Cardiovascular magnetic resonance native T1 mapping in Anderson-Fabry disease: a systematic review and meta-analysis

Screening for Fabry disease in patients with hypertrophic cardiomyopathy using cardiac magnetic resonance imaging

BACKGROUND

Fabry disease (FD) usually mimics hypertrophic cardiomyopathy (HCM). Decreased native T1 mapping and a unique late gadolinium enhancement (LGE) pattern by cardiac magnetic resonance (CMR) imaging are specific imaging markers for FD.

PURPOSE

Explore the performance of multiparametric CMR imaging in screening for FD in patients with a HCM phenotype.

MATERIALS AND METHODS

A prospective cohort of 602 patients with a HCM phenotype was assessed from April 2012 to December 2022. Participants underwent CMR imaging and genetic testing. FD diagnosis was according to genetic testing and enzyme-activity test of α-galactosidase A. Multiparameter CMR imaging included cardiac function, native T1 mapping, extracellular volume (ECV), T2 mapping, LGE, and myocardial strains. Diagnostic performance of CMR parameters in identifying FD from HCM was done by analysis of receiver operating characteristic (ROC) curves.

RESULTS

FD prevalence was 1.8% (11 cases) in this cohort with HCM. Native T1 mapping was significantly lower in FD compared with HCM (FD vs. HCM: native T1 mapping: 1174.08 ± 60.60 vs. 1293.94 ± 55.86, p < 0.001). Ventricular function, mass, ventricular wall thickness, and strains did not show significant differences between the two groups. Binary logistic regression and analysis of ROC curves demonstrated myocardial native T1 mapping of the left ventricular basal slice had the best performance in screening for FD in patients with a HCM phenotype (cutoff: 1216 ms; AUC: 0.947; sensitivity: 91%; specificity: 90%).

CONCLUSION

Native T1 mapping is the best parameter for screening FD in a Chinese population with a HCM phenotype.

KEY POINTS

Question The prevalence of Fabry Disease (FD) in the study population is unknown and the efficacy of cardiac MRI (CMR) parameter screening for FD needs validating. Findings We report the prevalence of FD among a Chinese hypertrophic cardiomyopathy (HCM) cohort and found T1 mapping is the best CMR parameter for screening FD. Clinical relevance Native T1 mapping is the best CMR parameter for screening FD in the HCM cohort, providing an effective method for rapid screening of FD in clinic, which may help identify patients for early treatment of FD.

The role of sex, training load, and sports type in athletic cardiac remodelling: Insights from T1 and T2 mapping via cardiac magnetic resonance

BACKGROUND

Cardiovascular magnetic resonance (CMR) imaging, utilising native T1 and T2 mapping, provides a non-invasive method for assessing myocardial tissue properties, contributing to the clinical evaluation of the athlete's heart.

OBJECTIVE

To evaluate T1 and T2 mapping alterations and their association with sex, training volume, sports type, and other standard CMR parameters of the athlete's heart.

METHODS

We conducted a cross-sectional analysis of healthy elite athletes (≥10 training hours/week) and sedentary controls (≤5 h/week) who underwent detailed cardiology screening. CMR was performed, and native T1 and T2 values were quantified.

RESULTS

Of the 199 healthy participants (115 elite athletes, 24 ± 5 years, 70 % males; 84 sedentary volunteers, 26 ± 3 years, 58 % males), athletes had higher ventricular volumes, left ventricular mass (LVMi), and lower ejection fractions than volunteers. Athletes showed lower T1 values (male athletes:941 ± 23 ms vs. 960 ± 21 ms, p < 0.01; female athletes:970 ± 20 ms vs. 982 ± 25 ms, p < 0.01). T1 negatively correlated with training hours and LVMi (Rho: -0.554, p < 0.001). T1 values were positively associated with female sex with 22 ms (CI 14.3, 29.7, p < 0.001) higher values than males, while each additional hour in weekly exercise volume was associated with a 0.5 ms (CI -0.84, -0.11, p = 0.011) decrease. Compared to strength and mixed athletes, endurance athletes showed more pronounced myocardial adaptation, reflected in lower T1.

