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Bhatt N, Orbach A, Biswas L, Strauss BH, Connelly K, Ghugre NR, Wright GA, Roifman I. Evaluating a novel accelerated free-breathing late gadolinium enhancement imaging sequence for assessment of myocardial injury. Magn Reson Imaging 2024; 108:40-46. [PMID: 38309379 DOI: 10.1016/j.mri.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/31/2024] [Accepted: 01/31/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Cardiac magnetic resonance imaging (MRI), including late gadolinium enhancement (LGE), plays an important role in the diagnosis and prognostication of ischemic and non-ischemic myocardial injury. Conventional LGE sequences require patients to perform multiple breath-holds and require long acquisition times. In this study, we compare image quality and assessment of myocardial LGE using an accelerated free-breathing sequence to the conventional standard-of-care sequence. METHODS In this prospective cohort study, a total of 41 patients post Coronavirus 2019 (COVID-19) infection were included. Studies were performed on a 1.5 Tesla scanner with LGE imaging acquired using a conventional inversion recovery rapid gradient echo (conventional LGE) sequence followed by the novel accelerated free-breathing (FB-LGE) sequence. Image quality was visually scored (ordinal scale from 1 to 5) and compared between conventional and free-breathing sequences using the Wilcoxon rank sum test. Presence of per-segment LGE was identified according to the American Heart Association 16-segment myocardial model and compared across both conventional LGE and FB-LGE sequences using a two-sided chi-square test. The perpatient LGE extent was also evaluated using both sequences and compared using the Wilcoxon rank sum test. Interobserver variability in detection of per-segment LGE and per-patient LGE extent was evaluated using Cohen's kappa statistic and interclass correlation (ICC), respectively. RESULTS The mean acquisition time for the FB-LGE sequence was 17 s compared to 413 s for the conventional LGE sequence (P < 0.001). Assessment of image quality was similar between both sequences (P = 0.19). There were no statistically significant differences in LGE assessed using the FB-LGE versus conventional LGE on a per-segment (P = 0.42) and per-patient (P = 0.06) basis. Interobserver variability in LGE assessment for FB-LGE was good for per-segment (= 0.71) and per-patient extent (ICC = 0.92) analyses. CONCLUSIONS The accelerated FB-LGE sequence performed comparably to the conventional standard-of-care LGE sequence in a cohort of patients post COVID-19 infection in a fraction of the time and without the need for breath-holding. Such a sequence could impact clinical practice by increasing cardiac MRI throughput and accessibility for frail or acutely ill patients unable to perform breath-holding.
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Affiliation(s)
- Nitish Bhatt
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ady Orbach
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Labonny Biswas
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bradley H Strauss
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kim Connelly
- Division of Cardiology, St. Michael's Hospital, Toronto, ON, Canada
| | - Nilesh R Ghugre
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Graham A Wright
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Physical Sciences Platform, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Idan Roifman
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Khachatoorian Y, Fuisz A, Frishman WH, Aronow WS, Ranjan P. The Significance of Parametric Mapping in Advanced Cardiac Imaging. Cardiol Rev 2024:00045415-990000000-00243. [PMID: 38595125 DOI: 10.1097/crd.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
Cardiac magnetic resonance imaging has witnessed a transformative shift with the integration of parametric mapping techniques, such as T1 and T2 mapping and extracellular volume fraction. These techniques play a crucial role in advancing our understanding of cardiac function and structure, providing unique insights into myocardial tissue properties. Native T1 mapping is particularly valuable, correlating with histopathological fibrosis and serving as a marker for various cardiac pathologies. Extracellular volume fraction, an early indicator of myocardial remodeling, predicts adverse outcomes in heart failure. Elevated T2 relaxation time in cardiac MRI indicates myocardial edema, enabling noninvasive and early detection in conditions like myocarditis. These techniques offer precise insights into myocardial properties, enhancing the accuracy of diagnosis and prognosis across a spectrum of cardiac conditions, including myocardial infarction, autoimmune diseases, myocarditis, and sarcoidosis. Emphasizing the significance of these techniques in myocardial tissue analysis, the review provides a comprehensive overview of their applications and contributions to our understanding of cardiac diseases.
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Affiliation(s)
- Yeraz Khachatoorian
- From the Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
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Gatti M, Palmisano A, Gerboni M, Cau R, Pintus A, Porcu M, Tore D, Vignale D, Andreis A, Bergamasco L, De Ferrari GM, Esposito A, Saba L, Fonio P, Faletti R. Value of a short non-contrast CMR protocol in MINOCA. Eur Radiol 2024; 34:994-1002. [PMID: 37581660 PMCID: PMC10853081 DOI: 10.1007/s00330-023-10096-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/24/2023] [Accepted: 05/30/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVES To evaluate the diagnostic performance of a short non-contrast CMR (ShtCMR) protocol relative to a matched standard comprehensive CMR (StdCMR) protocol in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA). METHODS This multicenter retrospective study included patients with a working diagnosis of MINOCA who underwent a StdCMR between January 2019 and December 2020. An expert and a non-expert reader performed a blinded reading with the ShtCMR (long-axis cine images, T2w-STIR, T1- and T2-mapping). A consensus reading of the StdCMR (reference standard) was performed at least 3 months after the ShtCMR reading session. Readers were asked to report the following: (1) diagnosis; (2) level of confidence in their diagnosis with the ShtCMR; (3) number of myocardial segments involved, and (4) functional parameters. RESULTS A total of 179 patients were enrolled. The ShtCMR lasted 21 ± 9 min and the StdCMR 45 ± 11 min (p < 0.0001). ShtCMR allowed reaching the same diagnosis as StdCMR in 85% of patients when interpreted by expert readers (rising from 66% for poor confidence to 99% for good, p = 0.0001) and in 73% (p = 0.01) by non-expert ones (60% for poor vs 89% for good confidence, p = 0.0001). Overall, the ShtCMR overestimated the ejection fraction, underestimated cardiac volumes (p < 0.01), and underestimated the number of segments involved by pathology (p = 0.0008) when compared with the StdCMR. CONCLUSION The ShtCMR was found to be a debatable alternative to the StdCMR in patients with MINOCA. Nevertheless, when an experienced reader reaches a good or very good diagnostic confidence using the ShtCMR, the reader may choose to stop the examination, reducing the length of the CMR without affecting the patient's diagnosis. CLINICAL RELEVANCE STATEMENT A short non-contrast CMR protocol may be a viable alternative to standard protocols in selected CMR studies of patients with MINOCA, allowing for faster diagnosis while reducing time and resources and increasing the number of patients who can be scanned. KEY POINTS • The ShtCMR lasted 21 ± 9 min and the StdCMR 45 ± 11 min (p < 0.0001). • In 57% of patients with MINOCA, the experienced reader considers that contrast medium is probably not necessary for diagnosis without affecting the patient's diagnosis (99% of agreement rate between ShtCMR and StdCMR).
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Affiliation(s)
- Marco Gatti
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy.
| | - Anna Palmisano
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Mattia Gerboni
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Riccardo Cau
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Alessandra Pintus
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Michele Porcu
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Davide Tore
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Davide Vignale
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Andreis
- Division of Cardiology, Department Cardiovascular and Thoracic, Città Della Salute E Della Scienza Hospital, University of Turin, Turin, Italy
| | - Laura Bergamasco
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department Cardiovascular and Thoracic, Città Della Salute E Della Scienza Hospital, University of Turin, Turin, Italy
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Saba
- Department of Radiology, AOU Cagliari, University of Cagliari, Cagliari, Italy
| | - Paolo Fonio
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
| | - Riccardo Faletti
- Radiology Unit, Department of Surgical Sciences, University of Turin, Via Genova 3, 10126, Turin, Italy
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Liang K, Bisaccia G, Leo I, Williams MGL, Dastidar A, Strange JW, Sammut E, Johnson TW, Bucciarelli-Ducci C. CMR reclassifies the majority of patients with suspected MINOCA and non MINOCA. Eur Heart J Cardiovasc Imaging 2023; 25:8-15. [PMID: 37526288 DOI: 10.1093/ehjci/jead182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/16/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023] Open
Abstract
AIMS In ∼5-15% of all cases of acute coronary syndromes (ACS) have unobstructed coronaries on angiography. Cardiac magnetic resonance (CMR) has proven useful to identify in most patients the underlying diagnosis associated with this presentation. However, the role of CMR to reclassify patients from the initial suspected condition has not been clarified. The aim of this study was to assess the proportion of patients with suspected MINOCA, or non-MINOCA, that CMR reclassifies with an alternative diagnosis from the original clinical suspicion. METHODS AND RESULTS A retrospective cohort of patients in a tertiary cardiology centre was identified from a registry database. Patients who were referred for CMR for investigation of suspected MINOCA, and a diagnosis pre- and post-CMR was recorded to determine the proportion of diagnoses reclassified. A total of 888 patients were identified in the registry. CMR reclassified diagnosis in 78% of patients. Diagnosis of MINOCA was confirmed in only 243 patients (27%), whilst most patients had an alternative diagnosis (73%): myocarditis n = 217 (24%), Takotsubo syndrome n = 115 (13%), cardiomyopathies n = 97 (11%), and normal CMR/non-specific n = 216 (24%). CONCLUSION In a large single-centre cohort of patients presenting with ACS and unobstructed coronary arteries, most patients had a non-MINOCA diagnosis (73%) (myocarditis, Takotsubo, cardiomyopathies, or normal CMR/non-specific findings), whilst only a minority had confirmed MINOCA (27%). Performing CMR led to reclassifying patients' diagnosis in 78% of cases, thus confirming its important clinical role and underscoring the clinical challenge in diagnosing MINOCA and non MINOCA conditions.
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Affiliation(s)
- Kate Liang
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Upper Maudlin Street, Bristol, BS2 8HY, UK
| | - Giandomenico Bisaccia
- Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Trust, Royal Brompton Hospital, Sydney Street, Greater London, SW3 6NP, UK
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Isabella Leo
- Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Trust, Royal Brompton Hospital, Sydney Street, Greater London, SW3 6NP, UK
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Matthew G L Williams
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Upper Maudlin Street, Bristol, BS2 8HY, UK
| | - Amardeep Dastidar
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Upper Maudlin Street, Bristol, BS2 8HY, UK
| | - Julian W Strange
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Upper Maudlin Street, Bristol, BS2 8HY, UK
| | - Eva Sammut
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Upper Maudlin Street, Bristol, BS2 8HY, UK
| | - Thomas W Johnson
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Senate House, Tyndall Avenue, Bristol, BS8 1TH, UK
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Upper Maudlin Street, Bristol, BS2 8HY, UK
| | - Chiara Bucciarelli-Ducci
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Upper Maudlin Street, Bristol, BS2 8HY, UK
- Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Trust, Royal Brompton Hospital, Sydney Street, Greater London, SW3 6NP, UK
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, Westminster Bridge Road, Kings College London, Strand, London, WC2R 2LS, UK
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Fan HP, Rui JQ, Xin CX, Zhou Y, Jin J, Hu XF. Medium-Term Prognostic Implications of Cardiac Magnetic Resonance Imaging in Patients With Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): A Systematic Review and Meta-Analysis. Heart Lung Circ 2023; 32:1334-1346. [PMID: 37919116 DOI: 10.1016/j.hlc.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 08/22/2023] [Accepted: 09/04/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND This study aimed to evaluate the medium-term prognostic implications of cardiac magnetic resonance (CMR) imaging in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA). METHODS A systematic literature search of Embase, PubMed, and The Cochrane Library was performed. Eligible studies reported outcomes of CMR-assessed MINOCA with a mean follow-up period of >6 months. The primary endpoint was all-cause death. Secondary endpoints included cardiac death, reinfarction, and cardiovascular rehospitalisation. The pooled effect sizes with 95% confidence interval (CIs) were estimated using a random effect model. RESULTS A total of 3,050 patients from twenty-one studies were included in the meta-analysis. The prevalence of myocarditis, "true" myocardial infarction, Takotsubo cardiomyopathy, and normal CMR imaging was 36%, 25%, 14%, and 19%, respectively. Pooled data showed that the annualised event rates for all-cause mortality, cardiac mortality, reinfarction, and cardiovascular rehospitalisation were 1.01% (95% CI 0.59%-1.51%), 0.06% (95% CI 0.00%-0.39%), 0.68% (95% CI 0.18%-1.38%), and 5.67% (95% CI 3.11%-8.85%), respectively. Compared with patients with a diagnosis of myocarditis on CMR, patients with Takotsubo cardiomyopathy (RR 7.11; 95% CI 3.04-16.66) and "true" myocardial infarction (RR 3.82; 95% CI 1.65-8.86) were associated with a significantly higher risk of all-cause mortality, whereas a similar risk of all-cause mortality was observed in patients with normal imaging (RR 1.01; 95% CI 0.28-3.59). No association was found between CMR diagnoses and the risk of secondary endpoints in MINOCA. CONCLUSIONS In patients with MINOCA assessed by CMR, the overall absolute incidence rates of mortality and reinfarction were low. However, certain imaging diagnoses were associated with a higher risk of all-cause mortality, with most deaths attributed to non-cardiac causes. Additionally, these patients experienced a high burden of cardiovascular rehospitalisation. REGISTRATION PROSPERO (CRD42022323615).
