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Aims Long-term sequelae may occur after SARS-CoV-2 infection. We comprehensively assessed organ-specific functions in individuals after mild to moderate SARS-CoV-2 infection compared with controls from the general population. Methods and results Four hundred and forty-three mainly non-hospitalized individuals were examined in median 9.6 months after the first positive SARS-CoV-2 test and matched for age, sex, and education with 1328 controls from a population-based German cohort. We assessed pulmonary, cardiac, vascular, renal, and neurological status, as well as patient-related outcomes. Bodyplethysmography documented mildly lower total lung volume (regression coefficient −3.24, adjusted P = 0.014) and higher specific airway resistance (regression coefficient 8.11, adjusted P = 0.001) after SARS-CoV-2 infection. Cardiac assessment revealed slightly lower measures of left (regression coefficient for left ventricular ejection fraction on transthoracic echocardiography −0.93, adjusted P = 0.015) and right ventricular function and higher concentrations of cardiac biomarkers (factor 1.14 for high-sensitivity troponin, 1.41 for N-terminal pro-B-type natriuretic peptide, adjusted P ≤ 0.01) in post-SARS-CoV-2 patients compared with matched controls, but no significant differences in cardiac magnetic resonance imaging findings. Sonographically non-compressible femoral veins, suggesting deep vein thrombosis, were substantially more frequent after SARS-CoV-2 infection (odds ratio 2.68, adjusted P Conclusion Subjects who apparently recovered from mild to moderate SARS-CoV-2 infection show signs of subclinical multi-organ affection related to pulmonary, cardiac, thrombotic, and renal function without signs of structural brain damage, neurocognitive, or quality-of-life impairment. Respective screening may guide further patient management.

Background: Reliable reference intervals are crucial for clinical application of myocardial T1 and T2 mapping cardiovascular magnetic resonance imaging. This study evaluated the impact of sex and cardiovascular risk factors on myocardial T1, extracellular volume fraction (ECV), and T2 at 3T in the population-based HCHS (Hamburg City Health Study). Methods: The final study sample consisted of 1576 consecutive HCHS participants between 46 and 78 years without prevalent heart disease, including 1020 (67.3%) participants with hypertension and 110 (7.5%) with diabetes. T1 and T2 mapping were performed on a 3T scanner using 5b(3b)3b modified Look-Locker inversion recovery and T2 prepared, fast-low-angle shot sequence, respectively. Stepwise regression analyses were performed to identify variables with an independent impact on T1, ECV, and T2. Reference intervals were defined as the interval between the 2.5% and 97.5% quantiles. Results: Sex was the major independent influencing factor of myocardial native T1, ECV, and T2. Female patients had significantly higher upper limits of reference intervals for native T1 (1112–1261 versus 1079–1241 ms), ECV (23%–33% versus 22%–32%), and T2 (36–46 versus 35–45 ms) compared with male patients (all P P P =0.001). Conclusions: Sex needs to be considered as the major, independent influencing factor for clinical application of myocardial T1, ECV, and T2 measurements. Consequently, sex-specific reference intervals should be used in clinical routine. Our findings suggest that there is no need for specific reference intervals for myocardial T1 and ECV measurements in individuals with cardiovascular risk factors. However, hypertension should be considered as an additional factor for clinical application of T2 measurements. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03934957.

Aims CMR feature tracking strain (CMR-FT) provides prognostic information. However, there is a paucity of data in hypertrophic cardiomyopathy (HCM). We sought to analyze global CMR-FT parameters in all four cardiac chambers and to assess associations with NT-proBNP and cardiac troponin T (hsTnT) in patients with HCM. Methods This retrospective study included 144 HCM patients and 16 healthy controls with CMR at 1.5 T. Analyses were performed on standard steady-state free precession cine (SSFP) CMR data using a commercially available software. Global left ventricular (LV) strain was assessed as longitudinal (LVLAX-GLS), circumferential (LVLAX-GCS) and radial strain (LVLAX-GRS) on long -axis (LAX) and as LVSAX-GCS and LVSAX-GRS on short- axis (SAX). Right ventricular (RV-GLS), left atrial (LA-GLS) and right atrial (RA-GLS) strain were assessed on LAX. Results We found LVLAX-GLS [− 18.9 (− 22.0, − 16.0), − 23.5 (− 25.5, − 22.0) %, p = 0.0001), LVSAX-GRS [86.8 (65.9–115.5), 119.6 (91.3–143.7) %, p = 0.001] and LALAX-GLS [LA2CH-GLS 29.2 (19.1–37.7), LA2CH-GLS 38.2 (34.3–47.1) %, p = 0.0036; LA4CH-GLS 22.4 (14.6–30.7) vs. LA4CH-GLS 33.4 (28.4–37.3) %, p = 0.0033] to be impaired in HCM compared to healthy controls despite normal LVEF. Furthermore, LV and LA strain parameters were impaired in HCM with elevated NT-proBNP and/or hsTnT, despite preserved LVEF compared to HCM with normal biomarker levels. There was a moderate correlation of LV and LA CMR-FT with levels of NT-proBNP and hsTnT. Conclusion CMR-FT reveals LV and LA dysfunction in HCM despite normal LVEF. The association between impaired LV strain and elevated NT-proBNP and hsTnT indicates a link between unapparent functional abnormalities and disease severity in HCM. Graphic abstract Typical CMR-FT findings in patients with hypertrophic cardiomyopathy

