced chronic kidney disease stage showed significant positive correlation with global radial strain (r = 0.436, p < 0.001), global circumferential strain (r = 0.386, p < 0.001), native T1 (r = 0.5, p < 0.001) and T2 (r = 0.467, p < 0.001) values. In comparison with the group II patients, hemodialysis patients showed significantly lower T2 values (53.2 ± 0.7 vs. 50.1 ± 0.5, p = 0.002), but no significant difference in T1 values (1,041 ± 7 vs. 1,053 ± 6).

CONCLUSIONS

Our study showed that myocardial strain, native T1, and T2 values progressively got worse with advancing chronic kidney disease stage. The increased T1 values and decreased T2 values of hemodialysis patients might be due to increasing myocardial fibrosis but with reduction in oedema following effective fluid management.

TRIAL REGISTRATION NUMBER

ChiCTR2100053561 (http://www.chictr.org.cn/edit.aspx?pid=139737&htm=4).

Prognostic superiority of global longitudinal strain beyond four-tiered ventricular hypertrophy in asymptomatic individuals

BACKGROUND

This study aims to explore the clinical correlates of myocardial deformations using speckle-tracking algorithm and to determine the prognostic utility of such measures in asymptomatic ethnic Chinese population.

METHODS

Global longitudinal (GLS), circumferential strain (GCS), and torsion were analyzed using featured tissue-tracking algorithm among 4049 symptom-free ethnic Chinese population. Hypertrophy (LVH) was classified into 4 tiers: indeterminate, dilated, thick and thick/dilated, by gender-stratified partition of end-diastolic volume index (EDVi) and LV mass/EDV0.67.

RESULTS

LVH (7.3%) showed substantially lower GLS (-20.3 ± 1.82% vs. -18.9 ± 2.08%) yet higher torsion (2.20 ± 0.90 vs. 2.39 ± 1.01, p < 0.001) than non-LVH participants. Those with thick LVH (n = 123) were more obese, had higher blood pressure and increased high-sensitivity C-reactive protein (hs-CRP); with dilated/thick LVH (n = 26) group demonstrating highest pro-brain natriuretic peptide (NT-proBNP) and worse GLS compared to indeterminate-/non-LVH groups. There were independent associations among larger EDVi, higher NT-proBNP and decreased torsion, and among greater LV mass/EDV0.67, worse GLS, greater GCS/torsion and hs-CRP. Over a median of 2.3 years (IQR: 1.2-4.8), the dilated, thick, and dilated/thick LVH categorizations were associated with higher risk of composite all-cause death and heart failure (HF) compared to non-LVH (adjusted hazard ratio [HR]: 3.65, 3.72, 6.01, respectively, all p < 0.05). Per 1% GLS reduction was independently associated with higher risk (adjusted HR: 1.31, p < 0.001) and improved risk prediction (p ≤ 0.001 by integrated discrimination improvement [IDI]: 3.5%, 95% CI: 1.5%-5.6%, and continuous net reclassification improvement [NRI]: 42.3%, 95% CI: 24.0%-60.6%) over LVH.

CONCLUSION

GLS improved risk stratification of four-tiered classification of LVH in asymptomatic ethnic Chinese.

Sickle cell disease and ventricular myocardial strain: A systematic review

Cardiac disease is the primary cause of death in sickle cell disease (SCD). Cardiac abnormalities begin in childhood and progress throughout life. Right and left ventricular (RV, LV) myocardial strain are early markers of systolic dysfunction but are not well investigated among individuals with SCD. The objectives of this review were to (1) identify all published studies that have evaluated ventricular myocardial strain, (2) summarize their values, and (3) compare findings with those obtained from controls. From search results of four electronic databases-Medline, Embase, Scopus, and Web of Science-42 potential articles were identified, of which 18 articles and 17 studies met eligibility criteria for inclusion. The evaluated studies demonstrate that RV and LV myocardial strain are generally abnormal in individuals with SCD compared with controls, despite having normal ejection/shortening fraction. Myocardial strain has been inconsistently evaluated in this population and should be considered any time an echocardiogram is performed.

