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Davies RH, Augusto JB, Bhuva A, Xue H, Treibel TA, Ye Y, Hughes RK, Bai W, Lau C, Shiwani H, Fontana M, Kozor R, Herrey A, Lopes LR, Maestrini V, Rosmini S, Petersen SE, Kellman P, Rueckert D, Greenwood JP, Captur G, Manisty C, Schelbert E, Moon JC. Precision measurement of cardiac structure and function in cardiovascular magnetic resonance using machine learning. J Cardiovasc Magn Reson 2022; 24:16. [PMID: 35272664 PMCID: PMC8908603 DOI: 10.1186/s12968-022-00846-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 02/03/2022] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Measurement of cardiac structure and function from images (e.g. volumes, mass and derived parameters such as left ventricular (LV) ejection fraction [LVEF]) guides care for millions. This is best assessed using cardiovascular magnetic resonance (CMR), but image analysis is currently performed by individual clinicians, which introduces error. We sought to develop a machine learning algorithm for volumetric analysis of CMR images with demonstrably better precision than human analysis. METHODS A fully automated machine learning algorithm was trained on 1923 scans (10 scanner models, 13 institutions, 9 clinical conditions, 60,000 contours) and used to segment the LV blood volume and myocardium. Performance was quantified by measuring precision on an independent multi-site validation dataset with multiple pathologies with n = 109 patients, scanned twice. This dataset was augmented with a further 1277 patients scanned as part of routine clinical care to allow qualitative assessment of generalization ability by identifying mis-segmentations. Machine learning algorithm ('machine') performance was compared to three clinicians ('human') and a commercial tool (cvi42, Circle Cardiovascular Imaging). FINDINGS Machine analysis was quicker (20 s per patient) than human (13 min). Overall machine mis-segmentation rate was 1 in 479 images for the combined dataset, occurring mostly in rare pathologies not encountered in training. Without correcting these mis-segmentations, machine analysis had superior precision to three clinicians (e.g. scan-rescan coefficients of variation of human vs machine: LVEF 6.0% vs 4.2%, LV mass 4.8% vs. 3.6%; both P < 0.05), translating to a 46% reduction in required trial sample size using an LVEF endpoint. CONCLUSION We present a fully automated algorithm for measuring LV structure and global systolic function that betters human performance for speed and precision.
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Affiliation(s)
- Rhodri H Davies
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - João B Augusto
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Anish Bhuva
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, USA
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Yang Ye
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Rebecca K Hughes
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Wenjia Bai
- Data Science Institute, Imperial College London, London, UK
| | - Clement Lau
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Hunain Shiwani
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Marianna Fontana
- Institute of Cardiovascular Science, University College London, London, UK
- National Amyloidosis Centre, University College London, London, UK
| | - Rebecca Kozor
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Anna Herrey
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Luis R Lopes
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Stefania Rosmini
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Steffen E Petersen
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, USA
| | - Daniel Rueckert
- Biomedical Image Analysis Group, Department of Computing, Imperial College London, London, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Gabriella Captur
- Institute of Cardiovascular Science, University College London, London, UK
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, UK
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Erik Schelbert
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
- Minneapolis Heart Institute East, Saint Paul, MN, USA
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, UK.
- Bart's Heart Centre, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK.