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

The purpose of this prospective study was to analyze the relationship between ventricular morphology and parameters of cardiac function in two different athletic groups and controls, using feature tracking cardiac magnetic resonance (FT-CMR). Twenty-three professional soccer players (22 ± 4 years), 19 competitive triathletes (28 ± 6 years) and 16 controls (26 ± 3 years) were included in the study. CMR was performed using a 1.5 T scanner. Cardiac chamber volumes, mass and biventricular global myocardial strain were obtained and compared. In comparison to the control subjects, athletes were characterized by a higher cardiac volume (p p p p p 2, p p p p r = 0.47, p r = − 0.28, p

BackgroundThere is a paucity of data on cardiovascular magnetic resonance feature tracking (CMR-FT) in patients with dilated cardiomyopathy (DCM). We aimed at describing global and segmental myocardial strain patterns and a potential association with the presence of focal myocardial scarring in DCM patients by CMR-FT.MethodsThirty-nine patients with DCM and reduced left ventricular (LV) ejection fraction (mean 21±8%) underwent CMR including standard cine steady-state free precession (SSFP) sequences and late gadolinium enhancement (LGE). We measured global LV longitudinal as well as global and segmental circumferential and radial strain. The presence of focal myocardial fibrosis was assessed on LGE images.ResultsNineteen patients had focal myocardial fibrosis on LGE images with the highest prevalence in the basal septal segments II and III, which were affected in 12 (63%) and 13 (68%) patients. Furthermore, there was a significantly lower average short-axis LV radial strain (LVSAX-RS) in these segments (4.89 (−1.55 to 11.34) %) compared with the average of the other myocardial segments (21.20 (17.36 to 25.05)%; pSAX-RS values (17.65 (10.37 to 24.93) %) compared with those without LGE (19.40 (15.43 to 23.37) %), but this effect was not significant after adjusting for the presence of LBBB (p=0.630).ConclusionOur findings revealed a coincidence of impaired radial strain and focal myocardial fibrosis in the basal septal LV myocardial segments of patients with DCM. Regardless of this pattern, we did not find a general, significant effect of myocardial fibrosis on strain in our cohort. Future studies are required to assess the potential prognostic implications of myocardial strain patterns in addition to the assessment of myocardial fibrosis in patients with DCM.

Alterations in native myocardial T1 under vasodilation stress (“T1 reactivity”) were recently proposed as a non-contrast cardiovascular magnetic resonance (CMR) method to detect myocardial ischemia. This study evaluated the performance of a segmental, truly non-contrast stress T1 mapping CMR approach to detect inducible ischemia. One-hundred patients with suspected/known coronary artery disease underwent CMR at 3.0 or 1.5 T. T1 mapping was performed using the 5s(3s)3s-modified look-locker inversion-recovery (MOLLI) sequence at rest and under regadenoson stress. We defined T1 reactivity as the change in native T1 from rest to stress (1) in the 16-segment AHA model independent from perfusion images and (2) in focal regions of interest that were copied from perfusion images to T1 maps. We compared T1 reactivity between segments/regions with inducible ischemia, scar, and remote myocardium for both approaches. Segmental T1 reactivity was significantly lower in segments including inducible ischemia [− 1.15 (95% CI, − 2.16 to − 0.14)%] compared to remote segments [2.49 (95% CI, 1.87 to 3.11)%; p

Iron-induced cardiomyopathy with progressive heart failure is the leading cause of death in patients with systemic iron overload, and early detection is vital for chelator therapy ([1][1]). The transverse relaxation time T2∗ (=1/R2∗) nonlinearly reflects tissue iron concentration and allows pre

Objectives This study analyzed the presence of myocardial fibrosis detected by late gadolinium-enhancement (LGE) cardiac magnetic resonance (CMR) in correlation with the performance of competitive triathletes objectified by an exercise test and individual competition history. Background Myocardial fibrosis detected by LGE CMR has been reported to occur in 0% to 50% of asymptomatic athletes. However, the cause and mechanisms of myocardial fibrosis are unclear. Methods Eighty-three asymptomatic triathletes undergoing >10 training h per week (43 ± 10 years of age; 65% male) and 36 sedentary controls were studied by using LGE and extracellular volume (ECV) CMR. Parameters of physical fitness were measured by spiroergometry. Triathletes reported their lifetime competition results. Results LGE CMR revealed focal nonischemic myocardial fibrosis in 9 of 54 (17%) male triathletes (LGE + ) but in none of the female triathletes (p + triathletes had higher peak exercise systolic blood pressure (213 ± 24 mm Hg) than LGE − triathletes (194 ± 26 mm Hg; p + triathletes (93 ± 7 g/m 2 ) than in LGE − triathletes (84 ± 11 g/m 2 ; p 0.05). ECV in LGE − myocardium was higher in LGE + triathletes (26.3 ± 1.8%) than in LGE − triathletes (24.4 ± 2.2%; p + triathletes completed longer cumulative distances in swimming and cycling races and participated more often in middle and Iron Man distances than LGE − triathletes. A cycling race distance of >1,880 km completed during competition had the highest accuracy to predict LGE, with an area under the curve value of 0.876 (p Conclusions Myocardial fibrosis in asymptomatic triathletes seems to be associated with exercise-induced hypertension and the race distances. There appears to be a safe upper limit, beyond which exercise may result in myocardial fibrosis.

