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Aims: Early and late microvascular obstruction (MO) assessed by magnetic resonance imaging (MRI) are prognostic markers for combined clinical endpoints after ST-elevation myocardial infarction (STEMI). However, there are only limited data for hard endpoints and no consensus exists which of the two best predicts clinical outcome. Furthermore, it is unclear whether the assessment of MO by MRI adds incremental prognostic information independent of traditional outcome markers., Methods and Results: STEMI patients reperfused by primary angioplasty (n = 438) < 12 h after symptom onset underwent MRI at a median of 3 days after the index event. Microvascular obstruction was measured 1 and 15 min after gadolinium injection (early and late MO). Clinical follow-up was conducted after a median of 19 months. The primary endpoint was defined as a composite of death, non-fatal myocardial re-infarction, and congestive heart failure. In contrast to the presence and extent of early MO, the presence and extent of late MO were independently associated with the composite primary endpoint in the multivariable Cox regression analysis adjusting for post-percutaneous coronary intervention TIMI-flow, ST-resolution, TIMI-risk score, ejection fraction, and infarct size. The presence of late MO was identified as the strongest independent predictor for the occurrence of the composite endpoint (hazard ratio 4.23, 95%CI 1.73-10.34, P = 0.002). Furthermore, the presence and extent of late MO provided an incremental prognostic value above the traditional prognostic markers., Conclusion: In contrast to early MO, the presence and extent of late MO are strong independent prognosticators after STEMI. www.ClinicalTrials.gov: NCT00299377.

Nora's lesion, also known as "bizarre parosteal osteochondromatous proliferation" (BPOP), was first described in 1983 by the pathologist Nora. This lesion is defined as a proliferation of the bone. In most cases the lesion emanates from the intact cortical substance of short bones. It used to be assigned to reactive, heterotopic ossifications. More recent publications described constant genetic alterations supposing a tumorous genesis. Nora lesions are mostly found in the third or fourth decade of life; a preference of sexes is not described in the literature. They are characterized by a typical appearance in radiological diagnostics, but the diagnosis is ultimately determined by histopathological examination. Surgical resection is the therapy of choice.We report the case of a 29-year-old patient with an undetermined proliferation of the proximal ulna. The diagnosis of a Nora's lesion was made. The therapeutic approach, differential diagnosis and corresponding literature are presented and discussed.

Background: Intraaortic balloon pump (IABP) therapy is a widely used method of circulatory support. Based on frequent findings of balloon malposition with visceral arterial compromise on computerized tomographic (CT) imaging studies, we conducted a systematic review of cardiac surgical IABP patients with available CT scans to determine reasons, incidence, and clinical relevance of malposition., Methods and Results: From January 2007 to March 2009, a total of 621 of 7756 cardiac surgical patients (8.0%) received perioperative IABP support, of whom 63 (10.1%) received a thoracoabdominal CT scan during IABP support. Proximal and distal balloon positions were analyzed. The anatomic distance from the left subclavian artery to celiac trunk and aortic transverse diameter were measured in all patients and compared with implanted balloon dimensions. Mean age was 67.1±11.9 years; 33.3% were female, and height was 169±9 cm. Based on radiography, proximal balloon position was correct in 96.8% but only appropriate in 38.1% based on CT. In 61 of 63 patients, compromise of at least 1 visceral artery was found: celiac trunk, 96.8%; superior mesenteric artery, 87.3%; and renal arteries, 66.7%. Left subclavian artery to celiac trunk distance was 241±23 mm, and balloon length was 248±17 mm and corresponded to an anatomic to balloon length mismatch in 68.2%. Spinal deformations were found in 42.9%. Laparotomy for mesenteric ischemia was required in 23.8%. Hospital mortality rate was 60.3%., Conclusions: IABP malposition was commonly identified by CT. Reasons included incorrect proximal balloon position as well as an anatomic-to-balloon length mismatch. Thus, shorter than recommended balloon sizes and better positioning strategies had to be considered.