CONCLUSION

Sex, training volume, and type of sport significantly influence CMR-derived T1 and T2 values. This study highlights the critical need for sex- and sport-type-specific reference ranges in assessing myocardial remodelling in athletes, facilitating the distinction between benign athletic remodelling and (early) pathological changes.

Cardiac Magnetic Resonance Imaging in the Evaluation and Prognosis of Infiltrative Cardiomyopathies

Advancements in cardiac magnetic resonance (CMR) imaging quality and availability have made it an essential tool in the care of individuals living with cardiomyopathies. CMR complements clinical suspicion, electrocardiogram patterns, and echocardiographic findings to help elucidate the etiology of cardiomyopathies and can also be used to prognosticate and follow treatment responses. In this review, we highlight the common CMR findings in cardiac amyloidosis, cardiac sarcoidosis, iron overload cardiomyopathy, and Fabry disease. We also summarize prognostic findings and additional potential roles for CMR in the management of infiltrative cardiomyopathies.

Identification of an Ultra-Rare GLA Frameshift Variant in a South African Family With Hypertrophic Cardiomyopathy: A Case Report

Fabry disease (FD) is an X-linked deficiency in glycosphingolipid metabolism caused by pathogenic variation in GLA. FD can mimic hypertrophic cardiomyopathy (HCM). Here, we present a South African patient of European ancestry with HCM where subsequent genetic analysis led to a diagnosis of FD. He was diagnosed with HCM at the age of 53 when he presented with new-onset atrial fibrillation (AF) and a left occipital cerebral infarction. He reported receiving treatment for recurrent pneumothoraxes in his mid-20s and suffered a transient ischemic attack (TIA) seven years prior to his diagnosis. During follow-up, he developed progressive chronotropic incompetence with AF and symptomatic bradycardia requiring pacing, as well as progressive dyspnea with obstructive lung disease, mild proteinuria with grade 1 chronic kidney disease, and peripheral neuropathy. Genetic research led to the identification of a pathogenic frameshift variant (GLA c.774_775delAC; p.Pro259ArgfsTer5) in the patient and his mother. This is an ultra-rare 2 bp pathogenic deletion in the causative gene for FD. Therefore, a diagnosis of FD was considered in this family and subsequently confirmed by an enzyme activity test. The proband was started on enzyme replacement therapy (ERT) to preserve kidney function and prevent other organ involvement, although it was not expected to reverse cardiac hypertrophy. This case demonstrates that non-cardiac disease may precede cardiac presentation in FD, emphasizing the importance of a detailed medical history in patients presenting with HCM. Testing for GLA variation should be considered in patients with similar phenotypic presentation, as diagnosis of HCM phenocopies such as FD can have important implications on treatment and management. Timely treatment of FD with ERT is crucial to prevent end-stage organ damage and preserve quality of life.

Cardiac Manifestations in Fabry Disease: A Case Report on Two Siblings

Background/objectives: Anderson-Fabry disease (FD) is a rare hereditary disorder caused by deficient alpha-galactosidase A activity, which leads to multisystemic complications, including significant cardiac involvement. In this case report, we describe two siblings with distinct cardiac manifestations of FD. Methods: The medical data of two siblings who were managed and treated at a tertiary hospital center in Croatia were obtained by detailed analysis of electronic medical records. All available data were structured in chronological order. Results: A 42-year-old male with chronic renal failure and severe left ventricular hypertrophy (LVH) was diagnosed with FD during testing for inclusion on the kidney transplant waiting list. The diagnosis was confirmed by cardiac magnetic resonance imaging (CMR), which revealed non-ischemic fibrosis typical of FD. Following enzyme replacement therapy (ERT), he underwent a successful kidney transplantation. The second case describes the 36-year-old brother, who was diagnosed through family screening and, despite normal initial cardiac ultrasound findings, exhibited early cardiac involvement through reduced T1-mapping values. Immediate initiation of ERT led to normalization of T1 values and successful renal transplantation. Conclusions: This report underscores the importance of family screening and early diagnosis in FD and highlights the role of CMR in detecting preclinical cardiac involvement.