Aims Monitoring disease activity in myocarditis is important for tailored therapeutic strategies. This study evaluated the ability of T1 and T2 mapping cardiovascular magnetic resonance (CMR) to monitor the course of myocardial inflammation in healing myocarditis. Methods and results Forty-eight patients with strictly defined acute myocarditis underwent CMR at 1.5 T in the acute stage, at 3-months (n = 39), and at 12-months follow-up (FU) (n = 21). Normal values were obtained in a control group of 27 healthy subjects. The CMR protocol included standard ('Lake-Louise') sequences as well as T1 (modified Look-Locker inversion recovery sequence, MOLLI) and T2 (gradient- and spin-echo sequence, GraSE) mapping. T1, T2, and extracellular volume (ECV) maps were generated using an OsiriX plug-in. Native myocardial T1, T2, and ECV values were increased in the acute stage, but declined with healing of myocarditis. The performances of global native T1 and T2 to differentiate acute from healed myocarditis stages were significantly better compared with all other global CMR parameters with AUCs of 0.85 (95% CI, 0.76-0.94) and 0.83 (95% CI, 0.73-0.93). Furthermore, regional native T1 and T2 in myocarditis lesions provided AUCs of 0.97 (95% CI, 0.93-1.02) and 0.93 (95% CI, 0.85-1.01), which were significantly superior to any other global or regional CMR parameter. Conclusion Healing of myocarditis can be monitored by native myocardial T1 and T2 measurements without the need for contrast media. Both native myocardial T1 and T2 provide an excellent performance for assessing the stage of myocarditis by CMR.

Aims The aim of this study was to investigate the occurrence of myocardial injury and cardiac dysfunction after an endurance race by biomarkers and cardiac magnetic resonance in triathletes with and without myocardial fibrosis. Methods and results Thirty asymptomatic male triathletes (45 ± 10 years) with over 10 training hours per week and 55 ± 8 ml/kg per minute maximal oxygen uptake during exercise testing were studied before (baseline) and 2.4 ± 1.1 hours post-race. Baseline cardiac magnetic resonance included cine, T1/T2, late gadolinium enhancement (LGE) and extracellular volume imaging. Post-race non-contrast cardiac magnetic resonance included cine and T1/T2 mapping. Non-ischaemic myocardial fibrosis was present in 10 triathletes (LGE+) whereas 20 had no fibrosis (LGE–). At baseline, LGE + triathletes had higher peak exercise systolic blood pressure with 222 ± 21 mmHg compared to LGE– triathletes (192 ± 30 mmHg, P 2) compared to LGE + triathletes (161 ± 34 ml/s/m2, P 2, P 2, P = 0.747). Conclusion Despite post-race troponin T release, we did not find detectable myocardial oedema by cardiac magnetic resonance. However, the unfavourable blood pressure response during exercise testing seemed to be associated with post-race cardiac dysfunction, which could explain the occurrence of myocardial fibrosis in triathletes.

BACKGROUND Extensive and repeated substrate modification (SM) is frequently performed as an ablation strategy in persistent atrial fibrillation (persAF). The effect of these extended ablation strategies on atrial function has not been investigated sufficiently so far. The purpose was to assess atrial function by cardiac magnetic resonance (CMR) and its association with left atrial (LA) scar burden by electroanatomical voltage-mapping after multiple persAF ablation procedures. METHODS We included 16 persAF patients who had ≥2 SM procedures and a control group (CG) of 21 persAF patients without prior ablation. CMR was performed in sinus rhythm at least 4 weeks after the last cardioversion. Active left and right (RA) atrial emptying fractions (AEF) as well as peak active left atrial appendage (LAA) emptying velocities were obtained by CMR flow measurements. Furthermore, LA scar burden was quantified on electroanatomical voltage maps by the portion of points with local voltage amplitude

BACKGROUND Use of cocaine is widespread and associated with several cardiovascular diseases. Recent CMR studies indicate frequent myocardial scar/fibrosis in asymptomatic cocaine abusers (CA).Methods and Results:This study used a combination of advanced CMR tissue characterization techniques, including late gadolinium enhancement (LGE) for focal, and extracellular volume (ECV) imaging for diffuse myocardial injury/fibrosis, with circulating biomarkers for a comprehensive characterization of myocardial injury. We included 20 cardiac asymptomatic CA and a control group of 20 healthy volunteers. The comprehensive assessment included physical examination, resting ECG, exercise ECG, cardiac biomarkers, transthoracic echocardiogram and CMR. We did not find significant differences between CA and controls either in functional CMR parameters such as LVEDVi, LVESVi, LVEF, LV mass index, or in global myocardial ECV. Neither CA nor controls had evidence of myocardial edema on T2-weighted CMR, but 8 CA (40%), and none of the controls had focal myocardial scar (P

Background The purpose of this work is to describe the objectives and design of cardiovascular magnetic resonance (CMR) imaging in the single center, prospective, population-based Hamburg City Health study (HCHS). The HCHS aims at improving risk stratification for coronary artery disease (CAD), atrial fibrillation (AF) and heart failure (HF). Methods The HCHS will finally include 45,000 inhabitants of the city of Hamburg (Germany) between 45 and 74 years who undergo an extensive cardiovascular evaluation and collection of biomaterials. Risk-scores for CAD, AF and HF are used to create enriched subpopulations who are invited for CMR. A total number of approximately 12,362 subjects will undergo CMR and incident CAD, AF and HF will be assessed after 6 years follow-up. The standard CMR protocol includes cine-CMR, T1 and T2 mapping, aortic/mitral valve flow measurements, Late gadolinium enhancement, angiographies and measurements of aortic distensibility. A stress-perfusion scan is added in individuals at risk for CAD. The workflow of CMR data acquisition and analyses was evaluated in a pilot cohort of 200 unselected subjects. Results The obtained CMR findings in the pilot cohort agree with current reference values and demonstrate the ability of the established workflow to accomplish the objectives of HCHS. Conclusions CMR in HCHS promises novel insights into major cardiovascular diseases, their subclinical precursors and the prognostic value of novel imaging biomarkers. The HCHS database will facilitate combined analyses of imaging, clinical and molecular data (“Radiomics”).

