Myocardial Extracellular Volume Fraction and T1 Mapping by Cardiac Magnetic Resonance Compared Between Patients With and Without Type 2 Diabetes, and the Effect of ECV and T2D on Cardiovascular Outcomes

Shaping cardiac diagnostics: The role of myocardial tissue mapping in unraveling ring-like fibrosis

BACKGROUND

Patients with non-ischemic cardiomyopathy exhibit a range of myocardial fibrosis (MF) patterns on cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) imaging. Data suggests that ring-like MF is associated with worse prognosis. In the present study it was sought to analyze the prevalence of parametric mapping abnormalities in ring-like MF and their prognostic value for arrhythmic events.

METHODS

Patients undergoing clinical CMR at 1.5T/3T were evaluated for ring-like MF defined as midwall/subepicardial fibrosis involving ≥ 3 contiguous left ventricular segments. CMR protocol included cine imaging, T1 and T2 mapping, and LGE. Mean native T1, ECV, and T2 values and a number of mid short axis segments with elevated values were calculated. LGE extent was assessed segmentally. Arrhythmic outcomes were defined as appropriate device shock, premature ventricular contractions ≥ 10%, non-sustained/sustained ventricular tachycardia, or ventricular fibrillation.

RESULTS

In total 49 patients (53 ± 17 years, 26.5% female) were analyzed. Many patients had elevated global/segmental mapping values: 45%/76% in native T1, 57%/57% in T2, and 57%/78% in ECV. During median follow-up of 12 months, arrhythmic events occurred in 65% of patients. There was no association between native T1/T2 elevation or number of LGE segments and arrhythmic outcomes. There was a significant association between ECV and arrhythmic outcomes, both septal ECV (p = 0.036) and any segmental ECV elevation (p = 0.03).

CONCLUSION

T1 and T2 myocardial tissue abnormalities are common in patients with ring-like MF. ECV elevation was associated with arrhythmic events in this cohort. Further studies are needed to establish the diagnostic and prognostic value of parametric mapping in patients with ring-like MF.

Extracellular volume fraction and native T1 mapping in diabetic cardiomyopathy: a comprehensive meta-analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with myocardial fibrosis (MF), a major contributor to adverse cardiovascular outcomes. Cardiovascular magnetic resonance (CMR), specifically extracellular volume fraction (ECV) and native T1 mapping, offers a non-invasive approach to quantify MF. This study aims to evaluate the utility of ECV and native T1 mapping as biomarkers for cardiac fibrosis and to assess their relationship with diabetes severity, measured by hemoglobin A1C (HbA1C), in patients with T2DM.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. Comprehensive searches identified 19 eligible studies comprising 4,117 participants. Weighted mean differences (WMDs) were calculated for ECV and native T1 values between diabetic and non-diabetic groups. Meta-regression assessed the correlation between ECV and HbA1C. Sensitivity and subgroup analyses were performed to explore heterogeneity.

RESULTS

Diabetic patients exhibited significantly higher ECV values than controls (WMD: 2.17; 95% CI: 1.32-3.02), consistent across subgroups excluding cardiac comorbidities (WMD: 2.02; 95% CI: 0.74-3.31). HbA1C levels were also significantly elevated in diabetics (WMD: 1.78; 95% CI: 1.37-2.19). However, no significant difference in native T1 values was observed (WMD: 13.40; 95% CI: -13.98-40.79). Meta-regression revealed no significant correlation between ECV and HbA1C, potentially due to limited data and high heterogeneity (I²: 93.37%).

CONCLUSIONS

ECV is a promising marker for quantifying MF in T2DM, demonstrating significant differences between diabetics and controls. The lack of correlation between ECV and HbA1C underscores the complexity of MF in diabetes and highlights the need for further research. Future studies with standardized protocols are essential to validate these findings and refine the use of CMR in diabetic cardiomyopathy.