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Affiliation(s)
- Hua-Ping Fan
- Department of Cardiology, 63650 Military Hospital, Urumqi, China
| | - Jian-Qiao Rui
- Department of Internal Medicine, Jingxi Medical District, PLA General Hospital, Beijing, China
| | - Chen-Xi Xin
- School of International Education, Xinxiang Medical University, Xinxiang, China
| | - Yu Zhou
- Department of Cardiology, 63650 Military Hospital, Urumqi, China
| | - Jun Jin
- Institute of Cardiovascular Diseases, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiao-Fei Hu
- Department of Nuclear Medicine, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.
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Capasso R, Imperato MC, Serra N, Rodriguez R, Rivellini M, De Filippo M, Pinto A. Infarct-like versus Non-Infarct-like Clinical Presentation of Acute Myocarditis: Comparison of Cardiac Magnetic Resonance (CMR) Findings. Diagnostics (Basel) 2023; 13:2498. [PMID: 37568861 PMCID: PMC10416923 DOI: 10.3390/diagnostics13152498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/23/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The clinical presentation of acute myocarditis (AM) is widely variable, ranging from a subclinical disease to an infarct-like syndrome. Cardiac magnetic resonance (CMR) has become the reference non-invasive diagnostic tool for suspected AM, allowing the identification of the various hallmarks of myocardial inflammation (edema, fibrosis, and hyperemia). The aim of the study was to investigate any differences in morphological, functional, and tissue characterization CMR parameters between infarct-like AM in patients with unobstructed coronary arteries and non-infarct-like AM, diagnosed according to the original Lake-Louise Criteria (LLC); Methods: We retrospectively selected 39 patients diagnosed with AM according to LLC, divided into 2 groups according to the clinical presentation: infarct-like in group 1 patients and non-infarct-like in group 2 patients. CMR morphologic, functional, and tissue characterization parameters were analyzed and compared. RESULTS In group 1, CMR tissue characterization parameters were mainly altereda in septal location with mesocardial myocardial involvement; in group 2, CMR tissue characterization parameters were mainly altered in a lateral location with subepicardial myocardial involvement mainly at the mid-cavity. No significant differences in morphological or functional parameters were observed between the two study groups. CONCLUSIONS Our results showed differences in the localization and distribution of myocardial tissue damage assessed by CMR among forms of AM accompanied by an infarct-like clinical presentation compared with non-infarct-like presentations of AM. The mechanisms underlying the different preferential sites of damage observed in our study are not known, and we do not exclude the possibility of their prognostic implications.
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Affiliation(s)
- Raffaella Capasso
- Department of Radiology, CTO Hospital, Azienda Ospedaliera dei Colli, Viale Colli Aminei 21, 80141 Naples, Italy (M.R.); (A.P.)
| | - Maria Chiara Imperato
- Department of Radiology, Santa Maria Incoronata dell’Olmo Hospital, 84013 Cava de’Tirreni, Italy;
| | - Nicola Serra
- Department of Public Health, University Federico II of Naples, 80131 Naples, Italy;
| | - Reimy Rodriguez
- Department of Radiology, CTO Hospital, Azienda Ospedaliera dei Colli, Viale Colli Aminei 21, 80141 Naples, Italy (M.R.); (A.P.)
| | - Maria Rivellini
- Department of Radiology, CTO Hospital, Azienda Ospedaliera dei Colli, Viale Colli Aminei 21, 80141 Naples, Italy (M.R.); (A.P.)
| | - Massimo De Filippo
- Department of Medicine and Surgery (DiMec), Section of Radiology, University of Parma, Maggiore Hospital, Via Gramsci 14, 43126 Parma, Italy;
| | - Antonio Pinto
- Department of Radiology, CTO Hospital, Azienda Ospedaliera dei Colli, Viale Colli Aminei 21, 80141 Naples, Italy (M.R.); (A.P.)
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Yu C, Meier S, Bestawros D, Sun D, Trieu J, Yong ASC, Wong CCY, Yiannikas J, Kritharides L, Beltrame JF, Naoum C. Role of Cardiac Magnetic Resonance Imaging and Troponin T in Definitive Diagnosis of Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA). Can J Cardiol 2023; 39:936-944. [PMID: 37080291 DOI: 10.1016/j.cjca.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND It is unknown whether the degree of high-sensitivity troponin T (hsTropT) elevation in patients with suspected myocardial infarction without obstructive coronary arteries (MINOCA) presentations can help predict the likelihood of an abnormal cardiac magnetic resonance (CMR) scan. In this study we describe the diagnostic utility of CMR in patients with MINOCA and assesses the effect of peak hsTropT levels at presentation on CMR diagnostic yield. METHODS Records of consecutive patients (n = 1407) referred for CMR at a tertiary referral hospital between January 2016 and September 2021 were reviewed. A total of 70 patients met the criteria of MINOCA including ischemic chest pain, elevated peak hsTropT, and nonobstructive coronary artery disease (< 50% stenosis). The peak hsTropT levels within 72 hours of admission were identified. CMR images were generated using a 3.0 T Siemens scanner. Predictors of having an abnormal CMR were evaluated. RESULTS CMR established a diagnosis in 71% (n = 50) of patients, with the most common CMR diagnosis being myopericarditis (n = 27; 39%). Time to CMR was an independent predictor of a normal CMR scan (odds ratio, 0.98; 95% confidence interval, 0.97-0.999). Peak hsTropT had a high diagnostic accuracy for identifying patients with an abnormal CMR scan (area under the receiver operator characteristic curve, 0.81; P < 0.001). The optimal hsTropT cutoff was 166 ng/L, with 72% sensitivity and specificity. A troponin value ≥ 166 ng/L was independently predictive of an abnormal CMR scan (odds ratio, 4.76; 95% confidence interval, 1.32-17.11). CONCLUSIONS HsTropT and early CMR imaging are independently predictive of an abnormal CMR scan in patients with MINOCA. Additionally, the use of a hsTropT cutoff provides incremental predictive value to clinical parameters and time to CMR scanning in determining an abnormal scan.
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Affiliation(s)
- Christopher Yu
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Silvan Meier
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Dina Bestawros
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - David Sun
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Joseph Trieu
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Andy S C Yong
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher C Y Wong
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - John Yiannikas
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Leonard Kritharides
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - John F Beltrame
- Cardiology Department, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Christopher Naoum
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.
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Supeł K, Wieczorkiewicz P, Przybylak K, Zielińska M. 2D Strain Analysis in Myocarditis-Can We Be Any Closer to Diagnose the Acute Phase of the Disease? J Clin Med 2023; 12:jcm12082777. [PMID: 37109114 PMCID: PMC10146770 DOI: 10.3390/jcm12082777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/02/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The aim of present study was to assess left ventricular myocardial deformation detected by 2D STE in patients with suspected acute myocarditis (AM) early on admission in whom later cardiac magnetic resonance (CMR) evaluation was performed. METHODS A total of 47 patients with suspected AM based on clinical practice were prospectively enrolled. Coronary angiography was performed on all patients to rule out significant coronary artery disease. CMR confirmed myocardial inflammation, oedema, and regional necrosis meeting the Lake Louise criteria in 25 patients (53%, oedema (+) subgroup). In the remaining patients, only LGE was confirmed in the sub-epicardial or intramuscular localization (22 patients, 47%, oedema (-) subgroup). Early on admission, echocardiography with measurements of global and segmental longitudinal strains (GLS), circumferential strains (GCS) at the endocardial (endocardial GCS) and epicardial (epicardial GCS) layers, transmural GCS, and radial strains (RS) were performed. RESULTS Mild reduction of GLS, GRS, and transmural GCS values were found in patients with oedema (+) subgroup. The epicardial GCS turned out to be the diagnostic factor for oedema with a cut-off point of 13,0% (AUC 0.747, p = 0.0005). Twenty-two patients (all but three) with an acute phase of myocarditis and epicardial GCS -13.0% or less had oedema confirmed by CMR. CONCLUSIONS 2D STE can help to set the diagnosis of AM in patients with acute chest pain with a normal coronary angiogram. The epicardial GCS can serve as a diagnostic factor for oedema in patients with early stage of AM. In patients presenting with signs of AM (oedema in CMR), the epicardial GCS is modified in comparison with a subgroup without oedema; therefore, this parameter could be used to improve the performance of ultrasound.
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Affiliation(s)
- Karolina Supeł
- Department of Interventional Cardiology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Paulina Wieczorkiewicz
- Department of Interventional Cardiology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Katarzyna Przybylak
- Department of Interventional Cardiology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Marzenna Zielińska
- Department of Interventional Cardiology, Medical University of Lodz, 90-419 Lodz, Poland
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Sim JY, Kim SY, Kim EK. The incidence and clinical characteristics of myocarditis and pericarditis following mRNA-based COVID-19 vaccination in Republic of Korea adolescents from July 2021 to September 2022. Osong Public Health Res Perspect 2023; 14:76-88. [PMID: 37183328 PMCID: PMC10211448 DOI: 10.24171/j.phrp.2023.0032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/15/2023] [Accepted: 03/16/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES Age-specific information regarding myocarditis/pericarditis in adolescents following mRNA-based coronavirus disease 2019 (COVID-19) vaccination in Asia remains insufficient. This study investigated the incidence and clinical characteristics of myocarditis/pericarditis in Republic of Korea adolescents after mRNA-based COVID-19 vaccination. METHODS This retrospective descriptive study utilized patient data from the Korea Immunization Management System. Incidence rates were calculated according to age and sex. Clinical characteristics (symptoms/signs, laboratory values, and imaging results) were compared between mild and severe cases. RESULTS Between July 19, 2021 and September 30, 2022, 3,728,224 individuals aged 12 to 19 years received 6,484,165 mRNA-based COVID-19 vaccines, and 173 cases met the case definition for myocarditis/pericarditis: 151 mild (87.3%) and 22 severe (12.7%). The incidence was 3.8-fold higher in males than in females. Troponin I/ troponin T was elevated in 96% of myocarditis cases, demonstrating higher sensitivity than creatine kinase-myocardial band (67.6%) or C-reactive protein (75.2%). ST-segment or Twave on electrography abnormalities were found in 60.3% (85/141). Paroxysmal/sustained atrial/ventricular arrhythmias were more common in severe than in mild cases (45.5% vs. 16.8%, p=0.008). Edema on T2-weighted magnetic imaging occurred in 21.6% (8/37) and 62.5% (5/8) of mild and severe cases, respectively (p=0.03). Abnormal pericardial fluid collection or pericardial inflammation was found in 75.4% of pericarditis cases (49/65). CONCLUSION Myocarditis/pericarditis occurred in rare cases following mRNA-based COVID-19 vaccination. Most cases were mild, but the incidence was higher in adolescent males and after the second dose. As bivalent severe acute respiratory syndrome coronavirus 2 mRNA vaccination started in Republic of Korea in October 2022, the post-vaccination incidence of myocarditis/pericarditis should be closely monitored, considering clinical characteristics.
