The relative atrial volume ratio and late gadolinium enhancement provide additive information to differentiate constrictive pericarditis from restrictive cardiomyopathy

Cardiac magnetic resonance feature tracking derived left atrial strain in the diagnosis of patients with constrictive pericarditis and restrictive cardiomyopathy

Objective

To explore the diagnostic value of cardiac magnetic resonance feature tracking (CMR-FT) divided left atrial (LA) strain in differentiating constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM).

Methods

Patients with CP (n = 40) and RCM (n = 40), and another 40 normal control group were retrospectively enrolled over a period of 8 years at a tertiary cardiac centre. Left ventricular (LV) and biatrial strain and strain rate (SR) were measured. Atrial strain was used to differentiate between patients with CP and RCM. Then, patients were grouped according to their left ventricular ejection fraction (LVEF), either ≥50% or < 50%. A deeper analysis was done to evaluate the diagnostic value of atrial strain in these subgroups. Receiver operating characteristic curves (ROC) were used to assess the accuracy of myocardial strain based on CMR FT for the differential diagnosis of CP and RCM.

Results

LV and LA strain and SR were significantly lower in patients with CP and RCM than those in the normal controls (P < 0.05). LA strain and SR were significantly lower in the RCM group than in the CP group (P < 0.05). In patients with either LVEF≥50% or＜50%, LA strain were lower in the RCM group than in the CP group (P < 0.05). ROC analysis showed that LA stored strain (LA-εs) had a good differential diagnostic value for CP and RCM, with an area under the curve (AUC) of 0.811 and an optimal cutoff value of 6.98%, above this value it tends to develop CP. Further, an excellent differential diagnostic value was found in patients with LVEF＜50%, with an AUC of 0.955.

Conclusion

LA strain analysis obtained by CMR-FT provides good differential diagnostic value for distinguishing CP from RCM, especially in patients with LVEF＜50%.

Multimodality Imaging in Differentiating Constrictive Pericarditis From Restrictive Cardiomyopathy: A Comprehensive Overview for Clinicians and Imagers

In the evaluation of heart failure, 2 differential diagnostic considerations include constrictive pericarditis and restrictive cardiomyopathy. The often outwardly similar clinical presentation of these 2 pathologic entities routinely renders their clinical distinction difficult. Consequently, initial assessment requires a keen understanding of their separate pathophysiology, epidemiology, and hemodynamic effects. Following a detailed clinical evaluation, further assessment initially rests on comprehensive echocardiographic investigation, including detailed Doppler evaluation. With the combination of mitral inflow characterization, tissue Doppler assessment, and hepatic vein interrogation, initial differentiation of constrictive pericarditis and restrictive cardiomyopathy is often possible with high sensitivity and specificity. In conjunction with a compatible clinical presentation, successful differentiation enables both an accurate diagnosis and subsequent targeted management. In certain cases, however, the diagnosis remains unclear despite echocardiographic assessment, and additional evaluation is required. With advances in noninvasive tools, such evaluation can often continue in a stepwise, algorithmic fashion noninvasively, including both cross-sectional and nuclear imaging. Should this additional evaluation itself prove insufficient, invasive assessment with appropriate expertise may ultimately be necessary.

Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis

Constrictive pericarditis (CP) is a rare condition that can affect the pericardium after every pericardial disease process and has been described even after SARS-CoV-2 infection or vaccine. In CP, the affected pericardium, usually the inner layer, is noncompliant, constraining the heart to a fixed maximum volume and impairing the diastolic function. This leads to several clinical features, that, however, can be pleomorphic. In its difficult diagnostic workup, noninvasive multimodal imaging plays a central role, providing important morphological and functional data, like the enhanced ventricular interdependence and the dissociation between intrathoracic and intracardiac pressures. An early and proper diagnosis is crucial to set an appropriate therapy, changing the prognosis of patients affected by CP. In this review, we cover in detail the main elements of each imaging technique, after a reminder of pathophysiology useful for understanding the diagnostic findings.

Cardiac magnetic resonance imaging of pericardial diseases: a comprehensive guide

Cardiac magnetic resonance (CMR) imaging has been established as a valuable diagnostic tool in the assessment of pericardial diseases by providing information on cardiac anatomy and function, surrounding extra-cardiac structures, pericardial thickening and effusion, characterization of pericardial effusion, and the presence of active pericardial inflammation from the same scan. In addition, CMR imaging has excellent diagnostic accuracy for the non-invasive detection of constrictive physiology evading the need for invasive catheterization in most instances. Growing evidence in the field suggests that pericardial enhancement on CMR is not only diagnostic of pericarditis but also has prognostic value for pericarditis recurrence, although such evidence is derived from small patient cohorts. CMR findings could also be used to guide treatment de-escalation or up-titration in recurrent pericarditis and selecting patients most likely to benefit from novel treatments such as anakinra and rilonacept. This article is an overview of the CMR applications in pericardial syndromes as a primer for reporting physicians. We sought to provide a summary of the clinical protocols used and an interpretation of the major CMR findings in the setting of pericardial diseases. We also discuss points that are less well clear and delineate the strengths and weak points of CMR in pericardial diseases.

