The role of cardiac magnetic resonance-based feature-tracking strain analysis in the differential diagnosis and prognostic assessment of patients with left ventricular hypertrophy

Background

Cardiac magnetic resonance (CMR) examinations have an essential role in the diagnosis of myocardial diseases with left ventricular (LV) hypertrophy; however, limited data are available from CMR-based feature-tracking strain analysis in this patient population. The aim of our study was to investigate the differential diagnostic and prognostic importance of feature-tracking strain analysis in patients with LV hypertrophy caused by myocardial disease.

Methods

We investigated 404 patients who underwent CMR examination and were diagnosed with myocardial disease causing LV hypertrophy. Hypertrophic cardiomyopathy (HCM) was detected in 330 patients, cardiac amyloidosis (CA) in 46 patients, Fabry disease (FD) in 12 patients, and endomyocardial fibrosis (EMF) in 16 patients. LV strain analysis was performed with feature-tracking. Global longitudinal (GLS), circumferential (GCS) and radial (GRS) LV strain parameters were measured. Strain values for the six basal, six midventricular, and five apical segments were averaged to obtain regional longitudinal and circumferential strain values (basal LS, midventricular LS, apical LS, basal CS, midventricular CS, apical CS). The apex-to-base regional LS and CS ratios were calculated as apical LS/basal LS and apical CS/basal CS, respectively. To assess global dyssynchrony, mechanical dispersion (MD) was measured. The all-cause mortality of the patients was analyzed.

Results

In the differentiation of CA from HCM, GLS had the highest sensitivity with a cutoff of more than −23%, and basal LS and basal CS had the highest specificity with a cutoff of more than −16% and −38%, respectively (p<0.001). FD patients had the lowest longitudinal and circumferential MD values, meaning that compared to that of other patients with LV hypertrophy, global dyssynchrony is least pronounced in this patient population (p<0.01). EMF patients had impaired global and regional CS and the lowest apex-to-base CS and LS ratios. CA patients had the highest apex-to-base CS and LS ratios, suggestive of apical sparing (p<0.001). CA patients had the worst prognosis; the significant independent predictors of mortality were a diagnosis of CA, the LV stroke volume index and basal LS (p<0.01).

Conclusions

Myocardial diseases with left ventricular hypertrophy have remarkable differences in CMR-based strain characteristics which can be helpful in the differential diagnosis and provides incremental information on adverse outcomes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, Ministry for Innovation and Technology in Hungary

Extension of fitness evaluations with muscle oxygen saturation measurements based on near-infrared spectroscopy analysis during cardiopulmonary exercise testing in elite athletes

Introduction

Many cardiovascular parameters of sport adaptation have become an area of detailed research in recent decades. However, details of local circulatory and metabolic processes ongoing in the working muscles during physical exercise need to be revealed.

Purpose

Our aim was to extend cardiopulmonary exercise testing with near-infrared spectroscopy measurements to focus on observing local changes in the contracting muscles during running.

Methods

Mixed muscle oxygen saturation values (SmO2) measured in the left vastus lateralis muscle of athletes were analyzed by near-infrared spectroscopy during vita maxima treadmill cardiopulmonary exercise testing with 2-min fingertip lactate measurements. Body composition analysis was carried out with bioimpedance method. One-way repeated measures ANOVA, Tukey post-hoc test, Shapiro–Wilk test and Pearson correlation were used for statistical analysis.

Results

The results of 66 elite athletes (male: 40; age: 17.9±3.6 y; training: 17.7±6.6 h/w; water polo player: 56, wrestler: 8, basketball player: 2) were analyzed. The 10-second averaged values of the measured saturation values were examined at rest (65.8±11.1%), at the anaerobic threshold (40.7±22.8%), at maximum load (30.2±20.5%) and after 5 minutes of cool-down (70.9±12.8%). Significant differences were measured between the four measurement time points in all pairings. A negative correlation was found between the achieved maximal oxygen uptake and the muscle oxygen saturation values measured at the anaerobic threshold and at the maximal load (respectively r=−0.30, p<0.02; r=−0.32, p<0.01). Oxygen uptake at the end of cool-down was also negatively correlated with muscle oxygen saturation values measured at the anaerobic threshold and at the peak of exercise (respectively r=−0.27, p<0.05; r=−0.27, p<0.05). The fat-free mass of the identical limb showed negative correlation with the muscle oxygen saturation values measured at the anaerobic threshold, at the maximal load and at the cool-down (respectively r=−0.43, p<0.01; r=−0.44, p<0.01; r=−0.35, p<0.01), while positive interactions were observed between the body-fat mass of the same limb and the muscle oxygen saturation values (respectively r=0.51, p<0.01; r=0.55, p<0.01; r=0.41, p<0.01). Muscle oxygen saturation values showed no significant correlations with exercise time, lactate levels, or heart rate measurements.

Conclusions

By our results, muscle oxygen saturation measurements can be reliably applied during exercise physiological measurements. During exercise, muscle oxygen saturation values negatively correlated with oxygen uptake. At the cool-down phase, a rebound effect could be observed compared to the resting measurements. On the identical limb, the higher the muscle mass was, the higher muscle desaturation could be measured. This easy-to-perform test provides insight into muscle metabolism processes and can help with training planning and athlete follow-up.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 135076). Supported by the ÚNKP-21-3-I-SE-68 New National Excellence Program of the Ministry for Innovation and Technology from the Source of the National Research, Development and Innovation fund.

How native T1 and T2 mapping is influenced by sex and training load? Cardiac magnetic resonance imaging in young elite athletes and less active individuals

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This study was financed by the Ministry of Innovation and Technology NRDI Office within the framework of the Artificial Intelligence National Laboratory Program. LS is supported by the EACVI Research Grant 2021.

Introduction

Cardiac adaptation due to regular and intense exercise is a well-known phenomenon. Cardiac magnetic resonance (CMR) imaging is a well suited, highly reproducible technique that has a vital role in differentiating physiological adaptation and pathological alterations. Native T1 and T2 mapping enable the quantitative assessment of tissue characteristics without the administration of contrast material. These techniques are increasingly used in studies aiming to consider subtle differences. However, the sex-and training-dependence of native T1 and T2 mapping values remains incompletely understood.

Purpose

We aimed to describe the differences in native T1 and T2 mapping among healthy athletes and less active individuals.

Methods

We enrolled healthy elite athletes (n=88, 56 male, 25±5 years) and healthy volunteers (n=82, 46 male, 25±3 years) to undergo CMR examinations at our Centre. Healthy elite athletes performed high sports activity levels (>10 hours/week) and competed nationally or internationally. Sex- and age-matched healthy volunteers engaged in ≤6 hours/week of sports activity. Standardized CMR protocol included short- and long-axis cine images covering the entire left (LV) and right (RV) ventricle and native T1 and T2 mapping in basal, midventricular and apical slices.

Results

Athletes had consistently higher LV and RV volumes and mass indexes compared to healthy volunteers (p<.001 for all). Native T1 mapping was lower in athletes than in the control group (T1: 954±24 ms vs 970±23 ms; p <.001). T1 mapping showed a moderately strong negative correlation to markers of cardiac adaptation, including LV mass, end-diastolic volume and stroke volume indexes (p<.001 for all). Moreover, we found a negative correlation between native T1 and training hours (Rho: -0.302; p<.001). On the other hand, native T2 mapping showed no difference between athletes and less active controls. Furthermore, T2 correlated with LV shape features but not with training hours. We found that mapping values differed between sexes, both in the athletic and control groups. Females showed slightly higher values compared to their male counterparts (T2: 46±2 vs 43±2; p<.001). Finally, native T1 mapping was associated with training hours and sex in our multiple linear regression model, adjusted for age, resting heart rate, body mass index, body surface area and LVM (p<.001). While T2 mapping was associated only with sex considering the same covariates.

Conclusion

Our study demonstrates the importance of sex-matched controls in CMR studies evaluating mapping parameters. Moreover, the consideration of exercise load seems paramount in the case of T1 mapping.

Age- and sex-specific characteristics of right ventricular compacted and trabeculated myocardium by cardiac magnetic resonance

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry for Innovation and Technology in Hungary within the framework of the Therapeutic Development and Bioimaging Programs of Semmelweis University. National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme.

The sex-specific characteristics of right ventricular compacted (RV-CM) and RV-trabeculated myocardial mass (RV-TM) over time and the determinants of RV myocardium are less well studied; however, in different conditions, these might provide additional information to the diagnosis.

We aimed to describe the age- and sex-specific characteristics of RV-CMi, RV-TMi, and RV volumetric and functional parameters and investigate the determinants of RV myocardial mass with CMR.

Two hundred healthy Caucasian volunteers free of known cardiovascular or systemic diseases were enrolled in this study. Four different age groups were established with equal numbers of males and females: Group A (n = 50, 20-29 years, mean age: 24.3 ± 3.2 years), Group B (n = 50, 30-39 years, mean age: 33.6 ± 2.6 years), Group C (n = 50, 40-49 years, mean age: 44.7 ± 2.7 years), and Group D (n = 50, ≥ 50 years, mean age: 55.1 ± 3.9 years). RV volumetric and functional, RV-CMi and RV-TMi values were measured with a threshold-based postprocessing method for CMR.

The volumetric parameters, RV-CMi, and RV-TMi were larger in males, and the ejection fraction (EF) was higher in females. The RV-CMi did not correlate with age in either of the sexes, while the RV-TMi decreased with age in females but remained stable in males. The RV-TMi and RV-CMi correlated positively with RV volumetric parameters, the left ventricular (LV)-CMi, the LV-TMi, and each other in both sexes. LV-TMi, LV-CMi, RV end-systolic volume, and sex were independent predictors of RV-TMi.

Understanding the natural history of RV-trabeculated and RV-compacted myocardium might have additive value in diagnosing different conditions with RV hypertrophy or hypertrabeculation.

MR -specific characteristics of left ventricular noncompaction and dilated cardiomyopathy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Thematic Excellence Programme (Tématerületi Kiválósági Program, 2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary within the framework of the Therapeutic Development and Bioimaging Programs of Semmelweis University Development of Scientific Workshops of Medical, Health Sciences and Pharmaceutical Edication (Project identification number: EFOP- 3.6.3-VEKOP-16- 2017-00009) Project no. NVKP_16-1–2016-0017 (’National Heart Program’) has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. The research was supported by the Ministry of Innovation and Technology NRDI Office within the framework of the Artificial Intelligence National Laboratory Program.

The differentiation of dilated cardiomyopathy (DCM) and left ventricular noncompaction

(LVNC) is a recurring issue during cardiac imaging processes; thus, we aimed to compare the

left ventricular (LV) cardiac MRI (CMR) characteristics of DCM and LVNC patients.

Thirty-one nonischemic DCM patients, 42 LVNC patients with reduced EF and 42 healthy

controls were included in this retrospective study. The LV volumetric, functional and

myocardial mass parameters were measured with a threshold-based technique, while global

and segmental strain values and rotational patterns were analyzed with feature-tracking

strain analysis.

Of the LV volumetric and myocardial mass parameters, only the trabeculated and papillary

muscle mass (TPMi) values differed significantly between the patient groups and were higher

in the LVNC group compared to DCM (DCM vs LVNC: 43.2 ± 8.9 vs 51.6 ± 13.6 g/m2, p < 0.002).

The global longitudinal and circumferential strains were similar between the patient groups

and significantly worse than those of the controls. In comparing the segmental strain values

between the patient groups, only the circumferential apical strain was significantly lower in

the LVNC group (DCM vs LVNC: -30.5 ± 13.5 vs -24.5 ± 12.0%, p < 0.05). There was no difference

in the rotational pattern between the patient groups, and both the healthy and patient

populations showed heterogeneous rotational patterns.

Despite the similarities of DCM and LVNC in volumetric, global strain parameters, and

rotational patterns, we found some morphological and functional differences between the

patient groups. These minor alterations might be due to the morphological characteristics of

LVNC with a trabeculated apical region.

Biventricular mechanical pattern of the athlete"s heart: comprehensive characterization using 3D echocardiography

Funding Acknowledgements

Type of funding sources: None.

Regular, intense exercise results in complex morphological and functional cardiac remodeling, commonly referred to as the athlete"s heart. While left ventricular (LV) adaptation is thoroughly studied, data are scarce concerning the right ventricular (RV) mechanical changes and their continuum with exercise performance.

Accordingly, our aim was to characterize biventricular morphology and function and its relation to sex, age and sport classes in a large cohort of elite athletes using 3D echocardiography.

Four hundred and twenty-two elite, competitive athletes (male/female: 295/127, adult/adolescent: 207/215) from the 4 major sport classes (mixed type n = 293; endurance n = 88; power n = 33; skill n = 8) and healthy, sedentary volunteers (n = 55) were enrolled. 3D transthoracic echocardiographic datasets were acquired to quantify LV and RV end-diastolic volumes (EDVi), and ejection fractions (EF). In order to characterize biventricular mechanical parameters, LV and RV global longitudinal (GLS) and global circumferential strains (GCS) were measured using dedicated softwares. Additionally, all subjects underwent cardiopulmonary exercise testing in order to determine peak oxygen uptake (VO2/kg).

Athletes had significantly higher LV and RV EDVi compared with controls, whereas male athletes had larger volumes than female athletes, and adult athletes had also larger LV EDVi than adolescent athletes (all p < 0.05). However, RV EDVi was similar between the two age groups. Endurance athletes had significantly larger RV EDVi compared with the other sport classes (ANOVA p < 0.05). 

