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Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Imaging is pivotal in the evaluation of native valve regurgitation and echocardiography is the primary imaging modality for this purpose. The imaging assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy and function, and the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation largely relies on the results of imaging. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing native valve regurgitation. The present document aims to present clinical guidance for the multi-modality imaging assessment of native valvular regurgitation.

BackgroundCardiac sarcoidosis (CS) is an inflammatory granulomatous process of the myocardium that can be asymptomatic or have several different clinical phenotypes. One of its rarely described presentations consists of hypertrophy of the septal myocardium, similar to hypertrophic cardiomyopathy (HCM). Isolated cardiac sarcoidosis that haemodynamically mimics hypertrophic obstructive cardiomyopathy (HOCM) has been rarely described in the literature.Case summaryA 64-year-old Caucasian female previously diagnosed with non-critical aortic stenosis presented with pre-syncope, and echocardiography showed significant obstruction based on left ventricular outflow tract gradients, confirmed by cardiac magnetic resonance (CMR), concerning for a phenocopy of HCM. Septal myectomy was performed and pathology specimen revealed non-caseating granulomata consistent with cardiac sarcoidosis. She was started on oral corticosteroids and initial cardiac fluorodeoxyglucose positron emission tomography (FDG-PET) done after 1 month of treatment was negative. Repeat FDG-PET 15 months later, in the setting of haemodynamic decompensation, demonstrated diffuse FDG uptake in the myocardium without extra-cardiac involvement.DiscussionOur case brings together two entities: isolated cardiac sarcoidosis and its presentation mimicking HOCM, which has been very rarely described in the literature. And it also shows the scenario of surgical pathology diagnosis of sarcoidosis that was not suspected by initial CMR or FDG-PET, despite adequate preparation, only appearing on repeat FDG-PET done 15 months later. Isolated cardiac sarcoidosis should remain a differential diagnosis for any non-ischaemic cardiomyopathy without a clear cause, despite imaging evidence of HCM.

Although pericardial diseases are common in the daily clinical practice and can result in a significant morbidity and mortality, imaging of patients with suspected or known pericardial disorders remain challenging. Multimodality imaging is part of the management of pericardial diseases. Echocardiography, cardiac computed tomography, and cardiovascular magnetic resonance are often used as complementary imaging modalities. The choice of one or multiple imaging modalities is driven by the clinical context or conditions of the patient. The scope of the present document is to highlight the respective role of each technique according to the clinical context in the diagnosis and management of pericardial diseases.

Deep neural networks (DNNs) have been extensively studied in medical image segmentation. However, existing DNNs often need to train shape models for each object to be segmented, which may yield results that violate cardiac anatomical structure when segmenting cardiac magnetic resonance imaging (MRI). In this paper, we propose a capsule-based neural network, named Seg-CapNet, to model multiple regions simultaneously within a single training process. The Seg-CapNet model consists of the encoder and the decoder. The encoder transforms the input image into feature vectors that represent objects to be segmented by convolutional layers, capsule layers, and fully-connected layers. And the decoder transforms the feature vectors into segmentation masks by up-sampling. Feature maps of each down-sampling layer in the encoder are connected to the corresponding up-sampling layers, which are conducive to the backpropagation of the model. The output vectors of Seg-CapNet contain low-level image features such as grayscale and texture, as well as semantic features including the position and size of the objects, which is beneficial for improving the segmentation accuracy. The proposed model is validated on the open dataset of the Automated Cardiac Diagnosis Challenge 2017 (ACDC 2017) and the Sunnybrook Cardiac Magnetic Resonance Imaging (MRI) segmentation challenge. Experimental results show that the mean Dice coefficient of Seg-CapNet is increased by 4.7% and the average Hausdorff distance is reduced by 22%. The proposed model also reduces the model parameters and improves the training speed while obtaining the accurate segmentation of multiple regions. Supplementary Information The online version contains supplementary material available at 10.1007/s11390-021-0782-5.

Cardiac magnetic resonance imaging (CMRI) represents the main imaging modality for diagnosing acute myocarditis. However, its limited availability could entail missing or delayed diagnosis. A reduction of left ventricular global longitudinal strain (LV GLS) by speckle tracking echocardiography (STE) correlates with amount of oedema in acute myocarditis and here may be early detected. Aim was to evaluate the diagnostic and prognostic role of 3-layers LV GLS in patients with acute myocarditis. Out of 122 patients with suspected acute myocarditis, a total of 86 consecutive patients with CMRI-confirmed acute myocarditis admitted in two Italian institutions were retrospectively screened. Exclusion criteria were met in 29 patients because of poor acoustic window or missing data. A total of 57 patients were then included. Clinical characteristics, laboratory examinations, transthoracic echocardiography data and STE parameters were collected early after hospitalization. In the study population, mean age was 38.8 ± 15.6 years, the prevalence of male gender was 90%. On admission, 22 patients (39%) had fever (body temperature > 37.5 °), mean white blood cell (WBC) count was 10.9 ± 1.7/10^3 and overall LV ejection fraction was 50.1% ± 11.2. An epicardial LV GLS 10.0/10^3 was able to identify all patients with CMRI-diagnosed acute myocarditis. An epicardial LV GLS

To evaluate the association between impaired left ventricular (LV) longitudinal function and LV underfilling in patients with pulmonary arterial hypertension (PAH). Thirty-nine patients with PAH and 18 age and sex-matched healthy controls were included. LV volume and left atrial volume (LAV) were delineated in short-axis cardiac magnetic resonance (CMR) cine images. LV longitudinal function was assessed from atrio-ventricular plane displacement (AVPD) and global longitudinal strain (GLS) was assessed using feature tracking in three long-axis views. LV filling was assessed by LAV and by pulmonary artery wedge pressure (PAWP) using right heart catheterisation. Patients had a smaller LAV, LV volume and stroke volume as well as a lower LV-AVPD and LV-GLS than controls. PAWP was 6 [IQR 5––9] mmHg in patients. LV ejection fraction did not differ between groups. LV stroke volume correlated with LV-AVPD (r = 0.445, p = .001), LV-GLS (r = − 0.549, p

