Prospective multiparametric CMR characterization and MicroRNA profiling of anthracycline cardiotoxicity: A pilot translational study

Background

Anthracycline cardiotoxicity is a significant clinical challenge. Biomarkers to improve risk stratification and identify early cardiac injury are required.

Objectives

The purpose of this pilot study was to prospectively characterize anthracycline cardiotoxicity using cardiovascular magnetic resonance (CMR), echocardiography and MicroRNAs (MiRNAs), and identify baseline predictors of LVEF recovery.

Methods

Twenty-four patients (age 56 range 18-75 years; 42 % female) with haematological malignancy scheduled to receive anthracycline chemotherapy (median dose 272 mg/m2 doxorubicin equivalent) were recruited and evaluated at three timepoints (baseline, completion of chemotherapy, and 6 months after completion of chemotherapy) with multiparametric 1.5 T CMR, echocardiography and circulating miRNAs sequencing.

Results

Seventeen complete datasets were obtained. CMR left ventricular ejection fraction (LVEF) fell significantly between baseline and completion of chemotherapy (61 ± 3 vs 53 ± 3 %, p < 0.001), before recovering significantly at 6-month follow-up (55 ± 3 %, p = 0.018). Similar results were observed for 3D echocardiography-derived LVEF and CMR-derived longitudinal, circumferential and radial feature-tracking strain. Patients were divided into tertiles according to LVEF recovery (poor recovery, partial recovery, good recovery). CMR-derived mitral annular plane systolic excursion (MAPSE) was significantly different at baseline in patients exhibiting poor LVEF recovery (11.7 ± 1.5 mm) in comparison to partial recovery (13.7 ± 2.7 mm), and good recovery (15.7 ± 3.1 mm; p = 0.028). Furthermore, baseline miRNA-181-5p and miRNA-221-3p expression were significantly higher in this group. T2 mapping increased significantly on completion of chemotherapy compared to baseline (54.0 ± 4.6 to 57.8 ± 4.9 ms, p = 0.001), but was not predictive of LVEF recovery. No changes to LV mass, extracellular volume fraction, T1 mapping or late gadolinium enhancement were observed.

Conclusions

Baseline CMR-derived MAPSE, circulating miRNA-181-5p, and miRNA-221-3p were associated with poor recovery of LVEF 6 months after completion of anthracycline chemotherapy, suggesting their potential predictive role in this context. T2 mapping increased significantly on completion of chemotherapy but was not predictive of LVEF recovery.

Cardiovascular magnetic resonance characterisation of anthracycline cardiotoxicity in adults with normal left ventricular ejection fraction

BACKGROUND

Anthracycline therapy may lead to changes in cardiac structure and function not detectable by solely evaluating left ventricular ejection fraction (LVEF).

OBJECTIVES

We hypothesized that cardiovascular magnetic resonance (CMR) would identify structural and functional myocardial abnormalities in anthracycline-treated cancer survivors with normal LVEF, compared to a matched control population.

METHODS

Forty-five cancer survivors (56 ± 16 yrs., 60% female) with normal LVEF (59.5 ± 4.1%) were studied a median of 11 months (range 3-36) following administration of 237 ± 83 mg/m² anthracycline, and compared with forty-five healthy control subjects of similar age and sex (53 ± 16 yrs., 60% female) with normal LVEF (60.8 ± 2.4%) using 1.5 T CMR.

RESULTS

Significantly smaller indexed left ventricular mass (45.6 ± 8.7 vs 50.3 ± 10.1 g/m², p = 0.02) and indexed myocardial cell volume (30.5 ± 5.7 vs 34.8 ± 7.2 ml/m², p = 0.002) were evident in cancer survivors and the latter was inversely associated with cumulative anthracycline dose (r = -0.31, p = 0.02). Surrogate CMR markers of myocardial fibrosis were significantly increased in cancer survivors (native myocardial T₁: 1021 ± 40 vs 996 ± 35 ms, p = 0.002; extracellular volume: 29.5 ± 4.5 vs 27.4 ± 2.3%, p = 0.006). CMR-derived feature-tracking global longitudinal strain (GLS) was significantly impaired in cancer survivors (2D GLS -18.3 ± 2.6 vs -20.0 ± 2.0%, p < 0.001; 3D GLS -14.5 ± 2.3 vs -16.4 ± 2.6%, p < 0.001). Parameters exhibited good to excellent (ICC = 0.86-0.98) inter- and intra-observer reproducibility.