Concerning biventricular functional parameters, athletes had significantly lower resting LV and RV EF (athletes vs. controls; LVEF: 57 ± 4 vs. 61 ± 5%; RVEF: 55 ± 5 vs. 59 ± 5%; p < 0.001) as well as LV GLS (-19.2 ± 2.3 vs. -21.2 ± 2.0%), LV GCS (-27.7 ± 3.0 vs. -31.0 ± 3.5%), and RV GCS (-20.9 ± 4.4 vs. -24.5 ± 4.5%; all p < 0.001) compared with controls. In contrast, RV GLS (-21.8 ± 3.4 vs. -22.2 ± 3.6%) did not differ between athletes and controls. The exercise-induced relative decrease in LV GLS (9.5 ± 10.7%) and LV GCS (10.7 ± 9.8%) was similar, however, the decrement in RV GCS (14.8 ± 17.8%) was disproportionately larger compared with RV GLS (1.7 ± 15.4%, p < 0.01) in the athlete population. By multivariable linear regression analysis among echocardiographic parameters using ordinary least squares, RVEDVi was found to be the strongest and independent predictor of VO2/kg, followed by RV GCS and LV EDVi.

Regular physical exercise results in significant and specific changes in LV and RV geometry and function. Resting LV mechanics of the athlete"s heart is characterized by a balanced decrement in GLS and GCS, however, in the RV the circumferential shortening decreases disproportionately compared with the longitudinal shortening. Moreover, this mechanical pattern is associated with better exercise capacity, which emphasizes the importance of the RV in determining athletic performance.

Sex- and age- specific normal values with threshold-based trabeculae quantification

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ÚNKP-19-3-II New National Excellence Program of the Ministry for Innovation and Technology National Research, Development and Innovation Office of Hungary (NKFIA; NVKP_16-1-2016-0017 National Heart Program) Thematic Excellence Program (Tématerületi Kiválósági Program 2020-4.1.1-TKP2020)

The threshold-based (TB) trabeculated and papillary muscle mass (TPM) quantification method for cardiac MRI (CMR) calculates different values than conventional contouring techniques.

We aimed to identify the sex- and age-related normal reference ranges for left ventricular (LV) myocardial mass values, volumetric and functional parameters and the correspondence of these parameters using the TB method.

Healthy European adults (n = 200, age: 39.4 ± 12 years, males: 100) were examined with CMR and evaluated with a TB postprocessing method. They were stratified by sex and age (Group A: 18-29, Group B: 30-39, Group C: 40-49, Group D: >50 years). The calculated parameters were indexed to body surface area (i).

The normal reference ranges for the studied parameters were assessed in each age group. Significant biometric differences in LV parameters and mass-to-volume ratios were found between males and females, and the left ventricular compacted myocardial mass (LVCMi) and TPMi differences remained significant after stratification by age. Unlike other LV volumetric and functional parameters and mass-to-volume ratios, the TPMi, the LVCMi and the TPMi-to-LVCMi ratio did not differ among age groups in males or females. This finding was strengthened by the lack of correlation between TPMi and age.

Age- and sex-related normal reference ranges for LV volumetric and functional parameters and LVCMi and TPMi values were established using a TB postprocessing method. TPMi, LVCMi and their ratio did not change over time. The TPMi-to-LVCMi and the mass-to-volume ratios might have clinical utility in the differential diagnosis of conditions with LV hypertrabeculation.

The diagnostic accuracy of truncated cardiovascular MR protocols for detecting non-ischemic cardiomyopathies

Cardiovascular magnetic resonance imaging is one of the most important diagnostic modalities in the evaluation of cardiomyopathies. However, significant limitations are the complex and time-consuming workflows and the need of contrast agents. The aim of this multi-center retrospective study was to assess workflows and diagnostic value of a short, contrast agent-free cardiac magnetic resonance protocol. 160 patients from Heidelberg, Germany and 119 patients from Montreal, Canada with suspected cardiomyopathy and 20 healthy volunteers have been enrolled. Scans were performed at a 1.5Tesla or 3Tesla scanner in Heidelberg and at a 3Tesla scanner in Montreal. We used single-slice T1 map only. A stepwise analysis of images has been performed. The possible differential diagnosis after each step has been defined. T1-values and color-encoded T1 maps significantly contributed to the differential diagnosis in 54% of the cases (161/299); the final diagnosis has been done without late gadolinium enhancement images in 83% of healthy individuals, in 99% of patients with dilated cardiomyopathy, in 93% of amyloidosis patients, in 94% of patients with hypertrophic cardiomyopathy and in 85% of patients with hypertensive heart disease, respectively. Comparing the scan time with (48 ± 7 min) vs. without contrast agent (23 ± 5 min), significant time saving could be reached by the short protocol. Subgroup analysis showed the most additional diagnostic value of T1 maps in amyloidosis and hypertrophic cardiomyopathy or in confirmation of normal findings. In patients with unclear left ventricular hypertrophy, a short, non-contrast protocol can be used for diagnostic decision-making, if the quality of the T1 map is diagnostic, even if only one slice is available.

The role of feature-tracking strain analysis in the differentiation of cardiac amyloidosis from hypertrophic cardiomyopathy

 

Cardiac magnetic resonance (CMR) examinations have an essential role in the differentiation of cardiac involvement of amyloidosis (CA) from hypertrophic cardiomyopathy (HCM). The CMR diagnosis is traditionally based on morphologic features and the pattern of late gadolinium enhancement (LGE). However, in patients contraindicated for contrast agent administration, the diagnosis can be challenging. Novel CMR techniques, including strain analysis, can help in the differentiation of these patients.

The aim of our study was to investigate the differential diagnostic and prognostic importance of feature-tracking strain analysis in patients with left ventricular hypertrophy caused by CA or HCM.

We investigated 89 HCM patients (48 males; 50±18 years) and 46 CA patients (29 males; 64±10 years) who underwent CMR examination. The left ventricular ejection fraction (LVEF), volumes (end-diastolic volume: LVEDV, end-systolic volume: LVESV, stroke volume: LVSV), mass (LVM), and the amount of LGE were quantified. Global longitudinal (GLS), circumferential (GCS) and radial (GRS) LV strain parameters, and basal, midventricular, and apical LS and CS were measured. The apex-to-base regional LS and CS ratios were calculated. The all-cause mortality of the patients was analyzed. The characteristics of groups were compared with an independent t-test or Mann-Whitney test, as appropriate. ROC curve analysis was performed to analyze the diagnostic accuracy of a parameter and to identify optimal cutoff values. The prognostic value of CMR parameters was assessed with Cox proportional hazard regression analyses. Survival probability was analyzed with Kaplan-Meier curves and compared by the log-rank test.

CA patients had significantly lower LVEF (51±11 vs. 63±8%; p<0.0001), lower LVSVi (43±12 vs. 54±12 ml/m2; p<0.0001), higher LVMi (94±24 vs. 79±24 g/m2; p<0.001), higher amount of LGE (29±15 vs. 8±8%; p<0.0001), and more impaired global and regional strain values (GRS: 55±22 vs. 93±29%; GCS: −33±10 vs. −42±8%; GLS: −18±4 vs. −25±6%; basal CS: −26±9 vs. −39±7%; basal LS: −15±4 vs. −22±6%; p<0.0001) than HCM patients. The apex-to-base CS and LS ratios were higher in CA patients, suggestive of apical sparing (1.71±0.68 vs. 1.29±0.33; p<0.0001; 1.88±0.76 vs. 1.57±0.62; p<0.05; respectively). In the differentiation of CA and HCM, LGE, basal CS, basal LS, GRS, and GLS had the highest diagnostic accuracies (AUCs: 0.911, 0.866, 0.848, 0.859, 0.849). During the mean 2.1±2.0 years of follow-up, three HCM patients (3.4%) and 29 CA patients (63%) died (p<0.0001). The significant independent predictors of mortality were a diagnosis of CA, LVSVi and basal LS.

Our results show that CMR-based strain analysis might be a useful method for differentiating cardiac involvement of amyloidosis from HCM. Furthermore, this technique provides additional information for the assessment of prognosis in this patient population.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Research, Development and Innovation Office of Hungary; Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University

Training- and sex related alterations of global feature-tracking strain values of highly trained athletes using cardiac magnetic resonance imaging

Introduction

Cardiac magnetic resonance imaging (CMR) is a reference method for assessing the morphological and functional parameters of the heart, and more recently, strain analysis can detect mechanical features. Based on echocardiographic data, strain parameters may help to differentiate between physiological athlete adaptation and pathological hypertrophy, however, there are still little data available among elite athletes regarding strain values using CMR.

Aims

Our aim was to study the strain characteristics of the athlete's heart using CMR imaging.

Methods

Overall, 228 (149 male, 24±5 years) highly trained adult (18–35 years), Caucasian athletes (≥10h training hours/ week) who underwent CMR examination as part of their screening were included in our study. Cine movie images in long- and short axis views were performed. Standard CMR parameters including left- and right ventricular (LV and RV) volumes, ejection fraction and muscle masses were measured. Feature-tracking strain analyses were performed, global LV longitudinal, circumferential and radial strain and RV longitudinal strain were calculated. CMR parameters of athletes were compared with healthy sex- and age matched sedentary control groups (n=105, 55 men).

Results

Athletes competed in mixed (n=99), endurance (n=99) and power (n=30) sport disciplines, and performed sport activity in quite high training hours (average: 21±5 hours/week). Regarding standard CMR parameters we found pronounced sports adaptation in both male and female athletes compared to sex- and age matched controls including lower LV and RV ejection fraction (p<0.05), elevated LV and RV volumes and masses (p<0.001). Strain analysis also revealed differences between athletes and controls: LV- GLS, GCS, GRS were lower in athletes compared to controls, regardless of their sex (p<0.05). RV-GLS was slightly lower in male athletes compared to male controls. Examining the effects of sport disciplines, we found the most marked sport adaptation in the case of endurance athletes. Training hours showed a positive correlation with LV-GLS and GCS values, and a negative correlation with GRS (p<0.001). We found that male athletes had more pronounced cardiac adaptation compared to females (p<0.001), and their LV-GLS and GRS values were lower (GLS: male athletes: −20±2% vs. female athletes: −22±2%; p<0.001), while GCS and RV-GLS showed no difference between sexes.

Conclusion

Our results suggest that in addition to standard CMR parameters, global strain values also show a small but consistent change during sport adaptation. Moreover, our results support the use of sex specific strain normal values in highly trained athletes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was financed by the Research Excellence Programme of the Ministry for Innovation and Technology in Hungary within the framework of the Bioimaging Thematic Programme of Semmelweis University. LS was supported by the ÚNKP-20-3-II-SE-61 New National Excellence Program of the Ministry for Innovation and Technology from the source of the National Research, Development and Innovation Fund.

Cardiopulmonary examinations of athletes returning to high-intensity sport activity following SARS-CoV-2 infection

 

During the pandemic, several studies were carried out on the short-term effects of acute SARS-CoV-2 infection in athletes. As some cases of young athletes with serious complications like myocarditis or thromboembolism and even sudden death were reported, strict recommendations for return to sport were published. However, we have less data about athletes who have already returned to high-intensity trainings after a SARS-CoV-2 infection.

Athletes underwent cardiology screening (personal history, physical examination, 12-lead resting ECG, laboratory tests with necroenzyme levels and echocardiography) 2 to 3 weeks after suffering a SARS-CoV-2 infection. In case of negative results, they were advised to start low intensity trainings and increase training intensity regularly until achieving maximal intensity a minimum of 3 weeks later. A second step of cardiology screening was also carried out after returning to maximal intensity trainings. The above mentioned screening protocol was repeated and was completed with vita maxima cardiopulmonary exercise testing (CPET) on running treadmill. If the previous examinations indicated, 24h Holter ECG recording, 24h ambulatory blood pressure monitoring or cardiac MR imaging were also carried out. Data are presented as mean±SD.

Two-step screening after SARS-CoV-2 infection was carried out in 111 athletes (male:74, age:22.4±7.4y, elite athlete:90%, training hours:14.8±5.8 h/w, ice hockey players:31.5%, water polo players:22.5%, wrestlers:18.9%, basketball players:18.0%). Second screenings were carried out 94.5±31.5 days after the first symptoms of the infection. A 5% of the athletes was still complaining of tiredness and decreased exercise capacity. Resting heart rate was 70.3±13.0 b.p.m., During CPET examinations, athletes achieved a maximal heart rate of 187.3±11.6 b.p.m., maximal relative aerobic capacity of 49.2±5.5 ml/kg/min, and maximal ventilation of 138.6±31.2 l/min. The athletes reached their anaerobic threshold at 87.8±6.3% of their maximal aerobic capacity, with a heart rate of 93.3±3.7% of their maximal values. Heart rate recovery was 29.9±9.2/min. During the CPET examinations, short supraventricular runs, repetititve ventricular premature beats + ventricular quadrigeminy and inferior ST depression were found in 1–1 cases. Slightly higher pulmonary pressure was measured on the echocardiography in 4 cases. Hypertension requiring drug treatment was found in 5.4% of the cases. Laboratory examinations revealed decreased vitamin D3 levels in 26 cases, decreased iron storage levels in 18 athletes. No SARS-CoV-2 infection related CMR changes were revealed in our athlete population.

