ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents

Screening and diagnosis of cardiovascular disease using artificial intelligence-enabled cardiac magnetic resonance imaging

Cardiac magnetic resonance imaging (CMR) is the gold standard for cardiac function assessment and plays a crucial role in diagnosing cardiovascular disease (CVD). However, its widespread application has been limited by the heavy resource burden of CMR interpretation. Here, to address this challenge, we developed and validated computerized CMR interpretation for screening and diagnosis of 11 types of CVD in 9,719 patients. We propose a two-stage paradigm consisting of noninvasive cine-based CVD screening followed by cine and late gadolinium enhancement-based diagnosis. The screening and diagnostic models achieved high performance (area under the curve of 0.988 ± 0.3% and 0.991 ± 0.0%, respectively) in both internal and external datasets. Furthermore, the diagnostic model outperformed cardiologists in diagnosing pulmonary arterial hypertension, demonstrating the ability of artificial intelligence-enabled CMR to detect previously unidentified CMR features. This proof-of-concept study holds the potential to substantially advance the efficiency and scalability of CMR interpretation, thereby improving CVD screening and diagnosis.

Prognostic value of right ventricular free wall strain in patients with sepsis

Background

Right ventricular systolic dysfunction (RVSD) in patients with sepsis is an area of growing interest, but its prognostic significance remains unclear and additional tools are needed to improve our understanding. Right ventricular free wall strain (RV-FWS) is a relatively new parameter to assess RV function. This study aimed to investigate the potential correlation between impaired RV-FWS and prognostic outcomes in patients with sepsis.

Methods

We prospectively assessed right ventricular function in patients with sepsis within the initial 24 h of their hospital admission. RV-FWS, right ventricular global strain (RV-GS), fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE) were examined. RVSD was defined as impaired RV-FWS. Moreover, the association between RVSD and 30-day mortality rate was assessed.

Results

This study included 89 patients. Among them, 27 (30.3%) succumbed to their illness within 30 days. The nonsurviving patients demonstrated significantly lower absolute RV-FWS (-19.7% ± 2.4% vs. -21.1% ± 2.1%, P = 0.008) and RV-GS (-17.7% ± 1.2% vs. -18.4% ± 1.4%, P = 0.032) values than the surviving patients. However, TAPSE and FAC values were not significantly different between the two groups. The optimal cutoff values for RV-FWS, RV-GS, FAC, and TAPSE were -19.0%, -17.9%, 36.5%, and 1.55 cm, respectively. Kaplan-Meier survival curves revealed that patients with impaired RV-FWS and RV-GS demonstrated lower 30-day survival rates, and the predictive performance of RV-FWS (hazard ratio [HR]: 3.97, 95% confidence interval [CI]: 1.85-8.51, P < 0.001) was slightly higher than FAC and TAPSE. However, multivariable Cox regression analysis revealed no association between impaired RV-FWS and mortality outcomes (HR: 1.85, 95% CI: 0.56-6.14, P = 0.316).

Conclusions

Impaired RV-FWS is not associated with short-term mortality outcomes, and RV strain imaging is of limited value in assessing the prognosis of sepsis.

Image and Clinical Characteristics of the Right Coronary Artery Originating From the Left Coronary Sinus: A Database Review

This article systematically explores the imaging and clinical characteristics of a relatively rare cardiac anomaly: the right coronary artery originating from the left coronary sinus. Through a comprehensive analysis of existing literature, this study aims to provide a comprehensive understanding of the prevalence, diagnostic methods, and potential clinical implications of this anatomical variation. Anatomical classification is introduced, along with clinical imaging diagnostic methods, including coronary angiography, computed tomography, and magnetic resonance imaging. Additionally, the review delves into the clinical significance of this anomaly, including its potential associations with myocardial ischemia, arrhythmias, and acute cardiac events, outlining clinical approaches to diagnosing myocardial ischemia. The study results consolidate current knowledge about this cardiac variation, emphasizing the importance of recognizing and appropriately managing it in clinical practice.

Trends in the Incidence and Mortality Rates of Myocarditis in the Chinese Population During 1990-2019: Joinpoint Regression and Age-Period-Cohort Analysis

BACKGROUND

This study aimed to analyze trends in the burden of myocarditis in the Chinese population during 1990-2019.

METHODS

The Global Burden of Disease (GBD) database aims to assess the burden of various diseases and injuries on a global scale, and the contribution of relevant risk factors to the burden of disease was also included. In this study, we collected age-standardized incidence and mortality rates for myocarditis in China from 1990 to 2019 using GBD 2019. The age-period-cohort model was utilized to calculate local drift, longitudinal age patterns, as well as the ratios of period and cohort.

RESULTS

The age-standardized incidence and mortality rates of myocarditis in both men and women presented a decreasing trend during 1990-2019 [average annual percentage change (AAPC) of men = -0.202 (95% CI: -0.213 to -0.191); AAPC of women = -0.263 (95% CI: -0.27 to -0.256) for incidence; AAPC of men = -0.233 (95% CI: -0.371 to -0.094); AAPC of women = -0.872 (95% CI: -1.112 to -0.631) for mortality]. Longitudinal age curves showed that myocarditis incidence and mortality rates elevated with age among individuals aged 15-95+ years, with a higher growth rate in men than in women. The period and cohort ratios for both men and women showed similar decreasing trends. Local drift values for the incidence and mortality rates of myocarditis showed an increasing trend among individuals aged 70-75 years and above.

CONCLUSION

Although the overall burden of myocarditis in China presented a decreasing trend during 1990-2019, the male and elderly populations still have a higher risk of incidence and mortality. Therefore, it is essential for the health-care system to introduce effective prevention and treatment measures for myocarditis.

Clinical and Echocardiographic Predictors for the Presence of Late Gadolinium Enhancement on Cardiac Magnetic Resonance Imaging in Patients with Carbon Monoxide Poisoning

Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMRI) reflects the burden of myocardial damage in carbon monoxide (CO) poisoning. This study aimed to identify the clinical and echocardiographic parameters that can predict myocardial LGE on CMRI in CO poisoning. This prospective observational study included patients who presented with acute CO poisoning and elevated troponin I and underwent echocardiography and CMRI to identify myocardial damage at a tertiary university hospital between August 2017 and May 2019 and August 2020 and July 2022. Based on the CMRI findings, participants were categorized into LGE and non-LGE groups. The median age of the 155 patients was 51.0 years, and 98 (63.2%) were males. Median times from emergency department arrival to either CMRI or echocardiography were 3.0 days each. The LGE group included 99 (63.9%) patients with LGE positivity on CMRIs. Time from rescue to hyperbaric oxygen therapy >4 h (odds ratio (OR): 3.31, 95% confidence interval (CI): 1.28-8.56, p = 0.01); serum lactate levels >2 mmol/L (OR: 2.62, 95% CI: 1.20-5.73, p = 0.02); and left ventricular global longitudinal strain >-16% (OR: 2.95, 95% CI: 1.35-6.47, p = 0.007) were significant predictors of LGE positivity. The area under the curve of these predictors was 0.711. Our prediction model, which combines the clinical parameters with left ventricular global longitudinal strain, may be helpful in the early detection of LGE positivity.

Segmental myocardial viability by echocardiography at rest

BACKGROUND

Myocardial viability assessment adds value to the therapeutic decision-making of patients with ischemic heart disease. In this feasibility study, we investigated whether established echocardiographic measurements of post-systolic shortening (PSS), strain, strain rate and wall motion score (WMS) can discover viable myocardial segments. Our hypothesis is that non-viable myocardial segments are both akinetic and without PSS.

METHODS

The study population consisted of 26 examinations strictly selected by visible dysfunction. We assessed WMS, strain by speckle tracking and strain rate by tissue Doppler. The segments (16*26 = 416) were categorized into either normokinetic/hypokinetic or akinetic/dyskinetic and whether there was PSS. The reference method was the presence of scar with segmental percentage volume scar fraction >50%, detected by late gadolinium-enhanced cardiovascular magnetic resonance. Agreement with echocardiography was evaluated by Kappa coefficient.

RESULTS

WMS had Kappa coefficient 0.43 (sensitivity 99%, specificity 35%). Kappa coefficient of strain was 0.28 (sensitivity 98%, specificity 23%). By combining PSS in akinetic segments with WMS and strain, the Kappa coefficient was 0.06 and 0.08 respectively.

