Cardiovascular magnetic resonance in cardiac sarcoidosis with MR conditional pacemaker in situ

Diagnostic accuracy of cardiac magnetic resonance imaging for cardiac sarcoidosis in complete heart block patients implanted with magnetic resonance-conditional pacemaker

BACKGROUND

Cardiac magnetic resonance (CMR) imaging has become the principal noninvasive imaging modality for the diagnosis of cardiac sarcoidosis (CS) patients. This study aimed to determine the diagnostic performance of CMR imaging for CS in new-onset complete heart block (CHB) patients implanted with magnetic resonance-conditional pacemaker (MRCP).

METHODS

Fifty CHB patients implanted with MRCP were enrolled in this study. Clinical CS was diagnosed if there was a histological diagnosis of extra-cardiac sarcoidosis in patients with CHB based on the consensus statement; clinical CS was the reference standard. The diagnostic performance of CMR sequences, including cine magnetic resonance imaging (MRI), increased T2-weighted signal (T2WS), and late gadolinium enhancement (LGE), for clinical CS was investigated. We also compared the diagnostic performance of CMR sequences between the entire left ventricle (LV) and the basal septum, which involves the electrical pathway of atrioventricular conduction.

RESULTS

In total, 8 of the 50 patients with CHB were confirmed to have extra-cardiac sarcoidosis and were diagnosed with clinical CS. The accuracy, sensitivity, and specificity of LGE in the basal septum and entire LV were 94%, 100%, and 93% and 80% (p = 0.023), 100% (p = 1.00), and 76% (p = 0.023), respectively. The accuracy, sensitivity, and specificity of increased T2WS and cine MRI in the basal septum were 94%, 75%, and 98% and 90%, 38%, and 100%, respectively. There was no statistical difference between the entire LV and the basal septum for the diagnostic performance of increased T2WS and cine MRI.

CONCLUSIONS

CMR can be a diagnostic tool for evaluating clinical CS in patients with CHB implanted with MRCP. LGE in the basal septum might provide the overall best diagnostic performance for clinical CS with CHB.

Cardiac sarcoidosis: Diagnosis, therapeutic management and prognostic factors

BACKGROUND

Cardiac sarcoidosis (CS) is a severe localization, observed mostly in cardiology departments. Despite appropriate cardiological treatment, CS is a potentially life-threatening condition, and accounts for 13-85% of sarcoidosis-related deaths.

AIMS

This retrospective study aimed to give an overview of CS in a non-cardiac unit, to analyse the effect of first-line immunosuppressive treatment on outcome and survival and to evaluate factors associated with relapses.

METHODS

From 534 cases of sarcoidosis, we selected 59 patients with CS according to "2006 international criteria". We performed an in-depth analysis regarding symptoms, physical signs and cardiac investigation results. Patients were followed for a median period of 60 months.

RESULTS

The median age at cardiac signs was 42 years. Echocardiography abnormalities, isotopic defects and abnormal magnetic resonance imaging findings were observed in 81%, 84% and 92% of patients, respectively. First-line treatment included steroids alone in 24 patients and steroids plus immunosuppressive therapy in 35 patients. Forty-seven (80%) patients recovered; 12 stabilized or worsened. The recovery rate was 75% in the steroids alone group versus 83% in the steroids plus immunosuppressive therapy group. Five (9%) patients died during follow-up, with two deaths attributed to CS. The overall 1- and 5-year survival rates were 98% and 92%, respectively.

CONCLUSION

Our series of patients with CS who received steroids alone or combined with immunosuppressive therapy had a good prognosis, with an overall 5-year survival rate of 92%. The recovery rate was 85%, with no significant difference between patients treated with steroids alone or plus immunosuppressive therapy.

Cardiovascular magnetic resonance in rheumatology: Current status and recommendations for use