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Menacho KD, Ramirez S, Perez A, Dragonetti L, Perez de Arenaza D, Katekaru D, Illatopa V, Munive S, Rodriguez B, Shimabukuro A, Cupe K, Bansal R, Bhargava V, Rodriguez I, Seraphim A, Knott K, Abdel-Gadir A, Guerrero S, Lazo M, Uscamaita D, Rivero M, Amaya N, Sharma S, Peix A, Treibel T, Manisty C, Mohiddin S, Litt H, Han Y, Fernandes J, Jacob R, Westwood M, Ntusi N, Herrey A, Walker JM, Moon J. Improving cardiovascular magnetic resonance access in low- and middle-income countries for cardiomyopathy assessment: rapid cardiovascular magnetic resonance. Eur Heart J 2022; 43:2496-2507. [PMID: 35139531 PMCID: PMC9259377 DOI: 10.1093/eurheartj/ehac035] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/30/2021] [Accepted: 01/18/2022] [Indexed: 02/01/2023] Open
Abstract
AIMS To evaluate the impact of a simplified, rapid cardiovascular magnetic resonance (CMR) protocol embedded in care and supported by a partner education programme on the management of cardiomyopathy (CMP) in low- and middle-income countries (LMICs). METHODS AND RESULTS Rapid CMR focused particularly on CMP was implemented in 11 centres, 7 cities, 5 countries, and 3 continents linked to training courses for local professionals. Patients were followed up for 24 months to assess impact. The rate of subsequent adoption was tracked. Five CMR conferences were delivered (920 attendees-potential referrers, radiographers, reporting cardiologists, or radiologists) and five new centres starting CMR. Six hundred and one patients were scanned. Cardiovascular magnetic resonance indications were 24% non-contrast T2* scans [myocardial iron overload (MIO)] and 72% suspected/known cardiomyopathies (including ischaemic and viability). Ninety-eighty per cent of studies were of diagnostic quality. The average scan time was 22 ± 6 min (contrast) and 12 ± 4 min (non-contrast), a potential cost/throughput reduction of between 30 and 60%. Cardiovascular magnetic resonance findings impacted management in 62%, including a new diagnosis in 22% and MIO detected in 30% of non-contrast scans. Nine centres continued using rapid CMR 2 years later (typically 1-2 days per week, 30 min slots). CONCLUSIONS Rapid CMR of diagnostic quality can be delivered using available technology in LMICs. When embedded in care and a training programme, costs are lower, care is improved, and services can be sustained over time.
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Affiliation(s)
- Katia Devorha Menacho
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | | | - Aylen Perez
- Cardiology and Cardiovascular Surgery National Institute, La Havana, Cuba
| | | | | | - Diana Katekaru
- Military National Hospital, Cardiac Imaging Department, Lima, Peru
| | | | - Sara Munive
- National Cardiovascular Institute—INCOR, Lima, Peru
| | | | - Ana Shimabukuro
- Guillermo Almenara Irigoyen Hospital, National Hospital, Lima, Peru
| | - Kelly Cupe
- Guillermo Almenara Irigoyen Hospital, National Hospital, Lima, Peru
| | - Rajiv Bansal
- Santokba Durlabhji Memorial Hospital Cum Medical Research Institute, Jaipur, India
| | | | | | - Andreas Seraphim
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Kris Knott
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Amna Abdel-Gadir
- Institute of Cardiovascular Science, University College London, London, UK
| | | | - Marco Lazo
- Ramiro Priale National Hospital, Huancayo, Peru
| | - David Uscamaita
- Edgardo Rebagliati Hospital, MRI and CT Department, Lima, Peru
| | | | - Neil Amaya
- Edgardo Rebagliati Hospital, MRI and CT Department, Lima, Peru
| | - Sanjiv Sharma
- AlI India Institute of Medical Sciences, New Delhi, India
| | - Amelia Peix
- Cardiology and Cardiovascular Surgery National Institute, La Havana, Cuba
| | - Thomas Treibel
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Sam Mohiddin
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Harold Litt
- Department of Medicine (Cardiovascular Division), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yuchi Han
- Department of Medicine (Cardiovascular Division), Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Ron Jacob
- Lancaster General Health Hospital, Lancaster, USA
| | - Mark Westwood
- St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - Ntobeko Ntusi
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Anna Herrey
- Institute of Cardiovascular Science, University College London, London, UK,St Bartholomew’s Hospital, Barts Heart Centre, London EC1A 7BE, UK
| | - John Malcolm Walker
- Institute of Cardiovascular Science, University College London, London, UK,The Hatter Cardiovascular Institute, University College London Hospital, London, UK
| | - James Moon
- Corresponding author. Tel: +44 203 8870566,
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Menacho Medina KD, Ramirez S, Katekaru D, Dragonetti L, Perez D, Illatopa V, Rodriguez B, Bansal R, Rodriguez I, Jacob R, Ntusi N, Herrey A, Westwood M, Walker M, Mooon J. 28Impact of non-invasive rapid cardiac magnetic resonance for the assessment of cardiomyopathies in developing countries. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Cardiovascular mortality is higher in developing countries. Part of that is suboptimal testing. Cardiac magnetic resonance (CMR) is the gold standard for measuring structure, function of the heart and adds incremental value by imaging scarring and to assess iron level. Despite the existence of MRI units, CMR is identified as a complex test, with poor training and availability in developing countries.
