Cardiac Magnetic Resonance for Prophylactic Implantable-Cardioverter Defibrillator Therapy in Ischemic Cardiomyopathy: The DERIVATE-ICM International Registry

BACKGROUND

Implantable cardioverter-defibrillator (ICD) therapy is the most effective prophylactic strategy against sudden cardiac death (SCD) in patients with ischemic cardiomyopathy (ICM) and left ventricle ejection fraction (LVEF) ≤35% as detected by transthoracic echocardiograpgy (TTE). This approach has been recently questioned because of the low rate of ICD interventions in patients who received implantation and the not-negligible percentage of patients who experienced SCD despite not fulfilling criteria for implantation.

OBJECTIVES

The DERIVATE-ICM registry (CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy; NCT03352648) is an international, multicenter, and multivendor study to assess the net reclassification improvement (NRI) for the indication of ICD implantation by the use of cardiac magnetic resonance (CMR) as compared to TTE in patients with ICM.

METHODS

A total of 861 patients with ICM (mean age 65 ± 11 years, 86% male) with chronic heart failure and TTE-LVEF <50% participated. Major adverse arrhythmic cardiac events (MAACE) were the primary endpoints.

RESULTS

During a median follow-up of 1,054 days, MAACE occurred in 88 (10.2%). Left ventricular end-diastolic volume index (HR: 1.007 [95% CI: 1.000-1.011]; P = 0.05), CMR-LVEF (HR: 0.972 [95% CI: 0.945-0.999]; P = 0.045) and late gadolinium enhancement (LGE) mass (HR: 1.010 [95% CI: 1.002-1.018]; P = 0.015) were independent predictors of MAACE. A multiparametric CMR weighted predictive derived score identifies subjects at high risk for MAACE compared with TTE-LVEF cutoff of 35% with a NRI of 31.7% (P = 0.007).

CONCLUSIONS

The DERIVATE-ICM registry is a large multicenter registry showing the additional value of CMR to stratify the risk for MAACE in a large cohort of patients with ICM compared with standard of care.

Cardiac magnetic resonance for prophylactic implantable-cardioverter defibrillator therapy international study: prognostic value of cardiac magnetic resonance-derived right ventricular parameters substudy

AIMS

Right ventricular systolic dysfunction (RVSD) is an important determinant of outcomes in heart failure (HF) cohorts. While the quantitative assessment of RV function is challenging using 2D-echocardiography, cardiac magnetic resonance (CMR) is the gold standard with its high spatial resolution and precise anatomical definition. We sought to investigate the prognostic value of CMR-derived RV systolic function in a large cohort of HF with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Study cohort comprised of patients enrolled in the CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DefibrillAtor ThErapy registry who had HFrEF and had simultaneous baseline CMR and echocardiography (n = 2449). RVSD was defined as RV ejection fraction (RVEF) <45%. Kaplan-Meier curves and cox regression were used to investigate the association between RVSD and all-cause mortality (ACM). Mean age was 59.8 ± 14.0 years, 42.0% were female, and mean left ventricular ejection fraction (LVEF) was 34.0 ± 10.8. Median follow-up was 959 days (interquartile range: 560-1590). RVSD was present in 936 (38.2%) and was an independent predictor of ACM (adjusted hazard ratio = 1.44; 95% CI [1.09-1.91]; P = 0.01). On subgroup analyses, the prognostic value of RVSD was more pronounced in NYHA I/II than in NYHA III/IV, in LVEF <35% than in LVEF ≥35%, and in patients with renal dysfunction when compared to those with normal renal function.

CONCLUSION

RV systolic dysfunction is an independent predictor of ACM in HFrEF, with a more pronounced prognostic value in select subgroups, likely reflecting the importance of RVSD in the early stages of HF progression.

AI Cardiac MRI Scar Analysis Aids Prediction of Major Arrhythmic Events in the Multicenter DERIVATE Registry

Background Scar burden with late gadolinium enhancement (LGE) cardiac MRI (CMR) predicts arrhythmic events in patients with postinfarction in single-center studies. However, LGE analysis requires experienced human observers, is time consuming, and introduces variability. Purpose To test whether postinfarct scar with LGE CMR can be quantified fully automatically by machines and to compare the ability of LGE CMR scar analyzed by humans and machines to predict arrhythmic events. Materials and Methods This study is a retrospective analysis of the multicenter, multivendor CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy (DERIVATE) registry. Patients with chronic heart failure, echocardiographic left ventricular ejection fraction (LVEF) of less than 50%, and LGE CMR were recruited (from January 2015 through December 2020). In the current study, only patients with ischemic cardiomyopathy were included. Quantification of total, dense, and nondense scars was carried out by two experienced readers or a Ternaus network, trained and tested with LGE images of 515 and 246 patients, respectively. Univariable and multivariable Cox analyses were used to assess patient and cardiac characteristics associated with a major adverse cardiac event (MACE). Area under the receiver operating characteristic curve (AUC) was used to compare model performances. Results In 761 patients (mean age, 65 years ± 11, 671 men), 83 MACEs occurred. With use of the testing group, univariable Cox-analysis found New York Heart Association class, left ventricle volume and/or function parameters (by echocardiography or CMR), guideline criterion (LVEF of ≤35% and New York Heart Association class II or III), and LGE scar analyzed by humans or the machine-learning algorithm as predictors of MACE. Machine-based dense or total scar conferred incremental value over the guideline criterion for the association with MACE (AUC: 0.68 vs 0.63, P = .02 and AUC: 0.67 vs 0.63, P = .01, respectively). Modeling with competing risks yielded for dense and total scar (AUC: 0.67 vs 0.61, P = .01 and AUC: 0.66 vs 0.61, P = .005, respectively). Conclusion In this analysis of the multicenter CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy (DERIVATE) registry, fully automatic machine learning-based late gadolinium enhancement analysis reliably quantifies myocardial scar mass and improves the current prediction model that uses guideline-based risk criteria for implantable cardioverter defibrillator implantation. ClinicalTrials.gov registration no.: NCT03352648 Published under a CC BY 4.0 license. Supplemental material is available for this article.