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Affiliation(s)
- Ju-Young Sim
- Division of Healthcare Associated Infection Control, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Seung-Yun Kim
- Adverse Event Investigation Team, COVID-19 Vaccination Task Force, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Eun-Kyoung Kim
- Division of Infectious Disease Control, Bureau of Infectious Disease Policy, Korea Disease Contrㅊol and Prevention Agency, Cheongju, Republic of Korea
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10
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Difficult and Thin-Walled: The Challenges of Imaging the Right Ventricle for Clinical Decision Making. JACC. CARDIOVASCULAR IMAGING 2023; 16:42-45. [PMID: 36599568 DOI: 10.1016/j.jcmg.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 01/07/2023]
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11
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Conceição AM, Pereira CAC, Rahal MJ, Ishikawa WY, Rochitte CE. Miocardite por COVID-19 Mimetizando Infarto Miocárdico com Supradesnivelamento de Segmento ST. Arq Bras Cardiol 2022; 119:480-484. [PMID: 35857945 PMCID: PMC9438540 DOI: 10.36660/abc.20210749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 03/09/2022] [Indexed: 12/02/2022] Open
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12
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Peak Troponin and CMR to Guide Management in Suspected ACS and Nonobstructive Coronary Arteries. JACC: CARDIOVASCULAR IMAGING 2022; 15:1578-1587. [DOI: 10.1016/j.jcmg.2022.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/18/2022] [Accepted: 03/10/2022] [Indexed: 12/25/2022]
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13
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Sun CLF, Jaffe E, Levi R. Increased emergency cardiovascular events among under-40 population in Israel during vaccine rollout and third COVID-19 wave. Sci Rep 2022; 12:6978. [PMID: 35484304 PMCID: PMC9048615 DOI: 10.1038/s41598-022-10928-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/14/2022] [Indexed: 01/10/2023] Open
Abstract
Cardiovascular adverse conditions are caused by coronavirus disease 2019 (COVID-19) infections and reported as side-effects of the COVID-19 vaccines. Enriching current vaccine safety surveillance systems with additional data sources may improve the understanding of COVID-19 vaccine safety. Using a unique dataset from Israel National Emergency Medical Services (EMS) from 2019 to 2021, the study aims to evaluate the association between the volume of cardiac arrest and acute coronary syndrome EMS calls in the 16-39-year-old population with potential factors including COVID-19 infection and vaccination rates. An increase of over 25% was detected in both call types during January-May 2021, compared with the years 2019-2020. Using Negative Binomial regression models, the weekly emergency call counts were significantly associated with the rates of 1st and 2nd vaccine doses administered to this age group but were not with COVID-19 infection rates. While not establishing causal relationships, the findings raise concerns regarding vaccine-induced undetected severe cardiovascular side-effects and underscore the already established causal relationship between vaccines and myocarditis, a frequent cause of unexpected cardiac arrest in young individuals. Surveillance of potential vaccine side-effects and COVID-19 outcomes should incorporate EMS and other health data to identify public health trends (e.g., increased in EMS calls), and promptly investigate potential underlying causes.
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Affiliation(s)
- Christopher L F Sun
- Sloan School of Management, Massachusetts Institute of Technology, 100 Main Street, Cambridge, MA, 02142-1347, USA
- Healthcare Systems Engineering, Massachusetts General Hospital, Boston, MA, USA
| | - Eli Jaffe
- Israel National Emergency Medical Services (Magen David Adom), Tel Aviv-Jaffo, Israel
- Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Retsef Levi
- Sloan School of Management, Massachusetts Institute of Technology, 100 Main Street, Cambridge, MA, 02142-1347, USA.
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14
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The Diagnostic and Prognostic Utility of Contemporary Cardiac Magnetic Resonance in Suspected Acute Myocarditis. Diagnostics (Basel) 2022; 12:diagnostics12010156. [PMID: 35054323 PMCID: PMC8774755 DOI: 10.3390/diagnostics12010156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 12/31/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) is used to investigate suspected acute myocarditis, however most supporting data is retrospective and few studies have included parametric mapping. We aimed to investigate the utility of contemporary multiparametric CMR in a large prospective cohort of patients with suspected acute myocarditis, the impact of real-world variations in practice, the relationship between clinical characteristics and CMR findings and factors predicting outcome. 540 consecutive patients we recruited. The 113 patients diagnosed with myocarditis on CMR performed within 40 days of presentation were followed-up for 674 (504–915) days. 39 patients underwent follow-up CMR at 189 (166–209) days. CMR provided a positive diagnosis in 72% of patients, including myocarditis (40%) and myocardial infarction (11%). In multivariable analysis, male sex and shorter presentation-to-scan interval were associated with a diagnosis of myocarditis. Presentation with heart failure (HF) was associated with lower left ventricular ejection fraction (LVEF), higher LGE burden and higher extracellular volume fraction. Lower baseline LVEF predicted follow-up LV dysfunction. Multiparametric CMR has a high diagnostic yield in suspected acute myocarditis. CMR should be performed early and include parametric mapping. Patients presenting with HF and reduced LVEF require closer follow-up while those with normal CMR may not require it.
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CMR Imaging 6 Months After Myocarditis Associated with the BNT162b2 mRNA COVID-19 Vaccine. Pediatr Cardiol 2022; 43:1522-1529. [PMID: 35320390 PMCID: PMC8941830 DOI: 10.1007/s00246-022-02878-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/15/2022] [Indexed: 12/19/2022]
Abstract
Temporal association between BNT162b2 mRNA COVID-19 vaccine and myocarditis (PCVM) has been reported. We herein present early and 6-month clinical follow-up and cardiac magnetic resonance imaging (CMR) of patients with PVCM. A retrospective collection of data from 15 patients with PCVM and abnormal CMR was performed. Clinical manifestation, laboratory data, hospitalizations, treatment protocols, and imaging studies were collected early (up to 2 months) and later. In nine patients, an additional CMR evaluation was performed 6 months after diagnosis. PCVM was diagnosed in 15 patients, mean age 17 ± 1 (median 17.2, range 14.9-19 years) years, predominantly in males. Mean time from vaccination to onset of symptoms was 4.4 ± 6.7 (median 3, range 0-28) days. All patients had CMR post diagnosis at 4 ± 3 (median 3, range 1-9) weeks, 4/5 patients had hyper enhancement on the T2 sequences representing edemaQuery, and 12 pathological Late glandolinium enhancement. A repeat scan performed after 5-6 months was positive for scar formation in 7/9 patients. PCVM is a rare complication, affecting predominantly males and appearing usually within the first week after administration of the second dose of the vaccine. It usually is a mild disease, with clinical resolution with anti-inflammatory treatment. Late CMR follow up demonstrated resolution of the edema in all patients, while some had evidence of residual myocardial scarring.
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Palmisano A, Vignale D, Tadic M, Moroni F, De Stefano D, Gatti M, Boccia E, Faletti R, Oppizzi M, Peretto G, Slavich M, Sala S, Montorfano M, Agricola E, Margonato A, De Cobelli F, Gentile F, Robella M, Cortese G, Esposito A. Myocardial Late Contrast Enhancement CT in Troponin-Positive Acute Chest Pain Syndrome. Radiology 2021; 302:545-553. [PMID: 34874200 DOI: 10.1148/radiol.211288] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Acute chest pain with mild troponin rise and inconclusive diagnosis after clinical evaluation represents a diagnostic challenge. Triple-rule-out (TRO) CT may exclude coronary artery disease (CAD), as well as acute aortic syndrome and pulmonary embolism, but cannot help identify other causes of myocardial injury. Purpose To investigate the diagnostic value of a comprehensive CT protocol including both an angiographic and a late contrast enhancement (LCE) scan in participants with troponin-positive acute chest pain. Materials and Methods In this prospective study, consecutive patients with troponin-positive acute chest pain or anginal equivalent and inconclusive diagnosis after clinical evaluation (symptoms, markers, electrocardiography, and echocardiography) who underwent TRO CT between June 2018 and September 2020 were enrolled. TRO CT was performed to evaluate the presence of obstructive CAD (stenosis ≥50%), acute aortic syndrome, and pulmonary embolism. If the findings on the TRO CT scan were negative, an LCE CT scan was acquired after 10 minutes to assess the presence and pattern of scar and quantify the myocardial extracellular volume fraction. CT-based diagnoses were compared with diagnoses obtained with reference standard methods, including invasive coronary angiography, cardiac MRI, and endomyocardial biopsy. Results Eighty-four patients (median age, 69 years [interquartile range, 50-77 years]; 45 men) were enrolled. TRO CT helped identify obstructive CAD in 35 participants (42%), acute aortic syndrome in one (1.2%), and pulmonary embolism in six (7.1%). LCE CT scans were acquired in the remaining 42 participants. The following diagnoses were reached with use of LCE CT: myocarditis (22 of 42 participants [52%]), takotsubo cardiomyopathy (four of 42 [10%]), amyloidosis (three of 42 [7.1%]), myocardial infarction with nonobstructed coronary arteries (three of 42 [7.1%]), dilated cardiomyopathy (two of 42 [4.8%]), and negative or inconclusive findings (eight of 42 [19%]). The addition of LCE CT improved the diagnostic rate of TRO CT from 42 of 84 participants (50% [95% CI: 38.9, 61.1]) to 76 of 84 (90% [95% CI: 82.1, 95.8]) (P < .001). Conclusion A CT protocol including triple-rule-out and late contrast enhancement CT scans improved diagnostic rate in participants presenting with acute chest pain syndrome. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Nagpal and Bluemke in this issue.
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Affiliation(s)
- Anna Palmisano
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Davide Vignale
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Marijana Tadic
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Francesco Moroni
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Domenico De Stefano
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Marco Gatti
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Edda Boccia
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Riccardo Faletti
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Michele Oppizzi
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Giovanni Peretto
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Massimo Slavich
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Simone Sala
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Matteo Montorfano
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Eustachio Agricola
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Alberto Margonato
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Francesco De Cobelli
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Francesco Gentile
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Mattia Robella
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Giancarlo Cortese
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
| | - Antonio Esposito
- From the Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy (A.P., D.V., D.D.S., F.D.C., A.E.); School of Medicine, Vita-Salute San Raffaele University, Milan, Italy (A.P., D.V., E.B., F.D.C., A.E.); Department of Cardiology, University Hospital Dr Dragiša Mišović Dedinje, Belgrade, Serbia (M.T.); Interventional Cardiology Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (F.M., M.M.); UOC Diagnostica per Immagini e Radiologia Interventistica, Policlinico Universitario Campus Bio-Medico, Rome, Italy (D.D.S.); Department of Surgical Sciences, Radiology Unit, University of Turin, Turin, Italy (M.G., R.F., F.G., M.R.); Clinical Cardiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele University Hospital, Milan, Italy (M.O., M.S., A.M.); Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy (G.P., S.S.); Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Scientific Institute, Milan, Italy (E.A.); and Department of Diagnostic Radiology, Ospedale Maria Vittoria, Turin, Italy (G.C.)
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Lindahl B, Baron T, Albertucci M, Prati F. Myocardial infarction with non-obstructive coronary artery disease. EUROINTERVENTION 2021; 17:e875-e887. [PMID: 34870600 PMCID: PMC9724940 DOI: 10.4244/eij-d-21-00426] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 11/23/2022]
Abstract
As a result of the increased use of coronary angiography in acute myocardial infarction in the last two decades, myocardial infarction with non-obstructive coronary arteries (MINOCA) has received growing attention in everyday clinical practice. At the same time, research interest in MINOCA has increased significantly. MINOCA is a heterogeneous disease entity seen in 5-10% of all patients with myocardial infarction, especially in women. Clinically, MINOCA may be difficult to distinguish from other non-ischaemic conditions that can cause similar symptoms and myocardial injury. There is still some confusion around the diagnosis, investigation and management of patients with MINOCA. The present review summarises the current knowledge of MINOCA regarding epidemiology, pathophysiology, investigation, and treatment, with a special focus on imaging modalities. In addition, remaining important knowledge gaps are highlighted.
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Affiliation(s)
- Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Elsafty HG, El Shafey M, El Arabawy R, Mahrous MR, Dawoud TM. Could native T1 mapping replace late gadolinium enhancement in the assessment of myocardial fibrosis in patients with cardiomyopathy? THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00520-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cardiomyopathy is a myocardial disease, which usually demonstrates improper ventricular morphology, function, or both. It is classified into two classes based on the organ involved. Primary cardiomyopathy is confined mainly to the myocardium and can be genetic, non-genetic, or acquired. Secondary cardiomyopathy is caused by generalized systemic disorder. Myocardial fibrosis produces abnormal myocardial stiffness and increases arrhythmias risk. Native T1-mapping is an innovative technique that provides quantitative assessment of edema, diffuse myocardial fibrosis, and inflammation in a number of disease states. Furthermore native T1 mapping provides a future method for quantifying myocardial fibrosis in advanced chronic kidney disease and dialysis patients without the use of gadolinium-based contrast agents. So our aim is to assess the potential value of segmental quantification of myocardial fibrosis using native T1 mapping in different types of cardiomyopathy in comparison to late gadolinium enhancement (LGE) imaging.
