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Aims Although the prevalence of coronary artery disease (CAD) is high among patients with atrial fibrillation (AF), studies on stress perfusion cardiac magnetic resonance (CMR) imaging frequently exclude patients with AF, and its prognostic and diagnostic value in high‐risk patients with suspected or known CAD remains unclear. Methods and results In this longitudinal cohort study, we included 164 consecutive patients with AF during vasodilator perfusion CMR. Diagnostic value was evaluated regarding invasive coronary angiography in a subset of patients. We targeted a follow‐up of >5 years and used CMR results as stratification, and the primary outcome was major adverse cardiac events [MACE, cardiovascular (CV) death and myocardial infarction (MI)]. Secondary outcomes included late coronary revascularization or stroke and the components of the primary outcome. Of the whole cohort (73.8% male, mean age 72.2 years ± 7.8 SD), 99.4% were successfully scanned (163/164 patients). Median CHA2DS2‐VASc score was 4 [interquartile range (IQR) 3–5], and median 10‐year risk for CV events based on SMART risk score was high (24%, IQR 16–32%). Thirty‐two patients (19.6%) presented with ischaemia and 52 patients (31.9%) with late gadolinium enhancement (LGE). A combination of LGE and inducible ischaemia was present in 20 patients (12.3%). Diagnostic accuracy was 86.2% [confidence interval (CI) 68.3–96.1%]. The median follow‐up was 6.6 years (IQR 3.6–7.8). Ischaemia in vasodilator perfusion CMR was significantly associated with the occurrence of MACE [P

We describe the transcatheter management of severe aortic regurgitation in a middle-aged patient with a porcelain aorta who underwent implantation of an apicoaortic valved conduit 12 years ago. Instantaneous relief of heart failure symptoms was achieved by restoring antegrade blood flow to the ascending aorta. (Level of Difficulty: Advanced.), Graphical abstract

We present not‐yet‐seen multimodal images of a 55‐year‐old female patient with isolated atrial amyloidosis (IAA) who clinically suffered from multiple atrial arrhythmias and heart failure symptoms with preserved left ventricular ejection fraction. We aim to show structural and functional abnormalities detected by electrophysiological voltage mapping, cardiac magnetic resonance imaging (MRI) [cMRI; atrial strain measurements, late gadolinium enhancement (LGE) visualization], and 99mTc‐DPD scintigraphy. Bipolar voltage mapping performed during two electrophysiological procedures showed diffuse left atrial low‐voltage areas (bipolar

Background: Despite the ongoing global pandemic, the impact of COVID-19 on cardiac structure and function is still not completely understood. Myocarditis is a rare but potentially serious complication of other viral infections with variable recovery, and is, in some cases, associated with long-term cardiac remodeling and functional impairment.Aim: To assess myocardial injury in patients who recently recovered from an acute SARS-CoV-2 infection with advanced cardiac magnetic resonance imaging (CMR) and endomyocardial biopsy (EMB).Methods: In total, 32 patients with persistent cardiac symptoms after a COVID-19 infection, 22 patients with acute classic myocarditis not related to COVID-19, and 16 healthy volunteers were included in this study and underwent a comprehensive baseline CMR scan. Of these, 10 patients post COVID-19 and 13 with non-COVID-19 myocarditis underwent a follow-up scan. In 10 of the post-COVID-19 and 15 of the non-COVID-19 patients with myocarditis endomyocardial biopsy (EMB) with histological, immunohistological, and molecular analysis was performed.Results: In total, 10 (31%) patients with COVID-19 showed evidence of myocardial injury, eight (25%) presented with myocardial oedema, eight (25%) exhibited global or regional systolic left ventricular (LV) dysfunction, and nine (28%) exhibited impaired right ventricular (RV) function. However, only three (9%) of COVID-19 patients fulfilled updated CMR–Lake Louise criteria (LLC) for acute myocarditis. Regarding EMB, none of the COVID-19 patients but 87% of the non-COVID-19 patients with myocarditis presented histological findings in keeping with acute or chronic inflammation. COVID-19 patients with severe disease on the WHO scale presented with reduced biventricular longitudinal function, increased RV mass, and longer native T1 times compared with those with only mild or moderate disease.Conclusions: In our cohort, CMR and EMB findings revealed that SARS-CoV-2 infection was associated with relatively mild but variable cardiac involvement. More symptomatic COVID-19 patients and those with higher clinical care demands were more likely to exhibit chronic inflammation and impaired cardiac function compared to patients with milder forms of the disease.