The Importance of Multimodality Imaging in the Diagnosis and Management of Patients with Infiltrative Cardiomyopathies: An Update

Infiltrative cardiomyopathies (ICMs) comprise a broad spectrum of inherited and acquired conditions (mainly amyloidosis, sarcoidosis, and hemochromatosis), where the progressive buildup of abnormal substances within the myocardium results in left ventricular hypertrophy and manifests as restrictive physiology. Noninvasive multimodality imaging has gradually eliminated endomyocardial biopsy from the diagnostic workup of infiltrative cardiac deposition diseases. However, even with modern imaging techniques’ widespread availability, these pathologies persist in being largely under- or misdiagnosed. Considering the advent of novel, revolutionary pharmacotherapies for cardiac amyloidosis, the archetypal example of ICM, a standardized diagnostic approach is warranted. Therefore, this review aims to emphasize the importance of contemporary cardiac imaging in identifying specific ICM and improving outcomes via the prompt initiation of a targeted treatment.

CMR publications from China of the last more than 30 years

Cardiovascular magnetic resonance (CMR) is a non-invasive imaging technology, gradually playing an irreplaceable role in the diagnosis and treatment of cardiovascular diseases. This review demonstrates the progress and research highlights of Chinese CMR publications of the last more than 30 years. At initial stage (1988 to 1997), CMR was introduced to evaluate cardiac anatomy, blood flow and ventricular function roughly in China. In the development stage (1998-2007), CMR began to play an important role in the diagnosis of cardiovascular and pericardial disease with the emergence of new techniques, such as myocardial perfusion imaging and magnetic resonance angiography. Since 2008, the development of CMR in China has reached a prosperous period. Cardiovascular disease can be both qualitatively and quantitatively assessment by CMR "one-stop" multi-parameter imaging, including the morphology, function, myocardial perfusion, tissue characteristics, metabolism and even the microstructure of myocardial fibers, which provides comprehensive assessment of the severity, risk stratification and prognosis of cardiovascular disease. Although CMR in China developed very rapidly in recent years, China still needs to put more efforts in CMR research and make greater contributions to the development of CMR in the world.

New Cardiac Imaging Algorithms to Diagnose Constrictive Pericarditis Versus Restrictive Cardiomyopathy

PURPOSE OF REVIEW

Echocardiography is the mainstay in the diagnostic evaluation of constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM), but no single echocardiographic parameter is sufficiently robust to accurately distinguish between the two conditions. The present review summarizes the recent advances in echocardiography that promise to improve its diagnostic performance for this purpose. The role of other imaging modalities such as cardiac computed tomography, magnetic resonance imaging, and invasive hemodynamic assessment in the overall diagnostic approach is also discussed briefly.

RECENT FINDINGS

A recent study has demonstrated improved diagnostic accuracy of echocardiography with integration of multiple conventional echocardiographic parameters in to a step-wise algorithm. Concurrently, the studies using speckle-tracking echocardiography have revealed distinct and disparate patterns of myocardial mechanical abnormalities in CP and RCM with their ability to distinguish between the two conditions. The incorporation of machine-learning algorithms into echocardiography workflow permits easy integration of the wealth of the diagnostic data available and promises to further enhance the diagnostic accuracy of echocardiography. New imaging algorithms are continuously being evolved to permit accurate distinction between CP and RCM. Further research is needed to validate the accuracy of these newer algorithms and to define their place in the overall diagnostic approach for this purpose.

Restrictive cardiomyopathy : Delayed occurrence after radiotherapy of breast cancer

A 74-year-old female patient was referred to our department in 2015 with dyspnea, cough and dysphagia. She had been diagnosed with adenocarcinoma of the right breast in 1986 and underwent mastectomy. When she presented with a local recurrence in 1988, she was receiving high-voltage radiation therapy. Transthoracic echocardiography and magnetic resonance imaging revealed tricuspid regurgitation grade III and unclear right heart failure with a massively dilated right atrium. Coronary heart disease could be ruled out. In summary, the patient's findings represented right ventricular myocardial restriction which we attributed to irradiation of the right anterior chest 17 years previously.