Texture Analysis of Native T1 Images as a Novel Method for Noninvasive Assessment of Uremic Cardiomyopathy

BACKGROUND

Noncontrast cardiac T₁ times are increased in dialysis patients which might indicate fibrotic alterations in uremic cardiomyopathy.

PURPOSE

To explore the application of the texture analysis (TA) of T₁ images in the assessment of myocardial alterations in dialysis patients.

STUDY TYPE

Case-control study.

POPULATION

A total of 117 subjects, including 22 on hemodialysis, 44 on peritoneal dialysis, and 51 healthy controls.

FIELD STRENGTH

A 3 T, steady-state free precession (SSFP) sequence, modified Look-Locker imaging (MOLLI).

ASSESSMENT

Two independent, blinded researchers manually delineated endocardial and epicardial borders of the left ventricle (LV) on midventricular T₁ maps for TA.

STATISTICAL TESTS

Texture feature selection was performed, incorporating reproducibility verification, machine learning, and collinearity analysis. Multivariate linear regressions were performed to examine the independent associations between the selected texture features and left ventricular function in dialysis patients. Texture features' performance in discrimination was evaluated by sensitivity and specificity. Reproducibility was estimated by the intraclass correlation coefficient (ICC).

RESULTS

Dialysis patients had greater T₁ values than normal (P < 0.05). Five texture features were filtered out through feature selection, and four showed a statistically significant difference between dialysis patients and healthy controls. Among the four features, vertical run-length nonuniformity (VRLN) had the most remarkable difference among the control and dialysis groups (144 ± 40 vs. 257 ± 74, P < 0.05), which overlap was much smaller than Global T₁ times (1268 ± 38 vs. 1308 ± 46 msec, P < 0.05). The VRLN values were notably elevated (cutoff = 170) in dialysis patients, with a specificity of 97% and a sensitivity of 88%, compared with T₁ times (specificity = 76%, sensitivity = 60%). In dialysis patients, VRLN was significantly and independently associated with left ventricular ejection fraction (P < 0.05), global longitudinal strain (P < 0.05), radial strain (P < 0.05), and circumferential strain (P < 0.05); however, T₁ was not.

DATA CONCLUSION

The texture features obtained by TA of T₁ images and VRLN may be a better parameter for assessing myocardial alterations than T₁ times.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 3.

Ventricular global longitudinal strain is altered in children with sickle cell disease

Cardiac disease is the primary cause of death in sickle cell disease (SCD). Right and left ventricular global longitudinal strain (RVGLS, LVGLS) are early markers of systolic dysfunction but are not well investigated among children with SCD. One hundred and forty-three patients with HbSS or HbSβ⁰ -thalassaemia (median age 11 years, range 5-19 years) and 71 controls matched for age and sex were compared. RVGLS and LVGLS were measured and compared with conventional measures of echocardiography and markers of haemolysis and inflammation. RVGLS was higher in children with SCD than in controls (-25·72% ± 3·45% vs. -24·54% ± 2·41%, P = 0·005); LVGLS was not different. RVGLS decreased with older age in children with SCD (ρ = 0·338, P < 0·001) but not among controls. Decreased RVGLS was associated with increased left atrial end diastolic volume (ρ = 0·181, P = 0·04); RVGLS increased with cardiac output (r = -0·279, P = 0·01). RVGLS and LVGLS were not associated with disease-modifying therapies, degree of anaemia or haemolysis markers. Elevated RVGLS may indicate an early RV compensatory mechanism in response to upstream myocardial insults and elevated cardiac output. Global longitudinal strain may serve as an early marker of altered myocardial function in children with SCD.