Three months after SARS-CoV-2 infection, most of the athletes examined had satisfactory fitness levels. However, some cases of decreased exercise capacity, decreased vitamin D3 or iron storage levels, arrhythmias, hypertension and elevated pulmonary pressure requiring further examinations, treatment or follow-up were revealed.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary; The research was financed by the Thematic Excellence Programme of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University

Frequent constriction-like echocardiographic findings in elite athletes following mild COVID-19: in the grasp of SARS-CoV-2?

 

The COVID-19 pandemic had a major impact on the sports community as well. Despite the vast majority of athletes experiencing mild symptoms, potential cardiac involvement and complications have to be explored to support a safe return to play. Accordingly, we were aimed at a comprehensive echocardiographic characterization of post-COVID athletes (P-CA) by comparing them to a propensity-matched healthy, non-COVID athlete (N-CA) cohort.

One hundred and seven elite athletes with COVID-19 were prospectively enrolled after an appropriate quarantine period and formed the P-CA group (23±6 years, 23% female). From our retrospective database comprising 425 elite athletes, 107 age-, gender-, body surface area-, and weekly training hours-matched subjects were selected as a reference group using propensity score matching (N-CA group). All athletes underwent a comprehensive clinical investigation protocol comprising 2D and 3D echocardiography. Left (LV) and right ventricular (RV) end-diastolic volumes (EDVi) and ejection fractions (EF) were quantified using dedicated softwares. To characterize LV longitudinal deformation, 2D global longitudinal strain (GLS) and the ratio of free wall versus septal longitudinal strain (FWLS/SLS) were also calculated. In order to describe septal flattening (SF – frequently seen in P-CA), LV eccentricity index (EI) was measured.

P-CA and N-CA athletes had comparable LV and RV EDVi (P-CA vs N-CA; 77±12 vs 78±13mL/m²; 79±16 vs 80±14mL/m², respectively). P-CA group had significantly higher LV EF (58±4 vs 56±4%, p<0.001) and GLS (−18.2±1.8 vs −17.6±2.2%, p<0.05). Eccentricity index was significantly lower in P-CA (0.89±0.10 vs 0.99±0.04, p<0.001), which was attributable to a distinct subgroup of P-CA athletes with a prominent SF (n=34, 32%), further provoked by inspiration. In this subgroup, the eccentricity index was markedly lower compared to the rest of the P-CA group (0.79±0.07 vs 0.95±0.07, p<0.001).

In the SF subgroup, LV EDVi was significantly higher (80±14 vs 75±11 mL/m², p<0.001), while RV EDVi did not differ (82±16 vs 78±15mL/m²). Moreover, the FWLS/SLS ratio was significantly lower in the SF subgroup (0.92±0.09 vs 0.97±0.08, p<0.01). Interestingly, P-CA athletes with SF experienced fatigue (17 vs 34%, p<0.05) or chest pain (0 vs 15%, p=N/A) less frequently during the course of the infection; however, the presence of a mild pericardial effusion was more common (41 vs 12%, p<0.01).

Elite athletes following COVID-19 showed distinct morphological and functional cardiac changes compared to a propensity score-matched control athlete group. These results are mainly driven by a subgroup, which presented with some echocardiographic features characteristic of constrictive pericarditis (septal flattening, lower FWLS/SLS ratio, pericardial effusion). Follow-up of athletes and further, higher case number studies are warranted to determine the clinical significance and potential effects on exercise capacity of these findings.

Funding Acknowledgement

Type of funding sources: None.

Changes of resting cardiac marker levels due to sport adaptation

Background

In acute and chronic heart diseases some cardiac necroenzymes and peptide fragments are essential during the diagnosis and following the progression of the diseases. Previous literature data are available about elevation of these cardiac markers after exhausting physical activity, but we do not have information about the resting levels in athletes.

Methods

In part of the extended cardiology screening of athletes in our institute, we analyzed the levels of hsTroponinT, CKMB, LDH and NT-proBNP from blood samples. All the samples were collected at least 12 hours after the last trainings or competitions. The results of the athletes were compared with a healthy sedentary non-athlete control group. After the blood collection all subject underwent echocardiography examinations and cardiopulmonary exercise testing. Depending on normality, groups were compared with two-tailed Student's t-test or Mann-Whitney U-test. Statistical analysis was processed in RStudio development environment.

Results

Results of 335 athletes from different sports (male: 162, age: 18.9±5.9 years, training: 15.8±5.9 hours/week) and 53 sedentary non-athletes (male: 23, age: 19.8±3.2 years, training: 2.7±2.3 hours/week) were compared. In athletes, increased level of hsTroponinT was found in 3.3% (n=11), of CKMB in 5.7% (n=18), of LDH in 2.7% (n=9) and of NT-proBNP in 1.2% (n=4). In the control group no elevation was found regarding the CKMB and hsTroponinT, while slightly elevated values of LDH and NT-proBNP were revealed in 1–1 cases. In athletes we measured higher CKMB (17.5±6.8 vs 12.3±3.4 U/l, p&lt;0.001) and LDH values (323.7±63.3 vs 286.0±51.1 U/l, p&lt;0.001), and lower values of NT-proBNP (27.2±29.2 vs 49 8±38.7 pg/ml, p&lt;0.001) compared to the control group, while in the hsTroponinT levels (4.3±1.4 vs 5.6±6.3 ng/l, p=0.33) no significant changes were measured. In term of the examined laboratory parameters significant correlation was found with maximal relative aerob capacity (CKMB: r=0.23, p&lt;0.001; LDH: r=0.18, p&lt;0.001; hsTroponinT: r=0.23, p&lt;0.001; NT-proBNP: r=−0.22, p&lt;0.001), but no correlation was found with age. Significant correlation was found between NT-proBNP levels and echocardiographic measurements of ventricular diameters and left ventricular wall thickness (LVEDD r=−0.15, p&lt;0.03; LVESD r=−0.18, p&lt;0.03; RVD: r=−0.15, p&lt;0.02; IVS: r=−0.22, p&lt;0.001; PWD r=−0.27, p&lt;0.001), CKMB levels correlated with left ventricular wall thickness (IVS: r=0.11, p&lt;0.05; PWD r=0.14, p&lt;0.02).

Conclusions

Based on our results, in connection with the sports adaptation of the heart, the resting levels of the cardiac markers also show significant changes, these changes are correlated with aerobic endurance and structural sport adaptation parameters as well. Our study draws attention to the importance of different assessment of cardiac markers in athletes.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 135076).Supported by the ÚNKP-20-3-I-SE-41 New National Excellence Program of the Ministry for Innovation and Technology from the Source of the National Research, Development and Innovation fund.

Tissue characteristics of the athlete"s heart: differentiation of physiological and pathological hypertrophy using parametric T1 and T2 mapping

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Fund of Hungary

Background

Intensive physical exercise leads to structural and functional cardiac adaptation termed athlete’s heart. Cardiac magnetic resonance (CMR) has an important role in the differentiation of physiological adaptation and pathological conditions. Beside the precise measurement of the ventricular volumes, mass, and function, it provides tissue specific information. Recently, native T1 mapping technique has been applied as a non-contrast method to detect myocardial fibrosis. Previous studies suggested that native T1 mapping can identify myocardial pathology before other CMR imaging techniques. T2 mapping values are elevated in case of myocardial edema.

Purpose

The aim of our study was to investigate the differences in CMR characteristics especially the native T1 and T2 mapping values of highly trained healthy athletes, healthy controls and patients with hypertrophic cardiomyopathy (HCM).

Methods

A total of 43 healthy athletes (water polo, swimming, football, 22 ± 8 training hours/week), 27 non-athlete healthy control and 25 HCM patients were involved in the study. Our inclusion criteria were: age &gt;18 years,  in the athlete group &gt;7 training hours per week . We evaluated the left ventricular (LV) end-systolic, end-diastolic (EDVi) and stroke volume (SVi) index, mass index (LVMi), ejection fraction (EF) and maximal end-diastolic wall thickness (EDWT). In a basal short axis slice the native T1 and T2 mapping values were evaluated.

Results

Athletes had significantly higher LV volumes compared to the control and HCM group (LVEDVi 114 ± 13 vs. 86 ± 11; 84 ± 15  ml/m2, LVSVi 64 ± 7 vs. 51 ± 7; 54 ± 10 ml/m2, respectively, p &lt; 0.0001). HCM patients had the highest LVMi (72 ± 14 g/m2) and EDWT (18 ± 4 mm) compared to athletes and controls, athletes had higher LVMi (60 ± 11 vs. 42 ± 8 g/m2) and EDWT (10 ± 2 vs. 8 ± 1 mm) compared to the controls (p &lt; 0.001). The native T1 mapping values differed significantly in the three groups, athletes had the lowest, HCM patients had the highest T1 values (athletes: 956 ± 19 ms, controls: 971 ± 20 ms, HCM patients: 993 ± 39 ms; p &lt; 0.0001). There was no difference in the T2 mapping values between athletes and controls (44 ± 2 vs. 43 ± 2 ms), HCM patients had higher T2 values (45 ± 2 ms) compared to the other two groups (p &lt; 0.01).

Conclusion

Intensive and regular training may lead to tissue specific changes of the myocardium. T1 and T2 mapping are potentially useful tools for differentiating between athlete"s heart and patients with hypertrophic cardiomyopathy.

Abstract Figure. T1 mapping in HCM and athlete

Left ventricular hypertrabeculation - an unanswered question

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Supported by the ÚNKP-19-3-II New National Excellence Program of the Ministry for Innovation and Technology

Left ventricular (LV) hypertrabeculation (H-TRAB) is a morphological description when the LV is highly trabeculated, but it remains below the diagnostic criterion of  noncompaction cardiomyopathy (NCMP). Although, it is a frequent finding on cardiac MRI scans its diagnostic and prognostic relevance remains controversial.  

In this cardiac MRI study, we aimed to describe the LV functional and feature-tracking strain values of healthy subjects with LV H-TRAB to decide whether it is a normal variant or an NCMP-like pattern.

We included 189 adult participants with good LV ejection fraction (EF), and without co-morbidities. 63 of them had a morphology of LV H-TRAB (H-TRAB, age: 37.1 ± 14.4 years; EF: 66.4 ± 5.1%), 63 patients were diagnosed with NCMP (age: 36.3 ± 14.0 years, EF: 65.8 ± 5.5%) and the remaining 63 people were healthy controls (38.3 ± 14.0 years, EF: 69.0 ± 4.9%). MR examinations were performed with 1,5T Philips Achieva and Siemens Aera devices. The  Medis Suite software was used for post-processing analysis, the MedCalc software for statistics, p &lt; 0.05 was considered statistically significant. No significant differences were found between the functional parameters of the H-TRAB and NCMP groups. However, the EF was decreased, the end-diastolic (EDVi),  and end-systolic volume (ESVi), the myocardial mass (LV-massi), and trabeculated muscle mass (LV-trabi) values were increased in both groups compared to controls (H-TRAB vs. control: EF: 6.4 ± 5.4 vs. 69.0 ± 5.0%, EDVi: 74.4 ± 14.3 vs. 69.7 ± 12.8 ml/m2, ESVi: 25.1 ± 6.7 vs. 21.7 ± 5.8 ml/m2, LV-massi: 77.0 ± 15.1 vs. 71.2 ± 12.3 g/m2, LV-trabi: 25.0 ± 5.1 vs. 20.1 ± 4.0 g/m2; NCMP vs. control: EF: 65.8 ± 5.5 vs. 69.0 ± 5.0%, EDVi: 77.8 ± 15.0 vs. 69.7 ± 12.8 ml/m2, ESVi: 26.7 ± 7.9 vs. 21.7 ± 5.8 ml/m2, LV-massi: 76.8 ± 18.0 vs. 71.2 ± 12.3 g/m2, LV-trabi: 25.9 ± 7.5 vs.

20.1 ± 4.0 g/m2; p ≤ 0.05). The global circumferential strain (GCS) differed significantly between these groups: its absolute value was the lowest in the NCMP and the highest in the control group (NCMP vs. H-TRAB vs. control: -30.2% vs. -34.3% vs. -35.9%; p &lt; 0.05). Similar results were found in the comparison of the mean segmental circumferential strain values of the apical-, mid- and basal-parts between the three groups. The absolute values of these parameters were the lowest in the NCMP patients, followed by the H-TRAB, and were the highest in the control group.

These results suggest that the LV functional and strain values of the H-TRAB population are more similar to NCMP patients than healthy controls. Further studies are necessary to determine the pathological implications and consequences of this morphology.

Right ventricular non-compaction: myth or reality?

Funding Acknowledgements

Type of funding sources: None.

Noncompaction cardiomyopathy (NCMP) is characterized by excessive left ventricular (LV) trabeculation. The involvement of the right ventricle (RV) is still questionable, furthermore, the normal range for RV trabeculation is undefined. 

Our aim was to describe the RV functional and strain values of patients with NCMP with preserved LV ejection fraction (EF) using cardiac MRI and to compare these parameters with healthy control subjects, furthermore, we aimed to define the normal range for RV trabeculation. 

We included 81 NCMP patients with good LV-EF (mean age: 37.0 ± 14 years; EF: 69.4 ± 13.2%) and without comorbidities. Their parameters were compared to an age and sex matched control group (mean age: 37.2 ± 13.7 years; EF: 77.2 ± 15.0%).