To study the long-term prognosis of early pre-discharge and late left ventricular (LV) dilatation in patients with first ST-elevation myocardial infarction (STEMI) treated by percutaneous coronary intervention (PCI) and contemporary medical therapy. Long-term follow-up > 15 years was available in 53 consecutive patients (55 ± 13 years) with first STEMI. Late gadolinium enhanced (LGE) cardiac magnetic resonance imaging (CMR) was obtained at baseline 5 ± 3 days and follow-up 8 ± 3 months after STEMI to measure LV function, volumes and infarct size. Early pre-discharge dilatation was defined as increased left ventricular end-diastolic volume index (LVEDVi) at baseline CMR with > 97 ml/m2 for males and > 90 ml/m2 for females. Late dilatation was defined as initially normal LVEDVi, which increased ≥ 20% at follow-up. Early dilatation was present in 7 patients (13%), whereas late dilatation occurred in 11 patients (21%). Patients with early LV dilatation had highest mortality (57%), whereas patients with late dilatation had similar mortality (27%) compared to patients without dilatation (26%). Multivariate Cox analysis showed that age (P P P P

Unlike echocardiography, cardiac magnetic resonance imaging (cardiac MRI) results in a near-exact assessment of cardiac structures and function. However, most veterinary studies have focused on dogs with normal cardiac function. We hypothesized that there would be significant differences in cardiac measurements between cardiac MRI and echocardiography when left ventricular (LV) function was abnormal. This study was undertaken to compare measurements of LV function produced by cardiac MRI and echocardiography in dogs whose LV function was altered by pharmacological agents. This study was conducted with six healthy beagle dogs. We increased left ventricular contractility by administration of dobutamine; we decreased cardiac contractility with esmolol. Stroke volume measurements were made by using both cardiac MRI and echocardiography under seven different conditions with general anesthesia: control, three doses of esmolol (100, 200, and 500 µg/kg/min), and three doses of dobutamine (10, 20, and 50 µg/kg/min). Experiments involving each condition were conducted at least 1 week apart. When LV contractility was normal, ejection fraction (EF) and stroke volume (SV), as measured by echocardiography and cardiac MRI, were not significantly different. However, when contractility was changed by pharmacological agents, EF and SV were overestimated by echocardiography, compared to MRI. Evaluation of cardiac function in patients treated with pharmacological agents should be conducted carefully because EF and SV measured by echocardiography can be overestimated, compared with EF and SV obtained by cardiac MRI.

Objective: We sought to investigate the possible association of a wide QRS-T angle on the surface EKG and myocardial fibrosis on contrast-enhanced cardiovascular magnetic (CMR) imaging in patients with hypertrophic cardiomyopathy (HCM). Background: Risk stratification in HCM patients is challenging. Late gadolinium enhancement (LGE) visualizes myocardial fibrosis with unique spatial resolution and is a strong and independent prognosticator in these patients. The QRS-T angle from the surface EKG is a promising prognostic marker in various cardiac pathologies. Methods: 70 patients with HCM obtained a standardized digital 12-lead EKG for the calculation of the QRS-T angle and underwent comprehensive CMR imaging for visualization of fibrosis by LGE. Patients were divided into groups according to the absence or presence of fibrosis on CMR. Results: 43 of 70 patients with HCM showed LGE on CMR following contrast administration. HCM patients with LGE (fibrosis) had wider QRS-T angles as compared to the patient group without LGE (100±54 vs. 46±31

The large number of available MRI sequences means patients cannot realistically undergo them all, so the range of sequences to be acquired during a scan are protocolled based on clinical details. Adapting this to unexpected findings identified early on in the scan requires experience and vigilance. We investigated whether deep learning of the images acquired in the first few minutes of a scan could provide an automated early alert of abnormal features. Anatomy sequences from 375 CMR scans were used as a training set. From these, we annotated 1500 individual slices and used these to train a convolutional neural network to perform automatic segmentation of the cardiac chambers, great vessels and any pleural effusions. 200 scans were used as a testing set. The system then assembled a 3D model of the thorax from which it made clinical measurements to identify important abnormalities. The system was successful in segmenting the anatomy slices (Dice 0.910) and identified multiple features which may guide further image acquisition. Diagnostic accuracy was 90.5% and 85.5% for left and right ventricular dilatation, 85% for left ventricular hypertrophy and 94.4% for ascending aorta dilatation. The area under ROC curve for diagnosing pleural effusions was 0.91. We present proof-of-concept that a neural network can segment and derive accurate clinical measurements from a 3D model of the thorax made from transaxial anatomy images acquired in the first few minutes of a scan. This early information could lead to dynamic adaptive scanning protocols, and by focusing scanner time appropriately and prioritizing cases for supervision and early reporting, improve patient experience and efficiency. Electronic supplementary material The online version of this article (10.1007/s10554-020-02050-w) contains supplementary material, which is available to authorized users.

The aim of this study is to provide a systematic assessment of the influence of the position on the arterial input function (AIF) for perfusion quantification. In 39 patients with a wide range of left ventricular function the AIF was determined using a diluted contrast bolus of a cardiac magnetic resonance imaging in three left ventricular levels (basal, mid, apex) as well as aortic sinus (AoS). Time to peak signal intensities, baseline corrected peak signal intensity and upslopes were determined and compared to those obtained in the AoS. The error induced by sampling the AIF in a position different to the AoS was determined by Fermi deconvolution. The time to peak signal intensity was strongly correlated (r2 > 0.9) for all positions with a systematic earlier arrival in the basal (− 2153 ± 818 ms), the mid (− 1429 ± 928 ms) and the apical slice (− 450 ± 739 ms) relative to the AoS (all p 2 > 0.9 for both) for all positions with a systematic overestimation in all positions relative to the AoS (all p