Myocardial oedema contributes to interstitial expansion and associates with mechanical and electrocardiographic changes in takotsubo syndrome: a CMR T1 and T2 mapping study

AIMS

myocardial oedema is largely represented in takotsubo syndrome (TTS) and may contribute to alter the myocardium morphology and function. The aim of the study is to describe relationships between oedema, mechanical, and electrical abnormalities in TTS.

METHODS AND RESULTS

the study included n = 32 hospitalized TTS patients and n = 23 controls. Cardiac magnetic resonance (CMR) with tissue mapping and feature tracking was performed with concomitant 12-lead electrocardiogram (ECG) recording. Mean age of TTS was 72 ± 12 years old, 94% women. Compared with controls, patients had higher left ventricular (LV) mass, worse systolic function, higher septal native T1 (1116 ± 73 msec vs. 970 ± 23 msec, P < 0.001), T2 (56 ± 5 msec vs. 46 ± 2 msec, P < 0.001), and extracellular volume (ECV) fraction (32 ± 5% vs. 24 ± 1%, P < 0.001). TTS patients had higher apicobasal gradient of T2 values (12 ± 6 msec vs. 2 ± 6 msec, P < 0.001); basal LV wall displayed higher native T1, T2, and ECV (all P < 0.002) but similar circumferential strain against controls (-23 ± 3% vs. -24 ± 4%, P = 0.351). In the TTS cohort, septal T2 values showed significant correlations with native T1 (r = 0.609, P < 0.001), ECV (r = 0.689, P < 0.001), left ventricular ejection fraction (r = -0.459, P = 0.008) and aVR voltage (r = -0.478, P = 0.009). Negative T-wave voltage and QTc length correlated with apicobasal T2 mapping gradient (r = 0.499, P = 0.007 and r = 0.372, P = 0.047, respectively) but not with other tissue mapping measurements.

CONCLUSIONS

CMR T1 and T2 mapping demonstrated increased myocardial water content conditioning interstitial expansion in acute TTS, detected even outside areas of abnormal wall motion. Oedema burden and distribution associated with mechanical and electrocardiographic changes, making it a potential prognostic marker and therapeutic target in TTS.

66 MYOCARDIAL EDEMA CONTRIBUTES TO INTERSTITIAL EXPANSION AND ASSOCIATES WITH MECHANICAL AND ELECTROCARDIOGRAPHIC CHANGES IN TAKOTSUBO SYNDROME: A CMR T1 AND T2 MAPPING STUDY

Background

myocardial edema has a central role in takotsubo syndrome (TTS). Relationships between edema, mechanical and electrical abnormalities in TTS are still elusive.

Methods

n=32 hospitalized TTS patients and n=23 controls were analyzed. We performed cardiac magnetic resonance (CMR) with tissue mapping for the assessment of edema and interstitial expansion, global longitudinal (GLS) and circumferential strain (GCS) were evaluated by CMR feature-tracking. Twelve-lead ECGs were recorded at the time of CMR in TTS patients, aVR voltage, negative T-wave voltage and QTc length were calculated.

Results

mean age of the TTS cohort was 72±12-year-old, 94% women, undergoing CMR at a median of 4 days (interquartile range 2, 6) after hospital admission. Compared with controls, patients had increased LV mass (55±11 g/m2 vs 46±8 g/m2, p&lt;0.001), worse left ventricular ejection fraction (LVEF), GLS and GCS (all p&lt;0.001), higher septal native T1 (1116±73 msec vs 970±23 msec, p&lt;0.001), T2 (56±5 msec vs 46±2 msec, p&lt;0.001) and extra-cellular volume (ECV) fraction (32±5% vs 24±1%, p&lt;0.001). TTS patients had higher apicobasal gradient of T2 values (12±6 msec vs 2±6 msec, p&lt;0.001), basal LV wall displayed higher native T1, T2 and ECV (all p&lt;0.002) but similar circumferential strain against controls (-23±3% vs -24±4%, p=0.351). In the TTS cohort, septal T2 value showed significant correlations with native T1 (r=0.609, p&lt;0.001), ECV (r=0.689, p&lt;0.001), LVEF (r=-0.459, p=0.008) and aVR voltage (r=-0.437, p&lt;0.05). Negative T waves voltage and QTc length significantly correlated with apicobasal T2 mapping gradient (r=0.499, p=0.007 and r=0.372, p=0.047 respectively) but not with other tissue mapping measurements.

Conclusions

CMR T1 and T2 mapping demonstrated increased myocardial water content conditioning interstitial expansion in acute TTS. Myocardial edema was detected even outside areas of abnormal wall motion, its burden and distribution associated with mechanical and electrocardiographic changes, making it a potential prognostic marker and therapeutic target in TTS.

66 Heart and lung tissue characterization of COVID-19 pneumonia by T1 and T2 mapping magnetic resonance imaging

Aims

Coronavirus disease 2019 (COVID-19) is a respiratory tract infection which can lead to systemic involvement including myocardial injury, severe respiratory failure and death. Magnetic resonance imaging (MRI) could potentially offer advantages in providing tissue characterization of lung parenchyma and heart muscle in COVID-19. The aim of the present study was to describe data on heart and lung MRI in a cohort of patients hospitalized due to COVID-19 pneumonia.