MR examinations were performed with 1,5T Philips Achieva and Siemens Aera devices. The Medis Suite software was used for post-processing analysis, the MedCalc software for statistics, p &lt; 0.05 was considered statistically significant. 

The RV trabecular mass index (RV-TRABi) was significantly greater and the RV-EF significantly smaller in the NCMP group compared with the controls (NCMP vs. control; TRABi: 20.6 ± 7.0 vs. 16.9 ± 4.2 g/m2; RV-EF: 62.8 ± 5.5 vs. 64.5 ± 4.5%; p &lt; 0.05).

As for the RV global longitudinal strain (GLS) the results were close to significant (NCMP vs. control: -25.1 ± 4.0 vs. -26.4 ± 4.3%; p = 0.05). We defined the normal range of RV-TRABi with a lower limit of 8.2 g/m2 (90% confidence interval (CI): 6.8-9.5) and the upper limit of 22.1 g/m2 (90% CI: 23.6-26.5). 27.2% of the NCMP patients exceeded the upper limit of RV-TRABi. 

The described differences in the RV-EF, RV-TRABi and RV-GLS draws attention to the possibility of the involvement of RV in patients with NCMP. Further follow-up studies would be necessary to evaluate the clinical importance of these alterations.

Temporal changes of left atrial function after orthotopic heart transplantation using cardiac magnetic resonance imaging in a single-center prospective study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ÚNKP-19-3-I New National Excellence Program of the Ministry for Innovation and Technology; National Research, Development and Innovation Office of Hungary (NKFIA; NVKP_16-1-2016-0017 National Heart Program)

Background

The geometry and function of the left atrium (LA) change after orthotopic heart transplantation (HTX) with bicaval technique, as the LA has a recipient part around the pulmonary veins and a donor part, and these often contract separately. Because of this altered LA function, the recognition of left ventricular diastolic dysfunction can be challenging. The standard echocardiographic diastolic parameters are often in abnormal range in HTX patients despite of normal left ventricular diastolic function.

Purpose

The aim of our prospective study was to investigate the LA volumes and function and their temporal changes after HTX  using cardiac magnetic resonance (CMR).

Method

To better understand the cardiac characteristics of HTX patients, we started a prospective trial in January 2018. CMR was performed at one, three and six months after HTX. Left atrial contour detection was performed in 2- and 4-chamber views. Patients who had ≥Grade II allograft rejection before the CMR examination, were excluded (n = 6). In the remaining HTX patients (n = 37, 52 ± 12y, 29 male) and in a control group (n = 20, 49 ± 5y, 15 male) LA ejection fraction (EF), BSA-corrected maximum and minimum LA volume (Vi), stroke volume (SVi) were evaluated using bi-plane mode. LA global longitudinal strain (GLS) was defined with CMR based deformation imaging, called feature tracking.

Results

HTX patients had significantly higher LA volumes (maxLAVi 65 ± 22 vs. 46 ± 7 ml/m2, minLAVi 47 ± 21 vs. 18 ± 6 ml/m2) lower LASVi (19 ± 5 vs. 29 ± 4 ml/m2), LAEF (31 ± 10 vs. 62 ± 8%) and LA-GLS (10 ± 4 vs. 39 ± 11%) compared to the control group (p &lt; 0.0001).  Analysing the temporal changes in HTX patients, we found an increase in the LA-GLS already at three months (10 ± 4 vs. 12 ± 3%, p &lt; 0.05). The LAEF improved significantly at six months (29 ± 10 vs. 33 ± 10%, p &lt; 0.05).

Conclusion

After HTX the LA volumes and function differ markedly from the normal population. The LA funcional parameters showed a moderate improvement after HTX. Better understanding the changes of left atrial function after HTX could help us to recognise  pathological conditions.

Abstract Figure. Strain analysis of the left atrium

Diagnostic and prognostic impact of cardiac magnetic resonance, including scar quantification and strain imaging in patients with malignant ventricular arrhythmias and nonobstructed coronary arteries

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, National Research, Development and Innovation Office

Background

In case of malignant ventricular arrhythmias (VA) and nonobstructed coronary arteries, the differential diagnosis of the  underlying diseases is still challenging, due to the board spectrum of possible causes. Cardiac magnetic resonance (CMR) provides functional, morphological and tissue specific information, including necrotic and scar-tissue. 

Aims

  We aimed to assess the diagnostic and prognostic implications of CMR parameters including global strain values and myocardial scar in patients after ventricular fibrillation (VF) or sustained ventricular tachycardia (SVT) and nonobstructed coronary arteries.

Methods

Between 2011 and 2019, 99 patients (42 ±17 years, 54 male) presenting with VF or SVT and nonobstructed coronary arteries, who underwent CMR examination before secondary prevention implantable cardioverter defibrillator (ICD) implantation were included in our study. Post-processing included feature-tracking strain analysis and left ventricular (LV) scar quantification. Patients were followed for the combined endpoint of all-cause-mortality and appropriate ICD therapy.

Results

CMR examination proved structural myocardial disease in 72%: dilated (n = 21), arrhythmogenic (n = 11), hypertrophic cardiomyopathy (n = 7) and other cardiomyopathies (n = 3). We found LGE patterns showing chronic myocardial infarction (n = 4), suggesting chronic myocarditis (n = 4) and aspecific nonischemic scar formation (n = 14). In 7 cases aspecific structural alterations without scar formation were detected. Overall, myocardial scar was found in 52%, with an average extent of 12 ± 8% of the LV myocardium. The CMR examination changed the clinical diagnosis in 55% of the patients.  During a median follow-up at 2 years, 6 patients died and 42 experienced appropriate ICD therapy. We found an association between cardiac events and the presence of structural abnormality and myocardial scar (logrank: 4,553, p &lt; 0.05 and 8.375, p &lt;0.01).  On Cox proportional-hazards modell LV ejection fraction, LV stroke volume index, the presence of structural abnormality, the presence and extent of  myocardial scar, global LV strain parameters including longitudinal and circumferential strain, and a global left ventricular dssynchrony parameter (mechanical dispersion) were univariate predictors of the combined endpoint of all-cause-mortality and appropriate ICD therapy(p &lt; 0.05). 

Conclusion

CMR performed in patients after malignant VA and nonobstructed coronary arteries not only establishes the diagnosis in a high proportion of patients, but may also provide additional prognostic factors. This may indicate that CMR could play a complementary role in the risk stratification in this patient population.

Abstract Figure.

The role of circumferential strain in the differential diagnosis of cardiomyopathies with left ventricular hypertrabeculation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by the ÚNKP-19-3-II New National Excellence Program of the Ministry for Innovation and Technology

Dilated (DCM), hypertrophic (HCM) and noncompaction cardiomyopathy (NCMP) are genetically and morphologically overlapping diseases, however they differ in clinical manifestation, treatment and prognosis. Cardiac MRI feature-tracking might help to differentiate between these cardiomyopathies with left ventricular (LV) hypertrabeculation.

We aimed to describe the differences in the functional and strain parameters of NCMP patients with good LV ejection fraction (EF, NCMP-G) compared with patients with HCM, and NCMP patients with reduced EF (NCMP-R) compared with patients with DCM .

We included 62 NCMP patients from which 31 had good LV function and 31 had decreased LV-EF. The NCMP-G group was compared with an HCM population (n = 31) and the NCMP-R group was compared with a DCM group (n = 31) matching in age and sex (age, EF; NCMP-G 46.0 ± 13.0 years, 65.5 ± 5.3% vs. HCM 47.2 ± 14.4 years, 74.8 ± 6.3%; NCMP-R 54.5 ± 12.1 years, 32.8 ± 10.1% vs. DCM 50.8 ± 16.7 years, 34.0 ± 8.2%). 

1.5 T Philips Achieva and Siemens Aera MRI machines were used for the scans, Medis Suite program was used for analysis and MedCalc software for statistics, p &lt; 0.05 was considered statistically significant.

Significant differences were found between the functional parameters of HCM and NCMP-G patients, while the DCM and NCMP-R groups differed only in the trabecular mass values (LV-trab, NCMP-G vs. HCM: 26.2 ± 7.5 vs. 30.7 ± 7.0 g/m2, NCMP-R vs. DCM:  48.2 ± 13.2 vs. 42.1 ± 10.1 g/m2, p &lt; 0.05). The global longitudinal strain values of the studied populations were not significantly different, however the global circumferential strain (GCS) values were significantly better in patients with HCM and DCM compared with the NCMP groups (GCS, NCMP-G vs. HCM: -31.2 ± 4.9 vs. -43.0 ± 8.4%, NCMP-R vs. DCM: -11.7 ± 7.3 vs. -16.9 ± 6.1%). The average circumferential strain values of the LV basal, mid and apical parts were significantly better in the HCM and DCM groups compared with the NCMP groups (NCMP-G vs. HCM: -35.7 ± 9.5 vs. -50.5 ± 14.1%, NCMP-R vs. DCM: -29.5 ± 13.2 vs. -15.6 ± 6,7%).  We assessed the cut-off point of the average LV apical circumferential strain to differentiate the studied populations (HCM vs. NCMP-G cut-off: -47.3% sens.: 83.9%, spec.: 67.7%, AUC: 0.81; DCM vs. NCMP-R cut-off: -19.3% sens.: 83.9%, spec.: 83.9%, AUC: 0.86).

The diverse circumferential strain values of the hypertrabeculated LV apical third could help the differential diagnosis of NCMP, DCM and HCM.

Contrast-agent free evaluation of cardiomyopathies with T1 mapping and the new fast strain-encoded (fSENC) magnetic resonance imaging

Background

Cardiomyopathies (CMP) may cause impairment of cardiac function and structure. Cardiac Magnetic Resonance Imaging (CMR) is used for analysis and risk stratification of CMP by Late Gadolinium Enhancement (LGE). However, T1 mapping (T1) and fast strain encoded (f-SENC) sequences allow contrast-free and faster exams. The aim of this study was to characterize CMP by T1 and f-SENC to develop a faster and safer CMR protocol (fast-CMR).

Methods

CMP scans from our CMR database were retrospectively analyzed. All patients were scanned at 1.5T/3T scanner. Study groups were divided as follows: Patients with normal findings, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), hypertensive heart disease (HHD) and cardiac amyloidosis. Global T1 times, longitudinal (GLS) and circumferential (GCS) strain using f-SENC of study groups were compared to healthy individuals (controls). Scan time and amount of gadolinium-based contrast agent (CA) in CMR-protocol with LGE were compared to fast-CMR.

Results

174 patients and 31 controls were recruited. T1 times, GLS and GCS were similar between controls and normal individuals. T1 times were significantly increased (p&lt;0.05), while GLS and GCS were significantly reduced (p&lt;0.05) in all CMR study groups compared to controls (Table 1). Using fast-CMR 21 (±6) min of scan time were saved, about 47%, and 9 (±2) ml of CA were saved per patient.

Conclusion

Normal findings could be identified by fast-CMR without contrast agent. Fast CMR might also be a useful tool to identify different forms of CMP.

Funding Acknowledgement

Type of funding source: None

Structural and functional cardiac changes after transplantation: experiences of the first year of the prospective Heart-TIming CMR substudy

Background

In case of heart transplantation (HTX) the heart is affected by several factors e.g. ischaemia/reperfusion, denervation, immunosuppression. During the adaptation, the heart may show marked temporal changes in terms of myocardial mechanics, function and tissue characteristics. To better understand cardiac temporal characteristics after orthotopic bicaval HTX we started the prospective Heart-TIming (Transplantation Imaging) trial in January 2018.

Purpose

In our CMR substudy we aimed to evaluate the physiological structural and functional left and right ventricular characteristics and their temporal changes after HTX using cardiac magnetic resonance.

Methods

As part of the study HTX patients underwent CMR at one, three, six and twelve months after HTX (n=49; 53±11y, 39 male). Cine images, T2-weighted, native T1 and T2 mapping, late gadolinium enhancement (LGE) and adenosine stress perfusion (at 1 and 12 month) images were acquired. In order to describe physiological characteristics of the transplanted heart we excluded pts with significant coronary artery disease, ischaemic scar, ≥Grade II allograft rejection from this present study (n=9). We evaluated the left (LV) and right ventricular (RV) ejection fractions (EF), volumes, masses (M) and the global LV strain values: longitudinal (GLS), circumferential (GCS) strain and the standard deviation (SD) of the peak longitudinal strain (LS) and the mechanical dispersion. In a basal short axis slice the native T1 and T2 mapping values were evaluated. We compared baseline CMR parameters to age and gender matched healthy controls (n=20; 48±10y, 16 male), and analyzed the temporal changes after HTX.

Results

Comparing the HTX patients' CMR parameters at one month with normal controls, HTX patients had lower end-diastolic volumes (LVEDVi: 74±15 vs 89±13 ml/m2; RVEDVi: 72±16 vs 89±15 ml/m2 p&lt;0.05), stroke volumes (LVSVi: 45±7 vs 55±8 ml/m2, RVSVi: 43±8 vs 54±8 ml/m2, p&lt;0.0001), higher LVMi (63±2 vs 55±3 g/m2, p&lt;0.05), increased SD of peak LS (14±2 vs 10±2, p&lt;0.0001) and more pronounced mechanical dispersion (18±5 vs 12±4, p&lt;0.0001). The native T1 mapping values were significantly higher in HTX pts (1007±40 vs 975±24 ms, p&lt;0,01). Examining temporal changes in HTX pts we found a decrease in LVMi (66±14 vs 59±10 g/m2, p&lt;0.01) already at three months. At 12 months LVMi decreased further, less negative GLS (−25±4 vs −20±4, p&lt;0.01) and GCS (−38±7 vs −34±4, p&lt;0.05), and lower SD of the peak LS (14±2 vs 11±2, p&lt;0.01) were measured.