Background Cardiac involvement has been described in idiopathic inflammatory myopathies (IIM), including non-specific ECG and echocardiographic findings. Aim of our study was to evaluate myocardial deformation parameters in IIM and to correlate them with late gadolinium enhancement (LGE) findings using cardiac magnetic resonance imaging (CMR). Methods Forty-seven consecutive patients with histologically proven IIM were included into our study. Twenty-five healthy volunteers were used as a control group. All patients and controls underwent CMR examination using a 1.5 T scanner including functional cine and LGE imaging. After a mean follow-up of 234.7 ± 79.5 days a second CMR examination was performed in IIM patients. Results In comparison to healthy volunteers, IIM patients had lower left ventricular mass and left ventricular global radial, circumferential and longitudinal strain. There was no significant difference in left ventricular ejection fraction. Patients with LGE (N = 28) had lower left ventricular ejection fraction (p = 0.016), global right and left ventricular longitudinal strain (p = 0.014 and p = 0.005) and global left ventricular diastolic longitudinal strain rate (p = 0.001) compared to patients without LGE (N = 19). In IIM patients, a significant decrease of left ventricular ejection fraction, left ventricular mass and all measured deformation parameters was observed between baseline and follow-up CMR. Conclusion Cardiac involvement in IIM is frequent. Impairment of systolic and diastolic deformation parameters and a worsening over time can be observed. CMR is a useful tool for cardiac diagnostic work-up of these patients.

Graphical abstract The reduction in LA and PV dimensions after ablation. Clinically successful PVI ablation decreased the PV and LA dimensions in AF patients (left panel). We make observations (right panel) that are compatible with the direct effect of ablation energy and subsequent scar formation causing the atrial downsizing., Background Ablative pulmonary vein isolation (PVI) decreases pulmonary vein (PV) and left atrial (LA) dimensions in atrial fibrillation (AF) patients. These changes are attributed to reverse structural remodeling following sinus rhythm restoration but evidence is lacking. We hypothesized that the downsizing is directly caused by the ablative energy and subsequent scar formation. Methods We studied cardiac magnetic resonance imaging in 21 paroxysmal AF patients before and 3 months after successful PVI and in healthy sheep (n = 12) before and after PVI of the right PV only. Results PVI decreased the PV diameter in patients and sheep by 11.0(10.3) and 9.2(11.0)%, (p

Background We sought to determine if an association exists between prehospital chest pain severity and markers of myocardial injury. Methods and Results Patients with confirmed ST elevation myocardial infarction (STEMI) treated by emergency medical services were included in this retrospective cohort analysis of the AVOID study. The primary endpoint was the association of pre-hospital initial chest pain severity, cardiac biomarkers and infarct size based on cardiac magnetic resonance imaging. Groups were categorized based on moderate to severe chest pain (numerical rating scale pain ≥ 5/10) or less than moderate severity to compare procedural and clinical outcomes. 414 patients were included in the analysis. There was a weak correlation between initial pre-hospital chest pain severity and peak creatine kinase (r = 0.16, p = 0.001) and peak cardiac troponin I (r = 0.14, p = 0.005). Both were no longer significant after adjusting for known confounders. There was no association between moderate to severe chest pain on arrival and major adverse cardiac events at 6 months (20% vs. 14%, p=0.12). There was a weak correlation between history of ischemic heart disease (r = 0.16, p = 0.001), percutaneous coronary intervention (r = 0.16, p = 0.001), left anterior descending artery (r = 0.12, p = 0.012) as the culprit vessel and a weak negative correlation between age (r = -0.14, p = 0.039) and chest pain. Conclusion Only a weak association between pre-hospital chest pain severity and markers of myocardial injury was identified, supporting more judicious use of opioid analgesia with a focus on patient comfort.

Background: Significant right ventricular (RV) dilatation has long been considered integral to the pathogenesis of functional tricuspid regurgitation (FTR). Objectives: To explore the relationship of RV dilatation and FTR in patients with ‘pure’ RV volume overload. Methods: Patients (>17yrs) with RV dilatation due to pre-tricuspid shunts (atrial septal defect; ASD and/or partial anomalous pulmonary venous drainage; PAPVD) referred to our service (2000–2019) were retrospectively identified. Those with pulmonary hypertension, primum ASD or left-heart disease were excluded. Using standard cardiac MRI protocols, RV, right atrial and TV parameters were measured and compared. Results: Of 52 consecutively eligible patients (42 ± 15yrs, 25 males), 25 had ASDs, 13 had PAPVD and 14 had both conditions. All were in sinus rhythm and none had pulmonary regurgitation. Left and right ventricular ejection fractions were normal (LVEF 63 ± 8%, RVEF 56 ± 8%). Indexed RV end-diastolic volumes (RVEDVi) were moderately increased (males 148 ± 33 mL/m2 and females 141 ± 42 mL/m2, range 95–267 mL/m2). Despite substantial RV volume overload, no patients had severe tricuspid regurgitation (TR). Only two had > mild TR. There was a weak correlation between tricuspid annular diameter and both degree of RV dilatation (r = 0.37; p = 0.01) and degree of TR (r = 0.38; p = 0.006). There was a similarly poor correlation between right atrial dimensions and the degree of TR (r = 0.34; p = 0.02). Conclusion: When RV dilatation is simply due to volume overload, we find that significant TR is extremely rare. This gives an important and novel insight; that RV dilatation per se does not result in FTR.