Left Ventricular Hemodynamic Forces Changes in Fabry Disease: A Cardiac Magnetic Resonance Study

BACKGROUND

Hemodynamic force (HDF) from cardiac MRI can indicate subclinical myocardial dysfunction, and help identify early cardiac changes in patients with Fabry disease (FD). The hemodynamic change in FD patients remains unclear.

PURPOSE

To explore HDF changes in FD and the potential of HDF measurements as diagnostic markers indicating early cardiac changes in FD.

STUDY TYPE

Single-center, prospective, observational study.

POPULATION

Forty-six FD patients (age: 38 ± 12, females: 45.65%) and 46 sex- and age-matched healthy controls (HCs).

FIELD STRENGTH/SEQUENCE

3 T, cardiac MRI including steady-state free precession cine imaging (during multiple breath-holds), phase-sensitive inversion recovery sequence for late gadolinium enhancement (LGE) imaging, and motion-corrected modified Look-Locker inversion recovery sequence for T1 mapping.

ASSESSMENT

Analysis of strains and HDF were performed on the cine imaging. HDF parameters includes apical-basal force, systolic impulse, systolic peak, systolic-diastolic transition, diastolic deceleration, and atrial thrust. Moreover, FD patients were categorized with left ventricular hypertrophy (LVH+) (the maximal wall thickness >12 mm) or without LVH (LVH-). Mainz Severity Score Index (MSSI) score was calculated to measure the progression of FD.

STATISTICAL TESTS

Group comparison tests, logistic regression, and receiver operating characteristic curve (ROC) were performed. A P-value <0.05 was considered statistically significant.

RESULTS

FD patients showed significantly lower native T1 (1161.1 ± 55.4 vs. 1202.8 ± 42.0 msec) and higher systolic impulse (33.8 ± 9.9 vs. 24.8 ± 9.5%). The systolic impulse in HDF analysis increased even in the pre-hypertrophic stage. The increased myocardial global longitudinal strain (r = 0.419) and systolic impulse (r = 0.333) showed positive correlations with a higher MSSI score. The AUC of systolic impulse and global native T1 showed no significant difference (0.764 vs. 0.790, P = 0.784).

DATA CONCLUSION

Increased systolic impulse and systolic peak can be observed in FD patients. Systolic impulse showed potential ability for screening pre-LVH FD patients and correlated with disease severity in FD patients.

PLAIN LANGUAGE SUMMARY

This study explored hemodynamic changes in patients with Fabry disease (FD) using hemodynamic force (HDF) analysis based on cardiac MRI. 46 FD patients were included and analysis of cardiac function, native T1, strains, and hemodynamic changes on cardiac MRI images were performed. The results showed that systolic impulse and systolic peak of HDF analysis were increased in FD patients, and systolic impulse may increase even in the pre-hypertrophic stage. Systolic impulse was correlated with disease severity in patients with FD, which may be a potential image-based diagnosis and monitoring marker in FD patients.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 2.

Alternating low-rank tensor reconstruction for improved multiparametric mapping with cardiovascular MR Multitasking

PURPOSE

To develop a novel low-rank tensor reconstruction approach leveraging the complete acquired data set to improve precision and repeatability of multiparametric mapping within the cardiovascular MR Multitasking framework.

METHODS

A novel approach that alternated between estimation of temporal components and spatial components using the entire data set acquired (i.e., including navigator data and imaging data) was developed to improve reconstruction. The precision and repeatability of the proposed approach were evaluated on numerical simulations, 10 healthy subjects, and 10 cardiomyopathy patients at multiple scan times for 2D myocardial T1/T2 mapping with MR Multitasking and were compared with those of the previous navigator-derived fixed-basis approach.