Targeted therapies in connective tissue diseases (CTDs) have led to improvements of disease-associated outcomes, but life expectancy remains lower compared to general population due to emerging co-morbidities, particularly due to excess cardiovascular risk. Cardiovascular magnetic resonance (CMR) is a noninvasive imaging technique which can provide detailed information about multiple cardiovascular pathologies without using ionizing radiation. CMR is considered the reference standard for quantitative evaluation of left and right ventricular volumes, mass and function, cardiac tissue characterization and assessment of thoracic vessels; it may also be used for the quantitative assessment of myocardial blood flow with high spatial resolution and for the evaluation of the proximal coronary arteries. These applications are of particular interest in CTDs, because of the potential of serious and variable involvement of the cardiovascular system during their course. The International Consensus Group on CMR in Rheumatology was formed in January 2012 aiming to achieve consensus among CMR and rheumatology experts in developing initial recommendations on the current state-of-the-art use of CMR in CTDs. The present report outlines the recommendations of the participating CMR and rheumatology experts with regards to: (a) indications for use of CMR in rheumatoid arthritis, the spondyloarthropathies, systemic lupus erythematosus, vasculitis of small, medium and large vessels, myositis, sarcoidosis (SRC), and scleroderma (SSc); (b) CMR protocols, terminology for reporting CMR and diagnostic CMR criteria for assessment and quantification of cardiovascular involvement in CTDs; and (c) a research agenda for the further development of this evolving field.

Cardiac MRI in patients with cardiac pacemakers: practical methods for reducing susceptibility artifacts and optimizing image quality

BACKGROUND

Magnetic resonance imaging (MRI) of pacemaker patients has become available despite of previous contraindications. However, pacing systems containing ferromagnetic material may hamper the diagnostic quality of cardiac MR (CMR) images.

PURPOSE

To study methods for reducing susceptibility-based artifacts in CMR examinations of pacemaker patients.

MATERIAL AND METHODS

Altogether 16 patients were scanned with 1.5T MRI scanner using cine balanced steady-state free-precession (bSSFP) and spoiled gradient echo (SPGR) sequences. The use of frequency-scout was also evaluated. For myocardial late gadolinium-enhanced (LGE) imaging, SPGR or bSSFP readout inversion-recovery prepared gradient echo sequences were used with and without phase-sensitive inversion-recovery (PSIR). Two radiologists subjectively compared the image quality (IQ) and the ranges of susceptibility artifacts were evaluated objectively.

RESULTS

The IQ proved adequate for diagnosing each patient, although in a few patients with a left-side implanted generator, artifacts hampered IQ in the anterior and anteroseptal segments of the myocardium in bSSFP cine and LGE sequences. In bSSFP cine, the use of frequency-scout could often transfer the banding artifacts away from the left ventricular myocardium. In LGE imaging, the artifacts were more pronounced in IR-bSSFP and PSIR than in IR-SPGR sequences. The ranges of generator-based artifacts were greater in bSSFP (10-12 cm) than in SPGR (6 cm) sequences due to banding artifacts.

CONCLUSION

The artifacts caused by pacemakers typically did not compromise the diagnostic IQ. The use of frequency-scout prior to bSSFP cine or the use of SPGR-based sequences could also improve IQ.

Clinical value of cardiovascular magnetic resonance in patients with MR-conditional pacemakers

AIMS

Magnetic resonance (MR) conditional pacemakers are increasingly implanted into patients who may need cardiovascular MR (CMR) subsequent to device implantation. We assessed the added value of CMR for diagnosis and management in this population.

METHODS AND RESULTS

CMR and pacing data from consecutive patients with MR conditional pacemakers were retrospectively reviewed. Images were acquired at 1.5 T (Siemens Magnetom Avanto). The indication for CMR and any resulting change in management was recorded. The quality of CMR was rated by an observer blinded to clinical details, and data on pacemaker and lead parameters were collected pre- and post-CMR. Seventy-two CMR scans on 69 patients performed between 2011 and 2015 were assessed. All scans were completed successfully with no significant change in lead thresholds or pacing parameters. Steady-state free precession (SSFP) cine imaging resulted in a greater frequency of non-diagnostic imaging (22 vs. 1%, P < 0.01) compared with gradient echo sequences (GRE). Right-sided pacemakers were associated with less artefact than left-sided pacemakers. Late gadolinium enhancement imaging was performed in 59 scans with only 2% of segments rated of non-diagnostic quality. The CMR data resulted in a new diagnosis in 27 (38%) of examinations; clinical management was changed in a further 18 (25%).

CONCLUSIONS

CMR in patients with MR conditional pacemakers provided diagnostic or management-changing information in the majority (63%) of our cohort. The use of gradient echo cine sequences can reduce rates of non-diagnostic imaging. Right-sided device implantation may be considered in patients likely to require CMR examination.