CONCLUSION

Segmental viability was best shown by the presence of systolic function. Post-systolic shortening adds no value to the assessment of segmental myocardial viability.

Magnetic Resonance Imaging of Cardiovascular Manifestations Following COVID-19

Globally, over 650 million people have had COVID-19 due to infection with the SARS-Cov-2 virus. Cardiac complications in the acute infectious and early recovery phase were recognized early in the pandemic, including myocardial injury and inflammation. With a decrease in the number of acute COVID-19 related deaths, there has been increased interest in postacute sequela of COVID-19 (PASC) and other longer-term cardiovascular complications. A proportion of patients recovered from COVID-19 have persistent cardiac symptoms and are at risk of cardiovascular disease. Cardiovascular imaging, including MRI, plays an important role in the detection of cardiovascular manifestations of COVID-19 in both the acute and longer-term phases after COVID-19. The purpose of this review is to highlight the role of cardiovascular imaging in the diagnosis and risk stratification of patients with acute and chronic cardiovascular manifestations of COVID-19 with a focus on cardiac MRI. EVIDENCE LEVEL: 4. TECHNICAL EFFICACY: Stage 3.

Quantitative assessment of radiotherapy-induced myocardial damage using MRI: a systematic review

PURPOSE

To determine the role of magnetic resonance imaging (MRI)-based metrics to quantify myocardial toxicity following radiotherapy (RT) in human subjects through review of current literature.

METHODS

Twenty-one MRI studies published between 2011-2022 were identified from available databases. Patients received chest irradiation with/without other treatments for various malignancies including breast, lung, esophageal cancer, Hodgkin's, and non-Hodgkin's lymphoma. In 11 longitudinal studies, the sample size, mean heart dose, and follow-up times ranged from 10-81 patients, 2.0-13.9 Gy, and 0-24 months after RT (in addition to a pre-RT assessment), respectively. In 10 cross-sectional studies, the sample size, mean heart dose, and follow-up times ranged from 5-80 patients, 2.1-22.9 Gy, and 2-24 years from RT completion, respectively. Global metrics of left ventricle ejection fraction (LVEF) and mass/dimensions of cardiac chambers were recorded, along with global/regional values of T1/T2 signal, extracellular volume (ECV), late gadolinium enhancement (LGE), and circumferential/radial/longitudinal strain.

RESULTS

LVEF tended to decline at >20 years follow-up and in patients treated with older RT techniques. Changes in global strain were observed after shorter follow-up (13±2 months) for concurrent chemoradiotherapy. In concurrent treatments with longer follow-up (8.3 years), increases in left ventricle (LV) mass index were correlated with LV mean dose. In pediatric patients, increases in LV diastolic volume were correlated with heart/LV dose at 2 years post-RT. Regional changes were observed earlier post-RT. Dose-dependent responses were reported for several parameters, including: increased T1 signal in high-dose regions, a 0.136% increase of ECV per Gy, progressive increase of LGE with increasing dose at regions receiving >30 Gy, and correlation between increases in LV scarring volume and LV mean/V10/V25 Gy dose.

CONCLUSION

Global metrics only detected changes over longer follow-up, in older RT techniques, in concurrent treatments, and in pediatric patients. In contrast, regional measurements detected myocardial damage at shorter follow-up and in RT treatments without concurrent treatment and had greater potential for dose-dependent response. The early detection of regional changes suggests the importance of regional quantification of RT-induced myocardial toxicity at early stages, before damage becomes irreversible. Further works with homogeneous cohorts are required to examine this matter.

Long-term outcomes after coronary artery bypass graft with or without surgical ventricular reconstruction in patients with severe left ventricular dysfunction

Background

Patients with chronic myocardial infarction (MI) and severe left ventricular (LV) dysfunction have poor clinical outcomes. This study aimed to determine whether coronary artery bypass graft (CABG) with surgical ventricular reconstruction (SVR) leads to further improvement in long-term patient outcomes compared with isolated CABG (I-CABG).

Methods

From April 2010 to June 2013, 140 consecutive patients with chronic MI and severe LV dysfunction who received contrast-enhanced cardiovascular magnetic resonance imaging (CE-CMR) within 1 month before surgery were enrolled in this study. The cardiovascular events (CVEs) and long-term survival of patients who underwent CABG and SVR were compared with those who met the criteria for SVR but received I-CABG.

Results

A total of 140 patients were included in the final analysis, including 70 patients who underwent CABG and SVR and 70 patients who underwent I-CABG. No differences were observed in the baseline characteristics, LV function, and late gadolinium enhancement (LGE) between the two groups. CABG+SVR patients experienced a longer cardiopulmonary bypass (CPB) time (116.0±35.0 vs. 100.2±23.8 minutes, P=0.002) and ventilation time [median (interquartile range): 22.0 (17.0, 37.0) vs. 20.0 (15.0, 24.0) hours, P=0.019] than I-CABG patients. During a mean follow-up of 123.1±12.7 months (range, 102-140 months), the CABG+SVR group had fewer rehospitalizations for congestive heart failure (CHF) (4.3% vs. 19.1%, P=0.007), but no statistical difference in the mortality rate was observed (2.9% vs. 4.4%, P=0.987). The cumulative CVE-free survival rate was significantly higher in CABG+SVR patients (87.0% vs. 67.6%, P=0.007).

Conclusions

Our findings indicated that patients with chronic MI and severe LV dysfunction experienced similar perioperative outcomes after CABG+SVR or I-CABG. However, the CABG+SVR group resulted in fewer rehospitalizations for CHF and a higher cumulative CVE-free survival rate.

Pericardial tamponade, a diagnostic chameleon: from the historical perspectives to contemporary management

BACKGROUND

Pericardial tamponade (PT) early after cardiac surgery is a challenging clinical entity, not infrequently misrecognized and often only detected late in its course. Because the clinical signs of pericardial tamponade can be very unspecific, a high degree of initial suspicion is required to establish the diagnosis. In addition to clinical examination the deployment of imaging techniques is almost always mandatory in order to avoid delays in diagnosis and to initiate any necessary interventions, such as pericardiocentesis or direct cardiac surgical interventions. After a brief overview of how knowledge of PT has developed throughout history, we report on an atypical life-threatening cardiac tamponade after cardiac surgery. A 74-year-old woman was admitted for elective biological aortic valve replacement and aorto-coronary-bypass grafting (left internal mammary artery to left anterior descending artery, single vein graft to right coronary artery). On the 10th postoperative day, the patient unexpectedly deteriorated. She rapidly developed epigastric pain radiating to the left upper abdomen, and features of low peripheral perfusion and shock. There were no clear signs of pericardial tamponade either clinically or echocardiographically. Therefore, for further differential diagnosis, a contrast-enhanced computed tomography scan was performed under clinical suspicion of acute abdomen. Unexpectedly, active bleeding distally from the right coronary anastomosis was revealed. While the patient was prepared for operative revision, she needed cardiopulmonary resuscitation, which was successful. Intraoperatively, the source of bleeding was located and surgically relieved. The subsequent postoperative course was uneventful.

CONCLUSIONS

In the first days after cardiac surgery, the occurrence of life-threatening situations, such as cardiac tamponade, must be expected. Especially if the symptoms are atypical, the entire diagnostic armamentarium must be applied to identify the origin of the complaints, which may be cardiac, but also non-cardiac.

CENTRAL MESSAGE

A high level of suspicion, immediate diagnostic confirmation, and rapid treatment are required to recognize and successfully treat such an emergency (Fig. 5).

PERSPECTIVE

Pericardial tamponade should always be considered as a complication of cardiac surgery, even when symptoms are atypical. The full range of diagnostic tools must be used to identify the origin of the complaints, which may be cardiac, but also non-cardiac (Fig. 5).

Effect of polygenic risk for schizophrenia on cardiac structure and function: a UK Biobank observational study

BACKGROUND

Cardiovascular disease is a major cause of excess mortality in people with schizophrenia. Several factors are responsible, including lifestyle and metabolic effects of antipsychotics. However, variations in cardiac structure and function are seen in people with schizophrenia in the absence of cardiovascular disease risk factors and after accounting for lifestyle and medication. Therefore, we aimed to explore whether shared genetic causes contribute to these cardiac variations.