Purpose
To assess the potential impact of a faster CMR protocol at a multicentre level in developing countries; implementing it with an education program, for the assessment cardiomyopathies.
Methods
An international partnership. A rapid CMR protocol for the evaluation of cardiac volumes, function and tissue characterization (Cardiac Iron T2* and LGE for scar) Figure 1a. We deployed the protocol as a multicentre study: Argentina, Peru, India and South Africa accompanied by a program of education. Pre-scan clinical information, scanning data: complications, image quality and post-scan follow-up of participants for the assessment on impact, between 3 to 24 months.
Results
510 scans (4 countries, 6 cities, 12 centres) were performed with the rapid CMR protocol. Contrast studies in 378 (74%). There were no scan-related complications. Quality of the studies was maintained in a high level as an average of 89%. 97% of studies responded referral's question. All patients with contrast CMR scan have had at least one 2D echocardiogram before CMR. Average scan duration was 21±6 mins for contrast studies and 12±3 for non-contrast T2* protocol. The most common underlying diagnoses were non-ischaemic cardiomyopathy in 73% of participants (including cardiac iron level assessment in 26%, HCM in 17%, DCM in 15%), 27% for ischaemic cardiomyopathy and 15% for other pathologies. 4 of the 12 participant centres started to incorporate CMR for the first time. Findings impacted management in 60% of patients, including new diagnosis in 21% of participants. See table 1, figure 1b. For just cardiac iron assessment: 1/3 of participants had iron deposited in the heart with 14% of patients in severe levels.
Conclusions
CMR can be delivered faster and easier. When this abbreviated protocol is enabled with education, it can be implemented in developing countries with existing technology. This protocol shows high quality exam, with an important impact on patient's management.
Characteristics and impact on management Contrast studies Non-contrast studies All patients (%) 378 (74) 132 (36) Age, mean (range) years 54 (16–93) 24 (13–41) Male (%) 151 (39) 64 (48) Pre-echocardiography exam (%) 370 (98) 42 (32) Scanning duration mean (SD) 21 (6) 12 (3) Good quality exam (%) 329 (87) 120 (91) Impact on management Total All patients (%) 510 (100) Completely new diagnosis (%) 105 (21) Change/Addition of Medication (%) 128 (25) Intervention/ Surgery (%) 31 (6) Invasive angiography/biopsy (%) 25 (5) Hospital discharge/admission (%) 15 (3) TOTAL 306 (60%) SD: Standard Deviation.