Conclusions

Understanding the temporal changes of cardiac mechanics, function and tissue characteristics, furthermore the establishment of physiological values may help in the early, noninvasive identification of pathological changes in HTX pts.

Tissue specific information in HTX pts

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. Supported by the ÚNKP-18-3-IV New National Excellence Program of Human Capacities.

Differentiation between physiological sport adaptation and hypertrophic cardiomyopathy in highly trained athletes using cardiac magnetic resonance

 

Differentiation between hypertrophic cardiomyopathy (HCM) patients and healthy athletes (HA) is a common clinical conundrum. We aimed to analyze cardiac magnetic resonance (CMR) characteristics of HA, sedentary HCM and athletic HCM patients and to determine CMR parameters which can help to diagnose HCM in athletes.

Male sedentary HCM patients with slightly elevated maximal end-diastolic wall thickness (EDWT 13–18 mm, n=40, 47.6±14.7y) and HA (n=30, 27.5±5.6y) were consecutively enrolled. Additionally, athletes with HCM were enrolled (n=16, 29.6±13.4 y), where a comprehensive investigation confirmed the diagnosis of HCM. We determined conventional CMR parameters (left ventricular (LV) ejection fraction (EF), end-diastolic (EDVi) and end-systolic volume index, mass index (Mi)), derived parameters such as EDWT/LVEDVi, LVM/LVEDV ratio and strain parameters such as global longitudinal (GLS), radial (GRS) and circumferential strain (GCS), SD of peak LS and CS using feature tracking. Presence of late gadolinium enhancement (LGE) was also determined. CMR parameters representing LV hypertrophy pattern or LV function were analyzed using a logistic regression to detect the best CMR parameters to predict HCM in athletes. To differentiate between HA and athletes with HCM optimal cut-off values for CMR parameters were calculated using receiver operating curve analysis.

Comparing the three groups significant differences were found regarding conventional and derived CMR parameters and strain values. None of the HA showed LGE, 75% of athletic HCM and 82% of sedentary HCM patients showed LGE. The univariate regression model showed that LVEF, EDWT, EDWT/LVMi, LVM/LVEDV, GCS, GRS, SD of peak LS and CS are determinants of the diagnosis of HCM among athletes. Multivariate regression revealed that EDWT/LVMi and GCS are independent disease predictors in athletes (p&lt;0.05).

Cut-off value for GCS ≤−32.5 and for EDWT/LVEDVi &gt;0.126 discriminate athletic HCM from HA with a sensitivity of 81.3 and 87.5% (AUC 0.93), and a specificity of 96.7 and 83.3% (AUC 0.95), respectively (Figure 1).

CMR characteristics of sedentary and athletic HCM may differ, therefore establishing diagnostic parameters based on comparison between athletic HCM and HA is essential. CMR based strain and derived parameters may help to differentiate between physiological and pathological left ventricular hypertrophy in athletes.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary (NKFIA) and National Research, Development and Innovation Office (NFKIH) of Hungary.

The influence of vigorous training on the structure and cardiorespiratory fitness in adolescent athletes

Introduction

The functional and morphological adaptation of the cardiovascular system to vigorous exercise in adolescents is less understood compared to adult athletes. Therefore, the differential diagnosis of normal cardiovascular adaptation from the possible pathological alterations is challenging. Cardiovascular magnetic resonance is an important method for assessing ventricular function and morphology. Maximal oxygen uptake (VO2 max) has been established as a reliable measure of the maximal ability to produce metabolic power aerobically.

Aims

The aim of this study was to examine left (LV) and right (RV) ventricular morphologic and functional remodeling in elite adolescent athletes using cardiac magnetic resonance imaging (CMR) and cardiopulmonary exercise test (CPET).

Methods

Between 2017 and 2019 116 asymptomatic adolescent (14–20 years) athletes (&gt;6 training hour/week) underwent CMR and CPET as part of a detailed sports cardiology screening. Cine movie images were performed for the quantification of the LV and RV volumes, masses and ejection fraction, and advanced post processing included feature-tracking strain analysis. CPET was performed on a dedicated athlete protocol.

Results

All athletes participated in sports with a high dynamic component. Male athletes (n=74, 16±1 years) demonstrated higher LV and RV end –diastolic volume index (EDVi), stroke volume index (SVi) and mass index (Mi) compared with female athletes (p&lt;0.001). We found significant difference regarding the global circumferential strain (GCS) and mechanical dispersion (MD) of male and female athletes (GCS −34±4 vs. −31±5%; MD 4±2 vs. 7±4% p&lt;0.05). VO2 showed positive correlation with the LV and RV volumetric parameters (EDVi, SVi) and Mi (p&lt;0.001) and the absolute value of GCS (p&lt;0.05), and negative correlation with the MD (p&lt;0.001). In 36 athletes the VO2 max exceeded the age-adjusted expected VO2 max by 130%, which was categorized as excellent. Besides gender, age, and body surface area CMR based LVEDVi and LVMi were independent predictors of VO2 max.

Conclusion

The functional and morphological adaptation of the adolescent cardiovascular system shows noteworthy differences between male and female athletes. VO2 max correlates with several CMR based values including LV and RV volumetric parameters, masses and strain parameters such as GCS and MD.

Strain analysis of an adolescent athlete

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. ÚNKP-19-3-I New National Excellence Program of the Ministry for Innovation and Technology.

The diagnostic value of cardiac magnetic resonance in athletes with suspected structural myocardial diseases

Introduction

Sudden cardiac death (SCD) is the leading cause of death in athletes occurring usually during intensive training. Cardiac magnetic resonance (CMR) is a reliable technique to assess ventricular volumes and function. Furthermore, it provides tissue-specific information and has a crucial role in detecting structural myocardial diseases.

Aim

We aimed to investigate the prevalence of myocardial structural heart diseases and the etiology of sudden cardiac death in highly trained athletes and their outcome during follow-up.

Method

We examined athletes (training ≥6 hours/week) who underwent CMR due to suspected structural myocardial disease at Semmelweis University Heart and Vascular Center between 2009 and 2019. Cine movie images and late gadolinium enhanced (LGE) images were performed. Athletes with structural myocardial alterations were followed for the endpoint of all-cause-mortality.

Results

CMR was performed on a total of 338 athletes (280 male, 24±11 age). The indications for CMR were as follows: aborted sudden cardiac death/sustained ventricular tachycardia (SVT) (4%), ECG alterations (36%), echocardiographic alterations (32%), positive family history of SCD or cardiomyopathies (CMP) (3%), and patients' complaints, e.g. palpitation, syncope, dyspnoea, chest complaints (25%). CMR confirmed structural myocardial disease in 82 athletes with the following distribution: 20 hypertrophic (HCM), 10 arrhythmogenic (AC), 8 dilated (DCM), and 7 non-compact (NCCMP) CMP. The CMR images of three patients indicated Fabry disease. We found post-myocardial infarction scars in 7 cases, and atypical non-ischemic scars in 28 athletes. Besides pathological conditions, we identified minor alterations in 58 patients (51 male, 25±12 age) such as: increased trabeculation, nonspecific LGE in left ventricular insertion point and myocardial crypts. Among athletes examined after aborted sudden cardiac death or SVT we found structural heart disease in 11 males and one female: AC (n=7), HCM (n=1), NCCMP (n=1) and atypical non-ischemic scars (n=3, in two patients the localisation was lateral subepicardial) were diagnosed. During the median follow up of five years one patient died in whom CMR showed lateral scar formation and only mildly reduced left ventricular ejection fraction (50%).

Conclusions

The most common structural alteration was non-ischaemic scar, the most common CMP was HCM, and the leading cause of sudden cardiac death or SVT in our competitive athletes was AC and lateral subepicardial scar formation.

LGE pattern in various cardiomyopathies

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Cardiac magnetic resonance features of acute myocarditis presenting as acute coronary syndrome

Background

Clinical presentation of myocarditis varies, one specific form of myocarditis appears with the clinical signs of acute coronary syndrome (ACS). Cardiac magnetic resonance (CMR) is an important method for assessing ventricular function and morphology, additionally provides accurate tissue specific and functional information of the heart.

Aims

Our aim was to investigate the characteristics, and prognosis of myocarditis presenting with ACS symptoms.

Methods

113 patients with the clinical signs of ACS but nonobstructed coronary arteries in whom the CMR revealed acute myocarditis were included in our study. CMR was performed in acute phase and at 3–6-month follow-up. Left ventricular (LV) volumes, mass and strain parameters expressing myocardial deformity were determined. Additional images were taken to represent tissue specific information. Relationships between laboratory and CMR parameters were investigated. Parameters predicting changes in LV ejection fraction (LVEF) were analyzed by logistic regression.

Results

A total of 113 patients with myocarditis (98 males, 31±11 years) underwent acute and follow-up CMR. Sixty two patients reported fever or infection before the beginning of their complaints, most commonly gastroenteritis (33%) and pharyngitis (32%). The creatinine kinase MB value measured in the acute phase showed positive correlation with the extent of necrosis, and the global longitudinal- and circumferential strain. The extent of the LV necrosis showed negative correlation with LVEF and positive correlation with global circumferential strain (GCS) (p&lt;0.05). On the control CMR examination LVEF and all global strain values improved, fibrosis persisted in 82% of cases but shrank (15±11 vs 5±4 g) and LV mass decreased (p&lt;0.01) compared to the acute phase. Compared to the acute phase, 21% of the patients had lower LVEF on the follow-up CMR. Lower initial LVEF, worse acute GCS, and greater LV necrosis were independent predictors of LVEF reduction in the logistic regression model. During a median follow-up of 6-years of patients treated at our clinic (n=39) no patient suffered cardiac death, heart failure, or documented ventricular arrhythmia but 21% of them had recurrent myocarditis.

Conclusion

Myocarditis mimicking ACS affects predominantly young men and shows functional improvement and good prognosis on follow-up, but it may reoccur in some cases. The reduction of LV function on control CMR may be predicted by worse initial LVEF, GCS, and a larger LV scar.

Strain, LGE in acute phase and follow-up

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Mechanical diversity in the adaptation of left and right ventricular function to long-term exercise: 3D echocardiographic study in a large cohort of competitive athletes

 

Regular physical exercise results in complex remodelling of the left- (LV) and right ventricle (RV), commonly referred as the athlete's heart. Despite the well-known changes in ventricular volumes and mass, data are scarce regarding ventricular mechanics and its connection to exercise performance.

Accordingly, our aim was to characterize biventricular morphological and functional changes and their association with peak exercise capacity in a large cohort of athletes using three-dimensional (3D) echocardiography.

Competitive athletes of various training regimes (n=525, age: 20±6 years, training: 15±7 hours/week, 30% female) were enrolled, while 73 age- and gender-matched sedentary volunteers served as the control group. Full volume 3D echocardiographic datasets focused on the LV or the RV were acquired for further analysis: LV and RV end-diastolic volume (EDVi), LV mass (Mi) indices and ejection fraction (EF) were quantified. To characterize biventricular mechanics, LV and RV global longitudinal strain (GLS) and global circumferential strain (GCS) were also measured using dedicated software. Athletes also underwent cardiopulmonary exercise testing to determine peak oxygen uptake (VO2/kg).

Athletes had significantly higher LV and RV EDVi (81±13 vs. 64±11 mL/m2; 83±14 vs. 63±11 mL/m2; both p&lt;0.001) and also LVMi (87±15 vs. 65±12 g/m2; p&lt;0.001) compared to controls. LV and RV EF were significantly lower in athletes (57±5 vs. 60±6%; 55±5 vs. 58±5%; both p&lt;0.001). LV GLS (−19.5±2.1 vs. −20.6±2.6%; p&lt;0.001) and also LV GCS (−27.9±3.2 vs. −29.8±4.4%; p&lt;0.001) was lower in athletes compared to controls. In opposed to the LV, RV GLS did not differ between the two groups (−29.3±5.8 vs. −29.5±5.3%; p=NS), however, RVGCS was decreased in athletes compared to controls (−24.4±6.1 vs. −28.6±7.3%; p&lt;0.001). In athletes, ventricular morphology measured by LV and RV EDVi correlated with VO2/kg (both r=0.37; p&lt;0.001), while functional measures, such as lower resting LV GLS (r=0.22; p&lt;0.001) and RV GCS (r=0.14; p&lt;0.01) also showed relationship with better exercise performance.

According to our results, regular physical exercise is associated with significant changes of LV and RV geometry and mechanics. Resting biventricular systolic function of the athlete's heart is characterized by a mild reduction, which is attributable to a lower longitudinal and circumferential shortening on the left side of the heart, while on the right side lower circumferential shortening can be seen along with a maintained longitudinal shortening. Moreover, this mechanical pattern also correlates with exercise performance.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): “National Heart Program” NVKP_16-1-2016-0017; NKFIH K_16 K120277 to BM

Cardiac changes after cardiac resynchronization therapy assessed using cardiac magnetic resonance imaging during biventricular pacing

 

Cardiac magnetic resonance (CMR) is a valuable tool in the assessment of left and right ventricular volumes and functions therefore establishing the effect of cardiac resynchronization therapy (CRT), but in majority of the devices MR safe mode does not include biventricular pacing as an option. We aimed to assess the effect of cardiac resynchronization using CMR with resynchronization on.