METHODS

For this observational study, we used data from the UK Biobank and included White British or Irish individuals without diagnosed schizophrenia with variable polygenic risk scores for the condition. To test the association between polygenic risk score for schizophrenia and cardiac phenotype, we used principal component analysis and regression. Robust regression was then used to explore the association between the polygenic risk score for schizophrenia and individual cardiac phenotypes. We repeated analyses with fibro-inflammatory pathway-specific polygenic risk scores for schizophrenia. Last, we investigated genome-wide sharing of common variants between schizophrenia and cardiac phenotypes using linkage disequilibrium score regression. The primary outcome was principal component regression.

FINDINGS

Of 33 353 individuals recruited, 32 279 participants had complete cardiac MRI data and were included in the analysis, of whom 16 625 (51·5%) were female and 15 654 (48·5%) were male. 1074 participants were excluded on the basis of incomplete cardiac MRI data (for all phenotypes). A model regressing polygenic risk scores for schizophrenia onto the first five cardiac principal components of the principal components analysis was significant (F=5·09; p=0·00012). Principal component 1 captured a pattern of increased cardiac volumes, increased absolute peak diastolic strain rates, and reduced ejection fractions; polygenic risk scores for schizophrenia and principal component 1 were negatively associated (β=-0·01 [SE 0·003]; p=0·017). Similar to the principal component analysis results, for individual cardiac phenotypes, we observed negative associations between polygenic risk scores for schizophrenia and indexed right ventricular end-systolic volume (β=-0·14 [0·04]; p=0·0013, pFDR=0·015), indexed right ventricular end-diastolic volume (β=-0·17 [0·08]); p=0·025; pFDR=0·082), and absolute longitudinal peak diastolic strain rates (β=-0·01 [0·003]; p=0·0024, pFDR=0·015), and a positive association between polygenic risk scores for schizophrenia and right ventricular ejection fraction (β=0·09 [0·03]; p=0·0041, pFDR=0·015). Models examining the transforming growth factor-β (TGF-β)-specific and acute inflammation-specific polygenic risk scores for schizophrenia found significant associations with the first five principal components (F=2·62, p=0·022; F=2·54, p=0·026). Using linkage disequilibrium score regression, we observed genetic overlap with schizophrenia for right ventricular end-systolic volume and right ventricular ejection fraction (p=0·0090, p=0·0077).

INTERPRETATION

High polygenic risk scores for schizophrenia are associated with decreased cardiac volumes, increased ejection fractions, and decreased absolute peak diastolic strain rates. TGF-β and inflammatory pathways might be implicated, and there is evidence of genetic overlap for some cardiac phenotypes. Reduced absolute peak diastolic strain rates indicate increased myocardial stiffness and diastolic dysfunction, which increases risk of cardiac disease. Thus, genetic risk for schizophrenia is associated with cardiac structural changes that can worsen cardiac outcomes. Further work is required to determine whether these associations are specific to schizophrenia or are also seen in other psychiatric conditions.

FUNDING

National Institute for Health Research, Maudsley Charity, Wellcome Trust, Medical Research Council, Academy of Medical Sciences, Edmond J Safra Foundation, British Heart Foundation.

Impact of glycemic control on biventricular function in patients with type 2 diabetes mellitus: a cardiac magnetic resonance tissue tracking study

BACKGROUND

Poor glycemic control is associated with left ventricular (LV) dysfunction in patients with type 2 diabetes mellitus (T2DM). Nonetheless, the association between glycemic control and right ventricular (RV) function in T2DM has not been studied. This study aimed to evaluate the correlation between glycemic control and biventricular function and assess whether one ventricular function was mediated by the other ventricular changes using cardiac magnetic resonance.

MATERIALS AND METHODS

A total of 91 T2DM patients with normal ejection fraction were enrolled and divided into two groups according to glycated hemoglobin (HbA1c) with a cut off 7%. Twenty controls were included. Biventricular ventricular strain parameters, including global peak systolic radial strain, global peak systolic circumferential strain (GCS), global peak systolic longitudinal strain (GLS), peak diastolic radial strain rate (RSR), peak diastolic circumferential strain rate (CSR) and peak diastolic longitudinal strain rate (LSR) were measured.

RESULTS

Compared with controls, patients with both HbA1c < 7% and HbA1c ≥ 7% showed significantly lower LVGCS, LVGLS, LVCSR, LVLSR, RVGLS, RVRSR, RVCSR and RVLSR. Patients with HbA1c ≥ 7% elicited significantly higher RVGCS than controls and lower LVGLS, LVCSR, LVLSR, RVGLS and RVLSR. Multivariable linear regression demonstrated that HbA1c was independently associated with LVGLS, LVLSR, RVGLS and RVLSR after adjustment for traditional risk factors. LV (RV) was not statistically mediated by the other ventricular alterations.

CONCLUSION

In T2DM patients, glycemic control was independently associated with impaired LV and RV systolic and diastolic function and these associations were not mediated by the other ventricular changes.

New therapeutic approach for tricuspid regurgitation: Transcatheter tricuspid valve replacement or repair

The tricuspid valve is a complex structure with normal function dependent on the leaflet morphology, right atrial and annular dynamics, and right ventricular and chordal support. Thus, the pathophysiology of tricuspid regurgitation (TR) is equally complex and current medical and surgical management options are limited. Transcatheter devices are currently being investigated as possible treatment options with lower morbidity and mortality than open surgical procedures. These devices can be divided by their implant location/mechanism of action: leaflet approximation devices, annuloplasty devices, orthotopic valve implants, and heterotopic valve implants. The current review will discuss each class of transcatheter device therapy, and further delve into the current understanding of who and when to treat. Finally, we will include a brief discussion of the future of device and surgical therapy trials for TR and the remaining questions to answer about this complex disease process.

Cardiac magnetic resonance predictors of left ventricular remodelling following acute ST elevation myocardial infarction: The VavirimS study

BACKGROUND

Left ventricular (LV) remodelling (REM) ensuing after ST-elevation myocardial infarction (STEMI), has typically been studied by echocardiography, which has limitations, or cardiac magnetic resonance (CMR) in early phase that may overestimate infarct size (IS) due to tissue edema and stunning. This prospective, multicenter study investigated LV-REM performing CMR in the subacute phase, and 6 months after STEMI.

METHODS AND RESULTS

patients with first STEMI undergoing successful primary angioplasty were consecutively enrolled. CMR was done at 30-days and 6-months. Primary endpoint was prevalence at 6 months of LV-REM [≥12% increase in LV end-diastolic volume index (LV-REMEDV)]; LV-REM by end-systolic volume index increase ≥12% (LV-REMESV) was also calculated. Of 325 patients enrolled, 193 with a full set of research-quality CMR images were analyzed. LV-REMEDV and LV-REMESV were present in 36/193 (19%) and 34/193 (18%) patients, respectively. At follow up, LV ejection fraction (EF) improved in patients with or without LV-REMEDV, whilst it decreased in those with LV-REMESV (p < 0.001 for interaction). Considering predictors of LV-REM, IS in the highest tertile was clearly separated from the two lower tertiles. In LV-REMEDV, the highest tertile was associated with significantly higher LV-EDV, LV-ESV, and lower EF.

CONCLUSIONS

In a contemporary cohort of STEMI patients studied by CMR, prevalence of LV-REMEDV was lower than previously reported. Importantly, our data indicate that LV-REMEDV might not be "adverse" per se, but rather "compensatory", being associated with LV-EF improvement at follow-up. Conversely, LV-REMESV might be an "adverse" phenomenon associated with decreased LV-EF, driven by IS.

Deep learning automates detection of wall motion abnormalities via measurement of longitudinal strain from ECG-gated CT images

Introduction

4D cardiac CT (cineCT) is increasingly used to evaluate cardiac dynamics. While echocardiography and CMR have demonstrated the utility of longitudinal strain (LS) measures, measuring LS from cineCT currently requires reformatting the 4D dataset into long-axis imaging planes and delineating the endocardial boundary across time. In this work, we demonstrate the ability of a recently published deep learning framework to automatically and accurately measure LS for detection of wall motion abnormalities (WMA).