Systematic review of non-invasive cardiovascular imaging in the diagnosis of constrictive pericarditis

Background

Diagnosis of constrictive pericarditis (CP) can be challenging. It can be nearly impossible to distinguish CP from other causes of right heart failure. Although various imaging modalities help in the diagnosis, no test is definitive. Several reviews have addressed the role of various imaging techniques in the diagnosis of CP but a systematic review has not yet been published.

Objective

Our intention was to study the ability of various non-invasive imaging modalities to diagnose CP in patients with surgically confirmed disease and to apply our findings to develop a clinically useful diagnostic algorithm.

Methods

A PubMed (NLM) search was performed with MeSH term “constrictive pericarditis”. Original articles that investigated the ability of various cardiovascular imaging modalities to noninvasively diagnose surgically confirmed CP were included in our review. Investigations that included any cases without surgical confirmation were excluded.

Results

The PubMed search yielded 3001 results with MeSH term “constrictive pericarditis” (January 8, 2016). We identified (40) studies on CP that matched our inclusion criteria. We summarized our results sorted by individual non-invasive CV imaging modalities – echocardiography, cardiac computed tomography (CT), and magnetic resonance imaging (MRI). Under each imaging modality, we grouped our discussion based on different parameters useful in CP diagnosis.

Conclusions

In conclusion, contemporary diagnosis of CP is based on clinical features and echocardiography. Cardiac MRI is recommended in patients where echocardiography is not diagnostic. Both cardiac MRI and CT can guide surgical planning but we prefer MRI as it provides both structural and functional information.

Mitigation of Variability among 3D Echocardiography-Derived Regional Strain Values Acquired by Multiple Ultrasound Systems by Vendor Independent Analysis

Introduction

This study compared the variability of 3D echo derived circumferential and longitudinal strain values computed from vendor-specific and vendor-independent analyses of images acquired using ultrasound systems from different vendors.

Methods

Ten freshly harvested porcine hearts were studied. Each heart was mounted on a custom designed phantom and driven to simulate normal cardiac motion. Cardiac rotation was digitally controlled and held constant at 5°, while pumped stroke volume (SV) ranged from 30-70ml. Full-volume image data was acquired using three different ultrasound systems from different vendors. The image data was analyzed for longitudinal and circumferential strains (LS, CS) using both vendor-specific and vendor-independent analysis packages.

Results

Good linear relationships were observed for each vendor-specific analysis package for both CS and LS at the mid-anterior segment, with correlation coefficients ranging from 0.82–0.91 (CS) and 0.86–0.89 (LS). Comparable linear regressions were observed for results determined by a vendor independent program (CS: R = 0.82–0.89; LS: R = 0.86–0.89). Variability between analysis packages was examined via a series of ANOVA tests. A statistical difference was found between vendor-specific analysis packages (p<0.001), while no such difference was observed between ultrasound systems when using the vendor-independent program (p>0.05).

Conclusions

Circumferential and longitudinal regional strain values differ when quantified by vendor-specific analysis packages; however, this variability is mitigated by use of a vendor-independent quantification method. These results suggest that echocardiograms acquired using different ultrasound systems could be meaningfully compared using vendor-independent software.

Three-dimensional phase-sensitive inversion-recovery Turbo FLASH sequence for the assessment of left ventricular myocardial scar in swine

OBJECTIVES

We sought to evaluate the feasibility and accuracy of free-breathing three-dimensional (3D) phase-sensitive inversion-recovery (PSIR) Turbo FLASH sequence for noninvasive assessment of left ventricular myocardial scar in swine models.

MATERIALS AND METHODS

Nine Chinese minipigs with experimentally induced acute myocardial infarction were studied. At 1 week and the study endpoint 4 weeks after myocardial infarction surgery, the 3D and 2D contrasted cardiac magnetic resonance (CMR) imaging were performed randomly by using a 1.5 T clinical MR imaging system. Comparisons of myocardial scar volume (in cubic centimeters), scar transmurality (on a 5 points scale) and image quality (on a 4 points Likert scale) were performed by using the Pearson correlation and Bland-Altman analysis (for myocardial scar volume) or κ statistics (for transmurality) or Wilcoxon signed rank test (for image quality).