RESULTS

In numerical simulations, the proposed approach outperformed the previous fixed-basis approach with lower T1 and T2 error against the ground truth at all scan times studied and showed better motion fidelity. In human subjects, the proposed approach showed no significantly different sharpness or T1/T2 measurement and significantly improved T1 precision by 20%-25%, T2 precision by 10%-15%, T1 repeatability by about 30%, and T2 repeatability by 25%-35% at 90-s and 50-s scan times The proposed approach at the 50-s scan time also showed comparable results with that of the previous fixed-basis approach at the 90-s scan time.

CONCLUSION

The proposed approach improved precision and repeatability for quantitative imaging with MR Multitasking while maintaining comparable motion fidelity, T1/T2 measurement, and septum sharpness and had the potential for further reducing scan time from 90 s to 50 s.

Cardiac magnetic resonance findings in cardiac amyloidosis

PURPOSE OF REVIEW

The purpose of this review is to highlight the increasing importance of cardiac magnetic resonance (CMR) imaging in diagnosing and managing cardiac amyloidosis, especially given the recent advancements in treatment options.

RECENT FINDINGS

This review emphasizes the crucial role of late gadolinium enhancement (LGE) with phase-sensitive inversion recovery (PSIR) techniques in both diagnosing and predicting patient outcomes in cardiac amyloidosis. The review also explores promising new techniques for diagnosing early-stage disease, such as native T1 mapping and ECV quantification. Additionally, it delves into experimental techniques like diffusion tensor imaging, MR elastography, and spectroscopy.

SUMMARY

This review underscores CMR as a powerful tool for diagnosing cardiac amyloidosis, assessing risk factors, and monitoring treatment response. While LGE imaging remains the current best practice for diagnosis, emerging techniques such as T1 mapping and ECV quantification offer promise for improved detection, particularly in early stages of the disease. This has significant implications for patient management as newer therapeutic options become available for cardiac amyloidosis.

Role of Cardiac Magnetic Resonance in Inflammatory and Infiltrative Cardiomyopathies: A Narrative Review

Cardiac magnetic resonance (CMR) has acquired a pivotal role in modern cardiology. It represents the gold standard for biventricular volume and systolic function assessment. Moreover, CMR allows for non-invasive myocardial tissue evaluation, highlighting tissue edema, fibrosis, fibro-fatty infiltration and iron overload. This manuscript aims to review the impact of CMR in the main inflammatory and infiltrative cardiomyopathies, providing details on specific imaging patterns and insights regarding the most relevant trials in the setting.

Imaging of Cardiac Fibrosis: An Update, From the AJR Special Series on Imaging of Fibrosis

Myocardial fibrosis (MF) is defined as excessive production and deposition of extra-cellular matrix proteins that result in pathologic myocardial remodeling. Three types of MF have been identified: replacement fibrosis from tissue necrosis, reactive fibrosis from myocardial stress, and infiltrative interstitial fibrosis from progressive deposition of nondegradable material such as amyloid. Although echocardiography, nuclear medicine, and CT play important roles in the assessment of MF, MRI is pivotal in the evaluation of MF, with the late gadolinium enhancement (LGE) technique used as a primary end point. The LGE technique focuses on the pattern and distribution of gadolinium accumulation in the myocardium and assists in the diagnosis and establishment of the cause of both ischemic and nonischemic cardiomyopathy. LGE MRI also aids prognostication and risk stratification. In addition, LGE MRI is used to guide the management of patients considered for ablation for arrhythmias. Parametric mapping techniques, including T1 mapping and extracellular volume measurement, allow detection and quantification of diffuse fibrosis, which may not be detected by LGE MRI. These techniques also allow monitoring of disease progression and therapy response. This review provides an update on the imaging of MF, including prognostication and risk stratification tools, electrophysiologic considerations, and disease monitoring.