NYHA class II-III patients with LVEF≤35% despite optimal medical therapy and complete LBBB with broad QRS (&gt;150 ms) were prospectively recruited (n=16, 65±7 years, 56% male, 69% nonischaemic). CMR examination was performed at baseline and at 6-month follow-up, applying both biventricular and AOO pacing. The following data were measured: conventional CMR parameters including left and right ventricular ejection fraction (LVEF), end-diastolic index (LVEDVi) and end-systolic volume index (LVESVi), stroke volume and mass, remodelling indices such as 3D sphericity and relative wall thickness (RWT: 2x end-diastolic wall thickness /end-diastolic long-axis diameter). Using feature tracking analysis global longitudinal, circumferential, radial strain, global dyssynchrony (mechanical dispersion (MD)) and regional dyssynchrony was measured.

Comparing the baseline and follow-up CMR parameters measured during biventricular pacing, we found a significant increase in LVEF (27±7 vs 45±9%; p&lt;0.001) and decrease in LVEDVi and LVESVi (LVEDVi: 149±28 vs 91±20ml/m2; LVESVi: 108±31 vs 51±17ml/m2; p&lt;0.001). Based on decrease in LVESVi 14 patients were classified as super-responder (&gt;30%), one responder (&gt;15%) and one non-responder (&lt;15%). ProBNP levels significantly decreased (1186±83 vs 323±271 pg/ml, p&lt;0.05). LV remodelling indices (3D sphericity: 0.46±0.13 vs 0.61±0.11, RWT: 0.33±0.07 vs 0.43±0.10), global longitudinal, circumferential and radial strain values showed significant improvement. Circumferential MD decreased (18.3±6.7 vs 13.3±3.4, p&lt;0.01), while longitudinal MD did not change. Regional dyssynchrony drastically improved (358±108 vs 98±61ms, p&lt;0.001). Applying AOO pacing resulted in an immediate deterioration in LVEF (45±9 vs 38±9%), LVESVi (51±17 vs 58±19 ml/m2), global circumferential and radial strain and regional dyssynchrony.

In conclusion CMR imaging during biventricular pacing is feasible and enables a more precise quantification of LV function, morphology and mechanics. As a result, it may contribute to a better understanding of the effects of resynchronization therapy and might improve responder rate in the future.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary (NKFIA)

Diagnostic impact of early cardiac magnetic resonance imaging in patients with the working diagnosis of MINOCA. Does the final diagnosis affect patients outcome?

Introduction

The diagnostic value of cardiac magnetic resonance (CMR) imaging has been suggested in determination of the cause in patients with the working diagnosis of Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). According to the current STEMI Guideline CMR is considered to have the best diagnostic performance, when CMR timing is within its optimal ≤2 weeks.

Aims

The aim of our study was to assess the diagnostic value of early (1–7 days) CMR examination in patients with signs of troponin positive acute coronary syndrome (ACS) but with nonobstructive coronary arteries. We also aimed to investigate how early CMR changes the provisional diagnosis. We investigated the mortality in each patient group.

Methods

273 consecutive patients (43±16 years, 64% male) with working diagnosis of MINOCA underwent CMR examination following coronary angiography in a mean length of time of 2.5 days between 2009–2020. Cine movie, T2-weighted and late gadolinium enhanced images (LGE) were performed. Left ventricular end-diastolic and end-systolic volumes (LVESVi), ejection fraction (LVEF), mass (LVM) and myocardial necrosis were evaluated. We analysed the risk factors and laboratory values of our patients. Patients were followed for all-cause mortality.

Results

CMR examination established a definitive diagnosis in 86% of the cases: acute myocardial infarction (MI) in 65 patients (47% male), acute myocarditis in 142 patients (87% male), Tako-Tsubo syndrome (TTS) in 27 woman, myocardial contusion in one case. The diagnosis of four patients remained inconclusive after CMR and in 34 pts (50% male) there was no CMR abnormality. CMR changed the provisional diagnosis in 53% of the patients. LVEF was lower, LVESVi was elevated in TTS patients compared to MI and myocarditis (LVEF: 43±9.5 vs 56±7.7 vs 54±6.7%; LVESVi: 52±12.8 vs 38±13.2 vs 42±9.1 ml/m2 p&lt;0.001). Myocarditis patients were younger (myocarditis: 34±10 vs MI 47±14.8 vs TTS 66±10.7 years; p&lt;0.001) and lower percentage had hypercholesterolaemia (myocarditis:18.8 vs MI: 40 vs TTS:54.5%, p&lt;0.01) or hypertension (myocarditis: 20 vs MI: 49 vs TTS: 60%, p&lt;0.001). Laboratory values showed significant elevation of hsTroponin and CKMB of MI and myocarditis patients compared to other groups (p&lt;0.05), but there was no difference between these two groups. During the median follow-up of 3-years 13 patients died. Mortality rate in deaths per patient-year was as follows: MI 2.6 vs Myocarditis 0.4 vs TTS 7.4%. We found a strong association between CMR diagnosis and mortality (logrank 22.3 p&lt;0.001).

Conclusion

Our study demonstrates the diagnostic value of early CMR in patients with the working diagnosis of MINOCA. It established a definite diagnosis in 86% of our patients and changed the provisional diagnosis in 53%. According to our results there is an association between CMR diagnosis and mortality.

Myocarditis, MI, TakoTsubo syndrome

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Resting levels of cardiac markers in athletes

Introduction

Examination of specific cardiac enzymes and peptide fragments is essential in cases of acute myocardial ischemia and heart failure. According to previous data, exhausting physical effort may cause temporary increase of cardiac necroenzyme levels, while no information is available on their resting values in athletes.

Methods

Resting serum levels of hsTroponinT, CKMB, LDH and NT-proBNP were measured as part of extended sports cardiology screening in healthy athletes and a healthy sedentary non-athlete control group. Depending on normality, groups were compared with two-tailed Student's t-test or Mann-Whitney U-test. Statistical analysis was processed in RStudio integrated development environment.

Results

Results of 237 healthy athletes from different sports (male: 144, age: 19.1±5.9 years, training: 16.0±6.7 hours/week) and 53 sedentary non-athletes (male: 23, age: 19.8±3.2 years, training: 2.6±2.3 hours/week) were analysed. In athletes, increased resting cardiac marker levels were measured as follows: CKMB: 6.3% (n=15), LDH: 3.4% (n=8), hsTroponinT: 4.2% (n=10), NT-proBNP: 0.8% (n=2) of the cases. No elevation of CKMB and hsTroponin T levels were measured in the control group, while only single cases of increased LDH and NT-proBNP were detected. We measured higher levels of CKMB (17.6±7.3 vs. 12.3±3.4 U/l, p&lt;0.001), LDH (322.4±60.8 vs. 286.0±51.1 U/l, p&lt;0.001) and hsTroponinT (6.2±4.7 vs. 4.3±1.4 ng/l, p&lt;0.05), while lower levels of NT-proBNP (23.9±27.2 vs. 49.8±38.7 pg/ml, p&lt;0.001) in athletes compared to the control group. In male athletes, higher levels of CKMB (18.5±6.6 vs. 16.0±8.2 U/l, p&lt;0.001), LDH (337.0±62.2 vs. 300.7±51.9 U/l, p&lt;0.001) and hsTroponinT (7.0±5.3 vs. 4.3±1.9 ng/l, p&lt;0.001), and lower levels of NT-proBNP (19.8±23.1 vs. 35.0±34.1 pg/ml, p&lt;0.001) were measured compared to female athletes. Levels of hsTroponinT decreased in athletes due to increasing age (r=−0.20, p&lt;0.05).

Discussion

According to our results, resting levels of cardiac markers show significant alterations due to sport adaptation of the heart. These changes depend on age and sex as well.

Conclusions

Our research attract attention to different assessment of cardiac markers in athletes in respect of recognition of cardiovascular pathologies.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary.

P1338 Anomalous left coronary artery from pulmonary artery syndrome diagnosed in adulthood: case of a mother of five

Funding Acknowledgements

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

Introduction

Bland-White-Garland syndrome or ALCAPA (anomalous left coronary artery from pulmonary artery) syndrome is a rare congenital disorder with a prevalence of 1: 300,000. This condition is one the most common causes of infant myocardial infarction. It can ultimately lead to heart failure before the age of one, however when pronounced left and right coronary artery collateralization is present, patients may remain asymptomatic until older age. Due to the development and availability of non-invasive imaging techniques, these patients diagnosed more frequently in recent years.

Case description: We present a 53-year-old patient with treated hypertension and five uncomplicated pregnancies. At the age of 40, the patient was referred to coronary angiography due to her dyspnea on exertion. The examination showed that the left main coronary artery (LMCA) originates from the pulmonary artery 7 mm above the pulmonary valve and the right coronary artery is significantly dilated. Based on the mild complaints and good left ventricle systolic function, conservative therapy was recommended by the cardiac surgery team. Since 2018 the patient has had gradually worsening complaints despite of the therapy adjusted for chronic heart failure. Q-waves were depicted on the 12-lead ECG in aVL and V1-V6 leads. Echocardiography showed dilated left ventricle (LV), LV hypertrophy, diffuse hypokinesia, decreased LV systolic function and diastolic dysfunction. At our clinic, we performed cardiac magnetic resonance imaging (CMR) which showed moderately reduced LV ejection fraction, diffuse LV hypokinesia, increased LV volume, septal LV hypertrophy. We visualized the retrograde flow on the LMCA, the shunt volume at the anomalous artery was 1,27 L/min. The CMR also showed irreversible damage of the subendocardial region of the myocardium via late gadolinium enhancement in the area supplied by the LMCA. Since we planned to reevaluate the surgical possibilities, the collateral network with tortuous and dilated left and right coronary arteries were visualized by coronary CT angiography. The surgical team at our institute decided to perform myocardial revascularization and restoration of dual coronary artery supply.

Discussion

ALCAPA is usually diagnosed in infancy however, in about 10-15% of cases the disease is only recognized in adulthood. The long-term morphological and functional characteristics of the syndrome may include reversible/irreversible ischemic damage, systolic and diastolic dysfunction, mitral regurgitation, significant collateral circulation, left-to-right shunt, dilated coronary arteries. Surgical myocardial revascularization and restoration of dual coronary artery supply is recommended even in adult patients.

Abstract P1338 Figure. CTA reconstruction and LGE CMR

P345 Temporal changes of left atrial function after orthotopic heart transplantation in a single-center prospective study

Funding Acknowledgements

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

The geometry and function of the left atrium (LA) change after orthotopic heart transplantation (HTX) with bicaval technique, as the LA has a recipient part around the pulmonary veins and a donor part, and these often contract separately. Because of this altered LA function, the recognition of left ventricular diastolic dysfunction can be challenging. The standard echocardiographic diastolic parameters are often in abnormal range in HTX patients despite of normal left ventricular diastolic function.

The aim of our prospective study was to investigate the LA volumes and function and their temporal changes after HTX using cardiac magnetic resonance (CMR).

To better understand the cardiac characteristics of HTX patients, we started a prospective trial in January 2018. CMR was performed at one, three and six months after HTX. Left atrial contour detection was performed in 2- and 4-chamber views. Patients who had ≥Grade II allograft rejection before the CMR examination, were excluded (n = 2). In the remaining HTX patients (n = 21) and in a control group (n = 21) LA ejection fraction (EF), BSA-corrected maximum and minimum LA volume (Vi), stroke volume (SVi) were evaluated using bi-plane mode. LA global longitudinal strain (GLS) was defined with CMR based deformation imaging, called feature tracking.

HTX patients had significantly higher LA volumes (maxLAVi 71 ± 22 vs. 47 ± 6 ml/m2, minLAVi 53 ± 22 vs. 18 ± 5 ml/m2) lower LASVi (19 ± 7 vs. 29 ± 4 ml/m2), LAEF (27 ± 10 vs. 62 ± 8%) and LA-GLS (8 ± 3 vs. 39 ± 10%) compared to the control group (p &lt; 0.0001).

Analysing the temporal changes in HTX patients, we found an increase in the LAEF (26 ± 8 vs. 30 ± 5%) and LA-GLS (8 ± 3 vs. 11 ± 3%) at three months (p &lt; 0.05), there was no significant difference between the LA parameters at three and six months.

Better understanding of the changes of left atrial function after HTX could help us to recognise pathological conditions.

Abstract P345 Figure. Strain analysis of the left atrium

P363 Cardiac magnetic resonance characteristics of patients in the grey zone of hypertrophy

Funding Acknowledgements

National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277); Project no. NVKP_16-1-2016-0017. Supported by the ÚNKP-18-3-IV

Background

Differentiation between athlete’s heart and hypertrophic cardiomyopathy (HCM) may cause difficulties especially in patients in the grey zone of hypertrophy.

Purpose

We aimed to analyse cardiac magnetic resonance (CMR) characteristics of healthy athletes, sedentary HCM and athletic HCM patients in the grey zone of hypertrophy.