Background: The QRS-T angle from the surface EKG is a promising prognostic marker in patients with coronary artery disease. Cardiovascular magnetic resonance (CMR) imaging with late gadolinium enhancement (LGE) offers high resolution imaging of myocardial damage. We investigated the association of the QRS-T angle and the extent of myocardial damage as assessed by LGE in patients with acute ST-segment myocardial infarction (STEMI) Methods: 169 patients with STEMI obtained a standardized digital 12-lead EKG on admission for the calculation of the QRS-T angle and underwent CMR imaging for analysis of infarct size by LGE within the first week. Patients were divided into groups: (1) abnormal QRS-T angle ≥ 90 degree and (2) QRS-T angle < 90 degree. Results: Patients with a QRS-T angle of 90 degree or more had larger infarcts (36.5±12.4 vs. 13.3±9.5; p

Objective Aortic distensibility (AD) represents a well-established parameter of aortic stiffness. It remains unclear, however, whether AD can be obtained with high reproducibility in standard 4-chamber cine CMR images of the descending aorta. This study investigated the intra- and inter-observer agreement of AD based on different angles of the aorta and provided a sample size calculation of AD for future trials. Methods Thirty-one patients underwent CMR. Angulation of the descending aorta was performed to obtain strictly transversal and orthogonal cross-sectional aortic areas. AD was obtained both area and diameter based. Results For area-based values, inter-observer agreement was highest for 4-chamber AD (ICC 0.97; 95% CI 0.93–99), followed by orthogonal AD (ICC 0.96; 95% CI 0.91–98) and transversal AD (ICC 0.93; 95% CI 0.80–97). For diameter-based values, agreement was also highest for 4-chamber AD (ICC 0.97; 95% CI 0.94–99), followed by orthogonal AD (ICC 0.96; 95% CI 0.92–98) and transversal AD (ICC 0.91; 95% CI 0.77–96). Bland–Altman plots confirmed a small variation among observers. Sample size calculation showed a sample size of 12 patients to detect a change in 4-chamber AD of 1 × 10−3 mmHg−1 with either the area or diameter approach. Conclusion AD measurements are highly reproducible and allow an accurate and rapid assessment of arterial compliance from standard 4-chamber cine CMR., Clinical Research in Cardiology, 109 (4)

Background: Elevated high-sensitive cardiac troponin (hs-cTn) can be found in more than 50% of the patients with acute ischemic stroke. The observational TRoponin ELevation in Acute ischemic Stroke (TRELAS) study revealed that about 25% of all stroke patients with elevated troponin had a coronary angiography-detected culprit lesion affording immediate intervention, and about 50% of all patients did not have any obstructive coronary artery disease. Given the risk of procedure-related complications, the identification of stroke patients in urgent need of invasive coronary angiography is desirable. Methods: TRELAS patients were prospectively enrolled into this sub-study. In addition to conventional coronary angiography, a cardiac magnetic resonance imaging (MRI) at 3T was performed during the in-hospital stay after acute ischemic stroke to compare the diagnostic value of both imaging modalities. Results:Nine stroke patients (median age 73 years [range 58–87]; four females; median NIH Stroke Severity score on admission 4 [range 0–6] with elevated hs-cTnT [median 74 ng/L, interquartile range 41–247] on admission) completed cardiac MRI and underwent coronary angiography. The absence of MRI-detected wall motion abnormalities and/or late gadolinium enhancement in 5 stroke patients corresponded with the exclusion of culprit lesions or significant coronary artery disease by coronary angiography. Four patients had abnormal MRI findings, whereof 2 showed evidence of myocardial infarction and in whom coronary angiography demonstrated a >70% stenosis of a coronary artery. Conclusions: The TRELAS sub-study indicates that noninvasive cardiac MRI may provide helpful information to identify stroke patients with or without acute coronary syndrome. Our findings might help to select stroke patients in urgent need of coronary angiography.

Background Pre-procedural assessment of patients undergoing cardiac resynchronization therapy (CRT) is heterogenous and patients implanted with unfavorable characteristics may account for non-response. A dedicated CRT pre-assessment clinic (CRT PAC) was developed to standardize the review process and undertake structured pre-procedural evaluation. The aim of this analysis was to determine the effectiveness on patient selection and outcomes. Methods A prospective database of consecutive patients attending the CRT PAC between 2013 and 2018 was analyzed. Pre-operative assessment included cardiac magnetic resonance (CMR) and cardiopulmonary exercise testing (CPET). Patients were considered CRT responders based on improvement in clinical composite score (CCS) and/or reduction in left ventricular end-systolic volume (LVESV) ≥ 15% at 6-months follow-up. Results Of 252 patients reviewed in the CRT PAC during the analysis period, 192 fulfilled consensus guidelines for implantation. Of the patients receiving CRT, 82% showed improvement in their CCS and 57% had a reduction in LVESV ≥ 15%. The presence of subendocardial scar on CMR and a peak VO2 ≤ 12 ml/kg/min on CPET predicted CRT non-response. Two patients were unsuitable for CRT as they had end-stage heart failure and died during follow-up. The majority of patients initially deemed unsuitable for CRT did not suffer from unexpected hospitalization for decompensated heart failure or died from cardiovascular disease; only 8 patients (13%) received CRT devices during follow-up because of symptomatic left ventricular systolic impairment. Conclusion A dedicated CRT PAC is able to appropriately select patients for CRT. Pre-procedural investigation/imaging can identify patients unlikely to respond to, or may not yet be suitable for CRT.

Background: Coronary collateral circulation and conditioning from remote ischemic coronary territories may protect culprit myocardium in the elderly, and younger STEMI patients could suffer from larger infarcts. We evaluated the impact of age on myocardial salvage and long-term prognosis in a contemporary STEMI cohort. Methods: Of 1603 included STEMI patients 807 underwent cardiac magnetic resonance. To assess the impact of age on infarct size and left ventricular ejection fraction (LVEF) as well as the composite endpoint of death and re-hospitalization for heart failure we stratified the patients by an age cut-off of 60 years. Results: Younger STEMI patients had smaller final infarcts (10% vs. 12%, P = 0.012) and higher final LVEF (60% vs. 58%, P = 0.042). After adjusting for multiple potential confounders age did not remain significantly associated with infarct size and LVEF. During 4-year follow-up, the composite endpoint occurred less often in the young (3.2% vs. 17.2%; P < 0.001) with a univariate hazard ratio of 5.77 (95% CI, 3.75–8.89; p < 0.001). Event estimates of 4 subgroups (young vs. elderly and infarct size beyond vs. below median) showed a gradual increase in the occurrence of the composite endpoint depending on both age and acute infarct size (log-rank p < 0.001). Conclusion: Having a STEMI after entering the seventh decade of life more than quadrupled the risk of future death or re-hospitalization for heart failure. Risk of death and re-hospitalization depended on both advanced age and infarct size, albeit no substantial difference was found in infarct size, LVEF and salvage potential between younger and elderly patients with STEMI.