Introduction Persistent cardiopulmonary symptoms after COVID-19 are reported in a large number of patients and the underlying pathology is still poorly understood. (1) Histopathologic studies revealed myocardial macrophage infiltrates in deceased patients, likely an unspecific finding of severe illness, and increased prevalence of micro- and macrovascular thrombi. (2) We examined whether microvascular perfusion, measured by quantitative cardiac magnetic resonance under vasodilator stress, was altered post COVID-19. Methods Our population consisted of 12 patients from the Pa-COVID-19-Study of the Charité Berlin, which received a cardiac MRI as part of a systematic follow up post discharge, 10 patients that presented at the German Heart Center Berlin with persistent cardiac symptoms post COVID-19 and 12 patients from the Kings College London referred for stress MRI and previous COVID-19. The scan protocol included standard functional, edema and scar imaging and quantitative stress and rest perfusion to assess both macro- and microvascular coronary artery disease. The pharmacological stress agent was regadenosone in 20 and adenosine in 13 of the patients. To control for the higher heart rate increase under regadenosone compared to adenosine, we calculated the myocardial blood flow per heartbeat (MBF_HRi) under stress. Results The median time between first positive PCR for COVID-19 and the CMR exam was 2 months (Range 0 to 12). None of the 33 patients exhibited signs of myocardial edema. One patient with a previous history of myocarditis had focal fibrosis. Three patients with known coronary artery disease showed ischemic Late Enhancement. Five patients had a small pericardial effusion; one of these four patients showed slight focal pericardial edema and LGE, consistent with mild focal pericarditis. Five Patients had a stress-induced focal perfusion deficit. Mean Stress MBF_HRi was 32.5±6.5 μl/beat/g. Stress MBF_HRi was negatively correlated with COVID-19 severity (rho=−0.361, P=0.039) and age (r=−0.452, P=0.009). The correlation with COVID-19 severity remained significant after controlling for age (rho=−0.390, P=0.027). There was no apparent difference in stress MBF_HRi between patients with and without persistent chest pain (34.5 vs. 31.5 μl/beat/g, P=0.229) Conclusion While vasodilator-stress myocardial blood flow after COVID-19 was negatively correlated to COVID-19 severity, it was not correlated to the presence of chest pain. The etiology of persistent cardiac symptoms after COVID-19 remains unclear. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Philips Figure 1. A) Quantitative regadenosone stress myocardial blood flow (MBF) map, medial short axis slice, in a patient with persistent cardiac symptoms after COVID-19. B) Boxplot of stress MBF per heart beat by COVID-19 severity, showing decreasing MBF with increasing COVID-19 severity.