Objectives: Acute uncomplicated Stanford type B aortic dissection (TBAD) is optimally managed with medical treatment. However, surgery and thoracic endovascular aortic repair (TEVAR) are occasionally indicated, particularly when end-organ ischaemia develops. This study assesses the perioperative and long-term outcomes of medical, interventional and surgical management of acute TBAD., Methods: A total of 135 consecutive patients with acute TBAD treated at our institution between 2000 and 2008 were analysed. Of these patients, 84 were treated medically (group A, median age: 65 years, interquartile range (IQR): 34-90), 46 patients received TEVAR (group B, median age: 65, IQR: 23-83) and five patients underwent open surgical management (group C, median age: 60 years, IQR: 44-69). Clinical data and information on complications, re-intervention and acute and long-term mortality were retrospectively collected and examined. Follow-up was made on 98% of patients with a median time span of 1107 days (IQR: 870-1343)., Results: There were no significant differences in age, gender, body mass index or co-morbidities among the three treatment groups. Group B patients had the highest rate of ruptures (n=7) and impending ruptures (n=19). Indications for surgery in group C were impending rupture with malperfusion (n=1), rupture (n=2) and refractory pain (n=2). The maximal diameter of dissection was significantly higher in group C (mean: 52.6mm, IQR: 36-82, p<0.05) than in group B (mean: 42.0mm, IQR: 20-74) and group A (mean: 40.6, IQR: 23-66). The 30-day and 5-year mortality rates, respectively, were 8.5% and 27.9% for group A, 20.0% and 43.7% for group B (p=0.018 for group A) and 20.0% for both time points for group C patients. The rate of re-intervention was significantly higher in group A (A: 22/84, 26.2% vs B: 8/46, 17.4%; p=0.049, and group C: 1/5, 20%). The rate of major complications (e.g., stroke, paraplegia and/or vascular problems) did not differ among groups., Conclusions: Medical, interventional and surgical management for acute TBAD result in acceptable survival rates. Although stent implantation and surgery were reserved for patients with complications of TBAD in the current study, results were good for both treatment modalities. Randomised prospective trials should be performed to determine whether conservative, TEVAR or surgical management is most advantageous for complicated acute TBAD patients., (Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: To quantify radiation dose reduction in cardiac computed tomography (CT) using a prospectively triggered mode compared with a retrospective ECG-gated helical mode., Methods: Absorbed organ doses in cardiac 64-row multidetector CT were quantified using an anthropomorphic male Alderson phantom with 74 thermoluminescence dosimeters. Three different imaging protocols were applied: retrospective ECG-gating, retrospective ECG-gating with additional ECG-pulsing, and a prospectively triggered mode. The measured organ doses were compared with dose estimation by a mathematical phantom., Results: Compared with the retrospective ECG-gating mode, the mean relative organ doses were reduced by 44% using ECG pulsing and by 76% using the prospectively triggered mode. The range of dose savings varied from 34% to 49% using ECG pulsing and from 65% to 87% using the prospectively triggered mode. The effective dose was 16.5 mSv using retrospective gating, 9.2 mSv using retrospective gating with ECG pulsing and 4.0 mSv using the prospectively triggered mode., Conclusions: Our measurements confirm the high dose-saving potential of the prospectively triggered technique in cardiac CT. The reduction in the organ doses measured corresponds to estimates determined by the mathematical phantom. The effective dose calculated by the mathematical phantom was, in some cases, significantly lower than that calculated using the anthropomorphic phantom.

The aim of this study was to examine the effect of coronary collateral flow before reperfusion on long-term clinical prognosis in patients with acute ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention. We studied 235 patients with STEMI within 12 hours after symptom onset. All patients had Thrombolysis In Myocardial Infarction grade < or =1 flow before percutaneous coronary intervention. Collateral flow was graded according to the Rentrop classification. Patients were categorized as having absent or poor collateral flow to the infarct-related artery (group A) or significant flow (group B). In 166 patients there was absent or weak collateral flow (group A), whereas 69 had significant flow (group B). Long-term follow-up was available in 227 patients (97%) at a median of 797 days. Overall, 25 patients died during the follow-up period, 22 patients (13.8%) in group A and 3 patients (4.4%) in group B (p = 0.04). A total of 12 (7.5%) nonfatal recurrent myocardial infarctions occurred in group A compared to 2 (2.9%) in group B (p = 0.18). The combined major adverse cardiovascular event end point (death or nonfatal reinfarction) showed a significantly lower event rate in group B (p = 0.02). Extensive collateral flow at baseline was a significant predictor for a favorable long-term clinical outcome on multivariable analysis after adjustment for established prognostic markers. In conclusion, the presence of a well-developed collateral network before mechanical reperfusion in patients with STEMI is associated with improved long-term survival and lower major adverse cardiovascular event rates., (2010 Elsevier Inc. All rights reserved.)