Results
The native T1 values of a total 1152 segments (16 segments in 72 patients of cardiomyopathy), 192 segments in 12 patients with hypertrophic cardiomyopathy (HCM), 800 segments in 50 patients with dilated cardiomyopathy (DCM), 80 segments in 5 patients with infiltrative cardiomyopathy, and 80 segments in 5 patients with non-compaction were assessed. These were compared with 160 segments of 10 healthy volunteers. Native T1 values were significantly higher in most of myocardial segments with LGE than in those without including the control group; non-contrast T1 values in mid LV septal segments were found the most significant (1130.85 ± 79.79 ms vs 1047.74 ± 42.74 ms; P = 0.001). Also the current study showed T1 values were significantly higher than normal even in segments unaffected by LGE (P<0.01) in both HCM and DCM groups. A receiver operating characteristic (ROC) analysis revealed the required cutoff value of 1070 ms for detecting myocardial fibrosis with a sensitivity 66% and specificity of 68%.
Conclusion
Contrast-free T1-mapping is a new technique for detecting myocardial fibrosis objectively with a high diagnostic performance especially in patients who cannot afford gadolinium contrast agents as patients with end-stage renal disease.
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Cardiac pathology 6 months after hospitalization for COVID-19 and association with the acute disease severity. Am Heart J 2021; 242:61-70. [PMID: 34400140 PMCID: PMC8363180 DOI: 10.1016/j.ahj.2021.08.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) may cause myocardial injury and myocarditis, and reports of persistent cardiac pathology after COVID-19 have raised concerns of long-term cardiac consequences. We aimed to assess the presence of abnormal cardiovascular resonance imaging (CMR) findings in patients recovered from moderate-to-severe COVID-19, and its association with markers of disease severity in the acute phase. METHODS Fifty-eight (49%) survivors from the prospective COVID MECH study, underwent CMR median 175 [IQR 105-217] days after COVID-19 hospitalization. Abnormal CMR was defined as left ventricular ejection fraction (LVEF) <50% or myocardial scar by late gadolinium enhancement. CMR indices were compared to healthy controls (n = 32), and to circulating biomarkers measured during the index hospitalization. RESULTS Abnormal CMR was present in 12 (21%) patients, of whom 3 were classified with major pathology (scar and LVEF <50% or LVEF <40%). There was no difference in the need of mechanical ventilation, length of hospital stay, and vital signs between patients with vs without abnormal CMR after 6 months. Severe acute respiratory syndrome coronavirus 2 viremia and concentrations of inflammatory biomarkers during the index hospitalization were not associated with persistent CMR pathology. Cardiac troponin T and N-terminal pro-B-type natriuretic peptide concentrations on admission, were higher in patients with CMR pathology, but these associations were not significant after adjusting for demographics and established cardiovascular disease. CONCLUSIONS CMR pathology 6 months after moderate-to-severe COVID-19 was present in 21% of patients and did not correlate with severity of the disease. Cardiovascular biomarkers during COVID-19 were higher in patients with CMR pathology, but with no significant association after adjusting for confounders. TRIAL REGISTRATION COVID MECH Study ClinicalTrials.gov Identifier: NCT04314232.
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20
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The evolving role of cardiac imaging in patients with myocardial infarction and non-obstructive coronary arteries. Prog Cardiovasc Dis 2021; 68:78-87. [PMID: 34600948 DOI: 10.1016/j.pcad.2021.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 08/29/2021] [Indexed: 01/02/2023]
Abstract
Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) represents a heterogeneous clinical conundrum accounting for about 6%-8% of all acute MI who are referred for coronary angiography. Current guidelines and consensus documents recommend that these patients are appropriately diagnosed, uncovering the causes of MINOCA, so that specific therapies can be prescribed. Indeed, there are a variety of causes that can result in this clinical condition, and for this reason diagnostic cardiac imaging has an emerging critical role in the assessment of patients with suspected or confirmed MINOCA. In last years, different cardiac imaging techniques have been evaluated in this context, and the comprehension of their strengths and limitations is of the utmost importance for their effective use in clinical practice. Moreover, recent evidence is clearly suggesting that a multimodality cardiac imaging approach, combining different techniques, seems to be crucial for a proper management of MINOCA. However, great variability still exists in clinical practice in the management of patients with suspected MINOCA, also depending on the availability of diagnostic tools and local expertise. Herein, we review the current knowledge supporting the use of different cardiac imaging techniques in patients with MINOCA, underscoring the importance of a comprehensive multimodality cardiac imaging approach and proposing a practical diagnostic algorithm to properly identify and treat the specific causes of MINOCA, in order to improve prognosis and the quality of life in these patients.
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Arangalage D, Pavon AG, Özdemir BC, Michielin O, Schwitter J, Monney P. Acute cardiac manifestations under immune checkpoint inhibitors-beware of the obvious: a case report. Eur Heart J Case Rep 2021; 5:ytab262. [PMID: 34423240 PMCID: PMC8374985 DOI: 10.1093/ehjcr/ytab262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/11/2021] [Accepted: 06/16/2021] [Indexed: 11/12/2022]
Abstract
Background Immune checkpoint inhibitors (ICI) have revolutionized the management of many cancer types by drastically improving the median survival rate of patients. However, this efficiency comes at the cost of a high rate of immune-related adverse events, including lethal cardiac manifestations. Rapidly fatal cases of ICI-induced myocarditis have been reported and drawn considerable attention over the past years. However, it is essential to bear in mind that not all cardiac events occurring under ICI therapy are necessarily myocarditis. Case summary A 61-year-old female treated with pembrolizumab for a stage IV melanoma was admitted for chest pain leading to the diagnosis of ICI-related myocarditis based on the description of a discrete left ventricular subepicardial late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging. ICI were suspended and intravenous methylprednisolone initiated. A second line anti-MEK therapy was initiated. After a month of treatment, similar chest pain occurred. CMR revealed a midventricular stress cardiomyopathy and no LGE was detected. A posteriori interrogation revealed emotional stressors preceding both episodes. Review of the first CMR, performed 2 weeks after symptom onset, indicated a pattern compatible with the recovery phase of a stress cardiomyopathy and the presence of LGE was questioned. ICI were reintroduced without recurrence of cardiac events. Discussion Not all cardiac manifestations occurring under ICI therapy are drug-related adverse events, therefore differential diagnoses must systematically be considered as the contraindication of ICI may have a major impact on patient prognosis. Cardiac imaging should be performed early and plays a key role in the management strategy.
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Affiliation(s)
- Dimitri Arangalage
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Anna Giulia Pavon
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland.,Centre of Cardiac Magnetic Resonance, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Berna C Özdemir
- Department of Oncology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Olivier Michielin
- Department of Oncology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland.,University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jurg Schwitter
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland.,Centre of Cardiac Magnetic Resonance, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland.,University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland.,Centre of Cardiac Magnetic Resonance, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland.,University of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Ammirati E, Veronese G, Bottiroli M, Wang DW, Cipriani M, Garascia A, Pedrotti P, Adler ED, Frigerio M. Update on acute myocarditis. Trends Cardiovasc Med 2021; 31:370-379. [PMID: 32497572 PMCID: PMC7263216 DOI: 10.1016/j.tcm.2020.05.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/09/2020] [Accepted: 05/26/2020] [Indexed: 12/14/2022]
Abstract
Acute myocarditis (AM), a recent-onset inflammation of the heart, has heterogeneous clinical presentations, varying from minor symptoms to high-risk cardiac conditions with severe heart failure, refractory arrhythmias, and cardiogenic shock. AM is moving from being a definitive diagnosis based on histological evidence of inflammatory infiltrates on cardiac tissue to a working diagnosis supported by high sensitivity troponin increase in association with specific cardiac magnetic resonance imaging (CMRI) findings. Though experts still diverge between those advocating for histological definition versus those supporting a mainly clinical definition of myocarditis, in the real-world practice the diagnosis of AM has undoubtedly shifted from being mainly biopsy-based to solely CMRI-based in most of clinical scenarios. It is thus important to clearly define selected settings where EMB is a must, as information derived from histology is essential for an optimal management. As in other medical conditions, a risk-based approach should be promoted in order to identify the most severe AM cases requiring appropriate bundles of care, including early recognition, transfer to tertiary centers, aggressive circulatory supports with inotropes and mechanical devices, histologic confirmation and eventual immunosuppressive therapy. Despite improvements in recognition and treatment of AM, including a broader use of promising mechanical circulatory supports, severe forms of AM are still burdened by dismal outcomes. This review is focused on recent clinical studies and registries that shed new insights on AM. Attention will be paid to contemporary outcomes and predictors of prognosis, the emerging entity of immune checkpoint inhibitors-associated myocarditis, updated CMRI diagnostic criteria, new data on the use of temporary mechanical circulatory supports in fulminant myocarditis. The role of viruses as etiologic agents will be reviewed and a brief update on pediatric AM is also provided. Finally, we summarize a risk-based approach to AM, based on available evidence and clinical experience.
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Affiliation(s)
- Enrico Ammirati
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy.
| | - Giacomo Veronese
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy; School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Maurizio Bottiroli
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Manlio Cipriani
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
| | - Andrea Garascia
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
| | - Patrizia Pedrotti
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
| | - Eric D Adler
- Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, United States
| | - Maria Frigerio
- "De Gasperis" Cardio Center, Niguarda Hospital, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milan, Italy
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Luis SA, Luis CR, Habibian M, Lwin MT, Gadowski TC, Chan J, Hamilton-Craig C, Raffel OC. Prognostic Value of Cardiac Magnetic Resonance Imaging in Acute Coronary Syndrome Patients With Troponin Elevation and Nonobstructive Coronary Arteries. Mayo Clin Proc 2021; 96:1822-1834. [PMID: 33992454 DOI: 10.1016/j.mayocp.2020.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 10/27/2020] [Accepted: 11/04/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To define the diagnostic yield of cardiac magnetic resonance (CMR) in differentiating the underlying causes of myocardial infarction with nonobstructive coronary arteries (MINOCA) and to determine the long-term prognostic implications of such diagnoses. METHODS Cardiac magnetic resonance evaluation was performed in 227 patients (mean age, 56.4±14.9 years; 120 [53%] female) with a "working diagnosis" of MINOCA as defined by presentation with a troponin-positive acute coronary syndrome (troponin I >0.04 μg/L) and nonobstructed coronary arteries between January 1, 2007, and February 28, 2013. Follow-up was performed to assess the primary composite end point of myocardial infarction, heart failure, and all-cause mortality. RESULTS Cardiac magnetic resonance identified nonstructural cardiomyopathies in 97 (43%) patients, myocardial infarction in 55 (24%) patients, structural cardiomyopathies in 27 (12%) patients, and pulmonary embolism in 1 patient. No CMR abnormalities were identified in the remaining patients. Kaplan-Meier analysis demonstrated the ability of a CMR diagnosis to predict the risk of the primary composite end point (P=.005) at 5-year follow-up. Worse outcomes were seen among patients with "true" MINOCA and a normal CMR image compared with those with CMR-confirmed myocardial infarction (P=.02). Use of antiplatelets (78% [37/45] vs 95% [52/55]; P=.01), beta blockers (56% [25/45] vs 82% [45/55]; P=.004), and statins (64% [29/45] vs 85% [47/55]; P=.01) was significantly lower in patients with true MINOCA with normal CMR imaging compared with those with CMR-confirmed myocardial infarction. CONCLUSIONS Cardiac magnetic resonance carries a high diagnostic yield in patients with MINOCA and predicts long-term prognosis. Patients with MINOCA with normal CMR imaging had an increased rate of major adverse cardiac events and lower use of guideline-recommended myocardial infarction therapy compared with those with CMR-confirmed myocardial infarction.
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Affiliation(s)
- Sushil Allen Luis
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| | - Chris R Luis
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - Mohsen Habibian
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - Myo T Lwin
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Tahlia C Gadowski
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Jonathan Chan
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, Griffith University, Gold Coast, Australia
| | - Christian Hamilton-Craig
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - Owen Christopher Raffel
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
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Pershina ES, Shchekochikhin DY, Shaginyan GM, Shilova AS, Sherashov AV, Poltavskaya MG, Isaeva SK, Gilyarov MY, Svet AV, Sinitsyn VE. Cardiovascular magnetic resonance in myocardial infarction with non-obstructive coronary arteries. TERAPEVT ARKH 2021; 93:376-380. [DOI: 10.26442/00403660.2021.04.200676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/01/2021] [Indexed: 11/22/2022]
Abstract
Aim. To analyze diagnostic performance of cardiovascular magnetic resonance (CMR) in patients, presented with myocardial infarction with nonobstructed coronary arteries (MINOCA).
Materials ant methods. 46 consecutives patients presented with myocardial infarction without evidence of obstructive coronary disease on angiography between January, 1 2018 and October 1, 2019 were included in the study. All patients underwent CMR within 10 days after admission. MRI was performed on 1.5 T Magnetic Resonance Imaging (MRI) using comprehensive protocol (T2-images, Cine-CMR, late gadolinium enhancement (LGE)).