Diffuse Myocardial Interstitial Fibrosis and Dysfunction in Early Chronic Kidney Disease

Patients with chronic kidney disease (CKD) have a disproportionately high risk of cardiovascular (CV) morbidity and mortality from the very early stages of CKD. This excess risk is believed to be the result of myocardial disease commonly termed uremic cardiomyopathy (UC). It has been suggested that interstitial myocardial fibrosis progresses with advancing kidney disease and may be the key mediator of UC. This longitudinal study reports data on the myocardial structure and function of 30 patients with CKD with no known cardiovascular disease and healthy controls. All patients underwent cardiac magnetic resonance imaging including T1 mapping and late gadolinium enhancement (if estimated glomerular filtration rate > 30 ml/min/1.73 m²). Over a mean follow-up period of 2.7 ± 0.8 years, there was no change in left ventricular mass, volumes, ejection fraction, native myocardial T1 times, or extracellular volume with CKD or in healthy controls. Global longitudinal strain (20.6 ± 2.9 s⁻¹ vs 19.8 ± 2.9 s⁻¹, p = 0.03) and mitral annular planar systolic excursion (13 ± 2 mm vs 12 ± 2 mm, p = 0.009) decreased in CKD but were clinically insignificant. Midwall late gadolinium enhancement was present in 4 patients at baseline and was unchanged at follow-up. Renal function was stable in this cohort over follow-up (change in estimated glomerular filtration rate was −3 ml/min/1.73 m²) with no adverse clinical CV events. In conclusion, this study demonstrates that in a cohort of patients with stable CKD, left ventricular mass, native T1 times, and extracellular volume do not increase over a period of 2.7 years.

Novel cardiac nuclear magnetic resonance method for noninvasive assessment of myocardial fibrosis in hemodialysis patients

Left ventricular hypertrophy and myocardial fibrosis frequently occur in patients with end-stage renal disease receiving hemodialysis therapy and are associated with poor prognosis. Native T1 mapping is a novel cardiac magnetic resonance imaging technique that measures native myocardial T1 relaxation, a surrogate of myocardial fibrosis. Here we compared global and segmental native myocardial T1 time and global longitudinal, circumferential and segmental strain, and cardiac function of 35 hemodialysis patients and 22 control individuals. The median native global T1 time was significantly higher in the hemodialysis than the control group (1270 vs. 1085 ms), with the septal regions of hemodialysis patients having significantly higher median T1 times than nonseptal regions (1293 vs. 1252 ms). The mean peak global circumferential strain and global longitudinal strain were both significantly reduced in hemodialysis patients compared with controls (-18.3 vs. -21.7 and -16.1 vs. -20.4, respectively). Systolic strain was also significantly reduced in the septum compared with the nonseptal myocardium in hemodialysis patients (-16.2 vs. -21.9) but not in control subjects. Global circumferential strain and longitudinal strain significantly correlated with global native T1 values (r = 0.41 and 0.55, respectively), and the septal native T1 significantly correlated with the septal systolic strain (r = 0.46). Thus, myocardial fibrosis may be assessed noninvasively with native T1 mapping; the interventricular septum appears to be particularly prone to the development of fibrosis in hemodialysis patients.

Hypertension, Left Ventricular Hypertrophy, and Myocardial Ischemia

The risks associated with hypertension emerge through a series of complex interactions. Myocardial ischemia is the major contributor to this risk. The mechanisms driving ischemia reflect many of the key factors in hypertension, including endothelial and neurohumoral factors, fibrosis, and hemodynamics. Left ventricular hypertrophy and fibrosis are of fundamental importance and together with hemodynamics provide an optimal template for myocardial ischemia. Understanding the pathophysiology has aided a more rational management approach but challenges remain which, if surmounted, will have an impact on the morbidity and mortality caused by myocardial ischemia in patients with hypertension.