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.

Purpose: The aim of this study was to perform high-resolution functional MR imaging using accelerated density-weighted real-time acquisition (DE) and a combination of compressed sensing (CO) and parallel imaging for image reconstruction., Materials and Methods: Measurements were performed on a 3 T whole-body system equipped with a dedicated 32-channel body array coil. A one-dimensional density-weighted spin warp technique was used, i. e. non-equidistant phase encoding steps were acquired. The two acceleration techniques, compressed sensing and parallel imaging, were performed subsequently. From a complete Cartesian k-space, a four-fold uniformly undersampled k-space was created. In addition, each undersampled time frame was further undersampled by an additional acceleration factor of 2.1 using an individual density-weighted undersampling pattern for each time frame. Simulations were performed using data of a conventional human in-vivo cine examination and in-vivo measurements of the human heart were carried out employing an adapted real-time sequence., Results: High-quality DECO real-time images using parallel acquisition of the function of the human heart could be acquired. An acceleration factor of 8.4 could be achieved making it possible to maintain the high spatial and temporal resolution without significant noise enhancement., Conclusion: DECO parallel imaging facilitates high acceleration factors, which allows real-time MR acquisition of the heart dynamics and function with an image quality comparable to that conventionally achieved with clinically established triggered cine imaging., (Georg Thieme Verlag KG Stuttgart, New York.)

Objectives: The aim of the study was to determine the prognostic significance and determinants of myocardial salvage assessed by cardiovascular magnetic resonance (CMR) in reperfused ST-segment elevation myocardial infarction., Background: In acute myocardial infarction, CMR can retrospectively detect the myocardium at risk and the irreversible injury. This allows for quantifying the extent of salvaged myocardium after reperfusion as a potential strong end point for clinical trials and outcome., Methods: We analyzed 208 consecutive ST-segment elevation myocardial infarction patients undergoing primary angioplasty <12 h after symptom onset. T2-weighted and contrast-enhanced CMR was used to calculate the myocardial salvage index (MSI). Patients were categorized into 2 groups defined by the median MSI. The primary end point of the study was occurrence of major adverse cardiovascular events defined as death, reinfarction, and occurrence of new congestive heart failure within 6 months after the index event., Results: The median MSI was 48 (interquartile range 27 to 73). Major adverse cardiovascular events were significantly lower in the MSI >or= median group (2.9% vs. 22.1%, p < 0.001). The stepwise Cox proportional hazards model revealed that the MSI was the strongest predictor of major adverse cardiovascular events at 6-month follow-up (p < 0.001). All prognostic clinical (symptom onset to reperfusion), angiographic (Thrombolysis In Myocardial Infarction flow grade before angioplasty), and electrocardiographic (ST-segment resolution) parameters showed significant correlations with the MSI (p < 0.001 for all)., Conclusions: This study for the first time demonstrates that the MSI assessed by CMR predicts the outcome in acute reperfused ST-segment elevation myocardial infarction. Therefore, MSI assessment has important implications for patient prognosis as well as for the design of future trials intended to test new reperfusion therapy efficacy. (Myocardial Salvage Assessed by Cardiovascular Magnetic Resonance-Impact on Outcome; NCT00952224).