A comparative study of synthetic and venous hematocrit for calculating cardiovascular magnetic resonance-derived extracellular volume

The extracellular volume (ECV) fraction derived from cardiac magnetic resonance (CMR) can reflect various pathologies. The application of ECVs was limited by the strict requirement that hematocrit (Hct0) should be obtained within 24 hours of CMR scan. The aim of this study was to obtain accurate and convenient ECV calculated from the venous Hct and synthetic Hct in CMR. A total of 839 subjects were retrospectively enrolled. The subjects were divided into derivation cohort for local sex-specific models and validation cohort for assessing the accuracy of different ECVs. In the validation cohort, venous Hcts from 7 days before the scan (Hct1 - 7), outside 7 days (Hct> 7), the closest day (Hctclosest), and Hctsyn were compared with Hct0. The agreement and correlation of the conventional ECV (ECV0) with the corresponding ECVs were analyzed. The factors affecting the accuracy of ECVsyn were assessed. ECV1-7 and ECVclosest had the best correlation and smallest bias with ECV0 (R = 0.959 and 0.951, bias = 0.02% and - 0.03%). When using an absolute 2% error as the standard, the performance of ECV1-7 was the best, with an accuracy of 81.0%, followed by ECVclosest (78.8%), ECV> 7 (77.2%) and ECVsyn (70.7%). Abnormally low and high Hcts and decreased left ventricular ejection fractions were associated with miscalculation of ECVsyn, especially patients with dilated cardiomyopathy. We recommend extending the time interval between a Hct and a CMR scan to 7 days for ECV calculation. The synthetic ECV should be used cautiously, especially for patients with extremely low or high Hcts, decreased cardiac function, and dilated cardiomyopathy.

Parametric mapping by cardiovascular magnetic resonance imaging in sudden cardiac arrest survivors

Etiology of sudden cardiac arrest (SCA) is identified in less than 30% of survivors without coronary artery disease. We sought to assess the diagnostic role of myocardial parametric mapping using cardiovascular magnetic resonance (CMR) in identifying SCA etiology. Consecutive SCA survivors undergoing CMR with myocardial parametric mapping were included in the study. The determination if CMR was decisive or contributory in identifying SCA etiology was made if the diagnosis was unclear prior to CMR, and the discharge diagnosis was consistent with the CMR result. Parametric mapping was considered essential for establishing probable SCA etiology by CMR if the SCA cause could not have been determined without its utilization. If the CMR diagnosis could have been potentially based on the combination of cine and LGE imaging, parametric mapping was considered contributory. Of the 35 patients (mean age 46.9 ± 14.1 years; 57% males) included, SCA diagnosis was based on CMR in 23 (66%) patients. Of those, parametric mapping was essential for the diagnosis of myocarditis and tako-tsubo cardiomyopathy (11/48%) and contributed to the diagnosis in 10 (43%) additional cases. Inclusion of quantitative T1 and T2 parametric mapping in the SCA CMR protocol has the potential to increase diagnostic yield of CMR and further specify SCA etiology, especially myocarditis.

Cardiovascular Magnetic Resonance Imaging as an Adjunct to the Evaluation of Cardiovascular Involvement in Diabetes Mellitus

Diabetes mellitus (DM) is a new epidemic which has presented an immense increase in recent decades, due to the rapid increase in obesity. Cardiovascular disease (CVD) significantly reduces life expectancy and is the main cause of death in type 2 diabetes mellitus (T2DM). Strict glycemic control is a well-established method to combat microvascular CVD of type 1 diabetes mellitus (T1DM); its role against CVD of the T2DM risk has not been well documented. Therefore, the most efficient prevention is multifactorial risk factor reduction. Recently, the European Society of Cardiology published its 2019 recommendations on CVD in DM. Although all clinical points were discussed in this document, only a few comments were presented about when and how we should recommend cardiovascular (CV) imaging. Currently, CV imaging is the "must" in CV noninvasive evaluation. Alterations in CV imaging parameters can lead to early recognition of various types of CVD. In this paper, we briefly discuss the role of noninvasive imaging modalities, emphasizing the benefits of including cardiovascular magnetic resonance (CMR) in the evaluation of DM. CMR, in the same examination, can provide an assessment of tissue characterization, perfusion and function, with excellent reproducibility and without radiation or limitations, due to the body habitus. Therefore, it can play a dominant role in the prevention and risk stratification of DM. The suggested protocol for DM evaluation should include routine annual echocardiographic evaluation of all DM patients and CMR assessment of those with poorly controlled DM, microalbuminuria, heart failure, arrhythmia and recent alterations in clinical or echocardiographic evaluation.