Methods and results

n = 11 patients hospitalized with COVID-19 pneumonia underwent a comprehensive MRI examinations including lung and heart tissue mapping, findings were compared to those of an age- and sex-matched cohort of n = 11 individuals. Lung native T1 and T2 mapping assessments were performed by drawing a circular region of interest (ROI) with diameter of 2 cm in the parenchyma visualized from the cardiac four chamber long axis-oriented slice; vessels and areas of pleural effusion were carefully excluded. Myocardial native T1 and T2 mapping were assessed by drawing a ROI within the midventricular left ventricular (LV) septum. No patients had previous history of cardiovascular disease (including known coronary artery disease, heart failure, cardiomyopathy, atrial fibrillation). As compared to controls, patients with COVID-19 had similar cardiac function, higher mid-septum myocardial native T1 (1028 ms vs. 985, P = 0.05) and significantly higher lung native T1 and T2 within affected areas (1375 ms vs. 1201 ms, P = 0.016 and 70 ms vs. 30 ms, P < 0.001 respectively), whereas non-significant differences were observed between remote lung areas of patients and controls (1238 ms vs. 1152 ms, P = 0.088 and 29 ms vs. 33 ms, P = 0.797 respectively). No significant associations were observed between cardiac and lung mapping findings.

Conclusions

In our cohort of patients with COVID-19, T1 and T2 mapping lung MRI identified pneumonia related abnormalities as compared to healthy controls, likely representing oedema and ongoing inflammation at the lung site. Myocardial native T1 was elevated suggesting the presence of cardiac involvement. A comprehensive MRI examination can be potentially used to assess multiorgan involvement in COVID-19.

Semiquantitative ChestCT Severity Score Predicts Failure of Noninvasive Positive-Pressure Ventilation in Patients Hospitalized for COVID-19 Pneumonia

Objective

Noninvasive positive-pressure ventilation (NPPV) emerged as an efficient tool for treatment of COVID-19 pneumonia. The factors influencing NPPV failure still are elusive. The aim of the study was to investigate the relationships between semiquantitative chest computed tomography (CT) scoring and NPPV failure and mortality in patients with COVID-19.

Design

Observational study.

Setting

Nonintensive care setting.

Participants

A total of 112 patients consecutively admitted for COVID-19 pneumonia.

Interventions

Usual care including various degrees of respiratory support.

Measurements and Main Results

The semiquantitative CT score was calculated at hospital admission. Subgroups were identified according to the ventilation strategy used (oxygen delivered by Venturi mask n = 53; NPPV-responder n = 38; NPPV-failure n = 21). The study's primary endpoint was the use of NPPV. The secondary endpoints were NPPV failure and in-hospital death, respectively. CT score progressively increased among groups (six v nine v 14, p < 0.05 among all). CT score was an independent predictor of all study endpoints (primary endpoint: 1.25 [95% confidence interval {CI} 1.1-1.4], p = 0.001; NPPV failure: 1.41 [95% CI 1.18-1.69], p < 0.001; in-hospital mortality: 1.21 [95% CI 1.07-1.38], p = 0.003). According to receiver operator characteristics curve analysis, CT score was the most accurate variable for prediction of NPPV failure (area under the curve 0.862 with p < 0.001; p < 0.05 v other variables).

Conclusions

The authors reported the common and effective use of NPPV in patients with COVID-19 pneumonia. In the authors’ population, a semiquantitative chest CT analysis at hospital admission accurately identified those patients responding poorly to NPPV.

CarDiac magnEtic Resonance for prophylactic Implantable-cardioVerter defibrillAtor ThErapy in Non-Ischaemic dilated CardioMyopathy: an international Registry

AIMS

The aim of this registry was to evaluate the additional prognostic value of a composite cardiac magnetic resonance (CMR)-based risk score over standard-of-care (SOC) evaluation in a large cohort of consecutive unselected non-ischaemic cardiomyopathy (NICM) patients.

METHODS AND RESULTS

In the DERIVATE registry (www.clinicaltrials.gov/registration: RCT#NCT03352648), 1000 (derivation cohort) and 508 (validation cohort) NICM patients with chronic heart failure (HF) and left ventricular ejection fraction <50% were included. All-cause mortality and major adverse arrhythmic cardiac events (MAACE) were the primary and secondary endpoints, respectively. During a median follow-up of 959 days, all-cause mortality and MAACE occurred in 72 (7%) and 93 (9%) patients, respectively. Age and >3 segments with midwall fibrosis on late gadolinium enhancement (LGE) were the only independent predictors of all-cause mortality (HR: 1.036, 95% CI: 1.0117-1.056, P < 0.001 and HR: 2.077, 95% CI: 1.211-3.562, P = 0.008, respectively). For MAACE, the independent predictors were male gender, left ventricular end-diastolic volume index by CMR (CMR-LVEDVi), and >3 segments with midwall fibrosis on LGE (HR: 2.131, 95% CI: 1.231-3.690, P = 0.007; HR: 3.161, 95% CI: 1.750-5.709, P < 0.001; and HR: 1.693, 95% CI: 1.084-2.644, P = 0.021, respectively). A composite clinical and CMR-based risk score provided a net reclassification improvement of 63.7% (P < 0.001) for MAACE occurrence when added to the model based on SOC evaluation. These findings were confirmed in the validation cohort.