Objectives: The aim of this randomized, single-blind, controlled trial was to assess N-acetylcysteine effects on contrast-induced nephropathy and reperfusion injury in ST-segment elevation myocardial infarction patients undergoing primary angioplasty with moderate contrast volumes., Background: High-dose N-acetylcysteine reduced the incidence of contrast-induced nephropathy in patients with high contrast volumes and reduced reperfusion injury in animal trials., Methods: Patients undergoing primary angioplasty were randomized to either high-dose N-acetylcysteine (2 x 1,200 mg/day for 48 h; n = 126) or placebo plus optimal hydration (n = 125). The 2 primary end points were: 1) the occurrence of >25% increase in serum creatinine level <72 h after randomization; and 2) a reduction in reperfusion injury measured as myocardial salvage index by magnetic resonance imaging., Results: The median volume of an iso-osmolar contrast agent during angiography was 180 ml (interquartile range [IQR] 140 to 230 ml) in the N-acetylcysteine and 160 ml (IQR 120 to 220 ml) in the placebo group (p = 0.20). The primary end point contrast-induced nephropathy occurred in 14% of the N-acetylcysteine group and in 20% of the placebo group (p = 0.28). The myocardial salvage index was also not different between both treatment groups (43.5; IQR 25.4 to 71.9 vs. 51.5; IQR 29.5 to 75.3; p = 0.36). Activated oxygen protein products and oxidized low-density lipoprotein as markers for oxidative stress were reduced by as much as 20% in the N-acetylcysteine group (p < 0.05), whereas no change was evident in the placebo group., Conclusions: High-dose intravenous N-acetylcysteine reduces oxidative stress. However, it does not provide an additional clinical benefit to placebo with respect to CIN and myocardial reperfusion injury in nonselected patients undergoing angioplasty with moderate doses of contrast medium and optimal hydration. (Myocardial Salvage and Contrast Dye Induced Nephropathy Reduction by N-Acetylcysteine [LIPSIA-N-ACC]; NCT00463749).

The concept of density-weighted imaging and parallel acquisition for effective density-weighted (PLANED) imaging was transferred to saturation recovery (SR) sequences, in order to increase the SNR in first-pass myocardial perfusion imaging. Filtering in combination with density-weighted imaging allows SNR-optimized data weighting and the free choice of the corresponding spatial response function (SRF) simultaneously. This method was evaluated in simulations and applied successfully to phantom and in vivo first-pass myocardial perfusion studies. Unfiltered, Cartesian sampled images were compared to images acquired with SR-PLANED, which has been adjusted to result in an identical SRF as the Cartesian imaging. SNR-optimized SR-PLANED imaging improved the SNR up to 15% without changing acquisition time, the SRF or the field of view (FOV). The presented method provides high image quality and optimized SNR for first-pass myocardial perfusion imaging., (Copyright 2010 Elsevier Inc. All rights reserved.)

Objective: Takotsubo cardiomyopathy (TTC) is an increasingly recognised acute cardiac syndrome, whose underlying pathophysiological mechanisms remain unknown. Inflammation might play a role as this has been shown in endomyocardial biopsies. The aim of this study was to assess inflammatory parameters in patients with TTC using a comprehensive cardiovascular magnetic resonance imaging (CMR) approach., Methods: Thirty-seven patients with the suspected diagnosis of TTC underwent CMR. T2-weighted imaging to calculate the oedema ratio, T1-weighted imaging before and after contrast agent administration to calculate the global relative enhancement (gRE), and late gadolinium enhancement (LGE) imaging were performed., Results: In 11 patients CMR revealed the diagnosis of myocardial infarction (n = 7; 19%) or myocarditis (n = 4; 11%) with typical patterns of LGE. In all other patients (n = 26; 70%), no LGE was detected consistent with the diagnosis of TTC. Of these, in 16 patients (62%) both inflammatory markers (oedema ratio and gRE) were elevated with concomitant pericardial effusion, indicating acute inflammation. Follow-up CMR after 3 months showed complete normalisation of left ventricular function and inflammatory parameters in the absence of LGE and pericardial effusion., Conclusion: This CMR study provides further insights into the pathophysiological mechanisms in TTC, supporting the contribution of an inflammatory process in the acute setting.