Methods

One hundred clinical cineCT studies were evaluated by three experienced cardiac CT readers to identify whether each AHA segment had a WMA. Fifty cases were used for method development and an independent group of 50 were used for testing. A previously developed convolutional neural network was used to automatically segment the LV bloodpool and to define the 2, 3, and 4 CH long-axis imaging planes. LS was measured as the perimeter of the bloodpool for each long-axis plane. Two smoothing approaches were developed to avoid artifacts due to papillary muscle insertion and texture of the endocardial surface. The impact of the smoothing was evaluated by comparison of LS estimates to LV ejection fraction and the fractional area change of the corresponding view.

Results

The automated, DL approach successfully analyzed 48/50 patients in the training cohort and 47/50 in the testing cohort. The optimal LS cutoff for identification of WMA was -21.8, -15.4, and -16.6% for the 2-, 3-, and 4-CH views in the training cohort. This led to correct labeling of 85, 85, and 83% of 2-, 3-, and 4-CH views, respectively, in the testing cohort. Per-study accuracy was 83% (84% sensitivity and 82% specificity). Smoothing significantly improved agreement between LS and fractional area change (R 2: 2 CH = 0.38 vs. 0.89 vs. 0.92).

Conclusion

Automated LV blood pool segmentation and long-axis plane delineation via deep learning enables automatic LS assessment. LS values accurately identify regional wall motion abnormalities and may be used to complement standard visual assessments.

Heart Failure and Cardiorenal Syndrome: A Narrative Review on Pathophysiology, Diagnostic and Therapeutic Regimens-From a Cardiologist's View

In cardiorenal syndrome (CRS), heart failure and renal failure are pathophysiologically closely intertwined by the reciprocal relationship between cardiac and renal injury. Type 1 CRS is most common and associated with acute heart failure. A preexistent chronic kidney disease (CKD) is common and contributes to acute kidney injury (AKI) in CRS type 1 patients (acute cardiorenal syndrome). The remaining CRS types are found in patients with chronic heart failure (type 2), acute and chronic kidney diseases (types 3 and 4), and systemic diseases that affect both the heart and the kidney (type 5). Establishing the diagnosis of CRS requires various tools based on the type of CRS, including non-invasive imaging modalities such as TTE, CT, and MRI, adjuvant volume measurement techniques, invasive hemodynamic monitoring, and biomarkers. Albuminuria and Cystatin C (CysC) are biomarkers of glomerular filtration and integrity in CRS and have a prognostic impact. Comprehensive "all-in-one" magnetic resonance imaging (MRI) approaches, including cardiac magnetic resonance imaging (CMR) combined with functional MRI of the kidneys and with brain MRI are proposed for CRS. Hospitalizations due to CRS and mortality are high. Timely diagnosis and initiation of effective adequate therapy, as well as multidisciplinary care, are pertinent for the improvement of quality of life and survival. In addition to the standard pharmacological heart failure medication, including SGLT2 inhibitors (SGLT2i), renal aspects must be strongly considered in the context of CRS, including control of the volume overload (diuretics) with special caution on diuretic resistance. Devices involved in the improvement of myocardial function (e.g., cardiac resynchronization treatment in left bundle branch block, mechanical circulatory support in advanced heart failure) have also shown beneficial effects on renal function.

Cardiac MRI assessment of anthracycline-induced cardiotoxicity

The objective of this review article is to discuss how cardiovascular magnetic resonance (CMR) imaging measures left ventricular (LV) function, characterizes tissue, and identifies myocardial fibrosis in patients receiving anthracycline-based chemotherapy (Anth-bC). Specifically, CMR can measure LV ejection fraction (EF), volumes at end-diastole (LVEDV), and end-systole (LVESV), LV strain, and LV mass. Tissue characterization is accomplished through T1/T2-mapping, late gadolinium enhancement (LGE), and CMR perfusion imaging. Despite CMR’s accuracy and efficiency in collecting data about the myocardium, there are challenges that persist while monitoring a cardio-oncology patient undergoing Anth-bC, such as the presence of other cardiovascular risk factors and utility controversies. Furthermore, CMR can be a useful adjunct during cardiopulmonary exercise testing to pinpoint cardiovascular mediated exercise limitations, as well as to assess myocardial microcirculatory damage in patients undergoing Anth-bC.

Improved myocardial scar visualization with fast free-breathing motion-compensated black-blood T1-rho-prepared late gadolinium enhancement MRI

PURPOSE

Clinical guidelines recommend the use of bright-blood late gadolinium enhancement (BR-LGE) for the detection and quantification of regional myocardial fibrosis and scar. This technique, however, may suffer from poor contrast at the blood-scar interface, particularly in patients with subendocardial myocardial infarction. The purpose of this study was to assess the clinical performance of a two-dimensional black-blood LGE (BL-LGE) sequence, which combines free-breathing T₁-rho-prepared single-shot acquisitions with an advanced non-rigid motion-compensated patch-based reconstruction.

MATERIALS AND METHODS

Extended phase graph simulations and phantom experiments were performed to investigate the performance of the motion-correction algorithm and to assess the black-blood properties of the proposed sequence. Fifty-one patients (37 men, 14 women; mean age, 55 ± 15 [SD] years; age range: 19-81 years) with known or suspected cardiac disease prospectively underwent free-breathing T₁-rho-prepared BL-LGE imaging with inline non-rigid motion-compensated patch-based reconstruction at 1.5T. Conventional breath-held BR-LGE images were acquired for comparison purposes. Acquisition times were recorded. Two readers graded the image quality and relative contrasts were calculated. Presence, location, and extent of LGE were evaluated.

RESULTS

BL-LGE images were acquired with full ventricular coverage in 115 ± 25 (SD) sec (range: 64-160 sec). Image quality was significantly higher on free-breathing BL-LGE imaging than on its breath-held BR-LGE counterpart (3.6 ± 0.7 [SD] [range: 2-4] vs. 3.9 ± 0.2 [SD] [range: 3-4]) (P <0.01) and was graded as diagnostic for 44/51 (86%) patients. The mean scar-to-myocardium and scar-to-blood relative contrasts were significantly higher on BL-LGE images (P < 0.01 for both). The extent of LGE was larger on BL-LGE (median, 5 segments [IQR: 2, 7 segments] vs. median, 4 segments [IQR: 1, 6 segments]) (P < 0.01), the method being particularly sensitive in segments with LGE involving the subendocardium or papillary muscles. In eight patients (16%), BL-LGE could ascertain or rule out a diagnosis otherwise inconclusive on BR-LGE.

CONCLUSION

Free-breathing T₁-rho-prepared BL-LGE imaging with inline motion compensated reconstruction offers a promising diagnostic technology for the non-invasive assessment of myocardial injuries.

Atrial fibrillation cardiac radioablation target visibility on magnetic resonance imaging

Magnetic resonance imaging (MRI) guided cardiac radioablation (CR) for atrial fibrillation (AF) is a promising treatment concept. However, the visibility of AF CR targets on MRI acquisitions requires further exploration and MRI sequence and parameter optimization has not yet been performed for this application. This pilot study explores the feasibility of MRI-guided tracking of AF CR targets by evaluating AF CR target visualization on human participants using a selection of 3D and 2D MRI sequences.MRI datasets were acquired in healthy and AF participants using a range of MRI sequences and parameters. MRI acquisition categories included 3D free-breathing acquisitions (3D_acq), 2D breath-hold ECG-gated acquisitions (2D_ECG-gated), stacks of 2D breath-hold ECG-gated acquisitions which were retrospectively interpolated to 3D datasets (3D_interp), and 2D breath-hold ungated acquisitions (2D_real-time). The ease of target delineation and the presence of artifacts were qualitatively analyzed. Image quality was quantitatively analyzed using signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and non-uniformity. Confident 3D target delineation was achievable on all 3D_interp datasets but was not possible on any of the 3D_acq datasets. Fewer artifacts and significantly better SNR, CNR and non-uniformity metrics were observed with 3D_interp compared to 3D_acq. 2D_real-time datasets had slightly lower SNR and CNR than 2D_ECG-gated and 3D_{interp n} datasets. AF CR target visualization on MRI was qualitatively and quantitatively evaluated. The study findings indicate that AF CR target visualization is achievable despite the imaging challenges associated with these targets, warranting further investigation into MRI-guided AF CR treatments.