Cardiac involvement in antiphospholipid syndrome: The diagnostic role of noninvasive cardiac imaging

OBJECTIVES

The antiphospholipid syndrome (APS) is an autoimmune disorder of acquired hypercoagulability characterized by vascular thrombosis, increased pregnancy morbidity, and elevated levels of antiphospholipid antibodies. Cardiac involvement in APS may be presented as heart valve disease affecting approximately a third of patients or less frequently as intracardial thombosis, pulmonary hypertension, right or left ventricular dysfunction, micro-vascular thrombosis, coronary artery, or micro-vascular disease with overt or silent clinical presentation.

METHODS

Noninvasive cardiovascular imaging plays a crucial role in the evaluation of heart involvement in APS. Transthoracic or transoesophageal echocardiography enable early, accurate diagnosis and severity assessment of HVD as well as of ventricular dysfunction and pulmonary hypertension. Studies by echocardiography and nuclear imaging have detected abnormalities in myocardial perfusion in approximately 30% of primary APS. CT scan is the technique of choice for the assessment of pulmonary embolism and can effectively detect intracardiac thrombi. Myocardial perfusion defects have been detected by 13N-ammonia PET in 40% of APS. Cardiovascular magnetic resonance (CMR) has identified an unexpectedly high prevalence of occult myocardial scarring and endomyocardial fibrosis in APS, and is the technique of choice, if quantification of heart valve disease and stress myocardial perfusion-fibrosis is needed.

RESULTS

Noninvasive, nonradiating imaging techniques, such as echocardiography and CMR are superior to CT or nuclear techniques and are of great value for the diagnosis and follow-up of both clinically overt and silent cardiac disease in APS.

CONCLUSIONS

The high incidence of cardiac involvement in APS demands early diagnosis/treatment and multimodality cardiovascular imaging is of great importance.

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.

Magnetic resonance of the heart in a muscular dystrophy patient with an MR conditional ICD: assessment of safety, diagnostic value and technical limitations

Cardiovascular magnetic resonance (CMR) studies in patients with pacemakers or implantable cardioverter/defibrillators (ICD) are increasingly required in daily clinical practice. Therefore, in the last years the manufacturers developed not only MR-conditional pacemakers, but also MR-conditional ICDs. However, the clinical experience regarding the feasibility and limitations of MR studies of the heart in patients with ICDs is still limited. In particular, there are hardly any CMR studies in the same patients performed prior to and post ICD implantation allowing a one-to-one comparison of the obtained CMR images. This is the first presentation of a CMR study in a patient with the world's first and so far only MR-conditional ICD. In our case, a major problem related to the presence of the MR conditional ICD was an image artifact caused by the device's generator which hampered the visualization of the midventricular and apical anterior and antero-lateral segments in all sequences performed. Considering previous studies, right chest implantation of the ICD could probably have helped in this setting and may be preferred in future ICD implantations. Our case report nicely illustrates the real clinical need for specially designed implantable devices that ensure safe and high-quality imaging in patients in whom serial CMR is required.

Variability and homogeneity of cardiovascular magnetic resonance myocardial T2-mapping in volunteers compared to patients with edema

BACKGROUND

The aim of the study was to test the reproducibility and variability of myocardial T2 mapping in relation to sequence type and spatial orientation in a large group of healthy volunteers. For control T2 mapping was also applied in patients with true edema. Cardiovascular magnetic resonance (CMR) T2-mapping has potential for the detection and quantification of myocardial edema. Clinical experience is limited so far. The variability and potential pitfalls in broad application are unknown.

METHODS

Healthy volunteers (n = 73, 35 ± 13 years) and patients with edema (n = 28, 55 ± 17 years) underwent CMR at 1.5 T. Steady state free precession (SSFP) cine loops and T2-weighted spin echo images were obtained. In patients, additionally late gadolinium enhancement images were acquired. We obtained T2 maps in midventricular short axis (SAX) and four-chamber view (4CV) based on images with T2 preparation times of 0, 24, 55 ms and compared fast low angle shot (FLASH) and SSFP readout. 10 volunteers were scanned twice on separate days. Two observers analysed segmental and global T2 per slice.