Background: Cardiac MRI is important in the treatment of children with congenital heart disease, but sufficient normative data are lacking. For ventricular volumes and mass, we sought to deliver reference centiles and to investigate sex effects., Methods and Results: We included 114 healthy children and adolescents, uniformly distributed spanning an age range of 4 to 20 years, as required by the Lambda-Mu-Sigma method to achieve a percentile distribution, thus avoiding arbitrary age categories. Subjects underwent axial volumetry (1.5-T scanner) using standardized 2D steady-state free-precession and flow protocols. Percentiles were computed for age 8 to 20 years (99 subjects) because breath-holds were more consistent in this group. When indexed for body surface area or height, the centile curves of ventricular volumetric parameters showed allometric increase until adolescence, when a plateau was reached, with values comparable to published adult reference data. In contrast, ventricular mass centiles increased without plateau. There was a significant sex difference, with centiles reflecting larger values in boys than in girls (P<0.05) when ventricular volumes were indexed to body surface area or height but not when indexed to weight (exception: mass). There was excellent agreement of axial and short-axis volumetry and of volumetric and flow-derived stroke volumes., Conclusions: Percentiles for ventricular volumes and mass in healthy children have been established to serve as reference values in pediatric heart disease. Significant sex differences were noted when indexing volumes to body surface area or height. Unisex centiles related to weight may be considered for chamber volumes albeit not for mass.

Purpose: To investigate the impact of interinstitutional variance (=interobserver variance between institutions) for volumetric and flow cardiac MR (CMR) data and if training on image reading could improve bias., Materials and Methods: In a three-center study, a total of 32 adults with repaired Tetralogy of Fallot and 23 controls underwent CMR using standardized protocols for ventricular volumes/mass (by transverse and short-axis cine-MRI) and pulmonary/aortic blood flow by velocity-encoded MRI (VEC-MRI). Data were analyzed blinded and independently in each institution by experienced readers. Interinstitutional variance was determined before/after training on consented guidelines for image analysis., Results: In patients, initial interinstitutional variability of right ventricular parameters was substantial but decreased by training. On transverse planes, variation coefficient for end-diastolic/systolic volumes and ejection fraction decreased from 22%, 19%, and 19% to 7%, 10%, and 8%, respectively (P < 0.025). Left-ventricular variation coefficients improved for end-diastolic and stroke volumes from 8% and 15% to 4% and 6%, respectively (P < 0.007). For short-axis volumetry training resulted in narrowed limits of confidence. Variability did not significantly change in the controls. There was no significant difference between transverse/short-axis MRI. Interinstitutional variance for VEC-MRI in patients/controls was low (<4%)., Conclusion: Interinstitutional variance is an important source of variability in volumetric but not in flow CMR. Such variance can be reduced effectively by consented training.

Background: Aborted myocardial infarction (MI) is defined by major (> or =50%) ST-segment resolution and a lack of subsequent cardiac enzyme rise > or =2 the upper normal limit. This ultimate myocardial salvage has been observed in approximately 15% of ST-elevation MI (STEMI) patients after fibrinolysis. So far, the prognostic significance and magnetic resonance imaging (MRI) findings of an aborted MI after primary angioplasty have not been evaluated appropriately., Methods: We examined 420 consecutive STEMI patients undergoing primary angioplasty within 12 hours after symptom onset. All patients underwent MRI within 1 to 4 days. Clinical end points were major adverse cardiovascular events within 6 months after the index event., Results: Of the 420 STEMI patients, 58 (14%) fulfilled aborted MI criteria. As compared with true MI, patients with aborted MI had a significant lower infarct size, shorter pain-to-balloon time, and better left ventricular ejection fraction (P < .001, respectively). Aborted MI patients had a 6-month major adverse cardiovascular event rate of 1.7% versus 19.6% of true MI patients (P = .001). In aborted MI patients, MRI detected no myocardial scar in 30 (56%), and a minor necrosis/scar formation in 24 patients (44%)., Conclusion: The proven prognostic relevance of aborted MI makes it a meaningful end point and therapeutic target in future MI studies. MRI can further distinguish between true aborted MI with absence of myocardial scar and aborted MI with scar formations.