Methods

Male HCM patients with slightly elevated maximal end-diastolic wall thickness (EDWT 13-18 mm) and highly trained healthy athletes (n = 34, 20.4 ± 2.3 training hrs/week) were consecutively enrolled. HCM patient group was divided to sedentary (n = 35, &lt;7 training hrs/week) and athletic HCM group (n = 13; &gt;7 h/week, 13.2 ± 5.0 h training hrs/week).We determined conventional CMR parameters (left ventricular (LV) ejection fraction (EF),BSA-corrected end-diastolic (EDVi) and end-systolic volume (ESVi), mass (Mi)), derived parameters such as EDWT/LVEDVi, LVM/LVEDV and CMR based strain parameters such as global longitudinal (GLS), radial (GRS) and circumferential strain (GCS), standard deviation of peak LS, RS and CS (SD LS peak, SD RS peak, SD CS peak), standard deviation of time to peak LS, RS and CS (TTP LS, TTP RS, TTP CS) using feature tracking. Presence of late gadolinium enhancement (LGE) was determined on delayed contrast enhanced images. Inter-observer analysis for strain values was performed in a subgroup of 20 patients conducted by two blinded observer.

Results

Healthy athletes showed lower LVEF, GCS and GRS than sedentary and athletic HCM patients, respectively (57.9 ± 5.2 vs 65.3 ± 7.4, 62.7 ± 5.1; -19.7 ± 7.0 vs -24.4 ± 4.6, -22.8 ± 4.8; 61.7 ± 11.2 vs 75.4 ± 21.4, 69.3 ± 19.8). Both healthy athletes and athletes with HCM showed higher LVEDVi, LVESVi, LVSVi and LVMi than sedentary HCM patients. Although sedentary athletes showed higher SD peak strain values and more pronounced intraventricular dyssynchrony than healthy athletes (TTP LS 15.4 ± 4.9 vs 11.7 ± 4.3), none of the global strain values, SD of peak strain values or TTP strain values showed any difference between athletic HCM and healthy athletes. EDWT/LVEDVi ratio was significantly lower in healthy athletes than in sedentary and athletic HCM, respectively (0.11 ± 0.02 vs 0.19±.0.04; 0.18 ± 0.04). Inter-observer analysis showed good agreement in GLS (κ=0.77), GRS (κ=0.69) and TTP LS (κ=0.74), moderate agreement in GCS (κ=0.54), and only fair or poor agreement in SD peak strain, TTP CS and TTP RS values. None of the healthy athletes showed LGE, 62% of athletic HCM and 71% of sedentary HCM patients showed LGE in the hypertrophic segments or in the insertion points.

Conclusions

Based on our results CMR characteristics of sedentary and athletic HCM differs significantly, therefore establishing diagnostic parameters and cut-off values based on comparison between athletic HCM and healthy athletes would be essential. Presence of late gadolinium enhancement and derived parameters may have an important role in the differential diagnosis.

1642 Mitral annulus disjunction, a rare form of focal arrhythmogenic cardiomyopathy

Funding Acknowledgements

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

The rate of sudden cardiac death in mitral valve prolapse (MVP) patients is roughly twice that observed in the general population. Arrhythmogenic bileaflet MVP syndrome has been recently described and mitral annulus disjunction (MAD) has been found associated with papillary muscle fibrosis and ventricular arrhythmias even without severe mitral regurgitation. An underlying primary structural myocardial disease might be expected and the non-invasive imaging techniques are playing an increasingly important role in the detection of myocardial fibrosis as a focal arrhythmogenic substrate. Standard 2D-, 3D- and speckle tracking echocardiography and cardiac MRI can help to differentiate between the benign and malignant forms of MVP.

A 52-year-old man with a history of hypertension was referred for evaluation of frequent palpitations and presyncope. Ambulatory Holter monitoring showed paroxysmal atrial fibrillation and non-sustained ventricular tachycardias. Dilated left ventricle (LVEDD: 65mm, LVESD: 45 mm) and left atrium (LAVi: 52mL/m2), moderately reduced left ventricular (LV) systolic function (LVEF: 42%), and reduced LV global longitudinal strain (GLS: -13.5%) with severely decreased segmental longitudinal strain in the basal inferolateral segment were measured by transthoracic echocardiography. The diastolic function was preserved, however Pickelhaube sign was noticed in the lateral mitral annulus TDI curves. MAD (17 mm) and curling motion of the inferolateral basal segment of the left ventricle was observed. Transesophageal echocardiography showed bileaflet mitral valve prolapse with the involvement of all the six scallops (mitral valve prolapse volume: 10.2 mL). Severe mitral regurgitation (3D vena contracta area: 1cm2) and extremely dilated and dyskinetic mitral annulus (diameters: 55x72x12 mm, area: 34 cm2) was measured by 3D echocardiography. MRI showed transmural late gadolinium enhancement in the underlying myocardium of both papillary muscles and midmyocardial enhancement in the basal inferior, inferolateral and anteroseptal LV segments. During electrophysiology study ventricular fibrillation was easily induced and ICD was placed for primary prevention of sudden cardiac death. The patient was referred to the heart surgeon for mitral valve replacement.

This case highlights the importance of early recognition of MAD and arrhythmogenic MVP syndrome using novel non-invasive imaging techniques. The presence of MAD, the curling motion of the inferolateral basal LV segment, the Pickelhaube sign, the decreased LVEF and GLS, the characteristic segmental longitudinal strain pattern and the presence of late enhancement in the papillary muscles and the surrounding myocardium could be warning signs of the malignant form of MVP.

Abstract 1642 Figure. CMR images of arrhythmogenic MAD

P364 The first prospective study of non-compaction cardiomyopathy patients with preserved ejection fraction using cardiac magnetic resonance feature tracking

Feature tracking (FT) is a new cardiac magnetic resonance (CMR) technique for strain measurement to reveal changes e.g. in noncompaction cardiomyopathy (NCMP) patients with good ejection fraction (EF).

Our aim was to describe, first in the literature, the functional and CMR-FT strain values of NCMP patients with good EF and to compare them with their previous scans taken 4 years ago.

At the Heart and Vascular Center of Semmelweis University 6743 CMR examinations were done between 2009-2015 and 232 NCMP patients were diagnosed. We followed up 27 patients, who had a previous examination at least 4 years ago, had no co-morbidities and whoes EF were above 50% (mean age: 37 ± 14.4 years, 18 males, mean follow up: 5.7 ± 1.5 years). Their parameters were compared to a matched control (C) group.

The Medis Suite software was used for analysis, the MedCalc software for statistics, (p &lt; 0.05).

We compared the patient’s previous (PREV) and recent (REC) functional parameters but did not find significant changes. Comparing the global longitudinal and global circumferential strains (GLS, GCS) and rotation (R) no difference was found between the PREV and the REC values. The GCS showed significant difference between NCMP and C groups (-30.2 ± 5.0 vs -35.9 ± 4.5; p &lt; 0.0001). We compared the segmental longitudinal and circumferential strain values of PREV vs. REC groups and NCMP vs C groups and found significant differences just in a few segments. The left ventricular (LV) apical part’s mean longitudinal strain value showed significant decrease on the REC scans compared to the PREV (PREV vs REC: -24.4 ± 7.7 vs -20.6 ± 5.1%; p &lt; 0.05) and a non-significant decrease compared to the C (C vs REC: -22.8 ± 7.5 vs -20.6 ± 5.1%; p= n.s.).

The ratio of the average longitudinal strain value of the apical and basal part of the left ventricle was significantly smaller in the REC group compared to the PREV but did not differ from the C subjects ( PREV vs. REC: 1.5 ± 0.8 vs 1.0 ±0.3; C vs REC: 1.5 ± 0.3 vs 1.2 ± 0.5; p &lt; 0.05)

We did not find worsening in the functional parameters of NCMP patients with good EF by the end of the follow up period. However, subclinical changes can be detected in the affected apical part of LV when using FT suggesting the need for follow up.

P1824 Feature tracking strain values of noncompaction cardiomyopathy patients: differences in the light of ejection fraction

Feature tracking (FT) is a new cardiac magnetic resonance (CMR) technique for strain measurement which may give additional information about the progression of noncompaction cardiomyopathy (NCMP).

First in the literature, we compared the strain and functional parameters of NCMP patients with reduced (R) and good (G) ejection fraction (EF) using CMR-FT.

From the total of 164 CMR proven R NCMP patients, who were examined between 2009 and 2018 at the Heart and Vascular Center of Semmelweis University, we selected 26 non-ischaemic, contrast agent-free examinations (age: 56 ± 10.6 years; EF: 32.7 ± 10.0%; male = 19). According to their EF they were divided into medium (M; EF: 35-50%; n = 10) and significantly reduced EF (SR; EF &lt;35%; n = 16) subgroups. We searched 25 NCMP patients with good EF (age: 37 ± 14.4 years; EF: 65.9 ± 5.3%; male = 16) and 26 control persons (age: 52 ± 10.7 years; EF: 70.8 ± 5.1%; male = 16) to the above mentioned groups.

The Medis Suite program was used for analysis and the MedCalc software for statistics, (p &lt; 0.05).

Significant differences were found between the functional parameters of R and G patients. The global longitudinal strain (GLS) and global circumferential strain (GCS) values of the R group were decreased significantly compared to G and C groups. (R vs G; GLS: -9.5 ± 4.3 vs -20.9 + 3.2%; GCS: -12.5 ± 6.1 vs -30.5 ± 5.0%, p &lt; 0.0001; R vs C; GLS: -9.5 ± 4.3 vs -23.3 ± 4.4%; GCS: -12.5 ± 6.1 vs -35.6 ± 5.1%, p &lt; 0.0001).

All the segmental strain values of R group were decreased compared to G and C groups, moreover this significancy was observed between the M and SR subgroups as well.

The strain values of the R group in all the basal, mid and apical part of the left ventricle (LV) were reduced equally.

The average longitudinal strain values of the apical part of the LV in the SR subgroup were significantly reduced compared to the average strains of the basal part (apical vs basal: -8.9 ± 3.0 vs -11.9 ± 4.4 %, p &lt; 0.05). In addition, we found positive correlation in the R subgroup between the GCS and the mass of trabeculated muscle (r = 0.58, p = 0.002) .

Our study shows that the global and segmental strain values decreased significantly in proportion to the reduction of the EF which describes well the progression of heart failure in NCMP. However, the decreased strain values of the hypertrabeculated apical part might be specific to NCMP.

P3105Cardiopulmonary exercise testing normal values for young athletes and non-athletes

Introduction

Cardiopulmonary exercise testing (CPET) is an important diagnostic method to evaluate athletes and non-athletes, however we do not have widely accepted normal values for correct evaluation and interpretation in the young.

Goals

Our aim was to compare CPET parameters of young athletes and non-athletes and determine reference values.

Methods

Exercise tests were performed in young non-athletes, aged <18 years between 2011 to 2016 at Mayo Clinic. Athletes underwent detailed sports cardiology screening including CPET at Semmelweis University Heart and Vascular Center between 2016 and 2018. Individuals with cardiovascular disease were excluded. We created 2 subgroups in both sexes: 12–14 years (Group 1), 15–17 years (Group 2). Statistical analysis was performed using SAS with analysis of variance under the general linear model adjusting for age, body mass index and test effort based on peak respiratory exchange ratio (RER).

Results

A total of 212 athletes (92% male, 15.5±0.6ys) and 207 non-athletes (68% male, 15.0±0.7ys) were included in the analysis. In Group 1 boys, athletes have higher peak HR (200.0±9.2 vs 188.5±16.8 bpm, p<0.0001), HR reserve (117.1±14.5 vs 108.9±19.8 bpm p<0.05), VO2 max (53.7±6.6 vs 44.7±9.1 mL/kg/min p<0.0001), ventilation (VE) (120.3±25.0 vs 70.7±21.6 L/min p<0.0001) and RER (1.12±0.0 vs 1.07±0.08, p <.001) compared to controls. In Group 2 boys, there was no difference in peak HR and HR reserve, but athletes have higher VO2 max (57.2±4.7 vs 45.3±9.3 mL/kg/min, p<0.0001) and VE (150.7±23.7 vs 104.1±25.9 L/min, p<0.0001), similarly as Group 2 girls: VO2 max (46.3±3.6 vs 34.9±8.5 mL/kg/min p<0.0001), VE (118.7±12.5 vs 68.4±20.6 L/min, p<0.0001). In male athletes, peak HR (200.6±9.2 vs 196.5±7.4 bpm p<0.05) and HR recovery (34.2±9.8 vs 29.8±11.1 bpm p<0.05) decreases with age, while VO2 max (53.7±6.6 vs 57.2±4.7 mL/kg/min, p<0.001) and VE (120.3±24.9 vs 150.7±23.7 L/min, p<0.0001) increases. Lower cut-off values were determined in each group (Figure).

Lower-cut off values

Conclusion

We created a unique Mayo-Semmelweis database of young athletes and non-athletes. As a result of intensive training, athletes show higher levels of CPET variables vs non-athletes. Our study provides CPET reference values in the pediatric age group, applying them could contribute to correct evaluation and interpretation of CPET, increasing its diagnostic potential.