RESULTS

In 6 of the 9 pigs, all procedures were successfully completed. In these pigs, a total of 48 segments with myocardial scars were detected by both 3D and 2D sequences, and there was good agreement for classification of scar transmurality (κ=0.930). The scar volume determined by triphenyltetrazolium chloride (TTC) staining (3.52 ± 1.40 cm(3)) showed a good correlation with both 3D (3.54 ± 1.36 cm(3), r=0.957, P=0.003) and 2D sequence (3.53 ± 1.26 cm(3), r=0.942, P=0.005) at 4 weeks. And there were good correlation between scar volumes obtained from 3D and 2D techniques (r=0.859, P<0.001) at both time points. Both 3D and 2D images detected a small reduction of scar volume from week 1 to week 4 by a factor of 1.179 and 1.176, respectively. Although slightly more artifacts were observed on 2D PSIR images, the overall image quality was not significantly different between the two sequences (3.17 ± 0.83 for 2D vs. 3.25 ± 0.75 for 3D, P =0.655).

CONCLUSIONS

The free-breathing 3D PSIR Turbo FLASH sequence enables accurate assessment of left ventricular myocardial scar.

MR, CT, and PET imaging in pericardial disease

Although echocardiography remains the standard diagnostic tool for identifying pericardial diseases, procedures with better delineation of morphology and heart function are often required. The pericardium consists of an inner visceral (epicardium) and outer parietal layer (pericardium), which constitute for the pericardial cavity. Pericardial effusion can occur as transudate, exudate, pyopneumopericardium, or hemopericardium. Potential causes are inflammatory processes, that is, pericarditis due to autoimmune or infective reasons, neoplasms, irradiation, or systemic disorders, chronic renal failure, endocrine, or metabolic diseases. Pericardial fat can mimic pericardial effusion. Using various image-acquisition sequences, MRI allows identifying and separating fluid and solid structures. Fast spin-echo T1-weighted sequences with black-blood preparation are favourably used for morphological evaluation. Fast spin-echo T2-weighted sequences, particularly with fat saturation, and short-tau inversion-recovery sequences are useful to visualize oedema and inflammation. For further tissue characterization, delayed inversion-recovery imaging is used. Therefore, image acquisition is performed at 5-20 min subsequent to contrast agent administration, the so-called technique of late gadolinium enhancement. Ventricular volumes and myocardial mass can be assessed accurately by steady-state free-precession sequences, which is required to measure cardiac function and ventricular wall stress. Constrictive pericarditis usually results from chronic inflammatory processes leading to increased stiffness, which impedes the slippage of both pericardial layers and thereby the normal cardiac filling. CT imaging can favourably assess pericardial calcification. Thus, MR and CT imaging allow a comprehensive delineation of the pericardium. Superior to echocardiography, both methods provide a larger field of view and depiction of the complete chest including abnormalities of the surrounding mediastinum and lungs. PET provides unique information on the in vivo metabolism of 18-fluorodeoxyglucose that can be superimposed on CT findings and is useful for identifying inflammatory processes or masses, for example neoplasms. These imaging techniques provide advanced information of anatomy and cardiac function to optimize the pericardial access, for example by the AttachLifter system, for diagnosis and treatment.

Review of Journal of Cardiovascular Magnetic Resonance 2012

There were 90 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2012, which is an 8% increase in the number of articles since 2011. The quality of the submissions continues to increase. The editors are delighted to report that the 2011 JCMR Impact Factor (which is published in June 2012) has risen to 4.44, up from 3.72 for 2010 (as published in June 2011), a 20% increase. The 2011 impact factor means that the JCMR papers that were published in 2009 and 2010 were cited on average 4.44 times in 2011. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, the progress of the journal's impact over the last 5 years has been impressive. Our acceptance rate is approximately 25%, and has been falling as the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors have felt that it is useful once per calendar year to summarize the papers for the readership into broad areas of interest or theme, so that areas of interest can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.

[Clinical indications for the use of cardiac MRI. By the SIRM Study Group on Cardiac Imaging]

Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected.

Review of Journal of Cardiovascular Magnetic Resonance 2011

There were 83 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2011, which is an 11% increase in the number of articles since 2010. The quality of the submissions continues to increase. The editors had been delighted with the 2010 JCMR Impact Factor of 4.33, although this fell modestly to 3.72 for 2011. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, we remain very pleased with the progress of the journal's impact over the last 5 years. Our acceptance rate is approximately 25%, and has been falling as the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors feel it is useful to summarize the papers for the readership into broad areas of interest or theme, which we feel would be useful, so that areas of interest from the previous year can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.

Cardiovascular magnetic resonance: applications in daily practice

Over the last 10 years, the development of newer pulse sequences and applications in new clinical areas has enabled cardiovascular magnetic resonance to emerge as a powerful tool for the physicians to both diagnose and guide treatments of various cardiac pathologies. The greatest strengths of cardiovascular magnetic resonance include the assessment of ischemia and viability, evaluation of nonischemic cardiomyopathies, including myocarditis, pericardial disease, congenital heart disease, and tissue characterization of cardiac masses.