Background: In this study we sought to determine, first, whether maximal exercise capacity reflects ventricular function, and second, whether the age of the patient, and the age of completion of the Fontan circulation, influence ventricular function and exercise performance., Methods and Results: Cardiac magnetic resonance imaging and cardiopulmonary exercise testing were performed in 29 patients at a median time of 6.9 years after completion of the Fontan circulation. We divided the patients into 2 groups, the first 19 having their operation below the age of 18 years, and the second group, of 10 patients, having completion of the Fontan circulation when they were older than 18 years. Parameters for ventricular function and exercise were compared for both groups with controls. Compared to controls, the younger patients had normal end-diastolic ventricular volumes, but significantly impaired ventricular function, lower maximal work load and consumption of oxygen. The older patients had greater end-diastolic ventricular volumes, and significantly poorer ventricular function than both the younger patients and the controls. Maximal work load and consumption of oxygen were significantly lower in the older patients than in the younger ones and the controls., Conclusion: Patients with the Fontan circulation have an impaired systolic ventricular function, which correlates with maximal exercise capacity and uptake of oxygen. Those having completion of the Fontan circulation when younger than 18 years had significantly better ventricular function and exercise performance than those who had completion of the Fontan circulation at an older age. An early creation of the Fontan circulation may preserve cardiac function and exercise capacity.

Objectives: Different techniques for measuring of perfusion are clinically available, but these are usually applied to healthy brain tissue., Material and Methods: Five different techniques were used here in 12 patients with brain tumors to investigate the impact of tumor vascularization on the perfusion signal: three qualitative dynamic contrast-enhanced/susceptibility-contrast magnetic resonance imaging (DCE-MRI/DSC-MRI) techniques exploiting T(1), T(2), T(2)(*) contrast, and two quantitative techniques, pulsed arterial spin labeling (PASL) and H(2)(15)O positron emission tomography (H(2)(15)O-PET)., Results: In a first approximation, a linear correlation was found between all five imaging modalities regarding the perfusion signal of both, normal brain tissue and tumor. The estimated values for tumor perfusion differed significantly between the techniques (1=methodical mean in arbitrary units): PASL: 0.83, H(2)(15)O-PET: 0.62, T(1)-DCE: 1.73, T(2)-DCE: 0.69, T(2)(*)-DSC: 0.89., Conclusions: The tumor perfusion values, determined with different techniques are not comparable. The T(2)(*)-DSC, here applied with contrast agent presaturation of extravascular space, and PASL depict median perfusion most reliably.

Cardiovascular magnetic resonance (CMR) has become the primary tool for noninvasive assessment of myocardial inflammation in patients with suspected myocarditis. The International Consensus Group on CMR Diagnosis of Myocarditis was founded in 2006 to achieve consensus among CMR experts and develop recommendations on the current state-of-the-art use of CMR for myocarditis. The recommendations include indications for CMR in patients with suspected myocarditis, CMR protocol standards, terminology for reporting CMR findings, and diagnostic CMR criteria for myocarditis (i.e., "Lake Louise Criteria").

Background: Familial dilated cardiomyopathy is a highly heterogeneous genetic disease. Thus, identification of disease-causing mutations is a challenging and time-consuming task. Genotype-phenotype associations may alleviate identification of the underlying mutation., Objective: The purpose of this study was to investigate cardiac phenotypes within a family harboring a familial dilated cardiomyopathy-related mutation in the gene encoding phospholamban., Methods: Complete genetic and clinical analyses were performed in a family with familial dilated cardiomyopathy due to the PLN-R14Del mutation. Family relatives were studied by ECG, Holter ECG, echocardiography, ECG body surface potential mapping, and cardiac magnetic resonance imaging., Results: A candidate gene approach resulted in identification of a heterozygous deletion of arginine 14 in the gene encoding phospholamban (PLN-R14Del) segregating with dilated cardiomyopathy in the family pedigree. Mutation carriers suffered from familial dilated cardiomyopathy associated with cardiac death between the ages of 26 and 50 years. Interestingly, all adult mutation carriers revealed strikingly attenuated R amplitudes on standard ECG, regardless of the absence or presence of echocardiographic abnormalities. Gadolinium-enhanced cardiac magnetic resonance imaging showed late enhancement in PLN-R14Del carriers with preserved ejection fraction. Late enhancement was regionally related to areas of most pronounced R-amplitude attenuation as assessed by body surface potential mapping., Conclusion: Attenuated R amplitudes were identified as an early ECG phenotype in a family with familial dilated cardiomyopathy due to the PLN-R14Del mutation. All adults harboring PLN-R14Del had attenuated R waves irrespective of echocardiographic abnormalities. The study findings suggest a mutation-related remodeling process preceding ventricular dysfunction.