Results. CMR revealed myocardial infarction (MI) pattern in 14 patients (30.4%), myocarditis in 12 (26.1%), hypertrophic cardiomyopathy in 6 (13.1%). In 14 patients (30.4%) no LGE was observed. Notably in 2 patients without LGE features of takotsubo syndrome were noted. Mean age was significantly lower in patients with MI versus patient with non-ischemic causes of MINOCA (56.112.3 vs 64.612.8; p=0.04). ST elevation at admission frequency didnt differ between MI and non-ischemic patients (35.7% vs 25.0%; p=0.76). However MI patients had significantly increased troponin level, 0.87 [0.22; 1.85] vs 0.22 [0.07; 0.38]; p=0.008. CMR allowed to establish the prcised clinical diagnosis in 73.9% of the cases.
Conclusion. Clinical data doesnt allow to differentiate ischemic or non-ischemic causes of MINOCA. However, CMR establish the correct diagnosis in most cases.
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Sörensson P, Ekenbäck C, Lundin M, Agewall S, Bacsovics Brolin E, Caidahl K, Cederlund K, Collste O, Daniel M, Jensen J, Y-Hassan S, Henareh L, Hofman-Bang C, Lyngå P, Maret E, Sarkar N, Spaak J, Winnberg O, Ugander M, Tornvall P. Early Comprehensive Cardiovascular Magnetic Resonance Imaging in Patients With Myocardial Infarction With Nonobstructive Coronary Arteries. JACC Cardiovasc Imaging 2021; 14:1774-1783. [PMID: 33865778 DOI: 10.1016/j.jcmg.2021.02.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/12/2021] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The objective of the SMINC-2 (Stockholm Myocardial Infarction With Normal Coronaries 2) study was to determine if more than 70% of patients with myocardial infarction with nonobstructed coronary arteries (MINOCA), investigated early with comprehensive cardiovascular magnetic resonance (CMR), could receive a diagnosis entirely by imaging. BACKGROUND The etiology of MINOCA is heterogeneous, including coronary, cardiac, and noncardiac causes. Patients with MINOCA, therefore, represent a diagnostic challenge where CMR is increasingly used. METHODS The SMINC-2 study was a prospective study of 148 patients with MINOCA imaged with 1.5-T CMR with T1 and extracellular volume mapping early after hospital admission, compared to 150 patients with MINOCA imaged using 1.5-T CMR without mapping techniques from the SMINC-1 study as historic controls. RESULTS CMR was performed at a median of 3 (SMINC-2) versus 12 (SMINC-1) days after hospital admission. In total, 77% of patients received a diagnosis with CMR imaging in the SMINC-2 study compared to 47% in the SMINC-1 study (p < 0.001). Compared to SMINC-1, CMR in SMINC-2 detected higher proportions of myocarditis (17% vs. 7%; p = 0.01) and takotsubo syndrome (35% vs. 19%; p = 0.002) but similar proportions of myocardial infarction (22% vs. 19%; p = 0.56) and other cardiomyopathies (3% vs. 2%; p = 0.46). CONCLUSIONS The results of the SMINC-2 study show that 77% of all patients with MINOCA received a diagnosis when imaged early with CMR, including advanced tissue characterization, which was a considerable improvement in comparison to the SMINC-1 study. This supports the use of early CMR imaging as a diagnostic tool in the investigation of patients with MINOCA. (Stockholm Myocardial Infarction With Normal Coronaries [SMINC]-2 Study on Diagnosis Made by Cardiac MRI [SCMINC-2]; NCT02318498).
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Affiliation(s)
- Peder Sörensson
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden.
| | - Christina Ekenbäck
- Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden; Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
| | - Magnus Lundin
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Stefan Agewall
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Elin Bacsovics Brolin
- Department of Clinical Science, Intervention and Technology at Karolinska Institutet, Division of Medical Imaging and Technology, Stockholm, Sweden; Department of Radiology, Capio St: Görans Hospital, Stockholm, Sweden
| | - Kenneth Caidahl
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Kerstin Cederlund
- Department of Clinical Science, Intervention and Technology at Karolinska Institutet, Division of Medical Imaging and Technology, Stockholm, Sweden; Department of Radiology, Södertälje Hospital, Södertälje, Sweden
| | - Olov Collste
- Cardiology Unit, Södersjukhuset, Stockholm, Sweden
| | - Maria Daniel
- Cardiology Unit, Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Jens Jensen
- Department of Radiology, Capio St: Görans Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Shams Y-Hassan
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Loghman Henareh
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Claes Hofman-Bang
- Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden; Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
| | - Patrik Lyngå
- Cardiology Unit, Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Eva Maret
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden
| | - Nondita Sarkar
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Spaak
- Karolinska Institutet, Department of Clinical Sciences, Stockholm, Sweden; Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden
| | - Oscar Winnberg
- Department of Radiology, Capio St: Görans Hospital, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, Department of Molecular Medicine and Surgery, Stockholm, Sweden; Kolling Institute, Royal North Shore Hospital, Sydney, Australia; Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Per Tornvall
- Cardiology Unit, Södersjukhuset, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
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Li H, Zhu H, Yang Z, Tang D, Huang L, Xia L. Application of Multiparametric Quantitative Cardiac Magnetic Resonance for Detection and Monitoring of Myocardial Injury in Patients with Fulminant Myocarditis. Acad Radiol 2021; 28:e35-e43. [PMID: 32199722 DOI: 10.1016/j.acra.2020.01.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/29/2020] [Accepted: 01/29/2020] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES To investigate whether multiparametric cardiac magnetic resonance (CMR) could detect and monitor inflammatory myocardial alterations in fulminant myocarditis. MATERIALS AND METHODS Nineteen patients (35 ± 14 years, 37% male) with clinical diagnosis of fulminant myocarditis underwent CMR examinations at 3.0T in the acute phase and at 3-months follow up. The control group consisted of 19 healthy volunteers. The CMR protocol included cine, black blood T2-weighted imaging, T1 mapping, T2 mapping and late gadolinium enhancement (LGE). Cardiac parameters, such as edema ratio, LGE mass, native T1, T2 and extracellular volume were measured. RESULTS The left ventricular mass index (67 ± 15 versus 55 ± 12 g/m2, p < 0.05) and interventricular septum thickness (10.4 ± 1.5 versus 8.3 ± 1.8 mm, p < 0.001) in acute stage was significantly higher compared to controls, and normalized at the chronic stage. All quantitative inflammation metrics, including edema ratio, LGE mass, native T1, T2 and extracellular volume were significantly (all p < 0.001) decreased in the follow-up scan, but still higher compared to controls. Compared to the controls, all global strain indices including circumferential, longitudinal and radial strain values were significantly impaired in acute stage (all p < 0.001). Native T1 and T2 values led to excellent diagnostic accuracy for discriminating fulminant myocarditis from healed myocarditis, with AUC of 0.947 and 0.931. CONCLUSION Multiparametric CMR could detect and monitor inflammation myocardial injuries in patients with fulminant myocarditis. Native T1 and T2 values achieved excellent diagnostic performance in distinguishing acute from healed myocarditis.
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Wetscherek M, Rutschke W, Frank C, Stehning C, Lurz P, Grothoff M, Thiele H, Gutberlet M, Lücke C. High inter- and intra-observer agreement in mapping sequences compared to classical Lake Louise Criteria assessment of myocarditis by inexperienced observers. Clin Radiol 2020; 75:796.e17-796.e26. [DOI: 10.1016/j.crad.2020.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 05/08/2020] [Indexed: 11/24/2022]
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Hausvater A, Smilowitz NR, Li B, Redel-Traub G, Quien M, Qian Y, Zhong J, Nicholson JM, Camastra G, Bière L, Panovský R, Sá M, Gerbaud E, Selvanayagam JB, Al-Mallah MH, Emrich T, Reynolds HR. Myocarditis in Relation to Angiographic Findings in Patients With Provisional Diagnoses of MINOCA. JACC Cardiovasc Imaging 2020; 13:1906-1913. [DOI: 10.1016/j.jcmg.2020.02.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 02/14/2020] [Indexed: 12/26/2022]
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Yoo SM, Jang S, Kim JA, Chun EJ. Troponin-Positive Non-Obstructive Coronary Arteries and Myocardial Infarction with Non-Obstructive Coronary Arteries: Definition, Etiologies, and Role of CT and MR Imaging. Korean J Radiol 2020; 21:1305-1316. [PMID: 32783414 PMCID: PMC7689141 DOI: 10.3348/kjr.2020.0064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/28/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022] Open
Abstract
In approximately 10% of patients with acute myocardial infarction (MI), angiography does not reveal an obstructive coronary stenosis. This is known as myocardial infarction with non-obstructive coronary arteries (MINOCA), which has complex and multifactorial causes. However, this term can be confusing and open to dual interpretation, because MINOCA is also used to describe patients with acute myocardial injury caused by ischemia-related myocardial necrosis. Therefore, with regards to this specific context of MINOCA, the generic term for MINOCA should be replaced with troponin-positive with non-obstructive coronary arteries (TpNOCA). The causes of TpNOCA can be subcategorized into epicardial coronary (causes of MINOCA), myocardial, and extracardiac disorders. Cardiac magnetic resonance imaging can confirm MI and differentiate various myocardial causes, while cardiac computed tomography is useful to diagnose the extracardiac causes.
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Affiliation(s)
- Seung Min Yoo
- Department of Radiology, CHA University Bundang Medical Center, Seongnam, Korea
| | - Sowon Jang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong A Kim
- Department of Radiology, Yonsei University Yongin Severance Hospital, Yongin, Korea
| | - Eun Ju Chun
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea.
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An DA, Shi RY, Wu R, Suo S, Han TT, Xu JR, Pu J, Wu LM. Different Myocardial Perfusion Status in Acute Myocardial Infarction and Infarct-like Myocarditis: A Novel Intravoxel Incoherent Motion Diffusion-weighted Imaging based MRI Study. Acad Radiol 2020; 27:1093-1102. [PMID: 31780393 DOI: 10.1016/j.acra.2019.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/04/2019] [Accepted: 10/16/2019] [Indexed: 11/15/2022]
Abstract
PURPOSE The following study evaluated the diagnostic value of myocardial perfusion in patients with acute myocardial infarction (AMI) and "infarct-like myocarditis" using Intravoxel Incoherent Motion-Diffusion Weighted Imaging (IVIM-DWI imaging). METHOD CMR data from 20 patients with suspected AMI, 20 patients with "infarct-like myocarditis" and 20 volunteers were retrospectively analyzed. IVIM-DWI data were acquired using multi-b value single-shot spin-echo echo-planar imaging sequence. IVIM-DWI data were generated according to the 16-segments AHA-model. Cine sequences covering left and right ventricle in short axis and three long axis were analyzed using a dedicated tissue-tracking algorithm. RESULTS Overall, the AMI T2+ segments exhibited decreased apparent diffusion coefficient (ADC), ADCslow, ADC fast and f values (1.39 ± 0.23 μm2/ms, 1.36 ± 0.23 μm2/ms, 70.77 ± 7.04 μm2/ms, and 0.1243 ± 0.01, respectively) compared to infarct-like myocarditis T2+ (1.48 ± 0.11 μm2/ms, 1.44 ± 0.11 μm2/ms, 87.66 ± 12.50 μm2/ms, and 0.1411 ± 0.02, respectively) and normal controls (1.55 ± 0.07 μm2/ms, 1.52 ± 0.06 μm2/ms, 108.84 ± 4.06 μm2/ms, and 0.1599 ± 0.01, respectively) (all p < 0.05). In addition, AMI LGE+ segments showed significantly lower IVIM-DWI associated parameters (1.34 ± 0.21 μm2/ms, 1.31 ± 0.21 μm2/ms, 68.75 ± 6.33μm2/ms, and 0.1198 ± 0.01) compared to infarct-like myocarditis LGE+ (1.42 ± 0.06 μm2/ms, 1.38 ± 0.08 μm2/ms, 79.12 ± 5.70 μm2/ms, and 0.1313 ± 0.02) (p < 0.05). Moreover, left ventricular peak subendo and subepi radial, circumferential, and longitudinal strain were lower in AMI T2+ segments than in infarct-like myocarditis T2+ segments and normal controls (p < 0.05); AMI LGE+ segments exhibited the lowest strain in three orientations compared to other subgroups (p < 0.05). CONCLUSION These findings prove that IVIM-DWI may be used as a reliable sequence for evaluation of different myocardial perfusion patterns in AMI and infarct-like myocarditis. AMI may exhibit lower myocardial perfusion status compared to infarct-like myocarditis due to different pathophysiological process.