Aims Following the peak of the UK COVID-19 epidemic, a new multisystem inflammatory condition with significant cardiovascular effects emerged in young people. We utilized multimodality imaging to provide a detailed sequential description of the cardiac involvement. Methods and Results Twenty consecutive patients (mean age 10.6 ± 3.8 years) presenting to our institution underwent serial echocardiographic evaluation on admission (median day 5 of illness), the day coinciding with worst cardiac function (median day 7), and the day of discharge (median day 15). We performed cardiac computed tomography (CT) to assess coronary anatomy (median day 15) and cardiac magnetic resonance imaging (CMR) to assess dysfunction (median day 20). On admission, almost all patients displayed abnormal strain and tissue Doppler indices. Three-dimensional (3D) echocardiographic ejection fraction (EF) was Conclusions Pancarditis with cardiac dysfunction is common and associated with myocardial oedema. Patients require close monitoring due to coronary artery dilatation and the risk of thrombotic myocardial infarction.

The obstructive sleep apnoea syndrome (OSAS) is a disorder with a high prevalence and is associated with an elevated cardiovascular risk and increased morbidity and mortality. For longitudinal studies and functional analysis cardiac MRI is regarded as the gold standard. Aim of this study was to evaluate the long-term effect of continuous positive airway pressure (CPAP) therapy on cardiac functional parameters with cardiac Magnetic Resonance Imaging (cMRI). 54 patients with OSAS (mean apnea hypopnea index-AHI: 31) were prospectively enrolled in this study and cMRI was performed before and after 7 months of CPAP therapy. Data were acquired on a 1.5 T MRI and right and left ventricular cardiac function were analysed. CPAP treatment was considered compliant when used ≥ 4 h per night. 24-h blood pressure was measured at baseline and follow up. 33 patients could be assigned to the compliance group. Left ventricular stroke volume (LV SV) and right ventricular ejection fraction (RV EF) improved significantly with CPAP therapy (LV SV from 93 ± 19 to 99 ± 20 ml, p = 0.02; RV EF from 50 ± 6 to 52 ± 6%, p = 0.04). All other cardiac parameters did not change significantly while mean systolic and diastolic blood pressure improved significantly (p

Background: Increased sodium uptake has been shown to contribute to hypertension and cardiac endorgan damage. The sodium-proton-exchanger subtype 3 (NHE3) is an important mediator of intestinal sodium absorption. Whether a reduction in intestinal sodium absorption can prevent the development of an atrial arrhythmogenic substrate in hypertension is unknown.Methods: Eight-week-old obese spontaneously hypertensive rats (SHR-ob) were treated for six weeks with the gut-specific NHE3-inhibitor SAR (1-(beta-D-glucopyranosyl)-3-{3-[(4S)-6,8-dichloro-2-methyl-1, 2,3,4-tetrahydroiso-chinolin-4-yl]phenyl}urea, 1 mg/kg/d in chow, SHR-ob SAR, n = 7) and compared to aged-matched placebo-treated SHR-ob (SHR-ob PLAC, n = 8). Cardiac magnetic resonance imaging was performed at the end of the treatment period to assess atrial emptying function. Afterwards, local conduction disturbances and inducible atrial fibrillation (AF) duration were determined and histological analysis to quantify atrial fibrosis amount were performed.Results: Inhibition of intestinal NHE3 by SAR increased fecal sodium excretion, resulted in marked changes in feces electrolyte concentrations and water content, reduced blood pressure and preserved atrial emptying function (active total percent emptying: SHR-ob SAR: 0.47 +/- 0.05% vs. SHR-ob PLAC: 0.38 +/- 0.007, p Conclusions: Reduction of intestinal sodium absorption and subsequent changes in feces milieu by pharmacological NHE3 inhibition in the gut preserved atrial emptying function and reduced AF susceptibility. Whether pharmacological NHE3 inhibition in the gut prevents AF in humans warrants further study. (C) 2020 The Authors. Published by Elsevier B.V.

Left ventricular global longitudinal strain (LVGLS) analysis is a sensitive measurement of myocardial deformation most often done using speckle-tracking transthoracic echocardiography (TTE). We propose a novel approach to measure LVGLS using feature-tracking software on the magnitude dataset of 4D flow cardiovascular magnetic resonance (CMR) and compare it to dynamic computed tomography (CT) and speckle tracking TTE derived measurements. In this prospective cohort study 59 consecutive adult patients with a bicuspid aortic valve (BAV) were included. The study protocol consisted of TTE, CT, and CMR on the same day. Image analysis was done using dedicated feature-tracking (4D flow CMR and CT) and speckle-tracking (TTE) software, on apical 2-, 3-, and 4-chamber long-axis multiplanar reconstructions (4D flow CMR and CT) or standard apical 2-, 3-, and 4-chamber acquisitions (TTE). CMR and CT GLS analysis was feasible in all patients. Good correlations were observed for GLS measured by CMR (− 21 ± 3%) and CT (− 20 ± 3%) versus TTE (− 20 ± 3%, Pearson’s r: 0.67 and 0.65, p 0.61, p

To investigate the performance of a deep learning-based algorithm for fully automated quantification of left ventricular (LV) volumes and function in cardiac MRI. We retrospectively analysed MR examinations of 50 patients (74% men, median age 57 years). The most common indications were known or suspected ischemic heart disease, cardiomyopathies or myocarditis. Fully automated analysis of LV volumes and function was performed using a deep learning-based algorithm. The analysis was subsequently corrected by a senior cardiovascular radiologist. Manual volumetric analysis was performed by two radiology trainees. Volumetric results were compared using Bland–Altman statistics and intra-class correlation coefficient. The frequency of clinically relevant differences was analysed using re-classification rates. The fully automated volumetric analysis was completed in a median of 8 s. With expert review and corrections, the analysis required a median of 110 s. Median time required for manual analysis was 3.5 min for a cardiovascular imaging fellow and 9 min for a radiology resident (p