Acknowledgement/Funding
Global Engagement UCL, UK Foreign & Commonwealth Office and The Peruvian Scientific, Technological Development and Technological Innovation (FONDECYT)
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Affiliation(s)
| | - S Ramirez
- International Clinic, Lima – Peru, Cardiac Imaging Department, Lima, Peru
| | - D Katekaru
- Military Hospital, Cardiac Imaging Department, Lima, Peru
| | - L Dragonetti
- High Technology Medical Institute - IMAT, Radiology Department, Buenos Aires, Argentina
| | - D Perez
- Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - V Illatopa
- National Cardiovascular Institute - INCOR, Lima, Peru
| | - B Rodriguez
- Edgardo Rebagliati Hospital, MRI and CT Department, Lima, Peru
| | - R Bansal
- Bhawani Singh Marg Hospital and OK Diagnostic Centre, Jaipur, India
| | | | - R Jacob
- Lancaster General Health Hospital, Lancaster, United States of America
| | - N Ntusi
- University of Cape Town, Cape Town, South Africa
| | - A Herrey
- St Bartholomew's Hospital, Barts Hear Centre, London, United Kingdom
| | - M Westwood
- St Bartholomew's Hospital, Barts Hear Centre, London, United Kingdom
| | - M Walker
- University College London, London, United Kingdom
| | - J Mooon
- St Bartholomew's Hospital, Barts Hear Centre, London, United Kingdom
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4
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Karia N, Herrey A, Tyebally S, Moon J, Manisty C. P386A wolf in sheeps clothing. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez109.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- N Karia
- St Bartholomew"s Hospital, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - A Herrey
- St Bartholomew"s Hospital, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - S Tyebally
- St Bartholomew"s Hospital, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - J Moon
- St Bartholomew"s Hospital, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - C Manisty
- St Bartholomew"s Hospital, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
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Patel K, Scully P, Treibel T, Kennon S, Ozkor M, Mullen MJ, Herrey A, Menezes L, Moon J, Pugliese F. 190Clinical utility of CT angiography over and above TAVI procedural planning. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez144.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- K Patel
- Barts Health NHS Trust, Structural Heart disease, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - P Scully
- Barts Health NHS Trust, Cardiac Imaging, London, United Kingdom of Great Britain & Northern Ireland
| | - T Treibel
- Barts Health NHS Trust, Cardiac Imaging, London, United Kingdom of Great Britain & Northern Ireland
| | - S Kennon
- Barts Health NHS Trust, Structural Heart disease, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - M Ozkor
- Barts Health NHS Trust, Structural Heart disease, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - M J Mullen
- Barts Health NHS Trust, Structural Heart disease, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - A Herrey
- Barts Health NHS Trust, Cardiac Imaging, London, United Kingdom of Great Britain & Northern Ireland
| | - L Menezes
- Barts Health NHS Trust, Cardiac Imaging, London, United Kingdom of Great Britain & Northern Ireland
| | - J Moon
- Barts Health NHS Trust, Cardiac Imaging, London, United Kingdom of Great Britain & Northern Ireland
| | - F Pugliese
- Barts Health NHS Trust, Cardiac Imaging, London, United Kingdom of Great Britain & Northern Ireland
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Menacho Medina KD, Seraphim A, Ramirez S, Falcon L, Alave J, Banda C, Mejia F, Putri A, Salazar D, Culotta V, Torlascco C, Menacho J, Herrey A, Walker M, Moon J. 525Cardiac magnetic resonance detects early cardiac involvement in HIV patients: oedema and inflammation, which may be reversible with therapy. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez115.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- K D Menacho Medina
- University College London, Institute of Cardiovascular Science , London, United Kingdom of Great Britain & Northern Ireland
| | - A Seraphim
- St Bartholomew"s Hospital, Barts Hear Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - S Ramirez
- International Clinic, Lima – Peru, Cardiac Imaging Department, Lima, Peru
| | - L Falcon
- International Clinic, Lima – Peru, Cardiac Imaging Department, Lima, Peru
| | - J Alave
- Union Peruvian University, Medical School, Lima, Peru
| | - C Banda
- Cayetano Heredia Hospital, Lima – Peru, Infectology Department, Lima, Peru
| | - F Mejia
- Cayetano Heredia Hospital, Lima – Peru, Infectology Department, Lima, Peru
| | - A Putri
- University College London, Institute of Cardiovascular Science , London, United Kingdom of Great Britain & Northern Ireland
| | - D Salazar
- Cayetano Heredia Peruvian University, Lima, Peru
| | - V Culotta
- St Bartholomew"s Hospital, Barts Hear Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - C Torlascco
- St Bartholomew"s Hospital, Barts Hear Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - J Menacho
- Santiago Antunez de Mayolo University, Medical Science Department, Huaraz, Peru