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Affiliation(s)
- Dong-Aolei An
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dong Fang Road, Shanghai 200127, China
| | - Ruo-Yang Shi
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dong Fang Road, Shanghai 200127, China
| | - Rui Wu
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dong Fang Road, Shanghai 200127, China
| | - Shiteng Suo
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dong Fang Road, Shanghai 200127, China
| | - Tong-Tong Han
- Circle Cardiovascular Imaging, 250, 815 8th Ave SW Calgary, AB T2P 3P2 Canada
| | - Jian-Rong Xu
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dong Fang Road, Shanghai 200127, China
| | - Jun Pu
- Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200127, China
| | - Lian-Ming Wu
- Department of Radiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 1630 Dong Fang Road, Shanghai 200127, China.
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Rroku A, Kottwitz J, Heidecker B. Update on myocarditis - what we know so far and where we may be heading. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2020; 10:2048872620910109. [PMID: 32319308 DOI: 10.1177/2048872620910109] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Affiliation(s)
- Andi Rroku
- Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | | | - Bettina Heidecker
- Charite Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
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Gue YX, Kanji R, Gati S, Gorog DA. MI with Non-obstructive Coronary Artery Presenting with STEMI: A Review of Incidence, Aetiology, Assessment and Treatment. Eur Cardiol 2020; 15:e20. [PMID: 32419851 PMCID: PMC7215489 DOI: 10.15420/ecr.2019.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 02/25/2020] [Indexed: 12/11/2022] Open
Abstract
MI with non-obstructive coronary artery (MINOCA) is a condition previously thought to be benign that has recently been shown to have comparable mortality to that of acute coronary syndrome with obstructive coronary disease. The heterogeneity of the underlying aetiology makes the assessment, investigation and treatment of patients with MINOCA challenging. The majority of patients with MINOCA presenting with ST-segment elevation MI generally have an underlying coronary or myocardial cause, predominantly plaque disruption or myocarditis. In order to make the correct diagnosis, in addition to the cause of the presentation, a meticulous and methodical approach is required, with targeted investigations. Stratification of patients to guide investigations that are more likely to provide the diagnosis will allow the correct treatment to be initiated promptly. In this article, the authors review the contemporary incidence, aetiology, recommended assessment and treatment of patients with MINOCA presenting with ST-segment elevation MI.
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Affiliation(s)
- Ying X Gue
- University of Hertfordshire Hertfordshire, UK
| | - Rahim Kanji
- National Heart and Lung Institute, Imperial College London, UK
| | - Sabiha Gati
- University of Hertfordshire Hertfordshire, UK
| | - Diana A Gorog
- University of Hertfordshire Hertfordshire, UK
- National Heart and Lung Institute, Imperial College London, UK
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Hou YM, Han PX, Wu X, Lin JR, Zheng F, Lin L, Xu R. Myocarditis presenting as typical acute myocardial infarction: A case report and review of the literature. World J Clin Cases 2020; 8:415-424. [PMID: 32047794 PMCID: PMC7000954 DOI: 10.12998/wjcc.v8.i2.415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/17/2019] [Accepted: 12/22/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Myocarditis refers to a variety of myocardial inflammatory lesions. A variety of factors such as infection and physical and chemical factors can cause myocarditis. Depending on the severity of myocardial damage, myocarditis patients can manifest heart failure, cardiogenic shock, and even sudden death. Here we present a case of viral myocarditis that mimicked acute coronary syndrome.
CASE SUMMARY A middle-aged male patient presented with chest pain and elevated troponin I after a flu-like infection. This patient had a history of hypertension and a habit of alcohol and tobacco use. Electrocardiography showed typical changes in acute myocardial infarction, with the T-wave increasing. Coronary angiogram revealed no stenosis. Cardiac magnetic resonance imaging revealed edema of the middle and apical septal and apical anterior walls on T2-weighted images and the T1 mapping. Late gadolinium enhancement of the middle and apical septal and apical anterior walls could be found. Rubella virus immunoglobulin G and immunoglobulin M antibodies were abnormally elevated. The patient was given antiviral and antibiotic treatments, and serum biomarkers and electrocardiograph returned to normal after 5 d of treatment. After one-year follow-up, the patient showed no symptoms, and cardiac magnetic resonance showed that myocardial thickness was significantly thinner than before, and fibrosis was less than before.
CONCLUSION This case illustrates the utility of cardiac magnetic resonance for diagnosis of infarction-like myocarditis when the angiogram is normal.
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Affiliation(s)
- Ya-Min Hou
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, Shandong Province, China
| | - Peng-Xi Han
- Department of Radiology, The First Affiliated Hospital of Shandong First Medical University, Jinan 250014, Shandong Province, China
| | - Xia Wu
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, Shandong Province, China
| | - Jing-Ru Lin
- Department of Cardiology, Shandong Provincial Third Hospital, Jinan 250014, Shandong Province, China
| | - Fei Zheng
- Department of Cardiology, The First Affiliated Hospital of Shandong First Medical University, Jinan 250014, Shandong Province, China
| | - Lin Lin
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, Shandong Province, China
| | - Rui Xu
- Department of Cardiology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, Shandong Province, China
- Department of Cardiology, The First Affiliated Hospital of Shandong First Medical University, Jinan 250014, Shandong Province, China
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Dabir D, Vollbrecht TM, Luetkens JA, Kuetting DLR, Isaak A, Feisst A, Fimmers R, Sprinkart AM, Schild HH, Thomas D. Multiparametric cardiovascular magnetic resonance imaging in acute myocarditis: a comparison of different measurement approaches. J Cardiovasc Magn Reson 2019; 21:54. [PMID: 31462282 PMCID: PMC6714458 DOI: 10.1186/s12968-019-0568-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 07/23/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Myocardial T1 and T2 mapping are reliable diagnostic markers for the detection and follow up of acute myocarditis. The aim of this study was to compare the diagnostic performance of current mapping measurement approaches to differentiate between myocarditis patients and healthy individuals. METHODS Fifty patients with clinically defined acute myocarditis and 30 healthy controls underwent cardiovascular magnetic resonance (CMR). Myocardial T1 relaxation times, T2 relaxation times, left ventricular (LV) function, T2 ratio, early gadolinium enhancement ratio, and presence of late gadolinium enhancement (LGE) were analysed. Native T1 and T2 relaxation times, as well as extracellular volume fraction (ECV) were measured for the entire LV myocardium (global), within the midventricular short axis slice (mSAX), within the midventricular septal wall (ConSept), and within the remote myocardium (remote). Receiver operating characteristics analysis was performed to compare diagnostic performance. RESULTS All measurement approaches revealed significantly higher native T1 and T2 relaxation times as well as ECV values in patients compared to healthy controls (p < 0.05 for all parameters). The global measurement approach showed highest diagnostic performance regarding all mapping parameters (AUCs, native T1: 0.903, T2: 0.847, ECV: 0.731). Direct comparison of the different measurement approaches revealed significant differences in diagnostic performance between the global and the remote approach regarding T1 relaxation times and ECV (p = 0.001 and p = 0.002 respectively). Further, the global measurement approach revealed significantly higher T1 relaxation times compared to the ConSept approach (AUCs: 0.903 vs. 0.783; p = 0.003) and nearly significant differences compared to the mSAX approach (AUC: 0.850; p = 0.051). T2 relaxation times showed no significant differences between all measurement approaches (p > 0.050 for all parameters). CONCLUSIONS Native T1 and T2 mapping allow for accurate detection of acute myocarditis irrespective of the measurement approach used. Even measurements performed exclusively within remote myocardium allow for reliable detection of acute myocarditis, demonstrating diffuse involvement of disease despite a mostly regional or patchy distribution pattern of visible pathologies. The global measurement approach provides the overall best diagnostic performance in acute myocarditis for both T1 and T2 mapping.
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Affiliation(s)
- Darius Dabir
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Thomas M. Vollbrecht
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Julian A. Luetkens
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Daniel L. R. Kuetting
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Alexander Isaak
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Andreas Feisst
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Rolf Fimmers
- Department of Medical Biometry, Computer Science, and Epidemiology (IMBIE), University of Bonn, Bonn, Germany
| | - Alois M. Sprinkart
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Hans H. Schild
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
| | - Daniel Thomas
- Department of Radiology, University of Bonn, Sigmund-Freud-Str. 25, 53127 Bonn, Germany
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Harris JM, Brierley RC, Pufulete M, Bucciarelli-Ducci C, Stokes EA, Greenwood JP, Dorman SH, Anderson RA, Rogers CA, Wordsworth S, Berry S, Reeves BC. A national registry to assess the value of cardiovascular magnetic resonance imaging after primary percutaneous coronary intervention pathway activation: a feasibility cohort study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Cardiovascular magnetic resonance (CMR) is increasingly used in patients who activate the primary percutaneous coronary intervention (PPCI) pathway to assess heart function. It is uncertain whether having CMR influences patient management or the risk of major adverse cardiovascular events in these patients.
Objective
To determine whether or not it is feasible to set up a national registry, linking routinely collected data from hospital information systems (HISs), to investigate the role of CMR in patients who activate the PPCI pathway.
Design
A feasibility prospective cohort study.
Setting
Four 24/7 PPCI hospitals in England and Wales (two with and two without a dedicated CMR facility).
Participants
Patients who activated the PPCI pathway and underwent an emergency coronary angiogram.
Interventions
CMR either performed or not performed within 10 weeks of the index event.
Main outcome measures
A. Feasibility parameters – (1) patient consent implemented at all hospitals, (2) data extracted from more than one HIS and successfully linked for > 90% of consented patients at all four hospitals, (3) HIS data successfully linked with Hospital Episode Statistics (HES) and Patient Episode Database Wales (PEDW) for > 90% of consented patients at all four hospitals and (4) CMR requested and carried out for ≥ 10% of patients activating the PPCI pathway in CMR hospitals. B. Key drivers of cost-effectiveness for CMR (identified from simple cost-effectiveness models) in patients with (1) multivessel disease and (2) unobstructed coronary arteries. C. A change in clinical management arising from having CMR (defined using formal consensus and identified using HES follow-up data in the 12 months after the index event).
Results
A. (1) Consent was implemented (for all hospitals, consent rates were 59–74%) and 1670 participants were recruited. (2) Data submission was variable – clinical data available for ≥ 82% of patients across all hospitals, biochemistry and echocardiography (ECHO) data available for ≥ 98%, 34% and 87% of patients in three hospitals and medications data available for 97% of patients in one hospital. (3) HIS data were linked with hospital episode data for 99% of all consented patients. (4) At the two CMR hospitals, 14% and 20% of patients received CMR. B. In both (1) multivessel disease and (2) unobstructed coronary arteries, the difference in quality-adjusted life-years (QALYs) between CMR and no CMR [‘current’ comparator, stress ECHO and standard ECHO, respectively] was very small [0.0012, 95% confidence interval (CI) –0.0076 to 0.0093 and 0.0005, 95% CI –0.0050 to 0.0077, respectively]. The diagnostic accuracy of the ischaemia tests was the key driver of cost-effectiveness in sensitivity analyses for both patient subgroups. C. There was consensus that CMR leads to clinically important changes in management in five patient subgroups. Some changes in management were successfully identified in hospital episode data (e.g. new diagnoses/procedures, frequency of outpatient episodes related to cardiac events), others were not (e.g. changes in medications, new diagnostic tests).
Conclusions
A national registry is not currently feasible. Patients were consented successfully but conventional consent could not be implemented nationally. Linking HIS and hospital episode data was feasible but HIS data were not uniformly available. It is feasible to identify some, but not all, changes in management in the five patient subgroups using hospital episode data. The delay in obtaining hospital episode data influenced the relevance of some of our study objectives.
Future work
To test the feasibility of conducting the study using national data sets (e.g. HES, British Cardiovascular Intervention Society audit database, Diagnostic Imaging Dataset, Clinical Practice Research Datalink).
Funding
The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. This study was designed and delivered in collaboration with the Clinical Trials and Evaluation Unit, a UK Clinical Research Collaboration-registered clinical trials unit that, as part of the Bristol Trials Centre, is in receipt of NIHR clinical trials unit support funding.