The prevalence of undiagnosed cardiac involvement in granulomatosis with polyangiitis (GPA) is unknown. In this prospective study we investigated the utility of cardiovascular magnetic resonance (CMR) to identify myocardial abnormalities in GPA and their correlation with disease phenotype. Twenty-six patients with GPA and no cardiovascular disease or diabetes mellitus underwent contrast-enhanced CMR, including late gadolinium-enhancement (LGE), T1-mapping for native T1 and extra-cellular volume (ECV) quantification for assessment of myocardial fibrosis, cine imaging and tissue tagging for assessment of left ventricular (LV) function. Twenty-five healthy volunteers (HV) with comparable age, sex, BMI and arterial blood pressure served as controls. Patients with GPA had similar cardiovascular risk profile to HV. A focal, non-ischaemic LGE pattern of fibrosis was detected in 24% of patients and no controls (p = 0.010). Patients with myocardial LGE were less frequently PR3 ANCA (7% vs 93%, p = 0.007), and had involvement of the lower respiratory tract and skin. LGE scar mass was higher in patients presenting with renal involvement. Native T1 and ECV were higher in patients with GPA than HV; ECV was higher in those with relapsing disease, and native T1 was inversely associated with PR3 ANCA (β = − 0.664, p = 0.001). Peak systolic strain was slightly reduced in GPA compared to controls; LV ejection function was inversely correlated with disease duration (β = − 0.454, p = 0.026). Patients with GPA have significant myocardial abnormalities on CMR. ANCA, systemic involvement and disease severity were associated with myocardial fibrosis. CMR could be a useful tool for risk stratification of myocardial involvement in GPA. Electronic supplementary material The online version of this article (10.1007/s10554-020-02066-2) contains supplementary material, which is available to authorized users.

Background: Septal midwall late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) is a characteristic finding in nonischemic dilated cardiomyopathy (DCM) and is associated with adverse cardiac events. QRS-prolongation in DCM is also frequently present and a predictor of arrhythmic events and mortality. Since the His-Purkinje fibres are located in the interventricular septum, QRS-prolongation may directly result from septal fibrosis, visualized by LGE. Our aim was to study the correlation of the presence and extent of septal midwall LGE and QRS-duration. Methods: DCM-patients with left ventricular (LV) dysfunction (LVEF

Background: Oxidative posttranslational modifications (OPTM) impair the function of Sarcoplasmic/endoplasmic reticulum (SR) calcium (Ca2+) ATPase (SERCA) 2 and trigger cytosolic Ca2+ dysregulation. We investigated the extent of OPTM of SERCA2 in patients with non-ischemic cardiomyopathy (NICM). Methods and results: Endomyocardial biopsy (EMB) was obtained in 40 consecutive patients with NICM. Total expression and OPTM of SERCA2, including sulfonylation at cysteine-674 (S-SERCA2) and nitration at tyrosine-294/295 (N-SERCA2), were examined by immunohistochemical analysis. S-SERCA2 increased in the presence of late gadolinium enhancement on cardiac magnetic resonance imaging. S-SERCA2/SERCA2 and N-SERCA2/SERCA2 correlated with cardiac fibrosis evaluated by Masson’s trichrome staining of EMB. SERCA2 expression modestly increased in parallel with an upward trend in OPTM of SERCA2 with aging. This tendency became prominent only in patients aged >65 years. OPTM of SERCA2 positively correlated with brain natriuretic peptide (BNP) values only in patients aged ≤65 years. Composite major adverse cardiac events (MACE) increased more in the high OPTM group of younger patients; however, MACE-free survival was similar irrespective of the extent of OPTM in older patients. Conclusions: OPTM of SERCA2 correlate with myocardial fibrosis in NICM. In younger patients, OPTM of SERCA2 correlate with elevated BNP and increased composite MACE. Keywords: SERCA2, Oxidative posttranslational modification, Myocardial fibrosis, Non-ischemic cardiomyopathy

Background: We hypothesize that cardiac magnetic resonance (CMR) native T1 is associated with myocardial deformation in thalassaemia patients. The present study aimed to compare CMR native T1 values to conventional T2* values in patients with beta-thalassaemia and to explore relationships between these CMR parameters of myocardial iron overload and left ventricular (LV) and left atrial (LA) myocardial deformation. Methods: Thirty-four (16 males) patients aged 35.5 ± 9.2 years were studied. Myocardial T2* and T1 mapping were performed to assess the cardiac iron overload, while two-dimensional speckle-tracking echocardiography was performed in determine LV and LA myocardial deformation. Results: T2* was 36.4 ± 8.7 ms with 3 patients having myocardial iron load (T2*

Introduction The study aimed to evaluate the prevalence and predictors of left ventricular (LV) reverse remodeling and its impact on long-term prognosis in patients with anterior ST-segment elevation myocardial infarction (STEMI). Aim To assess the percentage of reverse remodeling and its prognostic factors in anterior STEMI patients. Material and methods This observational study included 40 patients with first ever STEMI of the anterior wall. LV reverse remodeling was defined as the reduction of left ventricular end-systolic volume (ΔLVESV) by ≥ 10% in 3D transthoracic echocardiography (3D-TTE) at 3-month follow-up. 3D-TTE and speckle tracking imaging were performed during index hospitalization, while 3D-TTE and cardiac magnetic resonance (CMR) were performed at 3 months following the procedure. Patients were followed up for a median time of 3.4 years in order to evaluate major adverse cardiovascular events. Results Left ventricular reverse remodeling at 3-month follow-up was confirmed in 15 (37.5%) patients. The presence of reverse remodeling was predicted by lower troponin levels (unit OR = 0.86, p = 0.02), lower sum of ST-segment elevations before (unit OR = 0.87, p = 0.03) and after PCI (unit OR = 0.40, p = 0.03), lower maximal ST-segment elevation after PCI (unit OR = 0.01, p = 0.03), lower wall motion score index (unit OR 0.40, p = 0.03) and more negative anterior wall global longitudinal strain (unit OR = 0.88, p = 0.045). Nine MACE were reported in the without reverse remodeling group only. Non-significantly better event-free survival in the reverse remodeling group was demonstrated (log-rank p = 0.07). Conclusions Development of reverse modeling in patients with optimal revascularization and tailored pharmacotherapy is relatively high. Further studies are warranted in order to adjudicate its prognostic role for the prediction of adverse events.