| | - A Herrey
- St Bartholomew"s Hospital, Barts Hear Centre, London, United Kingdom of Great Britain & Northern Ireland
| | - M Walker
- University College London, Institute of Cardiovascular Science , London, United Kingdom of Great Britain & Northern Ireland
| | - J Moon
- St Bartholomew"s Hospital, Barts Hear Centre, London, United Kingdom of Great Britain & Northern Ireland
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7
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Hayer MK, Edwards NC, Slinn G, Moody WE, Steeds RP, Ferro CJ, Price AM, Andujar C, Dutton M, Webster R, Webb DJ, Semple S, MacIntyre I, Melville V, Wilkinson IB, Hiemstra TF, Wheeler DC, Herrey A, Grant M, Mehta S, Ives N, Townend JN. A randomized, multicenter, open-label, blinded end point trial comparing the effects of spironolactone to chlorthalidone on left ventricular mass in patients with early-stage chronic kidney disease: Rationale and design of the SPIRO-CKD trial. Am Heart J 2017; 191:37-46. [PMID: 28888268 PMCID: PMC5603966 DOI: 10.1016/j.ahj.2017.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 05/18/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is associated with increased left ventricular (LV) mass and arterial stiffness. In a previous trial, spironolactone improved these end points compared with placebo in subjects with early-stage CKD, but it is not known whether these effects were specific to the drug or secondary to blood pressure lowering. AIM The aim was to investigate the hypothesis that spironolactone is superior to chlorthalidone in the reduction of LV mass while exerting similar effects on blood pressure. DESIGN This is a multicenter, prospective, randomized, open-label, blinded end point clinical trial initially designed to compare the effects of 40weeks of treatment with spironolactone 25mg once daily to chlorthalidone 25mg once daily on the co-primary end points of change in pulse wave velocity and change in LV mass in 350 patients with stages 2 and 3 CKD on established treatment with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Because of slow recruitment rates, it became apparent that it would not be possible to recruit this sample size within the funded time period. The study design was therefore changed to one with a single primary end point of LV mass requiring 150 patients. Recruitment was completed on 31 December 2016, at which time 154 patients had been recruited. Investigations included cardiac magnetic resonance imaging, applanation tonometry, 24-hour ambulatory blood pressure monitoring, and laboratory tests. Subjects are assessed before and after 40weeks of randomly allocated drug therapy and at 46weeks after discontinuation of the study drug.
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Affiliation(s)
- Manvir K Hayer
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - Nicola C Edwards
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - Gemma Slinn
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham
| | - William E Moody
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - Rick P Steeds
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - Charles J Ferro
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - Anna M Price
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - Cecilio Andujar
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - Mary Dutton
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - Rachel Webster
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham
| | - David J Webb
- Edinburgh Hypertension Excellence Centre and Clinical Research Centre, BHF Centre of Research Excellence, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, United Kingdom
| | - Scott Semple
- Edinburgh Hypertension Excellence Centre and Clinical Research Centre, BHF Centre of Research Excellence, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, United Kingdom
| | - Iain MacIntyre
- Edinburgh Hypertension Excellence Centre and Clinical Research Centre, BHF Centre of Research Excellence, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, United Kingdom
| | - Vanessa Melville
- Edinburgh Hypertension Excellence Centre and Clinical Research Centre, BHF Centre of Research Excellence, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, United Kingdom
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, and Cambridge Clinical Trials Unit, Cambridge University Hospitals, PO Box 98, Addenbrooke's Hospital, Cambridge
| | - Thomas F Hiemstra
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, and Cambridge Clinical Trials Unit, Cambridge University Hospitals, PO Box 98, Addenbrooke's Hospital, Cambridge
| | - David C Wheeler
- Department of Renal Medicine, Royal Free Hospital, Pond St, London
| | - Anna Herrey
- Department of Renal Medicine, Royal Free Hospital, Pond St, London
| | - Margaret Grant
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Samir Mehta
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Natalie Ives
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham
| | - Jonathan N Townend
- Birmingham Cardio-Renal Group (University of Birmingham Institute of Cardiovascular Sciences), Queen Elizabeth Hospital, Edgbaston, Birmingham.