Simple Predictors for Cardiac Fibrosis in Patients with Type 2 Diabetes Mellitus: The Role of Circulating Biomarkers and Pulse Wave Velocity

Cardiac fibrosis is the basis of structural and functional disorders in patients with diabetes mellitus (T2DM). A wide range of laboratory and instrumental methods is used for its prediction. The study aimed to identify simple predictors of cardiac fibrosis in patients with T2DM based on the analysis of circulating fibrosis biomarkers and arterial stiffness. The study included patients with T2DM (n = 37) and cardiovascular risk factors (RF, n = 27) who underwent ECHO, cardiac magnetic resonance imaging (MRI), pulse wave analysis (PWV), reactive hyperemia (RH), peripheral arterial tonometry, carotid ultrasonography, and assessment of serum fibrosis biomarkers. As a control group, 15 healthy subjects were examined. Left ventricular concentric hypertrophy was accompanied by an increased serum galectin-3 level in T2DM patients. There was a relationship between the PICP and HbA1c levels in both main groups (R2 = 0.309; p = 0.014). A negative correlation between PICP level and the global longitudinal strain (GLS) was found (r = −0.467; p = 0.004). The RH index had a negative correlation with the duration of diabetes (r = −0.356; p = 0.03), the carotid-femoral PWV (r = −0.371; p = 0.024), and the carotid intima-media thickness (r = −0.622; p < 0.001). The late gadolinium-enhanced (LGE) cardiac MRI was detected in 22 (59.5%) T2DM and in 4 (14.85%) RF patients. Diabetes, its baseline treatment with metformin, HbA1c and serum TIMP-1 levels, and left ventricle hypertrophy had moderate positive correlations with LGE findings (p < 0.05). Using the multivariate regression analysis, increased TIMP-1 level was identified as an independent factor associated with cardiac fibrosis.

Validation and quantification of left ventricular function during exercise and free breathing from real-time cardiac magnetic resonance images

Exercise cardiovascular magnetic resonance (CMR) can unmask cardiac pathology not evident at rest. Real-time CMR in free breathing can be used, but respiratory motion may compromise quantification of left ventricular (LV) function. We aimed to develop and validate a post-processing algorithm that semi-automatically sorts real-time CMR images according to breathing to facilitate quantification of LV function in free breathing exercise. A semi-automatic algorithm utilizing manifold learning (Laplacian Eigenmaps) was developed for respiratory sorting. Feasibility was tested in eight healthy volunteers and eight patients who underwent ECG-gated and real-time CMR at rest. Additionally, volunteers performed exercise CMR at 60% of maximum heart rate. The algorithm was validated for exercise by comparing LV mass during exercise to rest. Respiratory sorting to end expiration and end inspiration (processing time 20 to 40 min) succeeded in all research participants. Bias ± SD for LV mass was 0 ± 5 g when comparing real-time CMR at rest, and 0 ± 7 g when comparing real-time CMR during exercise to ECG-gated at rest. This study presents a semi-automatic algorithm to retrospectively perform respiratory sorting in free breathing real-time CMR. This can facilitate implementation of exercise CMR with non-ECG-gated free breathing real-time imaging, without any additional physiological input.

Assessment of Non-contrast-enhanced Dixon Water-fat Separation Compressed Sensing Whole-heart Coronary MR Angiography at 3.0 T: A Single-center Experience

RATIONALE AND OBJECTIVES

The clinical utility of Dixon water-fat separation coronary MR angiography (CMRA) with compressed sensing (CS) reconstruction has not been determined in a patient population. This study was designed to evaluate the performance of 3.0 T non-contrast-enhanced Dixon water-fat separation CS whole-heart CMRA sequence in vitro and in vivo.

MATERIALS AND METHODS

In vitro phantom MRI, we compared key parameters of the SENSE and CS images. And in this prospective in vivo study, from November 2019 to October 2020, 94 participants were recruited for 3.0 T non-contrast-enhanced Dixon water-fat separation CS whole-heart CMRA. The accuracy of CMRA for detecting a ≥ 50% reduction in diameter was determined using X-ray coronary angiography (CA) as the reference method.

RESULTS

Compared with SENSE, CS with an appropriate acceleration factor offers both higher SNR/CNR (p < 0.05) and a shortened acquisition. Fifty-eight patients successfully completed the CMRA and CA. The sensitivity, specificity, positive predictive values, negative predictive values, and accuracy of 3.0 T non-contrast-enhanced Dixon water-fat separation CS whole-heart CMRA according to a patient-based analysis were 96.4%, 66.7%, 73.0%, 95.2% and 81.0%, respectively. The area under the receiver-operator characteristic (ROC) curve (AUC) of 3.0 T non-contrast-enhanced Dixon water-fat separation CS whole-heart CMRA for detecting significant coronary artery stenosis is 0.908, 0.895, and 0.904 in patient-, vessel-, and segment-based analyses respectively.

CONCLUSION

3.0 T non-contrast-enhanced Dixon water-fat separation whole-heart CMRA using appropriate CS is a promising noninvasive and radiation-free technique to detect clinically significant coronary stenosis on patients with suspected CAD.

The Effect of Low Preoperative Ejection Fraction on Mortality After Cardiac Surgery in Indonesia

Background

Among cardiac surgery patients, low preoperative left ventricular ejection fraction (LVEF) is common and has been associated with poor outcomes. The objective of this study was to assess the association between LVEF and postoperative mortality in patients undergoing open-heart surgery in several hospitals in Indonesia.

Methods

We conducted a multicenter study with the retrospective design using data from patients undergoing open-heart surgery in 4 institutions in Indonesia. Data regarding LVEF and other potential risk factors were extracted from medical records and compiled in one datasheet. Statistical analyses were performed to assess if low LVEF was associated with postoperative mortality and identify other potential risk factors.

Results

A total of 4789 patients underwent cardiac surgery in participating centers during the study period. Of these, 189 subjects (3.9%) had poor preoperative LVEF. Poor LVEF was associated with postoperative mortality (adjusted OR 2.761, 95% CI 1.763–4.323, p < 0.001). Based on types of surgery, LVEF had a significant association with mortality only in CABG patients, while there was no such association in valve surgery and inconclusive in congenital surgery patients. Other significant independent predictors of in-hospital mortality included age more than 65 years old, non-elective surgery, the complexity of procedures, history of cardiac surgery, organ failure, CARE score ≥ 3, NYHA class ≥ III, and poor right ventricular function.

Conclusion

Patients with low preoperative LVEF undergoing open-heart surgery had a higher risk of postoperative mortality. Cardiac surgery can be performed with acceptable mortality rates. Accurate selection of patients, risk/benefit evaluation, and planning of surgical and anesthesiological management are mandatory to improve outcomes.

Cardiac Magnetic Resonance Left Ventricle Segmentation and Function Evaluation Using a Trained Deep-Learning Model

Cardiac MRI is the gold standard for evaluating left ventricular myocardial mass (LVMM), end-systolic volume (LVESV), end-diastolic volume (LVEDV), stroke volume (LVSV), and ejection fraction (LVEF). Deep convolutional neural networks (CNNs) can provide automatic segmentation of LV myocardium (LVF) and blood cavity (LVC) and quantification of LV function; however, the performance is typically degraded when applied to new datasets. A 2D U-net with Monte-Carlo dropout was trained on 45 cine MR images and the model was used to segment 10 subjects from the ACDC dataset. The initial segmentations were post-processed using a continuous kernel-cut method. The refined segmentations were employed to update the trained model. This procedure was iterated several times and the final updated U-net model was used to segment the remaining 90 ACDC subjects. Algorithm and manual segmentations were compared using Dice coefficient (DSC) and average surface distance in a symmetric manner (ASSD). The relationships between algorithm and manual LV indices were evaluated using Pearson correlation coefficient (r), Bland-Altman analyses, and paired t-tests. Direct application of the pre-trained model yielded DSC of 0.74 ± 0.12 for LVM and 0.87 ± 0.12 for LVC. After fine-tuning, DSC was 0.81 ± 0.09 for LVM and 0.90 ± 0.09 for LVC. Algorithm LV function measurements were strongly correlated with manual analyses (r = 0.86–0.99, p < 0.0001) with minimal biases of −8.8 g for LVMM, −0.9 mL for LVEDV, −0.2 mL for LVESV, −0.7 mL for LVSV, and −0.6% for LVEF. The procedure required ∼12 min for fine-tuning and approximately 1 s to contour a new image on a Linux (Ubuntu 14.02) desktop (Inter(R) CPU i7-7770, 4.2 GHz, 16 GB RAM) with a GPU (GeForce, GTX TITAN X, 12 GB Memory). This approach provides a way to incorporate a trained CNN to segment and quantify previously unseen cardiac MR datasets without needing manual annotation of the unseen datasets.

