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Objectives: To assess the incidence of acute adverse events (AAEs) in gadolinium-enhanced cardiac magnetic resonance (CMR) imaging., Methods: Gadolinium-based contrast agent (GBCA)-enhanced CMR data from the multinational, multicenter European Society of Cardiovascular Radiology MRCT Registry was included. AAE severity was classified according to the American College of Radiology Manual on Contrast Media (mild, moderate, severe). Multivariable generalized linear mixed effect models were used to assess the likelihood of AAEs in various GBCA, adjusting for pharmacological stressor, main indications (i.e., suspected or known coronary artery disease or myocarditis), age, sex, and submitting center as a random effect., Results: In the study population of 72,839 GBCA-enhanced CMRs, a total of 260 AAEs were reported (0.36%), with a minority of severe AAEs (n = 24, 0.033%). Allergic-like AAEs were less likely than physiologic AAEs (29% versus 71%). Patients without pharmacological stress imaging had a lower AAE rate (0.22%) compared to stress imaging (0.75%), with the highest AAE rates for regadenoson (2.95%). AAE rates also varied by GBCA subtype (overall p < 0.001). There was significant interaction between GBCA and pharmacological stressor (interaction p = 0.025), with AAE rates ranging between 0 and 10% for certain GBCA/stressor combinations. There was further marginal evidence that higher GBCA volume was associated with higher AAE incidence (OR = 1.02, p = 0.05)., Conclusion: GBCA-enhanced CMR imaging demonstrates low AAE rates comparable to those of other body regions. AAE likelihood correlates with GBCA subtype, pharmacological stressor, and imaging indication. Intravenous fluid administration in patients with cardiac impairment might contribute to these findings., Key Points: • Acute adverse event rates in cardiac magnetic resonance (CMR) imaging with gadolinium-based contrast agents (GBCAs) are low (0.36%), especially for severe adverse events (0.033%). • Mild and moderate adverse events are more frequent during stress CMR imaging. • Physiologic AAEs are more common than allergic AAEs in CMR imaging.

Background: Intramyocardial haemorrhage (IMH) and microvascular obstruction (MVO) represent reperfusion injury after reperfused ST-elevation myocardial infarction (STEMI) with prognostic impact and "hypointense core" (HIC) appearance in T2-weighted images. We aimed to distinguish between IMH and MVO by using T2 (*)-weighted cardiovascular magnetic resonance imaging (CMR) and analysed influencing factors for IMH development., Methods and Results: A total of 151 patients with acute STEMI underwent CMR after primary angioplasty. T2-STIR sequences were used to identify HIC, late gadolinium enhancement to visualise MVO and T2 (*)-weighted sequences to detect IMH. IMH(+)/IMH(-) patients were compared considering infarct size, myocardial salvage, thrombolysis in myocardial infarction (TIMI) flow, reperfusion time, ventricular volumes, function and pre-interventional medication. Seventy-six patients (50%) were IMH(+), 82 (54%) demonstrated HIC and 100 (66%) MVO. IMH was detectable without HIC in 16 %, without MVO in 5% and HIC without MVO in 6%. Multivariable analyses revealed that IMH was associated with significant lower left ventricular ejection fraction and myocardial salvage index, larger left ventricular volume and infarct size. Patients with TIMI flow grade ≤1 before angioplasty demonstrated IMH significantly more often., Conclusions: IMH is associated with impaired left ventricular function and higher infarct size. T2 and HIC imaging showed moderate agreement for IMH detection. T2 (*) imaging might be the preferred CMR imaging method for comprehensive IMH assessment., Key Points: Intramyocardial haemorrhage is a common finding in patients with acute reperfused myocardial-infarction. T 2 (*) imaging should be the preferred CMR method for assessment of intramyocardial haemorrhage. Intramyocardial haemorrhage can be considered as an important influencing factor on patient's outcome.

Objective: Comparing the diagnostic value of multi-sequential cardiac magnetic resonance imaging (CMR) with endomyocardial biopsy (EMB) for sub-clinical cardiac allograft rejection., Methods: One hundred and forty-six examinations in 73 patients (mean age 53 ± 12 years, 58 men) were performed using a 1.5 Tesla system and compared to EMB. Examinations included a STIR (short tau inversion recovery) sequence for calculation of edema ratio (ER), a T1-weighted spin-echo sequence for assessment of global relative enhancement (gRE), and inversion-recovery sequences to visualize late gadolinium enhancement (LGE). Histological grade ≥1B was considered relevant rejection., Results: One hundred and twenty-seven (127/146 = 87 %) EMBs demonstrated no or mild signs of rejection (grades ≤1A) and 19/146 (13 %) a relevant rejection (grade ≥1B). Sensitivity, specificity, positive predictive, and negative predictive values were as follows: ER: 63 %, 78 %, 30 %, and 93 %; gRE: 63 %, 70 %, 24 %, and 93 %; LGE: 68 %, 36 %, 13 %, and 87 %; with the combination of ER and gRE with at least one out of two positive: 84 %, 57 %, 23 %, and 96 %. ROC analysis revealed an area under the curve of 0.724 for ER and 0.659 for gRE., Conclusion: CMR parameters for myocarditis are useful to detect sub-clinical acute cellular rejection after heart transplantation. Comparable results to myocarditis can be achieved with a combination of parameters., Key Points: • Magnetic resonance imaging is useful for the assessment of cardiac allograft rejection. • CMR has a high negative predictive value for exclusion of allograft rejection. • Diagnostic performance is not yet good enough to replace endomyocardial biopsy.