Cardiovascular Magnetic Resonance Imaging in Myocardial Disease

Cardiovascular magnetic resonance (CMR) is the central non-invasive imaging investigation for the evaluation of myocardial disease. It is the well-established gold standard for measuring cardiac chamber volumes, systolic function, and left ventricular mass, and it brings unique information for therapeutic decisions. In addition, its tissue characterization capability, through T1, T2, and T2* mapping, as well as early and late gadolinium enhancement (LGE) sequences, allows to differentiate in many cases among ischemic, inflammatory, and infiltrative heart disease and permits the quantification of myocardial fibrosis, providing valuable diagnostic and prognostic information. This review aims to highlight the main CMR features of different cardiomyopathies.

Fabry Disease: More than a Phenocopy of Hypertrophic Cardiomyopathy

Fabry disease (FD) is a genetic lysosomal storage disease with frequent cardiovascular involvement, whose presence is a major determinant of adverse clinical outcomes. As a potentially treatable cause of left ventricular hypertrophy (LVH) and heart failure with preserved ejection fraction, the early recognition of FD is crucial to initiate enzyme replacement therapy and improve long-term prognosis. Multimodality imaging plays a central role in the evaluation of patients with FD and helps in the differential diagnosis of other conditions presenting with LVH. In the present review, we explore the current applications of multimodality cardiac imaging, in particular echocardiography and cardiovascular magnetic resonance, in the diagnosis, prognostic assessment, and follow-up of patients with FD.

Advanced CMR Techniques in Anderson-Fabry Disease: State of the Art

Anderson-Fabry disease (AFD) is a rare multisystem X-linked lysosomal storage disorder caused by α-galactosidase A enzyme deficiency. Long-term cardiac involvement in AFD results in left ventricular hypertrophy and myocardial fibrosis, inducing several complications, mainly arrhythmias, valvular dysfunction, and coronary artery disease. Cardiac magnetic resonance (CMR) represents the predominant noninvasive imaging modality for the assessment of cardiac involvement in the AFD, being able to comprehensively assess cardiac regional anatomy, ventricular function as well as to provide tissue characterization. This review aims to explore the role of the most advanced CMR techniques, such as myocardial strain, T1 and T2 mapping, perfusion and hybrid imaging, as diagnostic and prognostic biomarkers.

Anderson-Fabry disease cardiomyopathy: an update on epidemiology, diagnostic approach, management and monitoring strategies

Anderson-Fabry disease (AFD) is an X-linked lysosomal storage disorder caused by deficient activity of the enzyme alpha-galactosidase. While AFD is recognized as a progressive multi-system disorder, infiltrative cardiomyopathy causing a number of cardiovascular manifestations is recognized as an important complication of this disease. AFD affects both men and women, although the clinical presentation typically varies by sex, with men presenting at a younger age with more neurologic and renal phenotype and women developing a later onset variant with more cardiovascular manifestations. AFD is an important cause of increased myocardial wall thickness, and advances in imaging, in particular cardiac magnetic resonance imaging and T1 mapping techniques, have improved the ability to identify this disease non-invasively. Diagnosis is confirmed by the presence of low alpha-galactosidase activity and identification of a mutation in the GLA gene. Enzyme replacement therapy remains the mainstay of disease modifying therapy, with two formulations currently approved. In addition, newer treatments such as oral chaperone therapy are now available for select patients, with a number of other investigational therapies in development. The availability of these therapies has significantly improved outcomes for AFD patients. Improved survival and the availability of multiple agents has presented new clinical dilemmas regarding disease monitoring and surveillance using clinical, imaging and laboratory biomarkers, in addition to improved approaches to managing cardiovascular risk factors and AFD complications. This review will provide an update on clinical recognition and diagnostic approaches including differentiation from other causes of increased ventricular wall thickness, in addition to modern strategies for management and follow-up.