Background Phenylketonuria is the most common inborn error of amino acid metabolism, where oxidative stress and collateral metabolic abnormalities are likely to cause cardiac structural and functional modifications. We aim herein to characterize the cardiac phenotype of adult subjects with phenylketonuria using advanced cardiac imaging. Methods and Results Thirty‐nine adult patients with phenylketonuria (age, 30.5±8.7 years; 10‐year mean phenylalanine concentration, 924±330 µmol/L) and 39 age‐ and sex‐matched healthy controls were investigated. Participants underwent a comprehensive cardiac magnetic resonance and echocardiography examination. Ten‐year mean plasma levels of phenylalanine and tyrosine were used to quantify disease activity and adherence to treatment. Patients with phenylketonuria had thinner left ventricular walls (septal end‐diastolic thickness, 7.0±17 versus 8.8±1.7 mm [ P P =0.004]), more dilated left ventricular cavity (end‐diastolic volume, 87±14 versus 80±14 mL/m 2 [ P =0.0178]; end‐systolic volume, 36±9 versus 29±8 mL/m 2 [ P P P =0.027]), and lower left ventricular mass (38.2±7.9 versus 47.8±11.0 g/m 2 [ P P 1200 µmol/L (909±48 ms). Both mean phenylalanine ( P =0.013) and tyrosine ( P =0.035) levels were independently correlated with T1; and in a multiple regression model, higher phenylalanine levels and higher left ventricular mass associate with lower T1. Conclusions Cardiac phenotype of adult patients with phenylketonuria reveals some traits of an early‐stage cardiomyopathy. Regular cardiology follow‐up, tighter therapeutic control, and prophylaxis of cardiovascular risk factors, in particular dyslipidemia, are recommended.

Introduction: While cardiac tumors are rare, their identification and differentiation has wide clinical implications. Recent cardiac magnetic resonance (CMR) parametric mapping techniques allow for quantitative tissue characterization. Our aim was to examine the range of values encountered in cardiac myxomas in correlation to histological measurements.Methods and Results: Nine patients with histologically proven cardiac myxomas were included. CMR (1.5 Tesla, Philips) including parametric mapping was performed in all patients pre-operatively. All data are reported as mean ± standard deviation. Compared to myocardium, cardiac myxomas demonstrated higher native T1 relaxation times (1,554 ± 192 ms vs. 1,017 ± 58 ms, p < 0.001), ECV (46.9 ± 13.0% vs. 27.1 ± 2.6%, p = 0.001), and T2 relaxation times (209 ± 120 ms vs. 52 ± 3 ms, p = 0.008). Areas with LGE showed higher ECV than areas without (54.3 ± 17.8% vs. 32.7 ± 18.6%, p = 0.042), with differences in native T1 relaxation times (1,644 ± 217 ms vs. 1,482 ± 351 ms, p = 0.291) and T2 relaxation times (356 ± 236 ms vs. 129 ± 68 ms, p = 0.155) not reaching statistical significance.Conclusions: Parametric CMR showed elevated native T1 and T2 relaxation times and ECV values in cardiac myxomas compared to normal myocardium, reflecting an increased interstitial space and fluid content. This might help in the differentiation of cardiac myxomas from other tumor entities.

Die isolierte linksventrikulare Noncompaction-Kardiomyopathie (LVNC) gehort zu den seltenen Kardiomyopathien. Bei der LVNC bestehen typischerweise prominente Trabekel und tiefe Rezessus, die insgesamt als ein 2-schichtig verdicktes Myokard erscheinen. Dabei dominiert eine Schicht als nicht kompaktiertes und eine als kompaktiertes Myokard. Klinischer Standard zur Diagnostik der LVNC ist die Echokardiographie, wobei es verschiedene diagnostische Kriterien gibt. In schwierigen Fallen ist die kardiale Magnetresonanztomographie wegen ihres ausgezeichneten nativen Kontrastes zwischen Blut und Myokard hilfreich. Die meisten Patienten weisen Symptome einer chronischer Herzinsuffizienz auf. Haufig werden im Verlauf Thrombembolien und Arrhythmien beobachtet. Eine kausale Therapie gibt es nicht, daher sind Therapieansatze auf die Behandlung der Herzinsuffizienz und die Pravention von Thrombembolien begrenzt.