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Wang Y, Zweerink A, Bulluck H, Garg P, Rodrigues JCL, Hafyane T, Haifa A, Joannic D, Juillion P, Delassus P, Monnet A, Lalande A, Fontaine JF, Allaart CP, Wu L, Kuijer JPA, Beek AM, Croisille P, Clarysse P, van Rossum AC, Nijveldt R, Rosmini S, Abdel-Gadir A, Bhuva A, Treibel TA, White SK, Hammond-Haley M, Sirker A, Herrey A, Manisty C, Yellon DM, Kellman P, Moon JC, Hausenloy DJ, Hassell M, Foley J, Ripley D, Dobson L, Swoboda P, Fent G, Musa T, Erhayiem B, Haaf P, Greenwood J, Nijveldt R, Westenberg J, Geest R, Plein S, Amadu AM, Dastidar AG, Szantho G, Lyen S, Godsave C, Ratcliffe LEK, Burchell AE, Hart EC, Hamilton MCK, Nightingale AK, Paton JFR, Manghat NE, Bucciarelli-Ducci C, Teixeira T, Greiser A, Mongeon FP, Mohammed K, Redha B, Marc M, Steffen P. ORAL AB II QUICK FIRE BASIC1393Validation of aortic in-vitro strain measurement by Magnetic Resonance Imaging with realistic abdominal aortic aneurism phantom1474A novel method of Segment Length Tracking providing regional strain measures from standard CMR cine images in CRT candidates1623T1 mapping can quantify the area-at-risk and infarct size – no need for T2 mapping or conventional LGE imaging in acute STEMI at 1.5T1373Reliability and reproducibility of trans-valvular flow measurement by 4D flow magnetic resonance imaging in acute myocardial infarct patients: two centre study1588Insights into hypertensive heart disease phenotypes: spectrum of myocyte, interstitial and vascular changes by cardiovascular MRI1412Myocardial partition coefficient of gadolinium: A comparison between patients with acute myocarditis, chronic infarction and healthy volunteers1386A comparison of circumferential strain results from multiple software packages in healthy subjects. Eur Heart J Cardiovasc Imaging 2016. [DOI: 10.1093/ehjci/jew180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Bulluck H, White SK, Rosmini S, Bhuva A, Treibel TA, Fontana M, Abdel-Gadir A, Herrey A, Manisty C, Wan SMY, Groves A, Menezes L, Moon JC, Hausenloy DJ. T1 mapping and T2 mapping at 3T for quantifying the area-at-risk in reperfused STEMI patients. J Cardiovasc Magn Reson 2015; 17:73. [PMID: 26264813 PMCID: PMC4534126 DOI: 10.1186/s12968-015-0173-6] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/16/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Whether T1-mapping cardiovascular magnetic resonance (CMR) can accurately quantify the area-at-risk (AAR) as delineated by T2 mapping and assess myocardial salvage at 3T in reperfused ST-segment elevation myocardial infarction (STEMI) patients is not known and was investigated in this study. METHODS 18 STEMI patients underwent CMR at 3T (Siemens Bio-graph mMR) at a median of 5 (4-6) days post primary percutaneous coronary intervention using native T1 (MOLLI) and T2 mapping (WIP #699; Siemens Healthcare, UK). Matching short-axis T1 and T2 maps covering the entire left ventricle (LV) were assessed by two independent observers using manual, Otsu and 2 standard deviation thresholds. Inter- and intra-observer variability, correlation and agreement between the T1 and T2 mapping techniques on a per-slice and per patient basis were assessed. RESULTS A total of 125 matching T1 and T2 mapping short-axis slices were available for analysis from 18 patients. The acquisition times were identical for the T1 maps and T2 maps. 18 slices were excluded due to suboptimal image quality. Both mapping sequences were equally prone to susceptibility artifacts in the lateral wall and were equally likely to be affected by microvascular obstruction requiring manual correction. The Otsu thresholding technique performed best in terms of inter- and intra-observer variability for both T1 and T2 mapping CMR. The mean myocardial infarct size was 18.8 ± 9.4 % of the LV. There was no difference in either the mean AAR (32.3 ± 11.5 % of the LV versus 31.6 ± 11.2 % of the LV, P = 0.25) or myocardial salvage index (0.40 ± 0.26 versus 0.39 ± 0.27, P = 0.20) between the T1 and T2 mapping techniques. On a per-slice analysis, there was an excellent correlation between T1 mapping and T2 mapping in the quantification of the AAR with an R(2) of 0.95 (P < 0.001), with no bias (mean ± 2SD: bias 0.0 ± 9.6 %). On a per-patient analysis, the correlation and agreement remained excellent with no bias (R(2) 0.95, P < 0.0001, bias 0.7 ± 5.1 %). CONCLUSIONS T1 mapping CMR at 3T performed as well as T2 mapping in quantifying the AAR and assessing myocardial salvage in reperfused STEMI patients, thereby providing an alternative CMR measure of the the AAR.