CONCLUSION

In a large multicentre, multivendor cohort registry reflecting daily clinical practice in NICM work-up, a composite clinical and CMR-based risk score provides incremental prognostic value beyond SOC evaluation, which may have impact on the indication of implantable cardioverter-defibrillator implantation.

Myocardial edema, interstitial expansion and clinical correlates in takotsubo syndrome: a cardiac magnetic resonance tissue mapping study

Funding Acknowledgements

Type of funding sources: None.

Background

takotsubo syndrome (TTS) is an acute heart failure syndrome characterized by transient systolic dysfunction, widespread myocardial edema and not trivial rate of in-hospital complications. Tissue mapping by cardiac magnetic resonance (CMR) imaging provides measure of myocardial interstitial expansion. Few studies to date comprehensively examined native T1, T2 and extracellular volume (ECV) quantification by CMR in TTS.

Purpose

to describe T1 and T2 mapping findings by cardiac magnetic resonance (CMR) imaging in a cohort of TTS patients and control subjects.

Methods

we performed CMR imaging with native T1 and T2 mapping assessment as well as ECV and late gadolinium enhancement (LGE) imaging in n = 14 TTS patients at a median of 4 (3, 7) days after the acute event. Control group consisted of n = 14 healthy individuals with no known prior acute cardiac events. Extracellular-volume (ECV) fraction estimate was derived from native and post-contrast T1 of myocardium and blood pool corrected for hematocrit as reported in literature. All mapping measurements were performed in the interventricular septum from the mid-short-axis view.

Results

median age of the study population was 72 years, 84% female. Typical apical ballooning was present in 72% of the patients, atypical in 28%, with median left ventricular ejection fraction (LVEF) of 45%; mid interventricular septum was involved in all patients based on the presence of wall motion abnormalities at hospital admission. Median native T1, T2 and ECV were 1078 msec vs 965 msec, 55 msec vs 47 msec and 29% vs 25% in TTS and controls respectively (p &lt; 0.001 for all). A significant direct correlation was found between T2 and both native T1 and ECV in TTS (r = 0.759, p = 0.002 and r = 0.630, p = 0.018 respectively) but not in controls. Moreover, in TTS patients, native T2 inversely correlated with LVEF as assessed at hospital admission (r=-0.563, p = 0.037), whereas non-significant trends were observed between admission LVEF and both native T1 and ECV. No LGE was detected neither in TTS patients nor in controls.

Conclusions

myocardial edema, as signified by increased T2, is a prominent feature of TTS, likely driving interstitial expansion and increase of native T1 and ECV in the acute phase. Correlation of T2 with LVEF on admission suggests that CMR-based parametric assessment of myocardial edema could contribute to better characterize disease severity in TTS.

Lung Ultrasound in COVID-19: Clinical Correlates and Comparison with Chest Computed Tomography

Lung ultrasound (LUS) and chest computed tomography (chest CT) are largely employed to evaluate coronavirus disease 2019 (COVID-19) pneumonia. We investigated semi-quantitative LUS and CT scoring in hospitalized COVID-19 patients. LUS and chest CT were performed within 24 h upon admission. Both were analyzed according to semi-quantitative scoring systems. Subgroups were identified according to median LUS score. Patients within higher LUS score group were older (79 vs 60 years, p<0.001), had higher C-reactive protein (CRP) (7.2 mg/dl vs 1.3 mg/dl, p<0.001) and chest CT score (10 vs 4, p=0.027) as well as lower PaO2/FiO2 (286 vs 356, p=0.029) as compared to patients within lower scores. We found a significant correlation between scores (r=0.390, p=0.023). Both LUS and CT scores correlated directly with patients age (r=0.586, p<0.001 and r=0.399, p=0.021 respectively) and CRP (r=0.472, p=0.002 and r=0.518, p=0.002 respectively), inversely with PaO2/FiO2 (r=-0.485, p=0.003 and r=-0.440, p=0.017 respectively). LUS score only showed significant correlation with hs-troponin T, NT-pro-BNP, and creatinine (r=0.433, p=0.019; r=0.411, p=0.027, and r=0.497, p=0.001, respectively). Semi-quantitative bedside LUS is related to the severity of COVID-19 pneumonia similarly to chest CT. Correlation of LUS score with markers of cardiac and renal injury suggests that LUS might contribute to a more comprehensive evaluation of this heterogeneous population.

Hodgkin's Disease Stage I and II with Exclusive Subdiaphragmatic Presentation. The Experience of the Departments of Radiation Oncology and Hematology, University “La Sapienza” of Rome

During the period 1978 to 1994, 1054 patients with Hodgkin's disease were evaluated and treated at the Departments of Radiation Oncology and Hematology, University “La Sapienza”, Rome. A total of 549 patients presented with clinical or pathological stage I and II; 37 of these had Hodgkin's disease below the diaphragm (BDHD), and 512 above the diaphragm (ADHD). A comparison of patients with BDHD versus those with ADHD showed that the first group had a higher male to female ratio. A comparison of cases with stage II BDHD versus those with stage II ADHD showed that patients with BDHD were older (48 years vs 28 years), had different histologic features and a higher incidence of systemic symptoms (67% vs 33%). Stage II BDHD patients had a worse prognosis; in fact, there were significant differences in the overall survival and relapse-free-survival rates for cases with stage II BDHD versus those with stage II ADHD (overall survival, 46% vs 80%, P<0.001; relapse-free survival, 44% vs 69%, P<0.005). Stage was found to be the most important prognostic factor for BDHD cases without systemic symptoms treated with radiation therapy alone. The type of infradiaphragmatic presentation (intra-abdominal vs peripheral disease) did not influence outcome, probably due to the more aggressive therapy received by the intra-adbominal group. Treatment recommendations for BDHD cases should be tailored to the stage and the presence or absence of intra-abdominal localization. For patients with stage IA extended fields, irradiation (inverted Y) is sufficent. However, combined modality therapy should be the treatment of choice for stage II cases, particularly in the presence of intra-abdominal disease. Patients with systemic symptoms also require combined modalities.