Quantitative MRI in cardiometabolic disease: From conventional cardiac and liver tissue mapping techniques to multi-parametric approaches

Cardiometabolic disease refers to the spectrum of chronic conditions that include diabetes, hypertension, atheromatosis, non-alcoholic fatty liver disease, and their long-term impact on cardiovascular health. Histological studies have confirmed several modifications at the tissue level in cardiometabolic disease. Recently, quantitative MR methods have enabled non-invasive myocardial and liver tissue characterization. MR relaxation mapping techniques such as T₁, T_1ρ, T₂ and T₂* provide a pixel-by-pixel representation of the corresponding tissue specific relaxation times, which have been shown to correlate with fibrosis, altered tissue perfusion, oedema and iron levels. Proton density fat fraction mapping approaches allow measurement of lipid tissue in the organ of interest. Several studies have demonstrated their utility as early diagnostic biomarkers and their potential to bear prognostic implications. Conventionally, the quantification of these parameters by MRI relies on the acquisition of sequential scans, encoding and mapping only one parameter per scan. However, this methodology is time inefficient and suffers from the confounding effects of the relaxation parameters in each single map, limiting wider clinical and research applications. To address these limitations, several novel approaches have been proposed that encode multiple tissue parameters simultaneously, providing co-registered multiparametric information of the tissues of interest. This review aims to describe the multi-faceted myocardial and hepatic tissue alterations in cardiometabolic disease and to motivate the application of relaxometry and proton-density cardiac and liver tissue mapping techniques. Current approaches in myocardial and liver tissue characterization as well as latest technical developments in multiparametric quantitative MRI are included. Limitations and challenges of these novel approaches, and recommendations to facilitate clinical validation are also discussed.

Cardiac magnetic resonance T1 mapping for evaluating myocardial fibrosis in patients with type 2 diabetes mellitus: correlation with left ventricular longitudinal diastolic dysfunction

OBJECTIVES

We aimed to evaluate myocardial fibrosis using cardiac magnetic resonance (CMR) T1 mapping in type 2 diabetes mellitus (T2DM) patients and investigate the association between left ventricular (LV) subclinical myocardial dysfunction and myocardial fibrosis.

METHODS

The study included 37 short-term (≤ 5 years) and 44 longer-term (> 5 years) T2DM patients and 41 healthy controls. The LV global strain parameters and T1 mapping parameters were compared between the abovementioned three groups. The association of T1 mapping parameters with diabetes duration, in addition to other risk factors, was determined using multivariate linear regression analysis. The correlation between LV strain parameters and T1 mapping parameters was evaluated using Pearson's correlation.

RESULTS

The peak diastolic strain rates (PDSRs) were significantly lower in longer-term T2DM patients compared to those in healthy subjects and short-term T2DM patients (p < 0.05). The longitudinal peak systolic strain rate and peak strain were significantly lower in the longer-term T2DM compared with the short-term T2DM group (p < 0.05). The extracellular volumes (ECVs) were higher in both subgroups of T2DM patients compared with control subjects (all p < 0.05). Multivariate linear regression analysis showed that diabetes duration was independently associated with ECV (β = 0.413, p < 0.001) by taking covariates into account. Pearson's analysis showed that ECV was associated with longitudinal PDSR (r = - 0.441, p < 0.001).

CONCLUSION

T1 mapping could detect abnormal myocardial fibrosis early in patients with T2DM, which can cause a decline in the LV diastolic function.

KEY POINTS

• CMR T1 mapping could detect abnormal myocardial fibrosis early in patients with T2DM. • The diabetes duration was independently associated with ECV. • Myocardial fibrosis can cause a decline in the LV diastolic function in T2DM patients.