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Affiliation(s)
- Heerajnarain Bulluck
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, London, WC1E 6HX, UK.
- The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.
- The Heart Hospital, University College London Hospital, London, UK.
| | - Steven K White
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, London, WC1E 6HX, UK.
- The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.
- The Heart Hospital, University College London Hospital, London, UK.
| | - Stefania Rosmini
- The Heart Hospital, University College London Hospital, London, UK.
| | - Anish Bhuva
- The Heart Hospital, University College London Hospital, London, UK.
| | - Thomas A Treibel
- The Heart Hospital, University College London Hospital, London, UK.
| | - Marianna Fontana
- The Heart Hospital, University College London Hospital, London, UK.
| | - Amna Abdel-Gadir
- The Heart Hospital, University College London Hospital, London, UK.
| | - Anna Herrey
- The Heart Hospital, University College London Hospital, London, UK.
| | | | - Simon M Y Wan
- UCL Institute of Nuclear Medicine, University College London Hospital, London, UK.
| | - Ashley Groves
- UCL Institute of Nuclear Medicine, University College London Hospital, London, UK.
| | - Leon Menezes
- UCL Institute of Nuclear Medicine, University College London Hospital, London, UK.
| | - James C Moon
- The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.
- The Heart Hospital, University College London Hospital, London, UK.
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Science, University College London, London, WC1E 6HX, UK.
- The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.
- The Heart Hospital, University College London Hospital, London, UK.
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, Singapore, Singapore.
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore, Singapore.
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Flett AS, Maestrini V, Milliken D, Fontana M, Treibel TA, Harb R, Sado DM, Quarta G, Herrey A, Sneddon J, Elliott P, McKenna W, Moon JC. Diagnosis of apical hypertrophic cardiomyopathy: T-wave inversion and relative but not absolute apical left ventricular hypertrophy. Int J Cardiol 2015; 183:143-8. [PMID: 25666123 PMCID: PMC4392393 DOI: 10.1016/j.ijcard.2015.01.054] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 12/10/2014] [Accepted: 01/25/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diagnosis of apical HCM utilizes conventional wall thickness criteria. The normal left ventricular wall thins towards the apex such that normal values are lower in the apical versus the basal segments. The impact of this on the diagnosis of apical hypertrophic cardiomyopathy has not been evaluated. METHODS We performed a retrospective review of 2662 consecutive CMR referrals, of which 75 patients were identified in whom there was abnormal T-wave inversion on ECG and a clinical suspicion of hypertrophic cardiomyopathy. These were retrospectively analyzed for imaging features consistent with cardiomyopathy, specifically: relative apical hypertrophy, left atrial dilatation, scar, apical cavity obliteration or apical aneurysm. For comparison, the same evaluation was performed in 60 healthy volunteers and 50 hypertensive patients. RESULTS Of the 75 patients, 48 met conventional HCM diagnostic criteria and went on to act as another comparator group. Twenty-seven did not meet criteria for HCM and of these 5 had no relative apical hypertrophy and were not analyzed further. The remaining 22 patients had relative apical thickening with an apical:basal wall thickness ratio >1 and a higher prevalence of features consistent with a cardiomyopathy than in the control groups with 54% having 2 or more of the 4 features. No individual in the healthy volunteer group had more than one feature and no hypertension patient had more than 2. CONCLUSION A cohort of individuals exist with T wave inversion, relative apical hypertrophy and additional imaging features of HCM suggesting an apical HCM phenotype not captured by existing diagnostic criteria.