Incidental pathological findings are frequently found outside the investigated cardiovascular system in cardiac magnetic resonance (CMR) imaging. Some of these findings might have clinical importance.To evaluate the prevalence and significance of extracardiac findings (ECFs) in patients referred for CMR. The CMR has the ability to depict ECFs in the visualized thorax and upper abdomen. These incidental lesions can often present a challenge to physicians.A total of 192 CMR reports were retrospectively reviewed for extracardiac findings. ECFs were classified as benign, indeterminate, or of clinical significance at the time of image evaluation. Benign findings were those considered to be of little clinical significance with no follow-up needed. Indeterminate findings were those deemed of potential clinical importance, requiring correlation of the patient history or a follow-up study. Clinically significant findings were those felt to be of definite clinical importance requiring immediate evaluation or intervention.A total of 56 (29.2%) ECFs were found in 192 (29.2%) patients. Of those, 21 (37.5%) were considered benign, 23 (41%) indeterminate, and 12 (21.4%) clinically significant findings. In the clinically significant group, the most common findings were liver and pulmonary masses. Five malignancies were observed with certainty at CMR. All of them had been incidentally diagnosed on CMR for the first time, and the patients' management was subsequently changed.Extracardiac findings in clinically indicated CMR are common in the present study (about 29.2%). Radiologists and cardiologists should be aware of relevant extracardiac findings that might require additional diagnostics or treatment.Ocena występowania i znaczenia przypadkowych znalezisk pozakardiologicznych (ECF) u pacjentów skierowanych na badanie rezonansu magnetycznego serca (CMR). Badanie CMR umożliwia wykrycie zmian pozakardiologicznych w klatce piersiowej i górnej części jamy brzusznej. Zmiany te często stanowią wyzwanie dla lekarzy.Badaniu retrospektywnemu poddano ogółem 192 obrazy CMR pod kątem zmian pozakardiologicznych. Zmiany te klasyfikowano jako łagodne, nieokreślone lub istotne klinicznie w czasie oceny. Zmiany łagodne to zmiany o niewielkiej istotności klinicznej, niewymagajace obserwacji. Zmianami nieokreślonymi nazywa się zmiany potencjalnie istotne klinicznie, które wymagają zestawienia z historią pacjenta lub obserwacji, natomiast istotnymi klinicznie – zmiany, które mają określone znaczenie kliniczne i wymagają natychmiastowej oceny lub interwencji.Stwierdzono ogółem 56 (29,2%) zmian pozakardiologicznych u 192 pacjentów, z czego 21 (37,5%) uznano za łagodne, 23 (41%) – nieokreślone, a 12 (21,4%) – klinicznie istotne. W grupie zmian klinicznie istotnych najczęściej obserwowano masy w wątrobie lub płucach. W badaniu CMR odnotowano 5 guzów. Wszystkie guzy były zdiagnozowane przypadkowo w pierwszym badaniu CMR, a leczenie pacjentów zostało następnie zmienione.Zmiany pozakardiologiczne stwierdzone w badaniach CMR są częstym zjawiskiem (ok. 29,2%). Radiolodzy i kardiolodzy powinni wiedzieć o ważnych zmianach pozakardiologicznych, które mogą wymagać podjęcia dodatkowej diagnostyki lub leczenia.

Both, arrhythmogenic right ventricular cardiomyopathy (ARVC) and regular training are associated with right ventricular (RV) remodelling. Cardiac magnetic resonance (CMR) is given an important role in the diagnosis of ARVC in current task force criteria (TFC), however, they contain no cut-off values for athletes. We aimed to confirm the added value of feature tracking and to provide new cut-off values to differentiate between ARVC and athlete’s heart. Healthy athletes with training of minimal 15 h/week (n = 34), patients with definite ARVC (n = 34) and highly trained athletes with ARVC (n = 8) were examined by CMR. Left and right ventricular volumes and masses were determined. Global right and left ventricular, and regional strain analysis for the RV free wall was performed using feature tracking on balanced steady-state free precession cine images. 94% of healthy athletes showed RV dilatation of the proposed TFC, 14.7% showed RV ejection fraction (RVEF) between 45–50%, none of them had RVEF − 25.6 and > − 1.4, respectively) in all athletes with ARVC were the strain and strain rate of the midventricular RV free wall. Establishing RVEF and RV strain analysis provides an important tool to distinguish ARVC from athlete’s heart. CMR based regional strain and strain rate values may help to identify ARVC even in highly trained athletes with preserved RVEF.