CONCLUSIONS

Anthracycline-treated cancer survivors with normal LVEF have significant perturbations of LV mass, myocardial cell volume, native myocardial T1, ECV, CMR-derived 2D and 3D GLS, compared to controls, with good to excellent levels of inter- and intra-observer reproducibility.

Electrocardiography-gated CT for acute aortic syndrome: quantifying the potential impact of subspecialty national recommendations on emergency general radiology reporting

AIM

To evaluate the detection of acute aortic syndrome (AAS) and the prevalence of alternative diagnoses that may explain the presentation or require follow-up.

MATERIALS AND METHODS

This was a retrospective, blinded re-evaluation of consecutive electrocardiography (ECG)-gated computed tomography (CT) aortic studies by a cardiovascular radiologist performed between September 2019 and May 2020 in a tertiary-referral cardiothoracic centre.

RESULTS

There were 118 identified examinations, six examinations were excluded leaving 112 (mean age = 61 ± 17; 56% male). Three cases of AAS were present (prevalence 2.7%); only one was reported on initial review. There were no false-positive diagnoses of AAS. The heart was mentioned in 79 (70.5%) reports and 73 (65.2%) of reviews revealed a total of 114 new observations; 111 (97.4%) of these were cardiovascular with 44/112 (39.3%) patients potentially having a significant previously unsuspected cardiovascular diagnosis.

CONCLUSION

The implementation of national clinical guidance to increase testing and improve image quality led to a series of challenges. The real value of ECG-gated CT may lie in detecting other diseases that mimic AAS. With the additional workload, increased subspecialty expertise is required but there needs to be a willingness to learn with an adequate support infrastructure.

Long-term outcome of myocardial scarring and deformation with cardiovascular magnetic resonance in out of hospital cardiac arrest survivors

AIMS

Cardiovascular magnetic resonance (CMR) is increasingly recognized as a diagnostic and prognostic tool in out of hospital cardiac arrest (OHCA) survivors. After assessing CMR findings early after ventricular fibrillation (VF) OHCA, we sought to explore the long-term outcome of myocardial scarring and deformation.

METHODS AND RESULTS

We included 121 consecutive VF OHCA survivors (82% male, median 62 years) undergoing CMR within 2 weeks from cardiac arrest. Late gadolinium-enhancement (LGE) was quantified using the full width at half maximum method and tissue tracking analysis software was used to assess myocardial deformation. LGE was found in 71% of patients (median LGE mass 6.2% of the left ventricle, LV), mainly with an ischaemic pattern. Myocardial deformation was overall impaired and showed a significant correlation with LGE presence and extent (P < 0.001). A composite end-point of all-cause mortality and appropriate ICD discharge/anti-tachycardia pacing was met in 24% of patients. Patients meeting the end-point had significantly greater LGE extent (8.6% of LV myocardium vs. 4.1%, P = 0.02), while there was no difference with regards to myocardial deformation. Survival rate was significantly lower in patients with LGE (P = 0.05) and LGE mass >4.4% of the LV identified a group of patients at higher risk of adverse events (P = 0.005).

CONCLUSIONS

We found a high prevalence of LGE, early after OHCA, and an overall impaired myocardial deformation. On long-term follow-up both LGE presence and extent showed a significant association with recurrent adverse events, while LV ejection fraction and myocardial deformation did not identify patients with an unfavourable outcome.

Reduced orbitofrontal grey matter volume in myocardial infarction with non-obstructive coronary arteries (MINOCA)

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is seen in 6–10% of patients presenting acutely with suspected myocardial infarction. Cardiac magnetic resonance imaging (CMR) can identify an underlying cause in ∼80% of patients. These patients are more likely to have a history of mental health illness or an emotional or stressful precipitant.

Grey matter volume can be quantified in various anatomical regions of the brain and has been shown to be altered in common mental health conditions such as anxiety, stress and depression.