Reduced long axis strain is associated with heart failure and cardiovascular events in the multi-ethnic study of Atherosclerosis

PURPOSE

To propose long axis strain (LAS), a novel index of global left ventricle (LV) function, as a sensitive and powerful predictor of hard cardiovascular events and heart failure in the Multi-Ethnic Study of Atherosclerosis (MESA).

MATERIALS AND METHODS

Strain is an index of relative myocardial deformation, and enables normalization for differences in heart size. Measurement of strain conventionally requires dedicated software and protocols for image acquisition. LAS, however, can be analyzed using a caliper tool from conventional LV long axis magnetic resonance imaging (MRI) cine loops, reflecting the average myocardial contraction in the longitudinal direction. In all, 1651 participants (53% men) of the MESA study, without a history of myocardial infarction or heart failure, were assessed using conventional cine MR images. LV lengths were assessed at end-diastole (EDL ) and end-systole (ESL ), and LAS was calculated as 100*(EDL -ESL )/EDL . Participants were followed for 6.8 ± 1.8 years for a composite endpoint of congestive heart failure or hard cardiovascular events, and the predictive ability of LAS was tested, unadjusted and adjusted for established cardiovascular risk factors.

RESULTS

A total of 114 events were observed. Mean LAS was 11.7 ± 2.5% and 10.0 ± 2.7% in participants without and with events, respectively (P < 0.001). Increased LAS reduced the hazard ratio to 0.75 for univariate, and 0.88 for multivariate assessments, respectively (both P < 0.001).

CONCLUSION

Assessment of long axis LV deformation by LAS is feasible and reproducible. Moreover, LAS predicts hard cardiovascular events and congestive heart failure in a multi-ethnic population without overt cardiovascular disease at inclusion. J. Magn. Reson. Imaging 2016;44:178-185.

Simultaneous Assessment of Myocardial Perfusion, Wall Motion, and Deformation during Myocardial Contrast Echocardiography: A Feasibility Study

AIMS

Ultrasound contrast agents may be used for the assessment of regional wall motion and myocardial perfusion, but are generally considered not suitable for deformation analysis. The aim of our study was to assess the feasibility of deformation imaging on contrast-enhanced images using a novel methodology.

METHODS AND RESULTS

We prospectively enrolled 40 patients who underwent stress echocardiography with continuous intravenous infusion of SonoVue for the assessment of myocardial perfusion imaging with flash replenishment technique. We compared longitudinal strain (Lε) values, assessed with a vendor-independent software (2D CPA), on 68 resting contrast-enhanced and 68 resting noncontrast recordings. Strain analysis on contrast recordings was evaluated in the first cardiac cycles after the flash. Tracking of contrast images was deemed feasible in all subjects and in all views. Contrast administration improved image quality and increased the number of segments used for deformation analysis. Lε of noncontrast and contrast-enhanced images were statistically different (-18.8 ± 4.5% and -22.8 ± 5.4%, respectively; P < 0.001), but their correlation was good (ICC 0.65, 95%CI 0.42-0.78). Patients with resting wall-motion abnormalities showed lower Lε values on contrast recordings (-18.6 ± 6.0% vs. -24.2 ± 5.5%, respectively; P < 0.01). Intra-operator and inter-operator reproducibility was good for both noncontrast and contrast images with no statistical differences.

CONCLUSIONS

Our study shows that deformation analysis on postflash contrast-enhanced images is feasible and reproducible. Therefore, it would be possible to perform a simultaneous evaluation of wall-motion abnormalities, volumes, ejection fraction, perfusion defects, and cardiac deformation on the same contrast recording.

Comprehensive Echocardiographic Detection of Treatment-Related Cardiac Dysfunction in Adult Survivors of Childhood Cancer: Results From the St. Jude Lifetime Cohort Study

BACKGROUND

Treatment-related cardiac death is the primary, noncancer cause of mortality in adult survivors of childhood malignancies. Early detection of cardiac dysfunction may identify a high-risk subset of survivors for early intervention.

OBJECTIVES

This study sought to determine the prevalence of cardiac dysfunction in adult survivors of childhood malignancies.