Wir berichten uber einen 34-jahrigen Mann, der aufgrund einer Prasynkope stationar aufgenommen wurde. In der Vorgeschichte ist eine Myokarditis vor 5 Jahren und eine Infektion mit Echinococcus granulosus vor 4 Jahren ohne Beteiligung abdomineller Organe bekannt, die medikamentos mittels Albendazol behandelt wurde. Im EKG zeigte sich ein bereits bekannter Linksschenkelblock. Echokardiographisch wurden 2 Zysten in der posterolateralen Wand des linken Ventrikels mit echodichtem Randwall dargestellt. Die kardiale Magnetresonanztomographie zeigte in den Perfusionsuntersuchungen nach Kontrastmittelgabe eine Verbindung des Zysteninhalts mit der linken Herzkammer sowie in den Spataufnahmen nach Kontrastmittelgabe ein die Zysten umgebendes fibrotisches Gewebe. Es wurde die Diagnose einer kardialen zystischen Echinokokkose gestellt. Bei fehlender klinischer Symptomatik und negativer Serologie erfolgte keine weitere Therapie. Die kardiale Magnetresonanztomographie stellt bei dieser Erkrankung eine exzellente Moglichkeit der Bildgebung dar, da neben der Anatomie, der Zysteninhalt sowie die Beziehung zum Myokard zur Darstellung kommen.

A 48-year-old male patient was admitted with palpitations and presyncopes due to new onset ventricular extrasystole following respiratory tract infection. On admission the patient presented with symptomatic sustained ventricular tachycardia ( Panel A ) which was terminated by amiodarone. Initial blood tests showed mild leucocytosis, no increase in C-reactive …

Background Dobutamine stress cardiovascular magnetic resonance (DS-CMR) has been established for the detection of coronary artery disease (CAD). The novel technique feature tracking (FT) analyses left ventricular circumferential strain (Ecc) thus offering detailed information about myocardial deformation. The purpose of this study was to evaluate FT based Ecc for the detection of myocardial ischemia during DS-CMR. Methods A total of 25 patients (18 males; mean age 64 ± 10 years) with suspected or known CAD underwent a standardized high-dose DS-CMR protocol at 1.5 T. For FT analysis cine short axis (SAX) views (apical, medial, basal) at rest and during maximum dobutamine stress were used. None of the patients had wall motion abnormalities (WMAs) or impaired left ventricular function at rest or scar tissue. For analysis of Ecc the three SAX planes were divided into 16 segments (n = 400 segments). During stress 15 patients (34 segments) developed WMAs as assessed by visual analysis. All patients underwent x-ray coronary angiography for clinical reasons which served as the reference standard. Patients without WMAs during DS-CMR and exclusion of stenotic CAD were defined as normal (10 patients, 160 segments). In patients with significant CAD segments that were supplied by a vessel of >70% narrowing were defined as stenotic (n = 64). The remaining segments in patients with significant CAD were considered as remote (n = 176). Results At rest no differences in Ecc were observed between normal, stenotic and remote segments. High-dose dobutamine stress revealed highly significant differences between Ecc of normal and stenotic segments (p

Background Phenylketonuria (PKU) is one of the most common inherited metabolic disorders. The molecular pathway of neurological damage is not yet sufficiently understood. To date, there is a lack information about cardiac involvement related to the disease. This study aims to characterize cardiac morphology and function in adult patients with PKU using cardiovascular magnetic resonance (CMR).

Background Renal Denervation (RDN) is a novel therapy for patients with resistant hypertension. Its cardiac effects at followup are currently unknown. On the other hand, T1 mapping permits the assessment of myocardial extracellular volume (ECV), a parameter proposed to quantify diffuse myocardial fibrosis and independently associated with mortality and hard cardiovascular events. Our aim was to study the effects of RDN on ECV at 6-month follow-up. Methods 14 patients with resistant hypertension undergoing RD (RD group) and 4 resistant hypertensive patients not undergoing RD (control group) were prospectively included. A 1.5T cardiac MR including T1 mapping preand post-contrast was performed before the RD procedure and at 6-month follow-up in both groups. Blood hematocrit was determined at both time points. Images were post-processed using commercial software (Qmass, Medis

Background Dobutamine stress magnetic resonance (DSMR-wall motion) has been established as a valuable tool for the detection of inducible wall motion abnormalities. Additional perfusion imaging during DSMR (DSMR-perfusion) was shown to improve sensitivity for the detection of myocardial ischemia. Current experience is based on 1.5T only, mainly due to insufficient image quality of steady state free precession (SSFP) cine imaging at higher field strengths. Recently, image quality and diagnostic accuracy of SSFP sequences was significantly improved by dual-source parallel radiofrequency (RF) transmission for 3.0T. We examined whether the addition of myocardial perfusion imaging during DSMR at 3.0T is feasible and whether it provides incremental benefit for the evaluation of CAD.