Cardiac magnetic resonance in patients with acute cardiac injury and unobstructed coronary arteries

AIM

To define the role of cardiac magnetic resonance (CMR) by analyzing a particular group of patients with suspected acute coronary syndrome (ACS) and normal coronary angiogram.

METHODS

From January 2009 to December 2015, we examined 220 patients with clinical suspicion of ACS, Troponin elevation [the threshold used to define a positive Troponin T test (TnT) was 0.1 ng/mL] and no significant coronary disease at angiography (the patients were considered to have significant angiographic disease only a 50% stenosis was detected in any of their coronary arteries). The role of CMR with the late gadolinium enhancement was evaluated.

RESULTS

CMR was performed to 190 patients (86%) of this group which reveals: Myocarditis in 90 patients (47%); apical ballooning (Tako-Tsubo syndrome) in 32 patients (17%); myocardial infarction (MI) in 40 patients (21%) and no clear diagnosis identified by CMR in 28 patients (15%). A comparison with previous studies was also made. Clinical and echocardiographic follow-ups were performed at 12 ± 2 mo and no major adverse cardiac events were revealed.

CONCLUSION

There is a group of patients with clinical suspicion of ACS displaying normal coronary angiograms. CMR was demonstrated to be a valuable tool in the differential diagnosis evaluation of myocarditis, apical ballooning and MI.

Patterns of late gadolinium enhancement in Duchenne muscular dystrophy carriers

BACKGROUND

This study was designed to assess whether cardiovascular magnetic resonance imaging (CMR) in Duchenne muscular dystrophy carriers (DMDc) may index any cell milieu elements of LV dysfunction and whether this cardiac phenotype may be related to genotype. The null hypothesis was that myocardial fibrosis, assessed by late gadolinium enhancement (LGE), might be similarly accounted for in DMDc and gender and age-matched controls.

METHODS

Thirty DMDc patients had CMR and genotyping with 37 gender and age-matched controls. Systolic and diastolic LV function was assessed by 2D-echocardiography.

RESULTS

Absolute and percent LGE were higher in muscular symptomatic (sym) than asymptomatic (asy) DMDc (1.77 ± 0.27 vs 0.76 ± 0.17 ml; F = 19.6, p < 0.0001 and 1.86 ± 0.26% vs 0.68 ± 0.17%, F = 22.1, p < 0.0001, respectively). There was no correlation between LGE and age. LGE was seen most frequently in segments 5 and 6; segment 5 was involved in all asy-DMDc. Subepicardial LGE predominated, compared to the mid-myocardial one (11 out of 14 DMDc). LGE was absent in the subendocardium. No correlations were seen between genotyping (type of mutation, gene region and protein domain), confined to the exon's study, and cardiac phenotype.

CONCLUSIONS

A typical myocardial LGE-pattern location (LV segments 5 and 6) was a common finding in DMDc. LGE was more frequently subepicardial plus midmyocardial in sym-DMDc, with normal LV systolic and diastolic function. No genotype-phenothype correlation was found.

Italian registry of cardiac magnetic resonance

OBJECTIVES

Forty sites were involved in this multicenter and multivendor registry, which sought to evaluate indications, spectrum of protocols, impact on clinical decision making and safety profile of cardiac magnetic resonance (CMR).

MATERIALS AND METHODS

Data were prospectively collected on a 6-month period and included 3376 patients (47.2 ± 19 years; range 1-92 years). Recruited centers were asked to complete a preliminary general report followed by a single form/patient. Referral physicians were not required to exhibit any specific certificate of competency in CMR imaging.

RESULTS

Exams were performed with 1.5T scanners in 96% of cases followed by 3T (3%) and 1T (1%) magnets and contrast was administered in 84% of cases. The majority of cases were performed for the workup of inflammatory heart disease/cardiomyopathies representing overall 55.7% of exams followed by the assessment of myocardial viability and acute infarction (respectively 6.9% and 5.9% of patients). In 49% of cases the final diagnosis provided was considered relevant and with impact on patient's clinical/therapeutic management. Safety evaluation revealed 30 (0.88%) clinical events, most of which due to patient's preexisting conditions. Radiological reporting was recorded in 73% of exams.

CONCLUSIONS

CMR is performed in a large number of centers in Italy with relevant impact on clinical decision making and high safety profile.

Cardiac magnetic resonance imaging: diagnostic value and utility in the follow-up of patients with acute myocarditis mimicking myocardial infarction

PURPOSE

The aim of our study was to evaluate the efficacy of magnetic resonance imaging (MRI) in the differential diagnosis between active myocarditis and myocardial infarction in patients with clinical symptoms mimicking acute myocardial infarction.

MATERIALS AND METHODS

Between 1 January 2006 and 30 June 2007, 23 consecutive patients (21 men and 2 women) presenting with electrocardiographic abnormalities mimicking acute myocardial infarction and a clinical suspicion of acute myocarditis (fever, chest pain and elevated troponin levels) underwent contrast-enhanced cardiac MRI within a week of admission. All patients also underwent coronary angiography, which demonstrated the absence of significant coronary artery lesions. The mean follow-up period was 2+/-4 months.