Evaluation of cardiac mechanics in heart transplant recipients (HTR) is of paramount importance. Assessment of strain through echocardiography is suited to describe cardiac function and might allow characterizing patients with and without transplant vasculopathy (TVP) a risk factor of impaired organ function and rejection. For this study 41 HTR immediately after and 1-3 years after transplantation were examined in a retrospective approach with 2-dimensional speckle tracking echocardiography to assess longitudinal, radial and circumferential strain and strain rate. The cohort consists of 33 men and 8 women with a median age of 54 years (1st, 3rd; 45.7, 65.3) with seven cases diagnosed with TVP during follow-up, as diagnosed by coronary angiography. The overall cohort showed an improvement of global longitudinal strain from baseline to 1 and 3 years with -14.2% (-16.9, -12.3%) to -16.1% (-17.5, -14.3%) and -16.7% (-18, -13.7%), p = 0.036. For patients developing TVP, global longitudinal strain was not different from baseline up to the maximum of 3 years -16.6% (-16.7-13.8%) to -16.4% (-17.3, -14.7%) and -17.6% (-18.7, -16.9%) with p = 0.21. Radial strain and torsion showed a trend to decrease after transplantation with time. Circumferential strain remained stable in HTR but decreased in subjects with TVP. Longitudinal Strain and strain rate showed no relevant changes in HTR with and without TVP. Radial strain and torsion declined in HTR as well as TVP patients with time. Speckle tracking imaging is useful to assess organ function in HTR, however coronary angiography is still needed to rule out TVP.

Objectives This study evaluated the accuracy of T2, T1, and extracellular volume (ECV) quantification as novel quantitative tissue markers in comparison with standard “Lake-Louise” cardiac magnetic resonance (CMR) criteria to diagnose myocarditis. Background Novel approaches using T2 and T1 mapping may overcome the limitations of signal intensity-based parameters, which would potentially result in a better diagnostic accuracy compared with standard CMR techniques in suspected myocarditis. Methods CMR was performed in 104 patients with myocarditis and 21 control subjects at 1.5-T. Patients with myocarditis underwent CMR 2 weeks (interquartile range: 1 to 7 weeks) after presentation with new-onset heart failure (n = 66) or acute chest pain (n = 38). T2 and T1 mapping were implemented into a standard protocol including T2-weighted (T2w), early gadolinium enhancement (EGE) CMR, and late gadolinium enhancement (LGE) CMR. T2 quantification was performed using a free-breathing, navigator-gated multiecho sequence. T1 quantification was performed using the modified Look-Locker inversion recovery sequence before and after administration of 0.075 mmol/kg gadobenate dimeglumine. T2, T1, and ECV maps were generated using a plug-in for the OsiriX software (Pixmeo, Bernex, Switzerland) to calculate mean global myocardial T2, T1, and ECV values. Results The diagnostic accuracies of conventional CMR were 70% (95% confidence interval [CI]: 61% to 77%) for T2w CMR, 59% (95% CI: 56% to 73%) for EGE, and 67% (95% CI: 59% to 75%) for LGE. The diagnostic accuracies of mapping techniques were 63% (95% CI: 53% to 73%) for myocardial T2, 69% (95% CI: 60% to 76%) for native myocardial T1, and 76% (95% CI: 68% to 82%) for global myocardial ECV. The diagnostic accuracy of CMR was significantly improved to 90% (95% CI: 84% to 95%) by a stepwise approach, using the presence of LGE and myocardial ECV ≥27% as diagnostic criteria, compared with 79% (95% CI: 71% to 85%; p = 0.0043) for the Lake-Louise criteria. Conclusions In patients with clinical evidence for subacute, severe myocarditis, ECV quantification with LGE imaging significantly improved the diagnostic accuracy of CMR compared with standard Lake-Louise criteria.

Reversible Dysfunction After Persistent AF Ablation Introduction There is a paucity of data on atrial injury following ablation of persistent atrial fibrillation (AF). This study aimed at assessing reversibility of atrial dysfunction after successful persistent AF ablation using cardiovascular magnetic resonance (CMR). Methods and Results CMR was performed during sinus rhythm (SR) in 20 consecutive patients with persistent AF at baseline (BL) within 24 hours after ablation and after 6-month follow-up (FU). Catheter ablation included atrial substrate modification using the stepwise approach following pulmonary vein isolation (PVI) in order to attempt termination of persistent AF. Active left (LA) and right atrial (RA) function were quantified by calculating the active emptying fraction (AEF) from transvalvular flow profiles using velocity encoded (VENC) CMR. LA appendage (LAA) function was quantified by measurements of peak a-wave velocities from flow profiles perpendicular to the LAA orifice. Peri-atrial edema was assessed using black-blood T2-weighted CMR. A significant improvement was found in LA-AEF from 18 (12–26)% at BL to 25 (22–35)% at FU (P = 0.0001). Furthermore, RA-AEF significantly increased from 31 (19–35)% at BL to 40 (35–51)% at FU (P < 0.0001). A significant improvement was also found for LAA a-wave velocities from 45 (31–65) cm/s at BL to 62 (49–75) cm/s at FU (P < 0.01). The area of peri-atrial edema on T2-weighted CMR decreased from 1393 (1098–1797) mm2 at BL to 24 (1–92) mm2 at FU (P < 0.0001). Conclusion CMR demonstrates reversibility of LA, LAA, and RA dysfunction associated with resorption of peri-atrial edema in patients with SR after persistent AF ablation.