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Affiliation(s)
- Jessica M Harris
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Rachel C Brierley
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Maria Pufulete
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chiara Bucciarelli-Ducci
- National Institute for Health Research (NIHR) Bristol Cardiovascular Research Unit, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Stephen H Dorman
- National Institute for Health Research (NIHR) Bristol Cardiovascular Research Unit, Bristol Heart Institute, University of Bristol, Bristol, UK
| | | | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Sunita Berry
- NHS England, South West Clinical Networks and Senate, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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Díaz-Navarro R, Villagran F. Takotsubo cardiomyopathy and coronary artery disease: value of cardiac magnetic resonance imaging for diagnostic confirmation: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2019; 3:yty151. [PMID: 31020227 PMCID: PMC6439425 DOI: 10.1093/ehjcr/yty151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 11/21/2022]
Abstract
Background Takotsubo cardiomyopathy (TCM) is a reversible acute cardiac disease that mimics acute myocardial infarction (AMI). In patients with a history of an old myocardial infarction who develop TCM, cardiac magnetic resonance imaging (CMRI) is the first-line non-invasive diagnostic tool for clearly discriminating between AMI and TCM. Case summary A 65-year-old woman who suffered a myocardial infarction in 2012, was admitted to undergo sigmoid colon tumour surgery in January 2017. Soon after surgery, she developed angina associated with ST-segment elevation, as shown by electrocardiography and increased cardiac enzyme levels. Acute coronary syndrome was diagnosed. She had a good clinical response to treatment with intravenous nitroglycerine, opioids, clopidogrel, aspirin, bisoprolol, and atorvastatin. Transthoracic echocardiography (TTE) showed anteroseptal and apical left ventricular akinesia with balloon-like dilatation, akinesia of the inferior wall and inferior interventricular septum, and global systolic dysfunction. Coronary angiography did not identify coronary artery lesions, and a tentative diagnosis of TCM was made. Cardiac magnetic resonance imaging confirmed the segmental contraction abnormalities seen in the TTE and identified myocardial oedema without delayed hyperenhancement after gadolinium administration, which confirmed the diagnosis of TCM and ruled out acute ischaemic damage. She was discharged when asymptomatic. Cardiac magnetic resonance imaging at 2 months showed disappearance of the anteroseptal and apical contraction abnormality, regression of myocardial oedema and normalization of global left ventricular systolic function. Discussion This case confirms that CMRI is a non-invasive diagnostic method for accurately differentiating between AMI and TCM in patients with a prior myocardial infarction. cardiac magnetic resonance imaging should be incorporated as a diagnostic criterion for TCM.
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Affiliation(s)
- Rienzi Díaz-Navarro
- Departamento de Medicina Interna, Universidad de Valparaíso, 4 Poniente 332, Viña del Mar, Chile
| | - Francisco Villagran
- Departamento de Medicina Interna, Universidad de Valparaíso, 4 Poniente 332, Viña del Mar, Chile
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Abanador-Kamper N, Kamper L, Castello-Boerrigter L, Haage P, Seyfarth M. MRI findings in patients with acute coronary syndrome and unobstructed coronary arteries. ACTA ACUST UNITED AC 2019; 25:28-34. [PMID: 30582569 DOI: 10.5152/dir.2018.18004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE The underlying diagnosis in patients with acute coronary syndrome (ACS) and unobstructed coronary arteries remains a diagnostic challenge. We analyzed the value of magnetic resonance imaging (MRI) in this clinical setting. METHODS A total of 213 patients with ACS and unobstructed coronary arteries underwent MRI within a median of 2 days after initial presentation. Clinical, laboratory, and MRI data were analyzed. A consensus diagnosis was established for each case by an independent panel after reviewing the individual clinical, laboratory, and MRI data. Standardized interviews to determine patient outcomes were carried out after a median follow-up of 24 months. Clinical events were defined as a composite of death, stroke, myocardial infarction or recurrence of Takotsubo syndrome (TTS), new onset of heart failure with a left ventricular ejection fraction (LVEF) <30%, and occurrence of a new left ventricular thrombus formation. RESULTS Final diagnoses included acute myocardial infarction (AMI) (40%), acute myocarditis (24%) and TTS (33%). In 3% of patients, nonspecific findings lead to an indeterminate diagnosis. Patients with TTS showed a significantly impaired LVEF during the index event (50% vs. 60% in AMI and 60% in myocarditis, P = 0.001). The extent of myocardial edema was most pronounced in patients with TTS (13.4%±11.4 vs. 4.6%±7.9 in AMI and 1.8%±2.7 in myocarditis, P < 0.001). TTS patients had the highest event rate (16.9%). CONCLUSION Our study emphasizes the diagnostic utility of timely MRI in patients with ACS and unobstructed coronary arteries. We found a high prevalence of TTS patients, who had poorer outcomes compared with patients with a final diagnosis of AMI or myocarditis.
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Affiliation(s)
- Nadine Abanador-Kamper
- Department of Cardiology, HELIOS University Hospital, Wuppertal, Germany; Center for Clinical Medicine, University Faculty of Health, Witten/Herdecke, Germany
| | - Lars Kamper
- Department of Diagnostic HELIOS University Hospital, Wuppertal, Germany; Center for Clinical Medicine University Faculty of Health, Witten/Herdecke, Germany
| | | | - Patrick Haage
- Center for Clinical Medicine,University Faculty of Health, Witten/Herdecke, Germany
| | - Melchior Seyfarth
- Center for Clinical Medicine,University Faculty of Health, Witten/Herdecke, Germany
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Bhatia S, Anstine C, Jaffe AS, Gersh BJ, Chandrasekaran K, Foley TA, Hodge D, Anavekar NS. Cardiac magnetic resonance in patients with elevated troponin and normal coronary angiography. Heart 2019; 105:1231-1236. [PMID: 30948519 DOI: 10.1136/heartjnl-2018-314631] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/05/2019] [Accepted: 03/08/2019] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Invasive angiography in the setting of cardiac troponin elevation may reveal non-obstructive coronary arteries leading to uncertainty in diagnosis. Cardiac MR (CMR) may aid in diagnosis, however, the spectrum of diagnostic findings in the patient presenting with symptoms of cardiac ischaemia, elevated cardiac biomarkers and a negative invasive coronary angiogram is yet to be completely described. METHODS We queried the Mayo Clinic, Rochester inpatient record from 1 January 2000 to 31 December 2016 to identify patients who: (1) had an elevated troponin T during admission, (2) underwent coronary angiography within 30 days of troponin T elevation which was considered negative for obstructive coronary arterial disease and (3) underwent CMR within 30 days of troponin T elevation. CMR diagnoses were classified as either (1) myocarditis, (2) small area myocardial infarction, (3) stress cardiomyopathy, (4) non-ischaemic cardiomyopathy or (5) normal. RESULTS Of 215 patients, the spectrum of disease seen on CMR was myocarditis (32%), small area infarction (22%), non-ischaemic cardiomyopathy (20%) and stress cardiomyopathy (9.3%). CONCLUSION In the largest single-centre study assessing the role of CMR in patients admitted with elevated troponin T with a non-obstructive coronary disease on an angiogram, small area infarction was seen in 22% of patients.
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Affiliation(s)
- Subir Bhatia
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Bernard J Gersh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Thomas A Foley
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.,Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Dastidar AG, Baritussio A, De Garate E, Drobni Z, Biglino G, Singhal P, Milano EG, Angelini GD, Dorman S, Strange J, Johnson T, Bucciarelli-Ducci C. Prognostic Role of CMR and Conventional Risk Factors in Myocardial Infarction With Nonobstructed Coronary Arteries. JACC Cardiovasc Imaging 2019; 12:1973-1982. [PMID: 30772224 DOI: 10.1016/j.jcmg.2018.12.023] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 12/03/2018] [Accepted: 12/14/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES This study sought to assess the prognostic impact of cardiac magnetic resonance (CMR) and conventional risk factors in patients with myocardial infarction with nonobstructed coronaries (MINOCA). BACKGROUND Myocardial infarction with nonobstructed coronary arteries (MINOCA) represents a diagnostic dilemma, and the prognostic markers have not been clarified. METHODS A total of 388 consecutive patients with MINOCA undergoing CMR assessment were identified retrospectively from a registry database and prospectively followed for a primary clinical endpoint of all-cause mortality. A 1.5-T CMR was performed using a comprehensive protocol (cines, T2-weighted, and late gadolinium enhancement sequences). Patients were grouped into 4 categories based on their CMR findings: myocardial infarction (MI) (embolic/spontaneous recanalization), myocarditis, cardiomyopathy, and normal CMR. RESULTS CMR (performed at a median of 37 days from presentation) was able to identify the cause for the troponin rise in 74% of the patients (25% myocarditis, 25% MI, and 25% cardiomyopathy), whereas a normal CMR was identified in 26%. Over a median follow-up of 1,262 days (3.5 years), 5.7% patients died. The cardiomyopathy group had the worst prognosis (mortality 15%; log-rank test: 19.9; p < 0.001), MI had 4% mortality, and 2% in both myocarditis and normal CMR. In a multivariable Cox regression model (including clinical and CMR parameters), CMR diagnosis of cardiomyopathy and ST-segment elevation on presentation electrocardiogram (ECG) remained the only 2 significant predictors of mortality. Using presentation with ECG ST-segment elevation and CMR diagnosis of cardiomyopathy as risk markers, the mortality risk rates were 2%, 11%, and 21% for presence of 0, 1, and 2 factors, respectively (p < 0.0001). CONCLUSIONS In a large cohort of patients with MINOCA, CMR (median 37 days from presentation) identified a final diagnosis in 74% of patients. Cardiomyopathy had the highest mortality, followed by MI. The strongest predictors of mortality were a CMR diagnosis of cardiomyopathy and ST-segment elevation on presentation ECG.
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Affiliation(s)
- Amardeep Ghosh Dastidar
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Anna Baritussio
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Estefania De Garate
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom; Bristol National Institute of Health Research, Biomedical Research Centre, Bristol, United Kingdom
| | - Zsofia Drobni
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Giovanni Biglino
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Priyanka Singhal
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Elena G Milano
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Gianni D Angelini
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom; Bristol National Institute of Health Research, Biomedical Research Centre, Bristol, United Kingdom
| | - Stephen Dorman
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Julian Strange
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Thomas Johnson
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom; School of Clinical Sciences, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom; Bristol National Institute of Health Research, Biomedical Research Centre, Bristol, United Kingdom.
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Roghi A, Pedrotti P. The incremental role of cardiac magnetic resonance imaging as diagnostic and prognostic tool in cardiovascular diseases. HEART AND MIND 2018. [DOI: 10.4103/hm.hm_1_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Tsiaras SV, Safi LM, Ghoshhajra BB, Lindsay ME, Wood MJ. Case 39-2017. A 41-Year-Old Woman with Recurrent Chest Pain. N Engl J Med 2017; 377:2475-2484. [PMID: 29262281 DOI: 10.1056/nejmcpc1707558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Sarah V Tsiaras
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
| | - Lucy M Safi
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
| | - Brian B Ghoshhajra
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
| | - Mark E Lindsay
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
| | - Malissa J Wood
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
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Baeßler B, Treutlein M, Schaarschmidt F, Stehning C, Schnackenburg B, Michels G, Maintz D, Bunck AC. A novel multiparametric imaging approach to acute myocarditis using T2-mapping and CMR feature tracking. J Cardiovasc Magn Reson 2017; 19:71. [PMID: 28931401 PMCID: PMC5607501 DOI: 10.1186/s12968-017-0387-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 09/12/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate the diagnostic potential of a novel cardiovascular magnetic resonance (CMR) based multiparametric imaging approach in suspected myocarditis and to compare it to traditional Lake Louise criteria (LLC). METHODS CMR data from 67 patients with suspected acute myocarditis were retrospectively analyzed. Seventeen age- and gender-matched healthy subjects served as control. T2-mapping data were acquired using a Gradient-Spin-Echo T2-mapping sequence in short-axis orientation. T2-maps were segmented according to the 16-segments AHA-model and segmental T2 values and pixel-standard deviation (SD) were recorded. Afterwards, the parameters maxT2 (the highest segmental T2 value) and madSD (the mean absolute deviation (MAD) of the pixel-SDs) were calculated for each subject. Cine sequences in three long axes and a stack of short-axis views covering the left and right ventricle were analyzed using a dedicated feature tracking algorithm. RESULTS A multiparametric imaging model containing madSD and LV global circumferential strain (GCSLV) resulted in the highest diagnostic performance in receiver operating curve analyses (area under the curve [AUC] 0.84) when compared to any model containing a single imaging parameter or to LLC (AUC 0.79). Adding late gadolinium enhancement (LGE) to the model resulted in a further increased diagnostic performance (AUC 0.93) and yielded the highest diagnostic sensitivity of 97% and specificity of 77%. CONCLUSIONS A multiparametric CMR imaging model including the novel T2-mapping derived parameter madSD, the feature tracking derived strain parameter GCSLV and LGE yields superior diagnostic sensitivity in suspected acute myocarditis when compared to any imaging parameter alone and to LLC.