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Affiliation(s)
- Andrew S Flett
- Department of Cardiology, University Hospital Southampton, Tremona Road, Southampton SO166YD, United Kingdom
| | - Viviana Maestrini
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom
| | - Don Milliken
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom
| | - Mariana Fontana
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom
| | - Thomas A Treibel
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom
| | - Rami Harb
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom
| | - Daniel M Sado
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom; Institute of Cardiovascular Science, University College London, United Kingdom
| | - Giovanni Quarta
- Department of Cardiology, S Andrea Hospital, Universtiy Sapienza Rome, Italy; Cardiovascular Department, AO Papa Giovanni XXIII, Bergamo, Italy
| | - Anna Herrey
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom
| | - James Sneddon
- East Surrey Hospital, Canada Avenue, Redhill RH1 5RH, United Kingdom
| | - Perry Elliott
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom; Institute of Cardiovascular Science, University College London, United Kingdom
| | - William McKenna
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom; Institute of Cardiovascular Science, University College London, United Kingdom
| | - James C Moon
- The Heart Hospital, part of University College London Hospitals NHS Trust, 16-18 Westmoreland Street, London W1G 8P, United Kingdom; Institute of Cardiovascular Science, University College London, United Kingdom.
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Captur G, Mohun TJ, Finocchiaro G, Wilson R, Levine J, Conner L, Lopes L, Patel V, Sado DM, Li C, Bassett P, Herrey A, Tome Esteban M, McKenna WJ, Seidman C, Muthurangu V, Bluemke DA, Ho CY, Elliott PM, Moon JC. 126 Advanced Assessment of Cardiac Morphology and Prediction of Gene Carriage by CMR in Hypertrophic Cardiomyopathy - The HCMNET/UCL Collaboration. Heart 2014. [DOI: 10.1136/heartjnl-2014-306118.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Captur G, Flett A, Barison A, Sado D, Herrey A, McKenna WJ, Moon J. Reliability of left ventricular noncompaction imaging criteria - the fractal facts. J Cardiovasc Magn Reson 2013. [PMCID: PMC3559608 DOI: 10.1186/1532-429x-15-s1-p136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Schuler PK, Herrey A, Wade A, Brooks R, Peebles D, Lambiase P, Walker F. Pregnancy outcome and management of women with an implantable cardioverter defibrillator: a single centre experience. Europace 2012; 14:1740-5. [DOI: 10.1093/europace/eus172] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Valverde I, Arya A, Ben-Simon R, McCready JM, Herrey A, Lambiase PD. Noncontact mapping guided ablation of right ventricular outflow tract ectopy in a patient with interruption of the inferior vena cava and azygos continuation. Pacing Clin Electrophysiol 2011; 36:e129-31. [PMID: 21418244 DOI: 10.1111/j.1540-8159.2011.03064.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Revised: 12/06/2010] [Accepted: 12/14/2010] [Indexed: 11/29/2022]
Abstract
A 58-year-old woman with symptomatic multiple monomorphic premature ventricular beats of a right ventricular outflow tract origin was referred for ablation. An inferior vena cava interruption with azygos continuation was discovered during catheter placement. This case describes positioning of the noncontact mapping array and successful radiofrequency ablation in this challenging anatomy.
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Affiliation(s)
- Irene Valverde
- Electrophysiology Department, The Heart Hospital, University College Hospital & Institute of Cardiovascular Sciences, University College London, London
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