This study evaluated the ability of T1 and T2 mapping cardiovascular magnetic resonance (CMR) to detect myocardial injury in apparently normal myocardium of patients with myocarditis. We included 20 patients with “infarct-like” acute myocarditis who had typical focal myocardial lesions on late gadolinium enhancement (LGE) images as well as 20 healthy controls. The CMR protocol consisted of a standard myocarditis protocol which was combined with T1 (modified Look-Locker inversion recovery (MOLLI) with a 3(3)5 scheme and T2 mapping (hybrid gradient- and spin-echo multi-echo sequence, GraSE). First, LGE images were used to depict focal myocardial injury and apparently normal, remote myocardium. Second, native T1, T2 and ECV values were obtained in focal lesions but also in apparently normal myocardium. Third, native T1, T2 and ECV values ≥2 standard deviations above reference values obtained in healthy volunteers were used to quantify myocardial injury in patients with myocarditis. Apparently normal myocardium had significantly higher median native T1 [1095 (1055–1148) ms] and ECV [34 (32–35) %] values compared to reference values from healthy volunteers, which were 1051 (1021–1064) ms (p

Background: Cardiac magnetic resonance imaging uses contractile response to dobutamine (DCMR) and delayed contrast enhancement (DE) to assess myocardial viability. However, early after acute myocardial infarction (AMI) the optimal dose of dobutamine is unclear. Methods: In patients early after reperfused AMI, DCMR at 5, 10 and 20 µg*kg–1*min–1 and measurement of DE was performed. On three short-axis slices 18 segments were graded as no DE, DE 2 SD below normal or Results: Forty-nine patients participated. In segments with no DE, thickening increased continuously but contractile reserve was low (0.9 ± 3.2 mm) and dysfunctional segments were unchanged (rest: 13.1% vs. 20 µg: 14.8%). In segments with DE, contractile reserve was high (1.4 ± 3.0 mm and 1.5 ± 3.0 mm) and dysfunctional segments decreased from rest to 20 µg (50 vs. 24.8% and 79.9 vs. 43.2%). Between 5 and 10 µg no change of thickening and of dysfunctional segments occurred. Conclusion: Early after AMI, DCMR demonstrated no diagnostic benefit in segments with no DE. In segments with DE, higher dose of dobutamine can provide additional information on contractile reserve and dysfunctional segments.

Background— This study evaluated the performance of novel quantitative T1 and T2 mapping cardiovascular magnetic resonance (CMR) techniques to identify active myocarditis in patients with recent-onset heart failure. Methods and Results— Thirty-one consecutive patients with recent-onset heart failure, reduced left ventricular function and clinically suspected myocarditis underwent endomyocardial biopsy and CMR at 1.5 Tesla. The CMR protocol included standard Lake-Louise parameters as well as T1 mapping using a modified Look-Locker inversion recovery sequence and T2 mapping using a hybrid gradient and spin-echo sequence. Short-axis maps were generated using an OsiriX plug-in to calculate global myocardial T1, T2, and extracellular volume fraction. Active myocarditis was defined by ongoing inflammation on endomyocardial biopsy. Endomyocardial biopsy revealed active myocarditis in 16 (52%) of 31 patients. Neither clinical characteristics, standard Lake-Louise CMR parameters, global myocardial T1 nor extracellular volume fraction differed significantly between patients with and without active myocarditis. However, median global myocardial T2 was significantly higher in patients with active myocarditis (65 ms [Q1–Q3, 61–70 ms]) than in patients without active myocarditis (59 ms [Q1–Q3, 55–64 ms]; P Conclusions— T2 mapping seems to be superior when compared with standard CMR parameters, global myocardial T1, and extracellular volume fraction values for assessing the activity of myocarditis in patients with recent-onset heart failure and reduced left ventricular function.

Background T1 mapping and ECV imaging are promising diagnostic tools in patients with suspected myocarditis. However, there are currently no data on the potential influence of slice orientation on the derived T1 and ECV values. Thus, we compared global myocardial T1 and ECV values between slices with short and long axis orientation. Methods This study included 50 patients with clinically suspected myocarditis, who underwent CMR at 1.5 Tesla. T1 quantification was performed on three short (basis, center, apex) and on three long axis slices (2-, 3- and 4-chamber orientation), respectively. The modified Look-Locker inversionrecovery (MOLLI) sequence was used before and 15 minutes after administration of 0.075 mmol/kg GadoliniumBOPTA. Native T1, post-contrast T1 and extracellular volume (ECV) maps were calculated using a dedicated plug-in written for the OsiriX software. Mean native and post-contrast T1 as well as ECV were obtained from the three short and long axes, respectively. Results There were significantly lower median native myocardial T1 values on long axis slices (1079 (1040-1130.0)) compared to short axis slices (1103 (1069-1140); p=0.0026). However, there were no significant differences in postcontrast myocardial T1 values (median 554 (505-596) vs. 555 (509-601); p=0.2299) or ECV (median 30 (27-33) vs. 29 (26-33); p=0.6063) between short and long axis slices, respectively. Conclusions Slice orientation could be a potential confounding factor for the assessment of native global myocardial T1 values in myocarditis. Possible explanations for this finding include technical issues, such as variations in throughplane motion or partial-volume effects related to slice orientation, but also the heterogeneity of myocardial injury in myocarditis. However, our data indicate that global myocardial ECV values could be less sensitive to slice orientation.