Background Several studies have demonstrated the consistently high diagnostic and prognostic value of adenosine stress perfusion imaging with cardiovascular magnetic resonance (CMR). The feasibility and diagnostic accuracy of CMR stress perfusion in patients with atrial fibrillation is unknown. The purpose of this study was to assess the utility of CMR stress perfusion imaging in patients with atrial fibrillation who had suspected and known coronary artery disease (CAD).

To the Editor: In the present study we sought to investigate the predictive value of resting and inducible wall motion abnormalities (WMA) and of late gadolinium enhancement (LGE) for hard cardiac outcomes and for revascularization procedures in 3,138 patients undergoing dobutamine cardiac magnetic

We present preliminary data of the vascular hemodynamics in a novel, anatomically shaped ascending aortic graft in comparison to non-operated individuals by use of 3D magnetic resonance (MR) flow measurements. We examined a 72-year-old male patient after Tiron David I valve sparing aortic root reconstruction and replacement of the ascending aorta (AAo) with an anatomically curved prosthesis. Results from flow-sensitive MR at 3T were compared to 12 age-matched individuals with comparable diameters of the AAo. For 3D flow visualization, streamlines and time-resolved particle traces were applied. A visual analysis of hemodynamic properties including blood flow helicity, vorticity and retrograde flow was performed. In contrast to reported highly disturbed flow of straight aortic grafts in the literature, the patient analysis revealed smooth blood flow through the graft which gave rise to a right-handed helical flow in the reconstructed aorta. In comparison to non-operated volunteers, blood flow helicity was more pronounced. Flow jets or vortices were not encountered. While physiological retrograde flow was seen in the volunteers, it was absent in the patient which may be explained by the altered aortic compliance and thus reduced Windkessel effect. This promising finding will have to prove its validity in further comparative studies.

Objectives In light of the ongoing discussion about flow-mediated arterial remodeling, it was the aim of this report to demonstrate the detailed assessment of 3-dimensional vascular hemodynamics by high-field magnetic resonance imaging in healthy volunteers and to illustrate its potential in comparison with results in a patient with stenosis. Materials and Methods All examinations consisted of flow-sensitive 4-dimensional magnetic resonance imaging at 3 Tesla. Retrospective blood flow visualization and segmental quantification of wall shear stress and oscillatory shear index were performed. The results from 11 healthy individuals were compared with a 13-year-old patient with aortic stenosis who received a combined protocol with time-resolved 3-dimensional magnetic resonance angiography before and 5 and 9 months after intervention. Results Evaluation of normal blood flow characteristics demonstrated predominantly right-handed helical flow in the ascending aorta. Vortex formation was observed in 1 of 11 volunteers. Consistently high segmental wall shear stress was found along the circumference of the ascending aorta (average wall shear stress = 0.191 ± 0.06 N/m2) and descending aorta (average 0.191 ± 0.06 N/m2). Compared with volunteers, the patient revealed substantial flow changes proximal and distal to the stenosis. Blood flow alterations in the ascending aorta were also observed associated with changes in velocities and wall shear stress that gradually normalized after intervention. Conclusion Flow-sensitive 4-dimensional magnetic resonance imaging at 3 Tesla can provide deeper insights into hemodynamic alterations in the diagnosis and follow-up of aortic pathologies. These findings indicate the potential of the methodology for the evaluation of effects of localized pathologies on the entire vascular system, which will have to be confirmed in future studies.