30-minute CMR for common clinical indications: a Society for Cardiovascular Magnetic Resonance white paper

BACKGROUND

Despite decades of accruing evidence supporting the clinical utility of cardiovascular magnetic resonance (CMR), adoption of CMR in routine cardiovascular practice remains limited in many regions of the world. Persistent use of long scan times of 60 min or more contributes to limited adoption, though techniques available on most scanners afford routine CMR examination within 30 min. Incorporating such techniques into standardize protocols can answer common clinical questions in daily practice, including those related to heart failure, cardiomyopathy, ventricular arrhythmia, ischemic heart disease, and non-ischemic myocardial injury. BODY: In this white paper, we describe CMR protocols of 30 min or shorter duration with routine techniques with or without stress perfusion, plus specific approaches in patient and scanner room preparation for efficiency. Minimum requirements for the scanner gradient system, coil hardware and pulse sequences are detailed. Recent advances such as quantitative myocardial mapping and other add-on acquisitions can be incorporated into the proposed protocols without significant extension of scan duration for most patients.

CONCLUSION

Common questions in clinical cardiovascular practice can be answered in routine CMR protocols under 30 min; their incorporation warrants consideration to facilitate increased access to CMR worldwide.

The prospective randomized trial of the optimal evaluation of cardiac symptoms and revascularization: Rationale and design of the PRECISE trial

BACKGROUND

Clinicians vary widely in their preferred diagnostic approach to patients with non-acute chest pain. Such variation exposes patients to potentially avoidable risks, as well as inefficient care with increased costs and unresolved patient concerns.

METHODS

The Prospective Randomized Trial of the Optimal Evaluation of Cardiac Symptoms and Revascularization (PRECISE) trial (NCT03702244) compares an investigational "precision" diagnostic strategy to a usual care diagnostic strategy in participants with stable chest pain and suspected coronary artery disease (CAD).

RESULTS

PRECISE randomized 2103 participants with stable chest pain and a clinical recommendation for testing for suspected CAD at 68 outpatient international sites. The investigational precision evaluation strategy started with a pre-test risk assessment using the PROMISE Minimal Risk Tool. Those at lowest risk were assigned to deferred testing (no immediate testing), and the remainder received coronary computed tomographic angiography (cCTA) with selective fractional flow reserve (FFR_CT) for any stenosis meeting a threshold of ≥30% and <90%. For participants randomized to usual care, the clinical care team selected the initial noninvasive or invasive test (diagnostic angiography) according to customary practice. The use of cCTA as the initial diagnostic strategy was proscribed by protocol for the usual care strategy. The primary endpoint is time to a composite of major adverse cardiac events (MACE: all-cause death or non-fatal myocardial infarction) or invasive cardiac catheterization without obstructive CAD at 1 year. Secondary endpoints include health care costs and quality of life.

CONCLUSIONS

PRECISE will determine whether a precision approach comprising a strategically deployed combination of risk-based deferred testing and cCTA with selective FFR_CT improves the clinical outcomes and efficiency of the diagnostic evaluation of stable chest pain over usual care.

Diagnostic value of Cardiac Magnetic Resonance Imaging and Intracoronary Optical Coherence Tomography in patients with a working diagnosis of Myocardial Infarction with Non-obstructive Coronary Arteries - A Systematic review and Meta-analysis

BACKGROUND

We aimed to study the efficacy of cardiac magnetic resonance imaging (CMR) and intracoronary optical coherence tomography (OCT) in detecting the etiology of myocardial infarction with non-obstructive coronary arteries (MINOCA).

METHODS

A systematic search was conducted in PubMed, Medline, and Cochrane databases. Search terms used: Myocardial infarction, Coronary angiography, Normal coronary arteries, CMR, and OCT. Inclusion criteria was fulfilled by 18 studies. Meta-analysis was performed with 15 studies.

RESULTS

A total of 2697 patients were included. The mean age of all the patients was 51.5 and 56.4% were men. CMR established diagnosis in 74% of the patients; 29% had acute myocarditis, 18% had true myocardial infarction and 12% had takotsubo cardiomyopathy. Combining OCT with CMR was better at finding the etiology than either modality individually.

CONCLUSION

CMR is integral in identifying the etiology of MINOCA. Coupling OCT and CMR is better than either technique individually at finding the cause.

Hypochlorous acid-activated two-photon fluorescent probe for evaluation of anticancer drug-induced cardiotoxicity and screening of antioxidant drugs

THPIC was developed to detect HClO in lysosomes. The results showed that HClO could be used as a biomarker for evaluating drug-induced cardiotoxicity, and THPIC could be applied as a platform for screening drugs to prevent cardiotoxicitys.

Cardiovascular magnetic resonance imaging in suspected cardiac tumour: a multicentre outcomes study

AIMS

Cardiovascular magnetic resonance (CMR) imaging is a key diagnostic tool for the evaluation of patients with suspected cardiac tumours. Patient management is guided by the CMR diagnosis, including no further testing if a mass is excluded or if only a pseudomass is found. However, there are no outcomes studies validating this approach.

METHODS AND RESULTS

In this multicentre study of patients undergoing clinical CMR for suspected cardiac tumour, CMR diagnoses were assigned as no mass, pseudomass, thrombus, benign tumour, or malignant tumour. A final diagnosis was determined after follow-up using all available data. The primary endpoint was all-cause mortality. Among 903 patients, the CMR diagnosis was no mass in 25%, pseudomass in 16%, thrombus in 16%, benign tumour in 17%, and malignant tumour in 23%. Over a median of 4.9 years, 376 patients died. Compared with the final diagnosis, the CMR diagnosis was accurate in 98.4% of patients. Patients with CMR diagnoses of pseudomass and benign tumour had similar mortality to those with no mass, whereas those with malignant tumour [hazard ratio (HR) 3.31 (2.40-4.57)] and thrombus [HR 1.46 (1.00-2.11)] had greater mortality. The CMR diagnosis provided incremental prognostic value over clinical factors including left ventricular ejection fraction, coronary artery disease, and history of extracardiac malignancy (P < 0.001).

CONCLUSION

In patients with suspected cardiac tumour, CMR has high diagnostic accuracy. Patients with CMR diagnoses of no mass, pseudomass, and benign tumour have similar long-term mortality. The CMR diagnosis is a powerful independent predictor of mortality incremental to clinical risk factors.

Myocardial Perfusion Reserve in Children with Friedreich Ataxia

Children with Friedreich's ataxia (FA) are at risk of perioperative morbidity and mortality from severe unpredictable heart failure. There is currently no clear way of identifying patients at highest risk. We used myocardial perfusion reserve (MPR), an MRI technique used to assess the maximal myocardial blood flow above baseline, to help determine potential surgical risk in FA subjects. In total, seven children with genetically confirmed FA, ages 8-17 years, underwent MPR stress testing using regadenoson. Six of the seven demonstrated impaired endocardial perfusion during coronary hyperemia. The same six were also found to have evidence of ongoing myocardial damage as illustrated by cardiac troponin I leak (range 0.04-0.17 ng/mL, normal < 0.03 ng/mL). None of the patients had a reduced ejection fraction (range 59-74%) or elevated insulin level (range 2.46-14.23 mCU/mL). This retrospective study shows that children with FA develop MPR defects early in the disease process. It also suggests MPR may be a sensitive tool to evaluate underlying cardiac compromise and could be of use in directing surgical management decisions in children with FA.