Poster: "ECR 2015 / B-0469 / Serial native T1- and T2-mapping to quantitatively monitor resorption of myocardial edema following acute myocardial infarction" by: "E. Tahir, M. Sinn, M. Avanesov, U. Radunski, D. Saering, K. Muellerleile, C. Stehning, G. Adam, G. K. Lund; Hamburg/DE"

We thank Dr. Luetkens and colleagues for their interest in our work [(1)][1]. We agree that all novel diagnostic techniques require careful evaluation before clinical implementation, but some aspects of Luetkens et al. require clarification. In particular, we disagree that our inhomogeneous patient

Background Predicting mortality in patients with non-ischemic dilated cardiomyopathy (NIDCM) is currently demanding and requires complex models. Assessing the extracellular volume fraction (ECV) by T1-mapping cardiovascular magnetic resonance (CMR) is an attractive approach to quantify myocardial injury as a potential predictor of adverse events in these patients. This study evaluated ECV imaging by T1-mapping CMR in comparison with the established “Seattle Heart Failure Model” (SHFM; http://www.seattleheartfailuremodel.org). Methods This study included 50 patients with heart failure and reduced left ventricular (LV) ejection fraction due to non-ischemic cardiomyopathy. The SHFM was used to estimate 1, 2 and 5 year mortalities as well as life expectancy, respectively. T1 quantification was performed at 1.5 Tesla using the modified Look-Locker inversionrecovery (MOLLI) sequence on 3 short-axes before and 15 minutes after administration of 0.075 mmol/kg gadolinium-BOPTA. Global myocardial ECV was then calculated from native and post-contrast T1 maps generated by a dedicated plug-in written for the OsiriX software, respectively. Results Median predicted 1-, 2- and 5-year mortalities were 4% (interquartile range 2-6%), 7% (interquartile range 5-12%) and 16% (interquartile range 12-28%) in the study population, respectively. Median estimated life expectancy was 13 years (interquartile range 9-15 years). A significant correlation was found between global myocardial ECV and predicted 1- (r = 0.47; p < 0.001), 2- (r = 0.46; p < 0.001) and 5-year mortality (r = 0.46; p < 0.001), respectively. Furthermore, a significant inverse correlation was found between global myocardial ECV and predicted life expectancy (r = -0.37; p < 0.01). Conclusions Myocardial injury as quantified by ECV-imaging correlates well with predicted mortality and has great potential to improve risk stratification in patients with heart failure due to NIDCM. Funding

Background Assessing the extracellular volume fraction (ECV) by T1 mapping and T2 quantification are promising quantitative cardiovascular magnetic resonance (CMR) tools in acute myocardial injury. This study evaluated the diagnostic value of combining ECV imaging and T2 quantification in patients with clinically suspected myocarditis. Methods Short-axis T1 and T2 mapping were implemented into a standard CMR protocol at 1.5 Tesla in 36 patients with clinically suspected myocarditis. T1 quantification was performed for ECV calculation using the modified Look-Locker inversion-recovery (MOLLI) sequence before and 15 minutes after administration of 0.075 mmol/kg gadolinium BOPTA. T2 quantification was performed using a free-breathing, navigator-gated multiecho sequence. T1 and T2 maps were calculated with a dedicated plug-in written for the OsiriX software. Relaxation rates (1/T1 = R1) were calculated for myocardium and blood pool. The difference in R1 between pre- and post contrast media was calculated as ΔR1. Myocardial ECV was then estimated using the formula: ECV = 1-hematocrit * (ΔR1myocardium/ΔR1blood pool). Figure 1 demonstrates an example for a T2 map and T1 maps pre-/post contrast media in comparison with standard black-blood T2 STIR and late gadolinium enhancement (LGE) images.

Background Assessing the extracellular volume fraction (ECV) by T1 mapping is a promising cardiovascular magnetic resonance (CMR) approach to quantify myocardial injury. This study evaluated ECV imaging by T1 mapping CMR in patients with clinically suspected myocarditis. Methods T1 mapping was implemented into a standard CMR protocol in 113 patients with clinically suspected myocarditis at 1.5 Tesla. T1 quantification was performed for ECV -calculation using the modified Look-Locker inversionrecovery (MOLLI) sequence on three short-axes before and 15 minutes after administration of 0.075 mmol/kg gadolinium BOPTA, respectively. Global left ventricular ECV was calculated from T1 maps generated with a dedicated plug-in written for the OsiriX software: relaxation rates (1/T1 = R1) were calculated for myocardium and blood pool. The difference in R1 between pre- and post contrast media was calculated as ΔR1. Myocardial ECV was then estimated using the formula: ECV = 1-hematocrit * (ΔR1myocardium/ΔR1blood pool). Figure 1 demonstrates an example for T1 maps pre- and post contrast media in comparison with standard black-blood T2 STIR and late gadolinium enhancement (LGE) images. Results The final study population consisted of 96 patients after exclusion of 17 patients with concomitant coronary artery disease or severe left ventricular hypertrophy. Current clinical and CMR criteria identified 64 (67 %) patients with myocarditis and 32 (33 %) patients without myocarditis in the final study population. Global ECV was significantly larger in patients with myocarditis compared to patients without myocarditis (35±6 vs. 30±5 %, p

Background The presence of impaired left atrial appendage (LAA) function identifies patients who are prone to thrombus formation in the LAA and therefore being at high risk for subsequent cardioembolic stroke. LAA function is typically assessed by measurements of LAA emptying velocities using transesophageal echocardiography (TEE) in clinical routine. This study aimed at evaluating the feasibility of assessing LAA emptying by velocity encoded (VENC) cardiovascular magnetic resonance (CMR). Methods This study included 30 patients with sinus rhythm (n = 18) or atrial fibrillation (n = 12). VENC-CMR velocity measurements were performed perpendicular to the orifice of the LAA. Peak velocities were measured of passive diastolic LAA emptying (e-wave) in all patients. Peak velocities of active, late-diastolic LAA emptying (a-wave) were assessed in patients with sinus rhythm. Correlation and agreement was analyzed between VENC-CMR and TEE measurements of e- and a-wave peak velocities. Results A significant correlation and good agreement was found between VENC-CMR and TEE measurements of maximal e-wave velocities (r = 0.61, P Conclusions The assessment of active and passive LAA emptying by VENC-CMR is feasible. Further evaluation is required of potential future clinical applications such as risk stratification for cardioembolic stroke.