This is the first prospective study investigating the acute structural brain, cardiac and psychological changes using MRI in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) within 14 days of presentation compared to STEMI control patients.

Methods

Patients meeting the 2017 ESC definition of MINOCA were prospectively recruited with STEMI control patients from February to December 2019. All participants underwent brain and comprehensive cardiac MRI, bloods and baseline psychological evaluation. We used voxel-based morphometry (VBM) to quantify grey matter volume and changes were compared between groups.

Results

54 patients were included in this interim analysis (39 MINOCA, 15 STEMI controls). Demographics were largely similar but MINOCA patients were more likely to have a history of self-reported mental health disease (36% v 7%, p 0.03) and had significantly higher baseline anxiety (8.4 v 5.3, p 0.01) scores on the HADS questionnaire. We found that control patients have significantly greater grey matter volume in the orbitofrontal cortex (OFC) compared to MINOCA patients (pFWE-corr 0.002). The orbitofrontal cortex is involved in emotional processing and implicated in anxiety and depression. However, there was no association between grey matter volume in any brain region and anxiety, depression or perceived stress scale scores.

Conclusion

Patients with MINOCA are more likely to have a history of mental health disease and have higher anxiety scores at presentation than STEMI controls. They have less grey matter volume in the orbitofrontal cortex compared to STEMI controls.

Reduced Grey Matter Volume in the OFC

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Rosetrees Trust; James Tudor Foundation

CT imaging prior to transcatheter aortic valve implantation in the UK

Objective

This cross-sectional observational study sought to describe variations in CT in the context of transcatheter aortic valve implantation (CT-TAVI) as currently performed in the UK.

Methods

408 members of the British Society of Cardiovascular Imaging were invited to complete a 27-item online CT-TAVI survey.

Results

47 responses (12% response rate) were received from 40 cardiac centres, 23 (58%) of which performed TAVI on-site (TAVI centres). Only six respondents (13%) performed high-volume activity (>200 scans per year) compared with 13 (28%) performing moderate (100–200 scans per year) and 27 (59%) performing low (0–99 scans per year) volume activity. Acquisition protocols varied (41% retrospective, 12% prospective with wide padding, 47% prospective with narrow padding), as did the phase of reporting (45% systolic, 37% diastolic, 11% both, 6% unreported). Median dose length product was 675 mGy.cm (IQR 477–954 mGy.cm). Compared with non-TAVI centres, TAVI centres were more likely to report minimum iliofemoral luminal diameter (n=25, 96% vs n=7, 58%, p=0.003) and optimal tube angulation for intervention (n=12, 46% vs n=1, 8%, p=0.02).

Conclusions

This national survey formally describes current CT-TAVI practice in the UK. High-volume activity was only present at one in seven cardiac CT centres. There is wide variation in scan acquisition, scan reporting and radiation dose exposure in cardiac CT centres.

Magnetic Resonance Imaging to Detect Cardiovascular Effects of Cancer Therapy: JACC CardioOncology State-of-the-Art Review

This paper aims to empower and inform cardio-oncologists by providing a practical guide to the clinical application of cardiac magnetic resonance (CMR) in the rapidly evolving field of cardio-oncology. Specifically, we describe how CMR can be used to assess the cardiovascular effects of cancer therapy. The CMR literature, relevant societal guidelines, indication-specific imaging protocols, and methods to overcome some of the challenges encountered in performing and accessing CMR are reviewed.

Long term cardiovascular magnetic resonance phenotyping of anthracycline cardiomyopathy

BACKGROUND

Anthracycline cardiomyopathy contributes to the morbidity and mortality of cancer survivors but long-term data are lacking. This study sought to describe the phenotype of long-term anthracycline cardiomyopathy, the prevalence of myocardial fibrosis and its association with cardiac remodeling, systolic function and clinical outcomes.