RESULTS

Cardiac MRI with injection of contrast material showed late subepicardial and intramyocardial enhancement in all patients. Subendocardial late enhancement, a typical pattern of myocardial infarction, was never seen. In addition, in agreement with the literature, there was prevalent involvement of the lateral segments of the left ventricular wall.

CONCLUSIONS

Cardiac MRI could be a valuable tool for the early diagnosis of acute myocarditis, as it can demonstrate specific patterns that help rule out acute myocardial infarction.

Late enhancement detected by cardiac magnetic resonance imaging in acute myocarditis mimicking acute myocardial infarction: location patterns and lack of correlation with systolic function

OBJECTIVE

Clinical recognition of acute myocarditis is difficult. Late enhancement (LE) detected by magnetic resonance imaging appears to be a valuable tool for evaluating and monitoring inflammatory myocardial diseases. However, patterns of myocardial enhancement and its correlation with systolic function are not yet well defined. The aim of this study was to assess the extent and location of LE during the acute phase of active myocarditis mimicking acute myocardial infarction and at follow-up, in order to correlate LE with systolic function and to monitor disease progression.

METHODS

Magnetic resonance imaging was performed in 13 patients with clinical symptoms and signs of acute myocarditis.

RESULTS

All patients showed LE, which was located in the lateral free wall in 11 (85%) patients, at the basal level in eight (61%), at the mid level in nine (69%), and at the distal level in 10 (77%). Moreover, six (46%) patients showed LE in the posterior and inferior wall (P = 0.099 versus lateral wall), four (31%) patients in the septum and inferior wall (P = 0.017 versus lateral wall) and three (23%) patients in the anterior wall (P = 0.006 versus lateral wall). Left ventricular ejection fraction was 0.50 +/- 10 and it was severely reduced only in one patient (0.20). Conversely, in the remaining patients, left ventricular ejection fraction was preserved (> or =0.45) (P < 0.001). Multifocal LE was detected in eight (61%) patients, whereas pericardial effusion was observed only in two (15%) patients (P = 0.002). Twelve patients showed ST-segment elevation and chest pain, as it occurs in acute myocardial infarction, whereas one patient showed non-ST-segment elevation with dyspnoea, as it occurs in non-ST-elevation myocardial infarction. The mean follow-up duration was 4 +/- 12 months, and follow-up was complete for all but one patient who died. LE extent decreased in 11 (92%) patients, whereas new areas of LE were detected in one (8%) patient (P < 0.001).

CONCLUSIONS

Contrast enhancement is a frequent finding in the clinical setting of suspected myocarditis and is associated with active and/or persistent myocardial inflammation. Myocarditis detected by magnetic resonance imaging predominantly occurs in the lateral free wall and very rarely affects systolic function.

[Towards the standardization of sentinel lymph node analysis in women with breast cancer]

Sentinel lymph node biopsy allows enhanced pathology through serial sections and immunohistochemical analysis of the retrieved node, with detection of micrometastases and isolated tumor cells not otherwise recognized. We present our experience with a simple, effective, pathology protocol requiring six couples of sections at three different sentinel lymph node levels. Additional micrometastases or ITC were diagnosed in 51/416 patients (14.6%).

[Computerized tomography and magnetic resonance in radical and reconstructive surgery using pedunculated and revascularized flaps in advanced-stage tumors of the head and neck. Analysis of recurrences. II]

January, 1992, to October, 1995, sixty-four patients with advanced head and neck carcinoma were submitted to reconstructive surgery using pedunculated myocutaneous or revascularized flaps and then to CT and MRI. Myocutaneous flaps were used in 26 cases--12 tubular and 14 linear flaps--and revascularized flaps in 38--14 latissimus dorsi flaps, 12 temporal flaps, 7 jejunal flaps and 5 radial flaps. Twenty-six of 64 cases (41%) relapsed: MRI correctly depicted the recurrence in 24 cases and CT in 19, with 2 false positives and 2 false negatives at MRI and 6 false positives and 7 false negatives at CT. The sensitivity, specificity, accuracy, positive and negative predictive value of CT were 84%, 78%, 73%, 76% and 82%, respectively, while the corresponding MR rates were 95%, 94%, 92%, 92% and 95%. MRI was more accurate than CT in demonstrating postoperative and postirradiation changes (92% for MRI versus 73% for CT) thanks to its higher sensitivity in depicting tumor tissue on T2-weighted and post-Gd-DTPA images. CT is very useful in the early postoperative period, to follow-up poorly collaborative patients, because its acquisition time is short; MRI should be performed when CT findings are questionable and the revascularized flap is used to repair a large defect at the skull base.

[Anatomic changes after radical surgery and reconstruction with pedunculated or revascularized flaps in advanced head and neck tumors: computerized tomography and magnetic resonance findings]

January, 1992, to October, 1995, sixty-four patients with advanced head and neck cancer underwent head and neck reconstructive surgery using myocutaneous or revascularized flaps; in the same period, all patients were consecutively examined with CT and MRI. Myocutaneous flaps wer used in 26 patients: 12 flaps were tubular and 14 linear. Revascularized flaps were used in 38 patients: to repair a large defect in 26 patients (14 latissimus dorsi flaps and 12 temporal muscle flaps) and to repair an oral damage in 12 patients (5 revascularized radial and 7 jejunal flaps). CT and MR images of myocutaneous flaps showed the flaps as fatty areas, repairing large surgical defects, hypodense at CT and hyperintense at MRI, with no post-contrast enhancement. The postoperative scar around the flap exhibited soft-tissue density with slight post-contrast enhancement at CT and slightly hypodense on T2-weighted MR images. Post-contrast CT and MRI showed slight scar enhancement with no signal changes in the fatty component. The appearance of revascularized flaps at CT and MRI depends on the characteristics of the structure used to repair the surgical defect: jejunal and radial flaps appeared as mostly fatty thickened layers with both imaging methods. Temporal and latissimus dorsi flaps are made basically of muscular tissue, fatty tissue and occasionally skin (used to repair a mucosal defect): consequently, CT showed a structure with mostly parenchymal density in all cases and MRI depicted intermediate signal intensity. MRI was useful to detect 12 revascularized jejunal or radial flaps thanks to its higher contrast resolution and multiplanar capabilities showing even such thin structures as these flaps. Moreover, MRI permitted to study skull base reconstruction with revascularized (latissimus dorsi) flaps in 5 of our patients.