Summary This study aimed at assessing left ventricular (LV), left atrial (LA) and right ventricular (RV) volumes in patients before and after MitraClip™ implantation by cardiac magnetic resonance imaging (CMR). Background The MitraClip™ is a novel device for percutaneous mitral valve repair. Recent studies demonstrated a reduction of LV volumes after MitraClip™ implantation using echocardiography. CMR is currently the reference method to assess cardiac volumes but has not been used to assess LV remodeling after MitraClip™ implantation so far. Methods Twelve patients with functional (n=7) or degenerative (n=5) mitral valve regurgitation grade 3 to 4 underwent CMR at baseline (BL) before and at 6 month follow-up (FU) after successful MitraClip™ implantation. CMR protocol consisted of short- and long-axis slices using a steady-state-free-precession cine sequence for the assessment of LV, LA and RV volumes. Results Minor device-related artifacts were observed, enabling reliable delineation of endocardial borders in all patients at FU. Figure 1) demonstrates typical device-related artifacts 6 month after implantation (A) in comparison with a corresponding pre-implantation image (B). Mean intra- and inter-observer biases were 0.9±2.0 and 1.6 ±2.9 % for LV end-diastolic (LVEDV), 0.3±4.7 and 1.8 ±6.4 % for LV end systolic (LVESV), 0.1±2.9 and 2.2±3.7 % for RVEDV, 1.7±7.8 and 3.5±8.8 % for RVESV as well as 0.3±7.6 and 13.7±14.0 % for LA (LAV) volume indices at FU. No significant differences in intra- or inter-observer biases were observed between BL and FU. LVEDV (127 (96-150) vs. 112 (86-150) ml/m 2 ; p=0.03) as well as LVESV (82 (54-91) vs. 69 (48-99) ml/m 2 ; p=0.03) indices significantly decreased from BL to FU. No significant difference was found for RVEDV (94 (75103) vs. 99 (77-123) ml/m 2 ; p=0.91), RVESV (48 (42-80) vs. 51 (40-81) ml/m 2 ; p=0.48) and LAV (87 (55-124) vs. 92 (48-137) ml/m 2 ; p=0.20) indices between BL and FU.

Growing attention has been recently paid to the assessment of active LA emptying in patients after ablation of atrial fibrillation. Measurements of active LA emptying are typically performed by echocardiography in clinical routine. However, little is known about the role of cardiac MRI for this purpose. The present study evaluated the relative merits of biplane long-axis cine- and VENC-MRI for the assessment of active LA emptying.

Diastolic dysfunction was recently recognized as an important cause for heart failure in patients with preserved ejection fraction. Diastolic dysfunction is typically assessed in clinical routine using transmitral and pulmonary-venous flow characteristics by Doppler-echocardiography. We hypothesized that VENC-MRI has a similar ability to identify patients with diastolic dysfunction compared to Doppler-echocardiography.

The presence of reduced LAA flow velocities indicates patients who are prone to thrombus formation in the LAA and therefore being at high risk for subsequent cardioembolic stroke. LAA flow velocities are typically assessed by TEE in clinical routine. VENC-MRI is an established tool for the quantification of transvalvular flow, but the feasibility of LAA flow measurements by VENC-MRI has not been studied so far.

Methods The study included twenty patients with heart failure NYHA class III and reduced ejection fraction (24 (18-28) %), scheduled for CRT device implantation. All patients underwent cineand VENC-MRI before device implantation. Intra-ventricular dyssynchrony was measured by cine-MRI as the septal-to-lateral mechanical delay (SLMD). The inter-ventricular mechanical delay (IVMD) was assessed by VENC-MRI as the difference between onset of aortic and pulmonary flow. Clinical response to CRT was assessed at 6-month follow-up after device implantation.

Background Focal myocardial injury is an important diagnostic feature of myocarditis and is typically assessed by cardiovascular magnetic resonance (CMR) on late gadolinium enhancement (LGE) images. T1 mapping, T2 mapping, and extracellular volume (ECV) imaging are novel techniques which potentially improve the diagnostic value of CMR in myocarditis. This study evaluated the potential of T1 and T2 mapping CMR to assess focal myocardial lesions in myocarditis. Methods We included 20 patients with myocarditis who had typical focal myocardial lesions on LGE images as reference method. Native T1, T2, and ECV maps were acquired in addition to a conventional CMR protocol at 1.5 Tesla. Myocardial lesions were quantified on LGE images by a standard threshold technique using a region of interest in normal appearing myocardium as reference tissue. Furthermore, myocardial lesions were quantified using normal values for native myocardial T1, T2, and ECV obtained from a group of 20 matched healthy controls as reference tissue. Injured myocardium was defined by a signal-intensity, native myocardial T1, T2 and ECV ≥ 2 standard deviations above reference values and expressed in percent of LV myocardium. Results Median lesion size was 14% (9-20%) on LGE images. Areas with normal appearing myocardium on LGE images had significantly increased median native myocardial T1 and ECV values compared to myocardium of healthy volunteers (1085ms (1048-1120ms) vs. 1051ms (1021-1064ms); p

A 57-year-old woman presented with signs of recurrent right ventricular congestion and dyspnea. She had a history of mechanic aortic and mitral valve replacement resulting from acute endocarditis 7 years ago. At that time, endocarditis resulted in destruction of the aortic-mitral fibrous curtain and part of the left ventricular (LV) outflow tract, rendering implantation of prosthetic valves difficult. The cuffs of both prosthetic valves were sutured together directly to ensure stable fixation. Current echocardiographic evaluation revealed good LV contraction, normal function of the mechanic valves, and normal diameters of both ventricles. An arterially supplied neocavity was found between both atria (Figure 1). Transesophageal echocardiography suggested a dehiscence …

Background Cardiac magnetic resonance imaging (CMR) enables infarct and edema size measurement on LGEand T2wCMR, respectively. However, evaluation of infarct and edema size using a threshold method is time consuming and relies on accurate placement of normal regions of interest and manual delineation of the respective areas. The purpose of the study was to analyze the accuracy and expenditure of time of a new algorithm for infarct and edema size measurement using LGEand T2wCMR in comparison to a standard evaluation strategy.