P4429Cardiac magnetic resonance characteristics of professional athletes and hypertrophic cardiomyopathy patients in the grey zone of hypertrophy

Acknowledgement/Funding

National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277). Project no. NVKP_16-1-2016-0017

2388Differential diagnosis of MINOCA patients: the contribution of early cardiac magnetic resonance imaging to the final diagnosis in patients with normal coronary angiography

Introduction

The diagnostic value of cardiac magnetic resonance (CMR) imaging has been suggested in determination of the cause behind Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). According to the current STEMI Guideline CMR is considered to have the best diagnostic performance, when CMR timing is within its optimal ≤2 weeks.

Purpose

The aim of our study was to establish the prevalence of the underlying pathologies using early (1–7 days) CMR examination in patients with signs of troponin positive acute coronary syndrome (ACS) but normal coronary angiography (NCA). We also aimed to investigate how early CMR changes the provisional diagnosis, and to provide detailed information of CMR characteristics of our pts and to compare laboratory parameters and risk factors of each group.

Methods

Between 2010–2018 (n=234) consecutive pts (40.2±12.1y, 159 male) with troponin positive ACS underwent CMR examination following NCA (≤20% stenosis), in a mean length of time of 2.5 days. Cine movie, T2-weighted and late gadolinium enhanced images (LGE) were performed. Left ventricular end-diastolic and end-systolic volumes (LVESVi), ejection fraction (LVEF), mass (LVM) and myocardial necrosis were evaluated. We analysed the risk factors and laboratory values of our patients.

Results

CMR proved acute myocardial infarction (MI) in 42 pts (52% male), acute myocarditis in 138 pts (89% male), Tako-Tsubo cardiomyopathy (TTC) in 25 woman, myocardial contusion in one case, in three cases CMR raised the suspicion of sarcoidosis and in 25 pts (56% male) there was no CMR abnormality. LVEF was lower, LVESVi was elevated in TTC patients compared to MI and myocarditis (LVEF: 44±9.1 vs 56.5±7 vs 55±6.6%; LVESVi: 52.5±12.9 vs 41±16.8 vs 42.1±8.9 ml/m2 p<0.001). The most frequently affected areas of the myocardium by LGE were the basal and mid inferolateral segments in case of myocarditis (69% of pts). In MI pts the anterior wall was affected only in 16%, while the involvement of inferior wall was visible in 57% of the pts. Early CMR examination established a definitive diagnosis in 88% of the cases, in 11% there was no CMR abnormality and it remained inconclusive in only 1% of the cases. CMR changed the provisional diagnosis in 47% of the pts.

Myocarditis pts were younger (myocarditis: 32.5±10.8 vs MI 47.6±15.5 vs TTC 65.5±9.6 y; p<0.001) and lower percentage had hypercholesterinaemia (myocarditis: 18.8 vs MI: 40 vs TTC: 54.5%, p<0.01) or hypertension (myocarditis: 14.3 vs MI: 38.7 vs TTC: 55.6%, p<0.001). Laboratory values showed significant elevation of hsTroponin and CKMB of MI and myocarditis pts compared to other groups (p<0.05), but there was no difference between these two groups.

Underlying pathologies in MINOCA

Conclusion

In patients with the working diagnosis of MINOCA and normal coronary angiography early CMR established a definitive diagnosis in 88% of our patients and changed the provisional diagnosis in 47% of the pts.

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

P876Cardiac magnetic resonance based feature-tracking myocardial strain analysis in MINOCA patients

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

P1528The added value of cardiac magnetic resonance to the diagnosis of patients after aborted sudden cardiac death

Introduction

An estimated 25% of all cardiovascular deaths are due to sudden cardiac death (SCD). The primary cause of SCD is coronary artery disease, however cardiac diseases accounted for SCD differ in young vs. older individuals. In patients with normal coronary angiography (NCA) the differential diagnosis is still challenging, due to the broad spectrum of underlying cardiovascular abnormalities. Cardiac magnetic resonance (CMR) provides accurate tissue specific and functional information of the heart.

Purpose

We aimed to investigate patients after aborted sudden cardiac death but NCA using cardiac magnetic resonance imaging (CMR). Our goal was to evaluate left and right ventricular parameters, presence of late gadolinium enhancement (LGE) and to assess the diagnostic value of CMR.

Methods

We enrolled 84 consecutive patients (39±13 y; 51% male) after aborted SCD with NCA and without CMR contraindication. CMR examination including long- and short-axis cine, T2-weighted and LGE images were performed. Left and right ventricular parameters were evaluated. Presence and pattern of the oedema and LGE were also assessed.

Results

Structural myocardial abnormality was present in 57% of pts: dilated (n=13), arrhythmogenic right ventricular (n=6) and hypertrophic (n=4) cardiomyopathy (CMP), moreover acute (n=2) and chronic (n=3) myocardial infarction, acute (n=2) and chronic (n=2) myocarditis, Tako-Tsubo CMP (n=1), noncompaction CMP (n=1), endomyocardial fibrosis (n=1). In 13 cases aspecific structural alterations were detected with (n=7) and without (n=6) LGE. Only 13% of the patients showed ejection fraction lower than 35% (LVEF=52±9%), 54% showed LV dilation (LVEDVi>100 ml/m2 in males and >90 ml/m2 in females; LVEDVi=104±22 ml/m2). LGE was present in 36%, showing ischemic pattern in five cases and nonischaemic pattern in 25 cases. Eleven patients were elite athletes (28±10y, 91% male, training hours: >10 hours/week). Three of them showed ARVC based on the current Task Force criteria, another three athletes showed aspecific structural alteration with nonischaemic LGE.

The CMR examination confirmed the referral diagnosis in 22%, excluded the presence of structural myocardial alteration in 43% and changed the clinical diagnosis in 35% of the patients.

Conclusion

CMR has an important diagnostic value in patients after reanimation but NCA. More than half of these patients showed structural alteration and CMR provided a diagnosis in 42%.

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

4251Results from the Hungarian Cardiac Magnetic Resonance Registry of Structural Heart Disease and Aborted Sudden Cardiac Death in Athletes

Introduction

Sudden cardiac death (SCD) is the most common cause of death in athletes occurring usually during intensive training. Cardiac magnetic resonance (CMR) has a crucial role in the detection of structural myocardial abnormalities.

Aims

Our aim was to investigate the etiology of SCD and to estimate the prevalence of myocardial structural heart diseases among Hungarian athletes using CMR.

Methods

Between January 2011 and January 2019 we performed CMR scans on 228 athletes (199 males, age: 29.1±13.2) with suspected structural myocardial disease. Twelve athletes were investigated after aborted sudden cardiac death and normal coronary angiography.

Results

CMR confirmed the diagnosis of structural myocardial disease in 62 athletes (26.2%) (28.8±9.1 years, 59 male): hypertrophic cardiomyopathy (HCM) in 14 cases (22.6%), arrhythmogenic right ventricular cardiomyopathy (ARVC) in 9 cases (14.5%), noncompaction (NCCMP) in 6 cases (9.7%) and dilated cardiomyopathy (DCM) in 5 cases (8.1%). Subendocardial late gadolinium enhancement (LGE), reflecting myocardial scar, was typical of previous myocardial infarction (post MI) in 3 cases (5.5%). Acute myocarditis was found in 2 cases (3.6%). Nonischaemic LGE pattern was found in 20 cases (32.2%): patchy subepi-midmyocardial LGE suggesting previous myocarditis in 8 athletes, and with aspecific pattern in 12 athletes. Athletes with nonischaemic LGE had normal clinical and laboratory parameters without wall motion abnormalities, in their cases further investigations ruled out systemic disease. One athlete was diagnosed with Fabry-disease, one with coronary artery abnormality (anomalous origin of the left main coronary artery from the right sinus of Valsalva), one athlete showed pheochromocytoma-related Tako-Tsubo cardiomyopathy (each 1.6%). Five athletes with confirmed structural heart disease were investigated after sustained ventricular tachycardia, seven athletes after aborted SCD: ARVC (n=6), aspecific LGE pattern (n=4), HCM (n=1) and pheochromocytoma-related Tako-Tsubo cardiomyopathy (n=1) were diagnosed.

RVOT movie of an ARVC pts

Conclusion

In our national CMR registry the most common structural alteration was nonischaemic fibrosis, the most common cardiomyopathy was HCM, and the leading cause of SCD in Hungarian competitive athletes was ARVC. The national registers are highly important for a better understanding the etiology and the geographical differences of SCD in athletes.

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

P3558Cardiac magnetic resonance characteristics of the transplanted heart: first results of the prospective Heart-TIming CMR substudy

Background

In case of heart transplantation (HTX) the heart is affected by several factors e.g. ischaemia/reperfusion, denervation, immunosuppression. During the adaptation, the heart may show marked temporal changes in terms of myocardial mechanics, function and tissue characteristics. To better understand temporal characteristics after orthotopic bicaval HTX we started the prospective Heart-TIming (Transplantation Imaging) trial in January 2018 including standard 12-lead ECG, 24-hour Holter monitor, endomyocardial biopsy, transthoracic echocardiography, invasive coronary angiography with intravascular ultrasound and optical coherence tomography and cardiac magnetic resonance (CMR).

Aim

In our CMR substudy we aimed to evaluate the physiological structural and functional left and right ventricular characteristics and their temporal changes after HTX using CMR.

Methods

As part of the study HTX patients underwent CMR at 1, 3 and 6 months after HTX (n=31; 52±10.5y, 25 male). Cine images, T2-weighted, late gadolinium enhancement (LGE) and adenosine stress perfusion (at 1 month) images were acquired. In order to describe physiological characteristics of the transplanted heart we excluded pts with significant coronary artery disease, ischaemic scar, ≥Grade II allograft rejection from this present study (n=6). We assessed the left (LV) and right ventricular (RV) ejection fractions, volumes, masses (M) and LV strain. We assessed the global strain values: longitudinal, circumferential (GCS) strain and the standard deviation (SD) of the peak longitudinal strain (LS) and the left ventricular mechanical dispersion. We compared baseline volumetric and strain parameters to age matched healthy controls (n=20; 47±11.4y, 15 male), and the temporal changes between one, three and 6 months.

Results

Comparing the HTX patients' CMR parameters at one month with normal controls, HTX patients had lower LV and RV end-diastolic volumes (LVEDVi: 76.6±15.9 vs 90.6±11.6ml/m2; RVEDVi 74.5±17.5 vs 90.3±12.1ml/m2, p<0.05),stroke volumes (p<0.05) and higher LVMi (67.6±14.4 vs 57.2±11g/m2, p<0.05). CMR based strain analysis of the HTX pts showed hyperkinetic GCS (−40,5±6.3% vs −35.2±4.8%, p<0.05), increased SD of peak LS and more pronounced mechanical dispersion (p<0.001) compared to the controls. Examining temporal changes in HTX pts we found a decrease in LVMi (69.57±16.4 vs 61.7±9.8g/m2, p<0.05) already at three months, normalization of GCS (−37.7±5.5% vs −32.6±4.9%, p<0.05) and decrease in SD of peak LS (13.5±2.3 vs 11.4±2.4, p<0.05) at 6 months. Oedema was present in all pts at one month after HTX, and disappeared after three months. LGE with aspecific pattern was present in 42%.

LGE with aspecific pattern in HTX pts

Conclusions

Understanding the temporal changes of LV mechanics, function and tissue characteristics, furthermore the establishment of physiological values may help in the early, noninvasive identification of pathological changes in HTX pts.

NCT number: NCT03499197

Acknowledgement/Funding

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

P310Differentiation between arrhythmogenic right ventricular cardiomyopathy and athlete's heart using cardiac magnetic resonance based derived parameters and strain analysis

Acknowledgement/Funding

National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277), ÚNKP-18-3-IV New National Excellence Program of Human Capacities.

P5485The impact of meteorological parameters on the incidence of myocardial infarction

Introduction

The changing of some meteorological parameters have major burden on the human body. That's why it became necessary to adopt to the altering conditions. The air temperature, atmospheric pressure have a significant influence on the patient's physical shape, blood pressure and response to stress.

The aim of our study was to assess the impact of the fronts and all the factors forming the weather at the same time on the incidence of myocardial infarction and its prognosis.

Methods

We performed a retrospective analysis on the data of 11820 consecutive patients surviving acute myocardial infarction between 2005 and 2014. We used to scales applied in meteorology to characterise the days (Péczely Scale, Front Scale). We studied the incidence of the values of the different scales 2 days before and after the infarction.

Results

We had a database of 11820 patients, STEMI (n=5183) and NSTEMI (n=6004). We created different subgroups (age, 30-day mortality, occurrence of primary ventricle fibrillation) to make our estimation. Considering non VF patients the effect of Front 3 whereas among VF positive patients Front 5 is more significant. The incidence rates of Front 3 one day before and on the day of the infarction in the non-VF and NSTEMI group is 0.2041 and 0.1735, in the non-VF and STEMI group it is 0.1939 two days before the event. The incidence rate of Front 5 on the 2nd day in the NSTEMI and VF positive group is 0.0357, it is 0.0714 among STEMI and VF positive patients on the day of the event. The influence of the approaching warm front is significant (p<0.05).

Conclusion

The influence of the weather is not irrelevant in the occurrence of MI. The mortality rates are higher in several subgroups on days having a Péczely Scale 3. The different fronts have a major impact on the severity of the infarction. The Front 5 causes higher incidence of VF due to MI. We proved that warm fronts have a significant effect on patients dying within 30 days.