METHODS

Echocardiographic assessment included 3-dimensional (3D) left ventricular ejection fraction (LVEF), global longitudinal and circumferential myocardial strain, and diastolic function, graded per American Society of Echocardiography guidelines in 1,820 adult (median age 31 years; range: 18 to 65 years) survivors of childhood cancer (median time from diagnosis 23 years; range: 10 to 48 years) exposed to anthracycline chemotherapy (n = 1,050), chest-directed radiotherapy (n = 306), or both (n = 464).

RESULTS

Only 5.8% of survivors had abnormal 3D LVEFs (<50%). However, 32.1% of survivors with normal 3D LVEFs had evidence of cardiac dysfunction by global longitudinal strain (28%), American Society of Echocardiography-graded diastolic assessment (8.7%), or both. Abnormal global longitudinal strain was associated with chest-directed radiotherapy at 1 to 19.9 Gy (rate ratio [RR]: 1.38; 95% confidence interval [CI]: 1.14 to 1.66), 20 to 29.9 Gy (RR: 1.65; 95% CI: 1.31 to 2.08), and >30 Gy (RR: 2.39; 95% CI: 1.79 to 3.18) and anthracycline dose > 300 mg/m(2) (RR: 1.72; 95% CI: 1.31 to 2.26). Survivors with metabolic syndrome were twice as likely to have abnormal global longitudinal strain (RR: 1.94; 95% CI: 1.66 to 2.28) and abnormal diastolic function (RR: 1.68; 95% CI: 1.39 to 2.03) but not abnormal 3D LVEFs (RR: 1.07; 95% CI: 0.74 to 1.53).

CONCLUSIONS

Abnormal global longitudinal strain and diastolic function are more prevalent than reduced 3D LVEF and are associated with treatment exposure. They may identify a subset of survivors at higher risk for poor clinical cardiac outcomes who may benefit from early medical intervention.

Diffuse interstitial fibrosis and myocardial dysfunction in early chronic kidney disease

Early-stage chronic kidney disease (CKD) is an under-recognized highly prevalent cardiovascular (CV) risk factor. Despite a clustering of conventional atherosclerotic risk factors, it is hypothesized that nonatherosclerotic processes, including left ventricular (LV) hypertrophy and fibrosis, account for a significant excess of CV risk. This cross-sectional observational study of 129 age- (mean age 57±10 years) and gender-matched subjects examined: nondiabetic CKD stages 2 to 4 (mean glomerular filtration rate 50±22 ml/min/1.73 m2) with no history of CV disease, subjects who are hypertensive with normal renal function, and healthy controls. Cardiac magnetic resonance imaging was performed for assessment of LV volumes and systolic function (myocardial deformation). Diffuse myocardial fibrosis was assessed using T1 mapping for native myocardial T1 times before contrast and myocardial extracellular volume (ECV) after gadolinium administration in combination with standard late gadolinium enhancement techniques for detection of coarse fibrosis. Patients with CKD had increased native T1 times (986±37 ms) and ECV (0.28±0.04) compared with controls (955±30 ms, 0.25±0.03) and subjects who are hypertensive (956±31 ms, 0.25±0.02, p<0.05). Both T1 times and ECV were correlated with impaired systolic function as assessed by global longitudinal systolic strain (r=-0.22, p<0.05, and r=-0.43, p<0.01, respectively). There were no differences in LV volumes, ejection fraction, or LV mass. T1 times and ECV did not correlate with conventional CV risk factors. In conclusion, diffuse myocardial fibrosis is increased in early CKD and is associated with abnormal global longitudinal strain, an early feature of uremic cardiomyopathy and a key indicator of adverse CV prognosis.