Despite substantial declines in mortality following myocardial infarction (MI), subsequent left ventricular remodeling (LVRm) remains a significant long-term complication. Extracellular small non-coding RNAs (exRNAs) have been associated with cardiac inflammation and fibrosis and we hypothesized that they are associated with post-MI LVRm phenotypes. RNA sequencing of exRNAs was performed on plasma samples from patients with “beneficial” (decrease LVESVI ≥ 20%, n = 11) and “adverse” (increase LVESVI ≥ 15%, n = 11) LVRm. Selected differentially expressed exRNAs were validated by RT-qPCR (n = 331) and analyzed for their association with LVRm determined by cardiac MRI. Principal components of exRNAs were associated with LVRm phenotypes post-MI; specifically, LV mass, LV ejection fraction, LV end systolic volume index, and fibrosis. We then investigated the temporal regulation and cellular origin of exRNAs in murine and cell models and found that: 1) plasma and tissue miRNA expression was temporally regulated; 2) the majority of the miRNAs were increased acutely in tissue and at sub-acute or chronic time-points in plasma; 3) miRNA expression was cell-specific; and 4) cardiomyocytes release a subset of the identified miRNAs packaged in exosomes into culture media in response to hypoxia/reoxygenation. In conclusion, we find that plasma exRNAs are temporally regulated and are associated with measures of post-MI LVRm., Highlights • Plasma exRNA signatures were associated with post-MI remodeling as assessed by cardiac MRI. • Candidate exRNAs originated from different cell types, and were dynamically regulated in experimental models of ischemia. • Candidate exRNAs were predicted to regulate pathways of inflammation and fibrosis by bioinformatics analysis. Plasma RNA signatures are associated with heart remodeling following a myocardial infarction, and are predicted to regulate inflammation pathways. These extracellular RNAs are derived from different types of cells in the heart and are altered in the heart tissue as well as plasma in a mouse model of myocardial infarction, reflecting the complex and dynamic process of heart remodeling after myocardial infarction.

Background: Trials using echocardiographic mechanical dyssynchrony (MD) parameters in narrow QRS patients have shown a negative response to CRT. We hypothesized MD in these patients may relate to myocardial scar rather than electrical dyssynchrony. Methods: We determined the prevalence of cardiac magnetic resonance (CMR) derived measures of MD in 130 systolic heart failure patients with both broad (≥130 ms - BQRS) and narrow QRS duration (

Background: Functional follow-up modalities of hypertrophic cardiomyopathy (HCM) with left ventricular (LV) outflow tract obstruction (LVOTO) subjected to alcohol septal ablation (ASA) are limited. Methods: This retrospective cohort study included patients of HCM with LVOTO who underwent ASA and four-dimensional (4D) flow cardiac magnetic resonance imaging (MRI) both before and after ASA. We analyzed energy loss in one cardiac cycle within the three-chamber plane of the LV and aortic root, and compared between pre- and post-ASA measurements. Results: Of the 26 included patients, 10 (39%) were male, and median age was 71 (interquartile range 58–78) years. ASA significantly reduced not only LVOT pressure gradient (70 [19–50] to 9 [3–16], P

Author(s): Konstanty-Kalandyk, Janusz; Bartuś, Krzysztof; Piątek, Jacek; Vuddanda, Venkat; Lee, Randall; Kedziora, Anna; Sadowski, Jerzy; Lakkireddy, Dhanunjaya; Kapelak, Boguslaw | Abstract: IntroductionRefractory angina has limited effective therapeutic options and often contributes to frequent hospitalizations, morbidity and impaired quality of life.AimWe sought to examine midterm results of a bio-interventional therapy combining transmyocardial laser revascularization (TMLR) and intramyocardial injection of adipose derived stem cells (ADSC) in patients with refractory angina not amenable to percutaneous or surgical revascularization.Material and methodsWe included 15 patients with severe refractory angina and anterior wall ischemia who were ineligible for revascularization strategies. Adipose tissue was harvested and purified, giving the stem cell concentrate. All patients underwent left anterior thoracotomy and TMLR using a low-powered holmium : yttrium-aluminum-garnet laser and intramyocardial injection of ADSC using a combined delivery system.ResultsNo deaths or major adverse cardiovascular or cerebrovascular events were observed in the 6-month follow-up. Mean ejection fraction increased from 35% to 38%, and mean Canadian Cardiovascular Society Angina Score decreased from 3.2 to 1.4, with decreased necessity of nitrate usage. Seventy-three percent of patients reported health improvement particularly regarding general health and bodily pain. Improvement in endocardial movement, myocardial thickening and stroke volume index (35.26 to 46.23 ml/m2) on cardiac magnetic resonance imaging (MRI) was observed in 3 patients who had repeat CMR imaging after 6 months.ConclusionsOur study suggested that interventional therapy combining TMLR with intramyocardial implantation of ADSC may reduce symptoms and improve quality of life in patients with refractory angina. These early findings need further validation in large scale randomized controlled trials.

Aims To assess left-ventricular strain parameters before and after transcatheter aortic valve replacement (TAVR) by feature tracking cardiac magnetic resonance imaging (FT CMR) and to correlate the findings to hemodynamic state and left-ventricular remodeling. Methods and results Patients with symptomatic AS underwent FT CMR before and after TAVR. Patients were carefully evaluated by a comprehensive work-up including CMR, echocardiography and left and right heart catheterization. Thirty patients formed the study population. High-flow/high-gradient (HF/HG) aortic stenosis was diagnosed in 11 patients (36.7%), 6 patients (20.0%) exhibited low-flow/low-gradient AS (LF/LG) and 13 patients (43.3%) were classified to have so-called paradoxical low-flow/low-gradient (PLF/LG) AS. The HF/HG patients had a significantly reduced longitudinal strain which recovered after TAVR (−12.67 ± 4.60 to −15.46 ± 5.61%, p = 0.048). In the LF/LG group, an even more pronounced reduction of longitudinal strain and also an impairment of longitudinal velocity could be observed. Both parameters improved after therapy (strain: −5.06 ± 4.25 to −8.02 ± 3.28%, p = 0.045; velocity: 25.33 ± 9.63 to 37.13 ± 11.64 mm/s, p = 0.042). Patients with PLF/LG showed preserved longitudinal strain but a reduction of longitudinal velocity similar to the LF/LG group. These patients did not show a significant improvement of strain parameters after TAVR. Longitudinal velocity exhibited the highest predictive power for the identification of a low-flow state (sensitivity 75%, specificity 80%). Conclusion Improvement of longitudinal strain parameters after TAVR is dependent on the initial hemodynamically defined AS subgroup.