METHODS AND RESULTS

We undertook contrast-enhanced CMR in 81 cancer survivors at median 5 years after anthracycline (mean dose 279 SD 89 mg/m²). Participants were aged 55 SD 14 years; 68% were female. Mean LVEF was impaired (49 SD 12%), driven by a pathological increase in iLVESV (47 SD 23 ml/m²). 19% of participants exhibited LGE, which was associated with significant adverse left ventricular remodeling and reduced systolic function (iLVEDV: 102 SD 34 vs 83 SD 21 ml/m², p = 0.03; iLVESV 61 SD 32 vs 43 SD 20 ml/m², p = 0.03; LVEF: 43 SD 11 vs 50 SD 12%, p = 0.03). In subgroup analysis of 36 patients, 36% had elevated native T1 measurements, which was associated with significant adverse left ventricular remodeling (iLVEDV: 97 SD 22 vs 74 SD 19 ml/m², p = 0.002; iLVESV: 56 SD 22 vs 35 SD 15 ml/m², p = 0.005), reduced systolic function (LVEF 44 SD 13 vs 55 SD 9%, p = 0.01), and hospitalizations for heart failure (38% vs 9%, p = 0.03). Absolute native T1 measurements correlated significantly with iLVEDV (p ≤ 0.001, R² 0.33), iLVESV (p < 0.001, R² 0.36), LVEF (p < 0.001, R² 0.35), LAVi (p = 0.04, R² 0.12) and MAPSE (p = 0.02, R² 0.14).

CONCLUSIONS

Long-term anthracycline cardiomyopathy is characterized by pathologically increased iLVESV. Both LGE and elevated native T1 measurements were associated with significant adverse cardiac remodeling and reduced systolic function, and the latter with heart failure hospitalizations.

Connection between the heart and the gut

Clinical introduction

A 45-year-old man with ulcerative colitis was admitted with bloody diarrhoea and chest pain. Inflammatory markers and high-sensitivity troponin were elevated (C reactive protein 57 mg/L, white cell count 10.65×10⁹/L, neutrophil 6.6×10⁹/L, Troponin-I 663 mmol/L). The ECG showed inferior ST-elevation. Urgent coronary angiography revealed unobstructed coronary arteries. Inpatient cardiovascular magnetic resonance (CMR) was arranged to determine the aetiology of the myocardial infarction with non-obstructive coronary arteries. The imaging protocol at 1.5 T included balanced steady-state free precession cine images, T2-weighted oedema sequences, and early and late gadolinium enhancement (LGE). Native T1 and T2 mapping images provided advanced tissue characterisation (figure 1).

Question

What is the most likely diagnosis based on the MRI findings? 

Multiple embolic myocardial infarctions in the right coronary artery territory.

Acute autoimmune myocarditis.

Cardiac sarcoidosis.

Stress (Takotsubo) cardiomyopathy.

Multiple embolic myocardial infarctions in the left circumflex coronary artery territory.

Implementation of NICE clinical guideline 95 on chest pain of recent onset: experience in a district general hospital

The National Institute for Health and Care Excellence (NICE) CG95 clinical guideline on chest pain of recent onset was published in 2010. There is debate over whether the proposed strategy improves patient care and its implications on service costs. Following a six-month pilot, 472 consecutive patient records were audited for pre-test probability of significant coronary artery disease, investigations performed and outcomes. Low- and moderate-risk patients had an unexpectedly low rate of coronary disease and revascularisation. Computerised tomography coronary angiography (CTCA) and stress echocardiography performed similarly, though the latter was more resource intensive. High-/very high-risk patients frequently required revascularisation and greater than 10% of each group had prognostically significant disease, going against the recommendation that very high risk patients do not undergo angiography. There were frequent protocol deviations and training clinic staff in the new approach was challenging. In conclusion, implementing NICE CG95 is feasible but presents challenges. Staff require training to follow the protocol consistently. Functional testing had no benefits over anatomical testing with CTCA, which may allow cost savings in some departments.

Iatrogenic mitral stenosis following transcatheter aortic valve replacement (TAVR)

A 57 year old female underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Mild iatrogenic mitral stenosis was noted intraoperatively. Attempts to reposition the device were hampered by aortic angulation. One year later, severe mitral stenosis was confirmed on transoesophageal echocardiography. It is important to recognise that iatorgenic mitral stenosis due to TAVR may progress over time. Care should be taken to minimise the risk of this rare complication.