Tissue characterization of acute lesions during cardiac magnetic resonance-guided ablation of cavo-tricuspid isthmus-dependent atrial flutter: a feasibility study

AIMS

To characterize acute lesions during cardiac magnetic resonance (CMR)-guided radiofrequency (RF) ablation of cavo-tricuspid isthmus (CTI)-dependent atrial flutter by combining T2-weighted imaging (T2WI), T1 mapping, first-pass perfusion, and late gadolinium enhancement (LGE) imaging. CMR-guided catheter ablation offers a unique opportunity to investigate acute ablation lesions. Until present, studies only used T2WI and LGE CMR to assess acute lesions.

METHODS AND RESULTS

Fifteen patients with CTI-dependent atrial flutter scheduled for CMR-guided RF ablation were prospectively enrolled. Directly after achieving bidirectional block of the CTI line, CMR imaging was performed using: T2WI (n = 15), T1 mapping (n = 10), first-pass perfusion (n = 12), and LGE (n = 12) imaging. In case of acute reconnection, additional RF ablation was performed. In all patients, T2WI demonstrated oedema in the ablation region. Right atrial T1 mapping was feasible and could be analysed with a high inter-observer agreement (r = 0.931, ICC 0.921). The increase in T1 values post-ablation was significantly lower in regions showing acute reconnection compared with regions without reconnection [37 ± 90 ms vs. 115 ± 69 ms (P = 0.014), and 3.9 ± 9.0% vs. 11.1 ± 6.8% (P = 0.022)]. Perfusion defects were present in 12/12 patients. The LGE images demonstrated hyper-enhancement with a central area of hypo-enhancement in 12/12 patients.

CONCLUSION

Tissue characterization of acute lesions during CMR-guided CTI-dependent atrial flutter ablation demonstrates oedema, perfusion defects, and necrosis with a core of microvascular damage. Right atrial T1 mapping is feasible, and may identify regions of acute reconnection that require additional RF ablation.

Report of the European Medicines Agency Conference on RNA-Based Medicines

RNA-based medicines have potential to treat a large variety of diseases, and research in the field is very dynamic. Proactively, The European Medicines Agency (EMA) organized a virtual conference on February 2, 2023 to promote the development of RNA-based medicines. The initiative addresses the goal of the EMA Regulatory Science Strategy to 2025 to "catalyse the integration of science and technology in medicines development." The conference focused on RNA technologies (excluding RNA vaccines) and involved different stakeholders, including representatives from academia, industry, regulatory authorities, and patient organizations. The conference comprised presentations and discussion sessions conducted by panels of subject matter experts. In this meeting report, we summarize the presentations and recap the main themes of the panel discussions.

Feasibility of in-vivo estimation of the brachial artery area-pressure relation from CINE and real-time MRI during upper arm cuff inflations

OBJECTIVE

We investigate the basic feasibility of estimating the brachial artery area-pressure relationship from MRI data obtained during pressure cuff inflations in-vivo.

METHODS

We acquired cross-sectional real-time MR images and cardiac-gated CINE MR images from the upper arm of a single male subject at rest during supra-systolic pressure cuff inflations and deflations. We estimate from the MR images the lumen area changes of the brachial artery, and, simultaneously, from the cuff pressure the systemic blood pressure of the subject. We reconstruct the area-pressure curve from two real-time and three CINE independent measurements.

RESULTS

The area-pressure curve can be reconstructed, and it is plausible and appears largely consistent with the literature using other methods.

CONCLUSION

MR imaging during pressure cuff inflations is an easy to use, non-invasive candidate method to estimate the brachial artery pressure-area curve.