Acute nonlymphocytic leukemia: onset after treatment for Hodgkin's disease

This study was undertaken to examine the influence of various factors on the occurrence of acute nonlymphocytic leukemia (ANLL) in a group of longterm survivors of Hodgkin's disease (HD). From 1972 to 1992, 1045 patients with HD were assessed and treated at the Department of Radiation Oncology, the Institute of Radiology, and the Department of Human Biopathology, Hematology Section, University of Rome "La Sapienza". The average follow-up was 72 months. For a more accurate calculation of the risk of ANLL occurrence, the patients were first divided into three subgroups according to initial treatment and then according to the total treatment they had received. Moreover, to establish the probable connection between leukemia and splenic treatment the patients were also divided into three subgroups (splenectomy, splenic irradiation, and no splenectomy/no splenic irradiation). Sixteen cases of ANLL were recorded, giving an overall risk of 0.2% at 5 years and 3.4% at 20 years. In 12 patients overt leukemia was preceded by a myelodys-plastic syndrome. Five cases had evaluable chromosome analysis. Clonal chromosome abnormalities were demonstrated in two patients, whereas three patients showed an apparently normal karyotype. Bone marrow agar cultures were analyzed in two patients and were abnormal in both cases. In the radiotherapy (RT) group, the cumulative risk was 0.4% at 10 years and 3.2% at 15 and 20 years: in the chemotherapy (CT) group it was 1.2% at 10, 15, and 20 years; in the combined group it was 3.7% at 10 years and 4.9% at 15 and 20 years. In the multivariate analysis, MOPP treatment with or without RT is a statistically significant variable for ANLL occurrence (p = 0.009). This study demonstrates that splenic treatment does not lead to ANLL. Treatment with MOPP alone and with MOPP plus RT can increase the risk of ANLL.

Comparison between transrectal ultrasonography and computed tomography with rectal inflation of gas in preoperative staging of lower rectal cancer

Computed tomography with rectal air insufflation was compared with transrectal ultrasonography (TRUS) in 63 patients. The CT protocol involved pre- and postcontrast scans with 5 mm slice thickness following air insufflation in IV antiperistaltic agent. Of the patients, 79 % were scanned in the prone position. Results of the preoperative examinations were compared with the histological findings. The CT examination had an accuracy rate of 74 %, predicting perirectal spread with a sensitivity of 83 % and a specificity of 62 %, whereas the corresponding figures for TRUS were 83, 91 and 67 %. The accuracy, sensitivity and specificity of CT and TRUS for nodal involvement were 57, 56, 57, 66, 68 and 64 %-respectively. These findings confirm that TRUS is more accurate than CT in local tumour (T) staging and in detecting nodal (N) spread. However, the appropriate CT technique shows spread of tumour outside the rectal wall and locoregional lymph nodes with reasonable accuracy. Lymphatic spread correlated with nodal size. TRUS and CT correctly staged only 57 and 43 %, respectively, of cases with nodal metastases with maximum diameter of 5 mm. TRUS sometimes overstaged perirectal growth of tumour in 7 patients, due to inflammation (5 patients) or incorrect positioning of the balloon in relation to the tumour surface (2 patients).

[Role of computerized tomography following transrectal air insufflation and hypotonization and transrectal ultrasonography in the staging of rectal tumors]

Computed Tomography (CT) with rectal air inflation was compared with transrectal ultrasound (TRUS) in the preoperative staging of lower rectal cancer in 126 patients. Precontrast and postcontrast CT scans were performed with 5 mm thick slices; the rectum was previously inflated with air and antiperistaltic agents were administered. Preoperative results were compared with histologic findings. The accuracy, sensitivity and specificity of CT in predicting perirectal spread were 76%, 62% and 83%, whereas the corresponding figures for TRUS were 84%, 69% and 92%. The accuracy, sensitivity and specificity of CT and TRUS for nodal involvement were 58%, 60%, 57% and 72%, 68% and 66%, respectively. These results show that TRUS predicts perirectal spread and detects nodal metastases better than CT. However CT, when performed appropriately, shows tumor spread into perirectal fat and locoregional lymph nodes with high accuracy. Lymphatic involvement is strictly correlated with tumor size: TRUS and CT correctly staged only 57% and 43%, respectively, of the cases with nodal metastases and max. diameter of 5 mm. TRUS sometimes overstaged perirectal tumor growth (13 patients in our series) due to perirectal inflammation (9 cases) or artifacts caused by the presence of air bubbles between the probe and the tumor surface (4 patients). TRUS is a very useful tool for detecting tumor distance from the anal opening; in our series, the distance was incorrectly calculated only in one case (3 cm with TRUS versus 4 cm at surgery).