Background: The presence of pericardial effusion (PE) is considered to be suggestive of inflammation in suspected myocarditis. However, the incremental value of assessing for PE in addition to comprehensive cardiac magnetic resonance (CMR) imaging remains unclear., Methods: In total, 132 patients with suspected acute (AMC) or chronic myocarditis (CMC) were included. All patients underwent endomyocardial biopsy (EMB) and CMR. Imaging protocols included T2 imaging for the assessment of myocardial oedema (oedema ratio [ER]), T1 imaging before and after contrast agent administration for global relative enhancement (gRE) calculation, and late enhancement (LE). Furthermore, the presence and extent of PE were determined. The potential incremental diagnostic value of PE was determined by applying a two, three, or four out of four criteria approach including ER, gRE, LE, and PE., Results: PE was present in 84 of the 132 patients (63.6%) and was more common in suspected AMC vs. CMC (56 of 70 vs. 28 of 62; P < 0.001). According to EMB results, PE was found in 86% of patients with AMC, 67% with chronic myocarditis, and 56% without evidence of myocardial inflammation. Implementing PE into a three out of four approach did not result in improved accuracy compared with the established two out of three approach using ER, gRE, and LE (59 vs. 68% for the total population, 69 vs. 79% for suspected AMC, and 48 vs. 52% for suspected CMC)., Conclusion: The finding of PE in unselected patients with suspected AMC or CMC is not specific to myocarditis. Therefore, with the currently applied criteria and methods, assessment of PE does not improve the diagnostic performance of CMR in this patient cohort., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2013. For permissions please email: journals.permissions@oup.com.)

Objectives: To test the hypothesis that myocardial scars cause systolic dysfunction in patients with transposition of the great arteries and a systemic right ventricle., Methods: We retrospectively analyzed 20 consecutive patients (10 male, mean age 27.3 years) with a systemic right ventricle who underwent cardiac magnetic resonance imaging with 1.5 T. Cine steady-state free-precession sequences were performed to obtain volumes and function. Phase-sensitive inversion-recovery (PSIR) delayed-enhancement imaging was performed to detect myocardial scars. Tricuspid insufficiency was detected with echocardiography. Furthermore, the presence of arrhythmias and New York Heart Association (NYHA) class were assessed., Results: Mean ejection fraction of systemic right ventricles was 43 ± 11 %, mean end-diastolic volume index was 111 ± 37 ml/m(2). Delayed-enhancement imaging revealed only one myocardial scar in the wall of a right ventricular aneurysm. All patients but one (95 %) presented with tricuspid insufficiency. Clinically relevant arrhythmias were present in 13/20 patients (65 %). The majority of patients (90 %) were NYHA class I or II. Arrhythmias, tricuspid insufficiency and NYHA class were not associated with right ventricular ejection fraction., Conclusions: Although right ventricular function was clearly impaired in our patient cohort, there was only one myocardial scar. Our results show that myocardial scarring assessed by PSIR delayed-enhancement imaging is not the underlying pathology of systemic right ventricular failure.

Cardiovascular magnetic resonance imaging (CMRI) has become the primary tool for the non-invasive assessment in patients with suspected myocarditis, especially after exclusion of acute coronary syndrome (ACS) for the differential diagnosis. Various MRI parameters are available which have different accuracies. Volumetric and functional ventricular assessment and the occurrence of pericardial effusion alone demonstrate only a poor sensitivity and specificity. The calculation of the T2-ratio (edema assessment), the early or global relative myocardial enhancement (gRE) and the late gadolinium enhancement (LGE), which represents irreversibly injured myocardium, are more specific parameters. All MRI parameters demonstrate the best accuracy in infarct-like acute myocarditis, whereas in chronic myocarditis sensitivity and specificity are less accurate. Therefore, a multisequential (at least two out of three parameters are positive) approach is recommended. The assessment of the value of newer, more quantitative MRI sequences, such as T1 and T2-mapping is still under investigation.