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Affiliation(s)
- Bettina Baeßler
- Department of Radiology, University Hospital of Cologne, Kerpener Str. 62, D-50937 Cologne, Germany
| | - Melanie Treutlein
- Department of Radiology, University Hospital of Cologne, Kerpener Str. 62, D-50937 Cologne, Germany
| | - Frank Schaarschmidt
- Institute of Biostatistics, Faculty of Natural Sciences, Leibniz Universität Hannover, Hannover, Germany
| | | | | | - Guido Michels
- Department III of Internal Medicine, Heart Centre, University Hospital of Cologne, Cologne, Germany
| | - David Maintz
- Department of Radiology, University Hospital of Cologne, Kerpener Str. 62, D-50937 Cologne, Germany
| | - Alexander C. Bunck
- Department of Radiology, University Hospital of Cologne, Kerpener Str. 62, D-50937 Cologne, Germany
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Panovský R, Borová J, Pleva M, Feitová V, Novotný P, Kincl V, Holeček T, Meluzín J, Sochor O, Štěpánová R. The unique value of cardiovascular magnetic resonance in patients with suspected acute coronary syndrome and culprit-free coronary angiograms. BMC Cardiovasc Disord 2017; 17:170. [PMID: 28659139 PMCID: PMC5490179 DOI: 10.1186/s12872-017-0610-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 06/22/2017] [Indexed: 12/11/2022] Open
Abstract
Background Patients with chest pain, elevated troponin, and unobstructed coronary disease present a clinical dilemma. The purpose of this study was to investigate the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in a cohort of patients with suspected acute coronary syndrome (ACS) and unobstructed coronary arteries. Results Data files of patients meeting the inclusion criteria in two cardiology centres were searched and analysed. The inclusion criteria included: 1) thoracic pain suspected with ACS; 2) a significant increase in the high-sensitive Troponin T value; 3) ECG changes; 4) coronary arteries without any significant stenosis; 5) a CMR examination included in the diagnostic process; 6) an uncertain diagnosis before the CMR exam; and 7) the absence of known CMR and contrast media contraindications. Special attention was paid to the benefits of CMR in determining the final diagnosis. In total, 136 patients who underwent coronary angiography for chest pain were analysed. The most frequent underlying causes were myocarditis (38%) and perimyocarditis (18%), followed by angiographically unrecognised acute myocardial infarction (18%) and Takotsubo cardiomyopathy (15%). The final diagnosis remained unclear in 6% of the patients. The contribution of CMR in determining the final diagnosis determination was crucial in 57% of the patients. In another 35% of the patients, CMR confirmed the suspicion and, only 8% of the CMR examinations did not help at all and had no influence on diagnosis or treatment. Conclusion CMR provided a powerful incremental diagnostic value in the cohort of patients with suspected ACS and unobstructed coronary arteries. CMR is highly recommended to be incorporated as an inalienable part of the diagnostic algorithms in these patients.
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Affiliation(s)
- Roman Panovský
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic. .,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic.
| | - Júlia Borová
- The Department of Cardiology, Heart Centre, Hospital Podlesi, Trinec, Czech Republic
| | - Martin Pleva
- The Department of Cardiology, Heart Centre, Hospital Podlesi, Trinec, Czech Republic
| | - Věra Feitová
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The Department of Medical Imaging, St. Anne's Faculty Hospital and Masaryk University, Brno, Czech Republic
| | - Petr Novotný
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic
| | - Vladimír Kincl
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic
| | - Tomáš Holeček
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The Department of Medical Imaging, St. Anne's Faculty Hospital and Masaryk University, Brno, Czech Republic
| | - Jaroslav Meluzín
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic
| | - Ondřej Sochor
- The Department of Cardiovascular Diseases, International Clinical Research Centre, St. Anne's Faculty Hospital, Brno, Czech Republic.,The 1st Department of Internal Medicine/Cardioangiology, International Clinical Research Centre - ICRC, St. Anne's Hospital, Masaryk University, Pekařská 53, 656 91, Brno, Czech Republic
| | - Radka Štěpánová
- International Clinical Research Centre, St. Anne's University Hospital Brno, Brno, Czech Republic
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Pufulete M, Brierley RC, Bucciarelli-Ducci C, Greenwood JP, Dorman S, Anderson RA, Harris J, McAlindon E, Rogers CA, Reeves BC. Formal consensus to identify clinically important changes in management resulting from the use of cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway. BMJ Open 2017; 7:e014627. [PMID: 28645959 PMCID: PMC5541580 DOI: 10.1136/bmjopen-2016-014627] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To define important changes in management arising from the use of cardiovascular magnetic resonance (CMR) in patients who activate the primary percutaneous coronary intervention (PPCI) pathway. DESIGN Formal consensus study using literature review and cardiologist expert opinion to formulate consensus statements and setting up a consensus panel to review the statements (by completing a web-based survey, attending a face-to-face meeting to discuss survey results and modify the survey to reflect group discussion and completing the modified survey to determine which statements were in consensus). PARTICIPANTS Formulation of consensus statements: four cardiologists (two CMR and two interventional) and six non-clinical researchers. Formal consensus: seven cardiologists (two CMR and three interventional, one echocardiography and one heart failure). Forty-nine additional cardiologists completed the modified survey. RESULTS Thirty-seven draft statements describing changes in management following CMR were generated; these were condensed into 12 statements and reviewed through the formal consensus process. Three of 12 statements were classified in consensus in the first survey; these related to the role of CMR in identifying the cause of out-of-hospital cardiac arrest, providing a definitive diagnosis in patients found to have unobstructed arteries on angiography and identifying patients with left ventricular thrombus. Two additional statements were in consensus in the modified survey, relating to the ability of CMR to identify patients who have a poor prognosis after PPCI and assess ischaemia and viability in patients with multivessel disease. CONCLUSION There was consensus that CMR leads to clinically important changes in management in five subgroups of patients who activate the PPCI pathway.
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Affiliation(s)
- Maria Pufulete
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Rachel C Brierley
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Chiara Bucciarelli-Ducci
- NIHR Bristol Cardiovascular Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Stephen Dorman
- NIHR Bristol Cardiovascular Research Unit, Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Jessica Harris
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Elisa McAlindon
- Department of Cardiology, New Cross Hospital, Wolverhampton, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, UK
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Yield of Cardiac Magnetic Resonance Imaging in Patients With Acute Coronary Syndrome and No Obstructive Coronary Artery Disease. Crit Pathw Cardiol 2017; 16:58-61. [PMID: 28509705 DOI: 10.1097/hpc.0000000000000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Ten percent to 25% of women and 6%-10% of men with acute coronary syndrome (ACS) are found to have no obstructive coronary artery disease (CAD) on coronary computed tomography angiogram or invasive coronary angiography. The etiology of presentation is often unclear. We examined the diagnostic yield of cardiac magnetic resonance imaging (CMR) in patients with signs and symptoms suggestive of an ACS and no obstructive CAD. METHODS We retrospectively studied patients with signs and symptoms suggestive of an ACS and no obstructive CAD on coronary computed tomography angiogram or invasive coronary angiography who had CMR performed at St. Paul's Hospital, British Columbia, Canada, from 2013 to 2015. No obstructive CAD was defined as <50% stenosis in any epicardial artery. We compared CMR diagnostic yield in troponin-positive and troponin-negative patients and determined the etiology of presentation in each category. We also examined gender differences. RESULTS Ninety-eight patients met inclusion criteria. The average age was 55.8 years, 70% were female, and 60% were troponin positive upon presentation. Abnormal CMR was observed in 35.7% of patients, yielding a diagnosis in 27.9% of females and 53.5% of males (P = 0.02). Troponin-positive patients had a significantly higher prevalence of an abnormal CMR than did troponin-negative patients (44.1% vs. 23.1%; P = 0.03). Myocarditis was more common in troponin-positive patients (25.4% vs. 2.6%; P = 0.002). CONCLUSIONS Forty-four percent of patients with positive troponin and with signs and symptoms suggestive of an ACS, no obstructive CAD on invasive coronary angiography or coronary computed tomography angiogram, and unclear diagnosis had abnormalities on CMR that identified the diagnosis. CMR should be considered in patients with positive troponin values when the etiology for their presentation is unclear.
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Wu S, Yang YM, Zhu J, Wan HB, Wang J, Zhang H, Shao XH. Clinical characteristics and outcomes of patients with myocarditis mimicking ST-segment elevation myocardial infarction: Analysis of a case series. Medicine (Baltimore) 2017; 96:e6863. [PMID: 28489781 PMCID: PMC5428615 DOI: 10.1097/md.0000000000006863] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Acute myocarditis mimicking ST-segment elevation myocardial infarction (STEMI) is highly deceptive for an accurate diagnosis, and a systematic study is lacking with regard to the clinical features and prognosis of this distinct clinical entity.Patients with suspected STEMI and eventually diagnosed with myocarditis by cardiac magnetic resonance (CMR) from January 2012 to April 2016 at Fuwai Hospital were identified by reviewing medical records and electronic databases. Follow-up was conducted by clinical visits and phone contacts in a median duration of 17 months.A total of 18 patients were included in the study, with 17 males and 1 female. They were relatively young, and their mean age was 30.8 years. 94.4% of the patients had a high prevalence of infectious prodrome, and inflammatory biomarkers were notably elevated in all patients. Late gadolinium enhancement on CMR was detected in 13 patients. Three patients underwent fulminant course, and left ventricular ejection fraction (LVEF) <45% on admission occurred in 3 patients. The median LVEF improved from 59% on admission to 65% at discharge (P <.001), and none developed cardiac insufficiency, heart transplantation, or death during a median follow-up of 17 months.Myocarditis mimicking STEMI is featured by young age and an existence of flu-like prodrome. CMR benefits the differential diagnosis of this unique clinical entity. Notably, patients with myocarditis mimicking STEMI had a favorable prognosis, and establishing an accurate diagnosis is crucial to avoid unreasonable treatments for them.
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Role of cardiovascular magnetic resonance in acute and chronic ischemic heart disease. Int J Cardiovasc Imaging 2017; 34:67-80. [PMID: 28315985 PMCID: PMC5797568 DOI: 10.1007/s10554-017-1116-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/09/2017] [Indexed: 12/13/2022]
Abstract
Cardiovascular magnetic resonance (CMR) is a multi-parametric, multi-planar, non-invasive imaging technique, which allows accurate determination of biventricular function and precise myocardial tissue characterization in a one-stop-shop technique, free from the use of ionizing radiations. Though CMR has been increasingly applied over the last two decades in every-day clinical practice, its widest application has been in the assessment of ischemic cardiomyopathy.
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Tini G, Proietti G, Casenghi M, Colopi M, Bontempi K, Autore C, Volpe M, Musumeci B. Long-Term Outcome of Acute Coronary Syndromes in Young Patients. High Blood Press Cardiovasc Prev 2017; 24:77-84. [DOI: 10.1007/s40292-017-0183-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/19/2017] [Indexed: 10/20/2022] Open
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Lagan J, Schmitt M, Miller CA. Clinical applications of multi-parametric CMR in myocarditis and systemic inflammatory diseases. Int J Cardiovasc Imaging 2017; 34:35-54. [PMID: 28130644 PMCID: PMC5797564 DOI: 10.1007/s10554-017-1063-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 01/03/2017] [Indexed: 12/22/2022]
Abstract
Cardiac magnetic resonance (CMR) has changed the management of suspected viral myocarditis by providing a ‘positive’ diagnostic test and has lead to new insights into myocardial involvement in systemic inflammatory conditions. In this review we analyse the use of CMR tissue characterisation techniques across the available studies including T2 weighted imaging, early gadolinium enhancement, late gadolinium enhancement, Lake Louise Criteria, T2 mapping, T1 mapping and extracellular volume assessment. We also discuss the use of multiparametric CMR in acute cardiac transplant rejection and a variety of inflammatory conditions such as sarcoidosis, systemic lupus erythrematous, rheumatoid arthritis and systemic sclerosis.
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Affiliation(s)
- Jakub Lagan
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK
- Institute of Cardiovascular Sciences, Faculty of Medical & Human Sciences, University of Manchester, Manchester, M13 9NT, UK
| | - Matthias Schmitt
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK
| | - Christopher A Miller
- North West Heart Centre, University Hospital of South Manchester, Manchester, UK.
- Institute of Cardiovascular Sciences, Faculty of Medical & Human Sciences, University of Manchester, Manchester, M13 9NT, UK.
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