Long-term results of treatment of childhood and adolescent Hodgkin's disease in 73 patients: the experience of the Departments of Radiology and Hematology of the University of Rome "La Sapienza"

PURPOSE

Various experiences show no substantial differences between children and adults in the treatment of Hodgkin's disease. In consideration of some peculiar characteristics of these cases which might influence the therapeutical choice, particularly regarding long-term survival and therapeutical complications, we report the results of a series of 73 children and adolescents with Hodgkin's disease treated at the University of Rome "La Sapienza".

METHODS

Between 1976 and 1983, 73 untreated pediatric cases of stage I-IV Hodgkin's disease were treated with radiotherapy, alone or associated with chemotherapy, using high doses and extended fields.

RESULTS

Fifty-six patients (77%) were in continuous complete remission in April 1995 and seventeen (23%) had died.

CONCLUSIONS

The authors confirm the excellent results in the treatment of pediatric Hodgkin's disease, both in terms of overall and relapse free survival, in spite of a high incidence of complications caused by the aggressive treatment used in this series. Therefore the majority of authors suggest combined alternating low-dose radiation administered with small portals and short-term chemotherapy. These procedures provide optimal results together with a significant reduction of complications. Consequently, it is very important to evaluate all patient characteristics accurately in order to tailor optimal treatment and select cases with risk factors which might be undertreated and therefore undergo a higher risk of recurrence.

[Assessment of residual mediastinal tumor in patients with Hodgkin's lymphoma using computed tomography, magnetic resonance and 67Ga scintigraphy]

594 patients with Hodgkin's disease were treated from 1983 to 1993 at the Department of Radiotherapy and Institute of Hematology, "La Sapienza" University, Rome, Italy. 385 patients presented mediastinal involvement; CT and/or chest radiography showed residual mediastinal masses in 96 of them (25%). In this study we included only the patients treated after 1986; they were examined with MRI of the chest (24 patients) and 67Gallium scintigraphy of the mediastinum (44 patients) with or without SPECT, combined with high-dose 67Ga in some cases. Eighteen patients underwent both MRI and 67Gallium scintigraphy. MR accuracy, sensitivity and specificity were respectively 75%, 86% and 86%; gallium scintigraphy had 86%, 77% and 93%. These data were confirmed by the results fo the subgroup of 18 patients submitted to both exams; MRI had higher sensitivity (80% vs. 75%) and lower specificity and accuracy (83% vs. 80% and 72% vs. 67, respectively) than 67Gallium scintigraphy. The predictive value of MR-scintigraphy agreement is high: indeed, no false negatives or false positives were observed when MR and scintigraphy results were in agreement.

[Comparison of computerized tomography and magnetic resonance in staging of T and N parameters in head and neck neoplasms]

January 1990, through January 1994, eighty untreated patients with head and neck cancer were consecutively submitted to CT and MRI of the head and neck before surgery. CT and MR findings were then compared to operative histologic findings. Forty-eight of 52 T4 cases at CT were confirmed at surgery (89%), 7 of 13 T3 cases at CT were also confirmed (54%), as well as 8 of 15 T2 cases (53%). CT understaged 13 cases (6 T3 and 7 T2), which surgery staged as T4, CT overstaged 4 cases as T4, which were 2 pT2 and 2 pT3 at histology. All the 54 cases MRI staged as T4 were confirmed at surgery (100%), 3 of 12 MRI staged as T3 were pT4 at surgery (25%) and, finally, 4 of 14 cases MRI staged as T2 were pT4 at histology (28%). Only one case staged as pT4 at surgery and CT had been staged as T3 by MRI because the latter method had failed to depict hyoid involvement. On the other hand, in 6 cases MRI correctly modified CT staging. Overall CT accuracy was 79% and MR accuracy 91%. CT sensitivity was 70% versus 75% with MRI, specificity was 80% versus 78%, respectively, and overall accuracy 75% versus 76%. Only in two patients MRI correctly modified CT staging (N1 at surgery). Our results confirm various advantages of MRI over CT in the assessment of tumor mass ("T" parameter), mainly in T2 and T3 cases, because MRI yields higher soft tissue contrast resolution and has multiplanar capabilities. CT was superior to MRI only in the assessment of bone involvement. This study also confirmed similar CT and MR capabilities in detecting lymph node tumor spread. Finally, MRI did not allow earlier detection of micrometastases than CT.

[Hodgkin's disease in stages I and IIA. Analysis of results in a group of patients with a follow-up of at least 10 years treated at the onset of the disease with radiotherapy alone]

January, 1972, through December, 1982, ninety-four patients with Hodgkin's disease in stages I and IIA were treated in the Dept. of Radiation Oncology of the University "La Sapienza", Rome. All patients had a minimum follow-up of 10 years. After careful clinical and surgical examinations comprehensive of laparosplenectomy, all patients were submitted to extended field radiation treatment. Ninety-one of 94 patients (97%) obtained complete remission. Overall survival at 10 years was 91% and independent of stage (94% in stage I and 87% in stage II), while relapse-free survival at 10 years did depend on stage (83% in stage I and 49% in stage II); the difference was statistically significant (p < 0.01). Thirty-one of 94 patients relapsed, but fortunately 94% of them obtained a second complete remission after salvage chemotherapy. Our experience confirms the low tumorigenic potential of exclusive radiation therapy; only one of 4 secondary neoplasms (acute non-lymphatic leukemia) observed in this series had been treated with radiotherapy. The results of this study confirm the efficacy of exclusive irradiation in stage I patients, while treatment approach remains debated in stage II patients. The combination of short-time chemotherapy with curative irradiation is probably the best option to reduce both the incidence of recurrences and treatment-induced complications.