Background: Systemic right ventricle (RV) hypertrophy and impaired function occur after atrial switch for dextro-transposition of the great arteries (d-TGA). Echocardiography is limited in its ability to assess the RV. We sought to evaluate systemic RV myocardial-mass index (MMI) and function after atrial switch and to analyse the role of hypertrophy for ventricular function with special consideration of the interventricular septal (IVS) movement., Methods: Thirty-seven consecutive patients (median age 22.9 years) after atrial switch were studied using cardiac magnetic resonance imaging (1.5T Intera, Philips) with a dedicated 5-channel phased-array surface cardiac coil. Cine steady-state free-precession sequences were acquired to obtain myocardial masses and function. The systolic movement of the IVS was defined as positive when moving towards the centroid of the RV and was defined as non-positive otherwise. Patient parameters were compared to controls., Results: The systemic RVs were significantly larger (p < 0.001) than the left ventricles of the control group, systolic function was significantly impaired (p < 0.001) and MMI including the IVS was comparable (p = n.s.). RV-MMI excluding the IVS and RV ejection fraction (EF) demonstrated a quadratic correlation (r = 0.6, p < 0.001), meaning that patients with RV-MMI ≤29 g/m(2) and >68 g/m(2) had a reduced level of systolic function. Positive septal movement improved RV function compared with non-positive septal movement (p = 0.024)., Conclusions: There seems to be a range of beneficial RV hypertrophy after atrial switch in which a sufficient RV-EF can be expected. A positive septal movement, probably the result of hypertrophic septal RV fibres, improves RV function and might be regarded as a beneficial contraction pattern.

Objective: To retrospectively assess the prevalence and functional relevance of lipomatous metaplasia (LM) of the left ventricle in patients with chronic ischaemic heart disease (CIHD) using cardiac magnetic resonance imaging (cMRI) with steady state free precession (SSFP) sequences., Methods: We examined 315 patients (248 male, mean age 63 +/- 10 years) with a history of CIHD by cMRI. Standard SSFP sequences were applied and results were correlated with findings from cardiac catheterisation and computed tomography. In a subgroup of patients with LM (LM+) the functional results were correlated with patients without LM (LM-) as controls matched for age, body mass index, gender and infarct size., Results: Of 315 patients, 36 showed LM. LM+ patients showed a higher tendency to develop aneurysms compared with LM- (31% vs. 17%; not significant), but no differences in ejection fraction or volumetric parameters. LM occurred significantly more often in older infarcts and patients with hyperlipoproteinaemia, while other cardiac risk factors or medication did not have a significant influence on the development of LM., Conclusions: LM is a common finding (11%) in patients with CIHD. LM does not have a significant influence on global cardiac function or ventricular size, but on local function and probably also on the development of left ventricular aneurysms.

Background: Pulmonary regurgitation is a common finding in patients after correction of tetralogy of Fallot (TOF). Right ventricular impairment and even ventricular arrhythmia have been ascribed to pulmonary valve insufficiency (PI), which is therefore an important issue in follow-up examinations., Objective: To compare PI measured by echocardiography (ECHO) with data provided by cardiac MRI (CMR)., Materials and Methods: We studied 54 selected patients (18 female; median age 14.0 years, range 3.8-53.4 years) after surgical correction of TOF. To quantify pulmonary regurgitant fraction (PRF) by CMR, flow velocity mapping was performed. On Doppler ECHO, length, width and localization of regurgitant flow was measured. The severity of PI was categorized as mild, moderate or severe and compared to the data obtained by CMR., Results: On CMR the mean PRF was 29.2 +/- 13.4%. Patients with a transannular patch had a significantly higher PRF (39.9 +/- 11.6%) than patients with an intact annular ring (23.6 +/- 11.4%). Differentiation by Doppler ECHO between the categories mild, moderate and severe PI was confirmed by significant differences in PRF measured by CMR (mild vs. moderate P < 0.04; moderate vs. severe P < 0.014; mild vs. severe P < 0.001). Furthermore, PRF correlated with right ventricular end diastolic volume index (r = 0.45, P < 0.01) and right ventricular end systolic volume index (r = 0.39, P < 0.01)., Conclusion: Doppler ECHO can estimate the severity of PI after repair of TOF with acceptable results compared to CMR flow measurement. In univariate analysis there is only a weak influence of PRF on right ventricular volume.

The aim of this paper is to examine signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and image quality of cardiac CINE imaging at 1.5 T and 3.0 T. Twenty volunteers underwent cardiac magnetic resonance imaging (MRI) examinations using a 1.5-T and a 3.0-T scanner. Three different sets of breath-held, electrocardiogram-gated (ECG) CINE imaging techniques were employed, including: (1) unaccelerated SSFP (steady state free precession), (2) accelerated SSFP imaging and (3) gradient-echo-based myocardial tagging. Two-dimensional CINE SSFP at 3.0 T revealed an SNR improvement of 103% and a CNR increase of 19% as compared to the results obtained at 1.5 T. The SNR reduction in accelerated 2D CINE SSFP imaging was larger at 1.5 T (37%) compared to 3.0 T (26%). The mean SNR and CNR increase at 3.0 T obtained for the tagging sequence was 88% and 187%, respectively. At 3.0 T, the duration of the saturation bands persisted throughout the entire cardiac cycle. For comparison, the saturation bands were significantly diminished at 1.5 T during end-diastole. For 2D CINE SSFP imaging, no significant difference in the left ventricular volumetry and in the overall image quality was obtained. For myocardial tagging, image quality was significantly improved at 3.0 T. The SNR reduction in accelerated SSFP imaging was overcompensated by the increase in the baseline SNR at 3.0 T and did not result in any image quality degradation. For cardiac tagging techniques, 3.0 T was highly beneficial, which holds the promise to improve its diagnostic value.