Long-Term Monitoring of Cardiac Involvement under Migalastat Treatment Using Magnetic Resonance Tomography in Fabry Disease

Background: Fabry cardiomyopathy is characterized by left ventricular hypertrophy, myocardial fibrosis, arrhythmia, and premature death. Treatment with migalastat, an oral pharmacological chaperone, was associated with a stabilization of cardiac biomarkers and a reduction in left ventricular mass index, as measured by echocardiography. A recent study, using cardiac magnetic resonance (CMR) as the gold standard, found a stable course of myocardial involvement after 18 months of treatment with migalastat. Our study aimed to provide long-term CMR data for the treatment with migalastat. Methods: A total of 11 females and four males with pathogenic amenable GLA mutations were treated with migalastat and underwent 1.5T CMR imaging for routine treatment effect monitoring. The main outcome was a long-term myocardial structural change, reflected by CMR. Results: After migalastat treatment initiation, left ventricular mass index, end diastolic volume, interventricular septal thickness, posterior wall thickness, estimated glomerular filtration rate, and plasma lyso-Gb3 remained stable during the median follow-up time of 34 months (min.: 25; max.: 47). The T1 relaxation times, reflecting glycosphingolipid accumulation and subsequent processes up to fibrosis, fluctuated over the time without a clear trend. No new onset of late gadolinium enhancement (LGE) areas, reflecting local fibrosis or scar formation of the myocardium, could be detected. However, patients with initially present LGE showed an increase in LGE as a percentage of left ventricular mass. The median α-galactosidase A enzymatic activity increased from 37.3% (IQR 5.88-89.3) to 105% (IQR 37.2-177) of the lower limit of the respective reference level (p = 0.005). Conclusion: Our study confirms an overall stable course of LVMi in patients with FD, treated with migalastat. However, individual patients may experience disease progression, especially those who present with fibrosis of the myocardium already at the time of therapy initiation. Thus, a regular treatment re-evaluation including CMR is needed to provide the optimal management for each patient.

Cardiac Magnetic Resonance in Fabry Disease: Morphological, Functional, and Tissue Features

Fabry disease (FD) is an X-linked inheritable storage disease caused by a deficiency of alpha-galactosidase causing lysosomal overload of sphingolipids. FD cardiomyopathy is characterized by left ventricular (LV) hypertrophy and should be considered in differential diagnosis with all the other causes of LV hypertrophy. An early diagnosis of FD is very important because the enzyme replacement therapy (ERT) may change the fate of patients by blocking both cardiac and systemic involvement and improving prognosis. Diagnosis may be relatively easy in young patients with the typical signs and symptoms of FD, but in male patients with late onset of disease and in females, diagnosis may be very challenging. Morphological and functional aspects are not specific to FD, which cannot be diagnosed or excluded by echocardiography. Cardiac magnetic resonance (CMR) with tissue characterization capability is an accurate technique for the differential diagnosis of LV hypertrophy. The finding of decreased myocardial T1 value in LV hypertrophy is specific to FD. Late gadolinium enhancement (LGE) is found in the late stage of the disease, but it is useful to predict the cardiac response to ERT and to stratify the prognosis.

Certainties and Uncertainties of Cardiac Magnetic Resonance Imaging in Athletes

Prolonged and intensive exercise induces remodeling of all four cardiac chambers, a physiological process which is coined as the “athlete’s heart”. This cardiac adaptation, however, shows overlapping features with non-ischemic cardiomyopathies, such as dilated, arrhythmogenic and hypertrophic cardiomyopathy, also associated with athlete’s sudden cardiac death. Cardiac magnetic resonance (CMR) is a well-suited, highly reproducible imaging modality that can help differentiate athlete’s heart from cardiomyopathy. CMR allows accurate characterization of the morphology and function of cardiac chambers, providing full coverage of the ventricles. Moreover, it permits an in-depth understanding of the myocardial changes through specific techniques such as mapping or late gadolinium enhancement. In this narrative review, we will focus on the certainties and uncertainties of the role of CMR in sports cardiology. The main aspects of physiological adaptation due to regular and intensive sports activity and the application of CMR in highly trained athletes will be summarized.