Mixed-Valve Disease: Management of Patients with Aortic Stenosis and Mitral Regurgitation: Thresholds for Surgery Versus Percutaneous Therapies

Significant mitral regurgitation (MR), frequently seen in the presence of severe aortic stenosis (AS), results in an association that negatively affects prognosis and imposes particular challenges for both the assessment of the severity of valvular lesions and decisions regarding treatment allocation. This article reviews the available literature with regards to the assessment of MR and AS in the presence of both; surgical management and results in patients with concomitant AS and MR; the effect of MR on outcomes in patients undergoing transcatheter aortic valve replacement; the effect of transcatheter aortic valve replacement on MR severity; and percutaneous treatment for MR after transcatheter aortic valve implantation. The authors aim to provide assistance in the decision-making process to treat patients with either a higher-risk double-valve procedure or a simpler, but perhaps incomplete, single-valve option.

The epicardial delivery of cardiosphere derived cells or their extracellular vesicles is safe but of limited value in experimental infarction

The epicardial administration of therapeutics via the pericardial sac offers an attractive route, since it is minimally invasive and carries no risks of coronary embolization. The aim of this study was to assess viability, safety and effectiveness of cardiosphere-derived cells (CDCs), their extracellular vesicles (EVs) or placebo administered via a mini-thoracotomy 72 h after experimental infarction in swine. The epicardial administration was completed successfully in all cases in a surgery time (knife-to-skin) below 30 min. No significant differences between groups were found in cardiac function parameters evaluated using magnetic resonance imaging before therapy and at the end of the study, despite a trend towards improved function in CDC-treated animals. Moreover, infarct size at 10 weeks was smaller in treated animals, albeit not significantly. Arrhythmia inducibility did not differ between groups. Pathological examination showed no differences, nor were there any pericardial adhesions evidenced in any case 10 weeks after surgery. These results show that the epicardial delivery of CDCs or their EVs is safe and technically easy 3 days after experimental myocardial infarction in swine, but it does not appear to have any beneficial effect on cardiac function. Our results do not support clinical translation of these therapies as implemented in this work.

Implementation and prospective clinical validation of AI-based planning and shimming techniques in cardiac MRI

PURPOSE

Cardiovascular magnetic resonance (CMR) is a vital diagnostic tool in the management of cardiovascular diseases. The advent of advanced CMR technologies combined with artificial intelligence (AI) has the potential to simplify imaging, reduce image acquisition time without compromising image quality (IQ), and improve magnetic field uniformity. Here, we aim to implement two AI-based deep learning techniques for automatic slice alignment and cardiac shimming and evaluate their performance in clinical cardiac magnetic resonance imaging (MRI).

METHODS

Two deep neural networks were developed, trained, and validated on pre-acquired cardiac MRI datasets (>500 subjects) to achieve automatic slice planning and shimming (implemented in the scanner) for CMR. To examine the performance of our automated cardiac planning (EasyScan) and AI-based shim (AI shim), two prospective studies were performed subsequently. For the EasyScan validation, 10 healthy subjects underwent two identical CMR protocols: with manual cardiac planning and with AI-based EasyScan to assess protocol scan time difference and accuracy of cardiac plane prescriptions on a 1.5 T clinical MRI scanner. For the AI shim validation, a total of 20 subjects were recruited: 10 healthy and 10 cardio-oncology patients with referrals for a CMR examination. Cine images were obtained with standard cardiac volume shim and with AI shim to assess signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), overall IQ (sharpness and MR image degradation), ejection fraction (EF), and absolute wall thickening. A hybrid statistical method using of nonparametric (Wilcoxon) and parametric (t-test) assessments was employed for statistical analyses.

RESULTS

CMR protocol with AI-based plane prescriptions, EasyScan, minimized operator dependence and reduced overall scanning time by over 2 min (∼13 % faster, p < 0.001) compared to the protocol with manual cardiac planning. EasyScan plane prescriptions also demonstrated more accurate (less plane angulation errors from planes manually prescribed by a certified cardiac MRI technologist) cardiac planes than previously reported strategies. Additionally, AI shim resulted in improved B0 field homogeneity. Cine images obtained with AI shim revealed a significantly higher SNR (12.49%; p = 0.002) than those obtained with volume shim (volume shim: 32.90 ± 7.42 vs. AI shim: 37.01 ± 8.87) for the left ventricle (LV) myocardium. LV myocardium CNR was 12.48% higher for cine imaging with AI shim (149.02 ± 39.15) than volume shim (132.49 ± 33.94). Images obtained with AI shim resulted in sharper images than those obtained with volume shim (p = 0.012). The LVEF and absolute wall thickening also showed that differences exist between the two shimming methods. The LVEF by AI shim was shown to be slightly larger than LVEF by volume shim in two groups: 2.87% higher with AI shim for the healthy group and 1.70% higher with AI shim for the patient group. The LV absolute wall thickening (in mm) also showed that differences exist between shimming methods for each group with larger changes observed in the patient group (healthy: 3.31%, p = 0.234 and patient group: 7.29%, p = 0.059).

CONCLUSIONS

CMR exams using EasyScan for cardiac planning demonstrated accelerated cardiac exam compared to the CMR protocol with manual cardiac planning. Improved and more uniform B0 magnetic field homogeneity also achieved using AI shim technique compared to volume shimming.

High-resolution Free-breathing late gadolinium enhancement Cardiovascular magnetic resonance to diagnose myocardial injuries following COVID-19 infection

PURPOSE

High-resolution free-breathing late gadolinium enhancement (HR-LGE) was shown valuable for the diagnosis of acute coronary syndromes with non-obstructed coronary arteries. The method may be useful to detect COVID-related myocardial injuries but is hampered by prolonged acquisition times. We aimed to introduce an accelerated HR-LGE technique for the diagnosis of COVID-related myocardial injuries.

METHOD

An undersampled navigator-gated HR-LGE (acquired resolution of 1.25 mm3) sequence combined with advanced patch-based low-rank reconstruction was developed and validated in a phantom and in 23 patients with structural heart disease (test cohort; 15 men; 55 ± 16 years). Twenty patients with laboratory-confirmed COVID-19 infection associated with troponin rise (COVID cohort; 15 men; 46 ± 24 years) prospectively underwent cardiovascular magnetic resonance (CMR) with the proposed sequence in our center. Image sharpness, quality, signal intensity differences and diagnostic value of free-breathing HR-LGE were compared against conventional breath-held low-resolution LGE (LR-LGE, voxel size 1.8x1.4x6mm).

RESULTS

Structures sharpness in the phantom showed no differences with the fully sampled image up to an undersampling factor of x3.8 (P > 0.5). In patients (N = 43), this acceleration allowed for acquisition times of 7min21s ± 1min12s at 1.25 mm3 resolution. Compared with LR-LGE, HR-LGE showed higher image quality (P = 0.03) and comparable signal intensity differences (P > 0.5). In patients with structural heart disease, all LGE-positive segments on LR-LGE were also detected on HR-LGE (80/391) with 21 additional enhanced segments visible only on HR-LGE (101/391, P < 0.001). In 4 patients with COVID-19 history, HR-LGE was definitely positive while LR-LGE was either definitely negative (1 microinfarction and 1 myocarditis) or inconclusive (2 myocarditis).

CONCLUSIONS

Undersampled free-breathing isotropic HR-LGE can detect additional areas of late enhancement as compared to conventional breath-held LR-LGE. In patients with history of COVID-19 infection associated with troponin rise, the method allows for detailed characterization of myocardial injuries in acceptable scan times and without the need for repeated breath holds.

Established and Emerging Techniques for Pericardial Imaging with Cardiac Magnetic Resonance

PURPOSE OF REVIEW

Pericardial diseases include a wide range of pathologies and their diagnosis can often be challenging. The goal of this review is to describe the established and emerging CMR imaging techniques used in the assessment of common pericardial diseases and explain the role of pericardial characterization in their diagnosis and management.

RECENT FINDINGS

CMR is indicated in cases of diagnostic uncertainty and for a comprehensive evaluation of the pericardium and its impact on the heart. This includes assessment of pericardial anatomy and associated cardiac hemodynamics, quantification and characterization of an effusion, disease staging, tissue characterization, guiding management, and even prognostication in some diseases of the pericardium. An emerging technique, pericardial characterization, utilizes various sequences to diagnose and stage pericardial inflammation, act as a biomarker in recurrent pericarditis, and guide management in inflammatory pericardial conditions. Beyond imaging, it has ushered in an era of tailored therapy for patients with pericardial diseases. Future directions should aim at exploring the role of tissue characterization in various pericardial diseases.