Insights into oscillometry: An Experimental Study for Improvement of Cuff-Based Blood Pressure Measurement Technology

Non-invasive blood pressure (BP) measurements are usually performed by means of an empirical interpretation of arterial oscillations recorded via cuff based oscillometic methods. Extensive effort has been put into development of a theoretical treatment of oscillometry aiming at more accurate BP estimations and measurement of additional hemodynamic parameters. However, oscillometry is still basically a heuristic method for BP inference.This study introduces an experimental setup and discusses experimental results to improve understanding of cuff characteristics and the process by which oscillometric signals are produced, with the aim of improving cuff-based non-invasive BP measurement technology relevant in clinical practice. The work focuses on mechanical simulations of arm volume pulsations in cuff pressure signals. The effects of air compression within the cuff and the influence of viscoelastic properties of exterior cuff material are also investigated. Additionally, arm volume changes and compressibility of arm tissue due to external cuff pressure were studied with an MRI system. Our results reveal novel insights into oscillometry and enable understanding of transducer design for cuffs including the importance of viscoelastic material properties and effects of cuff inflation on arm tissue.

Essential requirement of CCAAT/enhancer binding proteins in embryogenesis

The CCAAT/enhancer binding proteins C/EBPalpha and C/EBPbeta are related transcription factors that are important for the function of various organs in the postnatal mouse. Gene replacement and tissue culture experiments have suggested partial redundancy of both transcription factors. Here we show that mouse embryos deficient of both C/EBPalpha and C/EBPbeta (C/EBPalphabeta(-/-)) die between embryonic day 10 (E10) and E11 and display defective placentas. In situ hybridization revealed that C/EBPalpha and C/EBPbeta are coexpressed in the chorionic plate at E9.5 and later in the trophoblasts of the labyrinthine layer. In C/EBPalphabeta(-/-) placentas, allantoic blood vessels invaded the chorion; however, vessel expansion and development of the labyrinthine layer was impaired. Furthermore, a single copy of either C/EBPalpha in the absence of C/EBPbeta or C/EBPbeta in the absence of C/EBPalpha is sufficient to complete development, suggesting complementation of these C/EBPs during embryogenesis. A single copy of C/EBPalpha in the absence of C/EBPbeta, however, fails to rescue survival after birth, suggesting haploinsufficiency of C/EBPalpha in newborns. Our data thus reveal novel essential, redundant, and dosage dependent functions of C/EBPs.

On the performance and accuracy of 2D navigator pulses

The purpose of this study was to investigate and to optimize the performance of two-dimensional spatially selective excitation pulses used for navigator applications on a clinical scanner. The influence of gradient imperfections, off-resonance effects, and incomplete k-space covering on the pencil beam-shaped spatial excitation profile of the 2D RF pulse was studied. The studies involved experiments performed on phantoms and in vivo. In addition, simulations were carried out by numerical integration of the Bloch equations. The accuracy of positioning of the pencil beam was increased by a factor of three by employing a simple correction scheme for the compensation of gradient distortions. The spatial selectivity of the 2D RF pulse was improved by taking sampling density corrections into account. The 2D RF pulse performance was found to be sufficient to monitor the diaphragm motion even at moderate gradient strength. For applications, where a high spatial resolution is required or a less characteristic contrast is present a strong gradient system is recommended.

Pharmacokinetic analysis of Gd-DTPA enhancement in dynamic three-dimensional MRI of breast lesions

The purpose of this study was to demonstrate that dynamic MRI covering both breasts can provide sensitivity for tumor detection as well as specificity and sensitivity for differentiation of tumor malignancy. Three-dimensional gradient echo scans were used covering both breasts. Before Gd-DTPA bolus injection, two scans were obtained with different flip angles, and after injection, a dynamic series followed. Thirty-two patients were scanned according to this protocol. From these scans. In addition to enhancement, the value of T1 before injection was obtained. This was used to estimate the concentration of Gd-DTPA as well as the pharmacokinetic parameters governing its time course. Signal enhancement in three-dimensional dynamic scanning was shown to be a sensitive basis for detection of tumors. In our series, all but two mammographically suspicious lesions did enhance, and in three cases, additional enhancing lesions were found, two of which were in the contralateral breast. The parameter most suited for classification of breast lesions into benign or malignant was shown to be the pharmacokinetically defined permeability k31, which, for that test, gave a sensitivity of 92% and a specificity of 70%. Our three-dimensional dynamic MRI data are sensitive for detection of mammographically occult breast tumors and specific for classification of these as benign or malignant.