Background Left ventricular myocardial motion analysis and the assessment of regional dysfunction are crucial for the detection and prognosis in different cardiac pathologies. Myocardial tagging (MT) is a cardiac magnetic resonance (CMR) based method for tracking myocardial motion, which has been established as reference standard for assessment of strain. Currently, strain can also be assessed by CMR using feature tracking (FT) or by echocardiography with speckle tracking (ST). Aim of our study was to evaluate intraindividually and compare myocardial circumferential strain (Ecc) using MT, FT and ST.

Background Adenosine stress magnetic resonance is highly accurate for the detection of myocardial perfusion abnormalities. Visual assessment of inducible wall motion abnormalities (IWMA) during adenosine has low sensitivity but high specificity since only high-grade perfusion defects are associated with detectable IWMAs. The novel technique Feature Tracking (FT) measures myocardial strain and gives detailed information about regional myocardial deformation. The aim of this study was to investigate FT for the detection of myocardial ischemia during adenosine stress.

Background Dobutamine stress magnetic resonance (DSMR) has been established for the detection of coronary artery disease (CAD) due to its high diagnostic accuracy and prognostic value. The novel technique feature tracking (FT) analyses regional myocardial strain and thereby offers detailed information about myocardial deformation. The purpose of this study was to examine how FT based circumferential strain (CS) compares to visually detected wall motion abnormalities (WMA) during DSMR and whether it adds beneficial information for detecting CAD. Methods A total of 25 patients (72% male; mean age 64 ± 8) with suspected or known CAD underwent a standardized high-dose DSMR protocol at 1.5 T. CMR images were acquired at rest and during stress in three short-axis views (SAX; apical, medial, basal). None of the patients had evidence for WMAs or impaired left ventricular function at rest or scar tissue based on late gadolinium enhancement (LGE). For strain analysis the SAX planes were divided into 16 segments (n = 400 segments). All patients underwent x-ray coronary angiography for clinical reasons. Patients without WMA during DSMR and exclusion of CAD by coronary angiography were defined as normal and served as control (10 patients, 160 segments). 15 patients developed WMA during DSMR (34 segments). Additionally, based on angiographic findings, segments that were supplied by a vessel with >75% were defined as stenotic (64 segments). The remaining segments, which did not develop a WMA or were supplied by a vessel

Summary We sought to assess late gadolinium enhancement (LGE) of the coronary artery wall and ascending aorta in patients with Takayasu arteritis (TA) compared to patients with stable CAD. Our findings suggest that LGE of the coronary artery wall can be demonstrated in patients with TA and seems to be similarly pronounced as in CAD patients. The observed coronary LGE seems rather unspecific and differentiation between coronary vessel wall fibrosis and inflammation still remains unclear.

Methods DSMR was performed in twenty-eight consecutive patients with suspected or known CAD scheduled for clinically indicated invasive coronary angiography. Each patient underwent routine DSMR including cine imaging at rest and during dobutamine infusion. Additionally, three standard short axis and longitudinal axis views were obtained after five, ten and fifteen minutes during the recovery period in order to detect persisting wall motion abnormalities in ischemic myocardial territories, which were assigned to coronary arteries based on the 17 segment model. Intermediate and severe coronary stenosis were defined as 50-75% and >75% luminal narrowing using invasive coronary angiography, respectively (figure 1). All patients received esmolol after stopping the dobutamine infusion to achieve a heart rate under 100bpm.

Summary We aimed to determine the prognostic value of wall motion assessment during high-dose dobutamine stress cardiac magnetic resonance imaging (DCMR) for the prediction of hard cardiac events in a large patient cohort and within a long follow-up duration. DCMR can accurately identify between patients with inducible ischemia who are at increased risk for future hard cardiac events and revascularization procedures. Within the ‘primary warranty time’ of 3 years after DCMR excellent outcomes (annual hard cardiac event rate 90 days after the MR-scans were prospectively collected at least 6 months after DCMR. Results