A Case of Cardiac Papillary Fibroelastoma - An Increasingly Described Cardiac Tumor with Fatal Consequences

Papillary fibroelastomas (PFE) are rare primary cardiac tumors characterized by non-malignant, pedunculated, endocardial lesions with a significant risk of embolic potential and death. With improvements in the imaging quality and availability of transthoracic echocardiograms (TTE), the diagnosis of PFE has become more common in the last 2 decades. PFE is changing from a rare "zebra" diagnosis to one that community providers will encounter in their practice and must appropriately treat to prevent morbidity and mortality. Data shows that there are significant survival and morbidity benefit associated with surgical excision over non-operative management, with the benefit of anticoagulation remaining unclear at this time. We report a case describing the diagnostic workup and management of a 58-year-old woman who presented with an unidentified endocardial mass determined to be a PFE. Based on current literature, we favor a strategy of early surgical excision of PFE for an optimal reduction in mortality and thromboembolic sequelae associated with this pathology.

Cardiovascular Magnetic Resonance (CMR) for the Evaluation of Myocardial Infarction in Patients with Non-obstructive Coronary Artery Disease (MINOCA)

Purpose of Review

Myocardial infarction in the absence of coronary artery disease is caused by a variety of clinical conditions, so it is important to detect the specific causes in order to perform a better prognostic stratification of these patients. The aim of this review is to summarize the most important findings that established the role of CMR (cardiovascular magnetic resonance) to detect the MINOCA (myocardial infarction with non-obstructive arteries) patients and the importance to differentiate them from myocardial infarction patients.

Recent Findings

The role of CMR is crucial to diagnose the principal diseases involved in MINOCA, as demonstrated. The several MR sequences used in all the MINOCA patients showed different results for all the different causes of MINOCA and, surely, high-resolution MR with gadolinium enhancement has been considered the best method to differentiate the transmural lesions.

Summary

Another fundamental aspect to be considered is the experience of CMR radiologists, which represent the most important element for the right diagnosis of MINOCA. Surely, in the future, CMR will be the most important technique of choice for MINOCA patients, playing a key role in their management.

Cardiorenal Syndrome: Emerging Role of Medical Imaging for Clinical Diagnosis and Management

Cardiorenal syndrome (CRS) concerns the interconnection between heart and kidneys in which the dysfunction of one organ leads to abnormalities of the other. The main clinical challenges associated with cardiorenal syndrome are the lack of tools for early diagnosis, prognosis, and evaluation of therapeutic effects. Ultrasound, computed tomography, nuclear medicine, and magnetic resonance imaging are increasingly used for clinical management of cardiovascular and renal diseases. In the last decade, rapid development of imaging techniques provides a number of promising biomarkers for functional evaluation and tissue characterization. This review summarizes the applicability as well as the future technological potential of each imaging modality in the assessment of CRS. Furthermore, opportunities for a comprehensive imaging approach for the evaluation of CRS are defined.

Value CMR: Towards a Comprehensive, Rapid, Cost-Effective Cardiovascular Magnetic Resonance Imaging

Cardiac magnetic resonance imaging (CMR) is considered the gold standard for measuring cardiac function. Further, in a single CMR exam, information about cardiac structure, tissue composition, and blood flow could be obtained. Nevertheless, CMR is underutilized due to long scanning times, the need for multiple breath-holds, use of a contrast agent, and relatively high cost. In this work, we propose a rapid, comprehensive, contrast-free CMR exam that does not require repeated breath-holds, based on recent developments in imaging sequences. Time-consuming conventional sequences have been replaced by advanced sequences in the proposed CMR exam. Specifically, conventional 2D cine and phase-contrast (PC) sequences have been replaced by optimized 3D-cine and 4D-flow sequences, respectively. Furthermore, conventional myocardial tagging has been replaced by fast strain-encoding (SENC) imaging. Finally, T1 and T2 mapping sequences are included in the proposed exam, which allows for myocardial tissue characterization. The proposed rapid exam has been tested in vivo. The proposed exam reduced the scan time from >1 hour with conventional sequences to <20 minutes. Corresponding cardiovascular measurements from the proposed rapid CMR exam showed good agreement with those from conventional sequences and showed that they can differentiate between healthy volunteers and patients. Compared to 2D cine imaging that requires 12-16 separate breath-holds, the implemented 3D-cine sequence allows for whole heart coverage in 1-2 breath-holds. The 4D-flow sequence allows for whole-chest coverage in less than 10 minutes. Finally, SENC imaging reduces scan time to only one slice per heartbeat. In conclusion, the proposed rapid, contrast-free, and comprehensive cardiovascular exam does not require repeated breath-holds or to be supervised by a cardiac imager. These improvements make it tolerable by patients and would help improve cost effectiveness of CMR and increase its adoption in clinical practice.

The diagnostic value of non-contrast magnetic resonance coronary angiography in the assessment of coronary artery disease: A systematic review and meta-analysis

Purpose

The current literature reports a wide range of diagnostic accuracy of non-contrast magnetic resonance coronary angiography (NC-MRCA) for the assessment of coronary artery disease (CAD). We aimed to compare the clinical effectiveness of NC-MRCA with that of invasive coronary angiography (ICA) in patients with suspected CAD using a systematic review and meta-analysis.

Methods

Two investigators independently extracted 36 published manuscripts between 2010 and 2019. Databases including Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane were searched using pre-established keywords. Analysis of the data followed the PRISMA statement for reporting systematic reviews and meta-analyses and primary analysis followed the Mantel-Hansel methodology. Correctness of classification for detecting coronary artery stenosis ≥50% (CAS) was measured using ICA as the gold standard.

Results

A total of five studies met inclusion criteria, with a total of 417 patients and 2883 coronary segments. The pooled per patient sensitivity and specificity of NC-MRCA for CAS in suspected patients was 90.3% (95% CI 85.6–95.1%) and 77.9% (95% CI 69.5–86.3%). Pooled per vessel assessment of NC- MRCA revealed a sensitivity of 83.7% (95%CI 79.7–87.8%) and specificity of 90.0% (95%CI 86.7–93.4%). Per-segment assessment of NC-MRCA showed a pooled sensitivity of 81.6% (95% CI 76.8–86.4) and specificity of 97.0% (95% CI 95.5–98.5). Mild to moderate heterogeneity was noted in most diagnostic parameters with larger heterogeneity noted in the per-segment analyses. There was less heterogeneity in sensitivity and NPV than specificity and PPV.

Conclusion

According to this meta-analysis, non-contrast coronary MRA resulted in adequate screening in patients with suspected CAD with high sensitivity and specificity. This result was true for per-patient, per-vessel, and per-segment assessment.

Epidemiological Impact of Myocarditis

Myocarditis is an inflammatory disease of the heart muscle with a wide range of potential etiological factors and consequently varying clinical patterns across the world. In this review, we address the epidemiology of myocarditis. Myocarditis was considered a rare disease until intensified research efforts in recent decades revealed its true epidemiological importance. While it remains a challenge to determine the true prevalence of myocarditis, studies are underway to obtain better approximations of the proportions of this disease. Nowadays, the prevalence of myocarditis has been reported from 10.2 to 105.6 per 100,000 worldwide, and its annual occurrence is estimated at about 1.8 million cases. This wide range of reported cases reflects the uncertainty surrounding the true prevalence and a potential underdiagnosis of this disease. Since myocarditis continues to be a significant public health issue, particularly in young adults in whom myocarditis is among the most common causes of sudden cardiac death, improved diagnostic and therapeutic procedures are necessary. This manuscript aims to summarize the current knowledge on the epidemiology of myocarditis, new diagnostic approaches and the current epidemiological impact of the COVID-19 pandemic.

Cardiac troponin and defining myocardial infarction

The 4th Universal Definition of Myocardial Infarction has stimulated considerable debate since its publication in 2018. The intention was to define the types of myocardial injury through the lens of their underpinning pathophysiology. In this review, we discuss how the 4th Universal Definition of Myocardial Infarction defines infarction and injury and the necessary pragmatic adjustments that appear in clinical guidelines to maximize triage of real-world patients.