Left ventricular strain and its pattern estimated from cine CMR and validation with DENSE

Measurement of local strain provides insight into the biomechanical significance of viable myocardium. We attempted to estimate myocardial strain from cine cardiovascular magnetic resonance (CMR) images by using a b-spline deformable image registration method. Three healthy volunteers and 41 patients with either recent or chronic myocardial infarction (MI) were studied at 1.5 Tesla with both cine and DENSE CMR. Regional circumferential and radial left ventricular strains were estimated from cine and DENSE acquisitions. In all healthy volunteers, there was no difference for peak circumferential strain (- 0.18 ± 0.04 versus - 0.18 ± 0.03, p = 0.76) between cine and DENSE CMR, however peak radial strain was overestimated from cine (0.84 ± 0.37 versus 0.49 ± 0.2, p < 0.01). In the patient study, the peak strain patterns predicted by cine were similar to the patterns from DENSE, including the strain evolution related to recovery time and strain patterns related to MI scar extent. Furthermore, cine-derived strain disclosed different strain patterns in MI and non-MI regions, and regions with transmural and non-transmural MI as DENSE. Although there were large variations with radial strain measurements from cine CMR images, useful circumferential strain information can be obtained from routine clinical CMR imaging. Cine strain analysis has potential to improve the diagnostic yield from routine CMR imaging in clinical practice.

Acute and chronic effects of smoking on myocardial function in healthy heavy smokers: a study of Doppler flow, Doppler tissue velocity, and two-dimensional speckle tracking echocardiography

BACKGROUND

The purpose of the study was to evaluate the acute and chronic effect of smoking on left ventricular function in healthy heavy smokers by conventional Doppler flow, tissue Doppler, and two-dimensional speckle tracking echocardiography (2D-STE).

METHODS

Echocardiograms were performed in 42 healthy heavy (>20 cigarettes/day) smokers (age 34 ± 5 years), before (group SM-1), 15 minutes (SM-2) and 30 minutes (SM-3) after starting smoking 2 cigarettes. Nonsmokers (n = 41, age 33 ± 4 years) served as controls. Transmitral flow, isovolumetric relaxation time (IVRT), and myocardial performance index (MPI) were measured. Tissue velocity measurements were averaged from lateral and septal mitral annulus. Longitudinal strain (GS), systolic (SRs), early diastolic (SRe), late diastolic (SRa), and isovolumetric relaxation (SRivr) strain rate were measured. The percent change in strain from end-systole to the first one-third of diastole (SI-DI = [(GS - strain at one-third diastole)/GS] × 100) was also measured.

RESULTS

IVRT and MPI were increased and early diastolic mitral annular velocity was decreased in SM-2; they returned to baseline in SM-3. There was no difference in GS and SRs. SRe and SRivr were reduced in SM-1 (P < 0.05), and remained significantly reduced in SM-2 and SM-3. SI-DI was lower in SM-1 (P = 0.011) and was further reduced in SM-2 and SM-3 (P < 0.001).

CONCLUSION

Acute and chronic smoking inhalation has adverse effects on myocardial function in healthy heavy smokers. 2D-STE is able to detect both baseline differences and late acute effects of smoking.

Myocardial strain estimated from standard cine MRI closely represents strain estimated from dedicated strain-encoded MRI

A method of non-rigid image registration was developed and evaluated for the purpose of quantifying myocardial displacement and strain from cine MRI using DENSE MRI as the reference standard. The objective of this paper was to study the potential use of cine MRI with image registration, as a means of measuring strain. The local displacement of the left ventricle was modelled by free-form deformations using b-splines. Cardiac MRI images were obtained from four healthy volunteers at 1.5T and analysed by the implementation of image registration algorithms in cine data and with DENSE view in DENSE data. The results indicated there was less than 3% difference between the strain values obtained from cine and DENSE scans averaging across the regions of the left ventricle in healthy subjects (n=4). There lies great potential in the implementation of cine MRI as a means of strain estimation. As such the measurement of strain from standard cine MRI poses an appealing and potentially clinically useful new option for assessing patients with myocardial dysfunction.