Background There is an overlapping phenotype in patients with newonset systolic heart failure due to myocarditis and dilative cardiomyopathy (DCM). Differentiation between both etiologies has important therapeutic and prognostic implications and is currently based on endomyocardial biopsy (EMB). In contrast, current cardiovascular magnetic resonance (CMR) techniques are of limited value in these patients with predominantly diffuse myocardial injury. This study evaluated the performance of quantitative T1- and T2-mapping CMR to differentiate between active myocarditis and DCM in patients with new-onset systolic heart failure. Methods This study included 26 patients with new-onset systolic heart failure and reduced left ventricular (LV) ejection fraction (32 ± 12 %), who underwent EMB and CMR at 1.5 Tesla. The protocol included conventional sequences (T2w-STIR), Early- (T1w-TSE) and Late-GadoliniumEnhancement (PSIR). Furthermore, T1 quantification was performed using the modified Look-Locker inversionrecovery (MOLLI) sequence before (native) and 15 minutes after administration of 0.075 mmol/kg GadoliniumBOPTA. T2 quantification was performed using a freebreathing, navigator-gated multi-echo sequence. Native T1, post-contrast T1, extracellular volume (ECV) and T2 maps were calculated with a dedicated plug-in written for the OsiriX software. Results EMB revealed variants of active myocarditis in 13 (50 %) and DCM in the remaining 13 (50 %) patients. The ROC areas-under-the-curve (AUC) to discriminate between both etiologies was 0.54 (p = 0.77) for Early-GadoliniumEnhancement, 0.63 (p = 0.23) for Late-GadoliniumEnhancement, 0.68 (p = 0.11) for T2w-STIR, 0.66 (p = 0.17) for native global myocardial T1, 0.72 (p = 0.05) for post-contrast global myocardial T1, 0.61 (p = 0.36) for global myocardial ECV and 0.74 (p < 0.05) for global myocardial T2. Sensitivity and specificity were 50 % and 83 % to discriminate between myocarditis and DCM using global myocardial T2 (optimal cut-off ≥ 60 ms). Conclusions Assessing myocardial inflammation by T2-mapping CMR could be helpful to discriminate between active myocarditis and DCM in patients with new-onset systolic heart failure. T2-mapping CMR appears to be superior compared to conventional techniques but also to T1-mapping CMR in this context. Funding

Background Cardiac magnetic resonance imaging (CMR) with delayed gadolinium enhancement (DE) enables accurate infarct size measurement, however, the evaluation of infarct size using a threshold method is time consuming and relies on accurate placement of normal regions of interest and manual delineation of the infarct size. The purpose of the study was to analyze the accuracy and expenditure of time of a new evaluation strategy for infarct size measurement using delayed enhancement CMR in comparison to a standard evaluation.

Background Cocaine abuse is associated with an increased risk for coronary artery disease and myocardial infarction. However, there is a paucity of data on myocardial injury in asymptomatic cocaine abusers. T1 mapping cardiovascular magnetic resonance (CMR) has the ability to quantify diffuse alterations in myocardial tissue composition by assessing the extracellular volume fraction (ECV). This study aimed at detecting silent myocardial injury in cocaine abusers using CMR. Methods CMR was performed in eleven cocaine abusers and eleven matched controls without a history of cardiovascular disease. CMR protocol consisted of standard cine-, T2-STIR- and late gadolinium enhancement (LGE) CMR sequences to assess cardiac volumes and function, myocardial edema and focal myocardial fibrosis, respectively. Myocardial extracellular volume fraction (ECV) was assessed using a T1 mapping sequence (MOLLI) before and after administration of 0.075 mmol/kg gadolinium BOPTA: T1 maps were calculated with a dedicated plug-in written for the OsiriX software. Relaxation rates (1/T1 = R1) were calculated for myocardium and blood pool. The difference in R1 between pre- and post contrast media was calculated as ΔR1. Myocardial ECV was then estimated using the formula: ECV = 1-hematocrit * (ΔR1myocardium/ΔR1blood pool).

Background Currently, myocardial edema monitoring after acute myocardial infarction (AMI) is based on visualization of the region with increased signal-intensity on T2-weighted images. T2-mapping is a promising novel cardiac magnetic resonance imaging (CMR) technique to quantitatively assess myocardial edema. The purpose of the study was to quantitatively evaluate resorption of myocardial edema following AMI using T2-mapping. Methods

A restrictive filling pattern is an independent prognostic marker for an increased mortality in patients with reduced systolic LV function. The diagnosis is currently established by characterization of transmitral and pulmonary-venous flow using Doppler-echocardiography. VENC-MRI enables robust quantification of transmitral as well as pulmonary-venous flow.

Summary This study evaluated the course of active left atrial (LA), LA appendage (LAA) and right atrial (RA) emptying with respect to ablation-related inflammation after persistent AF ablation by cardiac magnetic resonance imaging (CMR). Background Catheter ablation of persistent atrial fibrillation (AF) aims at reestablishing active atrial emptying. However, little is known on recovery of active atrial emptying and inflammation after successful ablation of persistent AF. Methods