RESULTS

In volunteers global myocardial T2 systematically differed depending on image orientation and sequence (FLASH 52 ± 5 vs. SSFP 55 ± 5 ms in SAX and 57 ± 6 vs. 59 ± 6 ms in 4CV; p < 0.0001 for both). Anteroseptal and apical segments had higher T2 than inferior and basal segments (SAX: 59 ± 6 vs. 48 ± 5 ms for FLASH and 59 ± 7 vs. 52 ± 4 ms for SSFP; p < 0.0001 for both). 14 volunteers had segments with T2 ≥ 70 ms. Mean intraobserver variability was 1.07 ± 1.03 ms (r = 0.94); interobserver variability was 1.6 ± 1.5 ms (r = 0.87). The coefficient of variation for repeated scans was 7.6% for SAX and 6.6% for 4CV. Mapping revealed focally increased T2 (73 ± 9 vs. 51 ± 3 ms in remote myocardium; p < 0.0001) in all patients with edema.

CONCLUSIONS

Myocardial T2 mapping is technically feasible and highly reproducible. It can detect focal edema and differentiate it from normal myocardium. Increased T2 was found in some volunteers most likely due to partial volume and residual motion.

Cardiovascular magnetic resonance with an MR compatible pacemaker

Magnetic resonance imaging (MRI) within FDA guidelines for the MRI-conditional pacemaker precludes placing the heart at the center of the magnet's bore. This in effect appears to preclude cardiovascular MR. In this manuscript, we describe a protocol for cardiovascular MR of patients with a Revo pacemaker system while operating within FDA guidelines, and the first US case of cardiovascular MR in a patient with a Revo MRI-conditional pacing system despite position constraints.

Clinical utility of a magnetic resonance-conditional pacemaker in a patient with cardiac sarcoidosis

We herein present a case of cardiac sarcoidosis with atrioventricular (AV) block that was evaluated using magnetic resonance imaging (MRI) before and after pacemaker implantation. An echocardiogram showed wall thinning in the basal septum. MRI showed late gadolinium enhancement in the interventricular septum and right ventricle. Fluorine-18-fluorodeoxyglucose positron emission tomography (PET) demonstrated abnormal uptake in the same area. An MR-conditional pacemaker was implanted to treat AV block. Steroid treatment resulted in the remission of the cardiac lesions and AV block, as confirmed by PET and MRI. MR-conditional pacemakers are thus considered to have great advantages in treating cardiac sarcoidosis with AV block.

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.

Heart failure in patients with normal coronary anatomy: diagnostic algorithm and disease pattern of various etiologies as defined by cardiac MRI

In a subgroup of patients with acute heart failure coronary artery disease can be excluded. To explain symptoms and optimize therapy cardiac magnetic resonance (CMR) imaging can contribute to elucidate the underlying pathology in non-ischemic heart disease. A diagnostic algorithm for the work-up of these patients using CMR is suggested. The review discusses various modules of a dedicated CMR protocol. It explains diagnostic markers and challenges of CMR imaging in non-ischemic heart disease. Based on these suggestions the literature in the field is reviewed.

Magnetic resonance imaging in patients with cardiac pacemakers: era of "MR Conditional" designs

Advances in cardiac device technology have led to the first generation of magnetic resonance imaging (MRI) conditional devices, providing more diagnostic imaging options for patients with these devices, but also new controversies. Prior studies of pacemakers in patients undergoing MRI procedures have provided groundwork for design improvements. Factors related to magnetic field interactions and transfer of electromagnetic energy led to specific design changes. Ferromagnetic content was minimized. Reed switches were modified. Leads were redesigned to reduce induced currents/heating. Circuitry filters and shielding were implemented to impede or limit the transfer of certain unwanted electromagnetic effects. Prospective multicenter clinical trials to assess the safety and efficacy of the first generation of MR conditional cardiac pacemakers demonstrated no significant alterations in pacing parameters compared to controls. There were no reported complications through the one month visit including no arrhythmias, electrical reset, inhibition of generator output, or adverse sensations. The safe implementation of these new technologies requires an understanding of the well-defined patient and MR system conditions. Although scanning a patient with an MR conditional device following the strictly defined patient and MR system conditions appears straightforward, issues related to patients with pre-existing devices remain complex. Until MR conditional devices are the routine platform for all of these devices, there will still be challenging decisions regarding imaging patients with pre-existing devices where MRI is required to diagnose and manage a potentially life threatening or serious scenario. A range of other devices including ICDs, biventricular devices, and implantable physiologic monitors as well as guidance of medical procedures using MRI technology will require further biomedical device design changes and testing. The development and implementation of cardiac MR conditional devices will continue to require the expertise and collaboration of multiple disciplines and will need to prove safety, effectiveness, and cost effectiveness in patient care.