Aim: To evaluate for the first time in an animal model the possibility of absolute regional quantification of renal medullary and cortical perfusion by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) using a blood pool contrast agent., Material and Methods: A total of 18 adult female pigs (age, 16-22 weeks; body weight, 45-65 kg; no dietary restrictions) were investigated by DCE-MRI. Absolute renal blood flow (RBF) measured by an ultrasound transit time flow probe around the renal vein was used as the standard of reference. An inflatable stainless cuff placed around the renal artery near its origin from the abdominal aorta was used to reduce RBF to 60%, 40%, and 20% of the baseline flow. The last measurement was performed with the cuff fully reopened. Absolute RBF values during these 4 perfusion states were compared with the results of DCE-MRI performed on a 1.5-T scanner with an 8-channel phased-array surface coil. All scans were acquired in breath-hold technique in the coronal plane using a field of view of 460 mm.Each dynamic scan commenced with a set of five 3D T1-weighted gradient echo sequences with different flip angles (alpha = 2 degrees, 5 degrees, 10 degrees, 20 degrees, 30 degrees): TE, 0.88 milliseconds; TR, 2.65 milliseconds; slice thickness, 8.8 mm for 4 slices; acquisition matrix, 128 x 128; and acquisitions, 4. These data served to calculate 3D intrinsic longitudinal relaxation rate maps (R10) and magnetization (M0). Immediately after these images, the dynamic 3D T1-weighted gradient echo images were acquired with the same parameters and a constant alpha = 30 degrees, half Fourier, 1 acquisition, 64 frames, a time interval of 1.65 seconds between each frame, and a total duration of 105.6. Three milliliters of an albumin-binding blood pool contrast agent (0.25 mmol/mL gadofosveset trisodium, Vasovist, Bayer Schering Pharma AG, Berlin, Germany) was injected at a rate of 3 mL/s. Perfusion was calculated using the arterial input function from the aorta, which was extracted from the dynamic relaxation rate change maps and perfusion images were calculated on a voxel-by-voxel basis using a singular value decomposition., Results: In 11 pigs, 4 different perfusion states were investigated sequentially. The reduced kidney perfusion measured by ultrasound highly correlated with total renal blood flow determined by DCE-MRI, P < 0.001. The correlation coefficient between both measurements was 0.843. Regional cortical and medullary renal flow was also highly correlated (r = 0.77/0.78, P < 0.001) with the degree of flow reduction. Perfusion values smaller than 50 mL/min/100 cm were overestimated by MRI, high perfusion values slightly underestimated., Conclusion: DCE-MRI using a blood pool contrast agent allows absolute quantification of total kidney perfusion as well as separate determination of cortical and medullary flow. The results show that our technique has sufficient accuracy and reproducibility to be transferred to the clinical setting.

A new approach for utilizing conjugate k-space symmetry for improved parallel MRI performance is presented. By generating virtual coils containing conjugate symmetric k-space signals from actual coils, additional image- and coil-phase information can be incorporated into the reconstruction process for parallel acquisition techniques. In that way the reconstruction conditions are improved, resulting in less noise enhancement. In particular in combination with generalized autocalibrating partially parallel acquisitions (GRAPPA), the virtual coil concept represents a practical approach since no explicit spatial phase information is required. In addition, the influence of phase variations originating from the complex receiver coils as well as from the background is investigated. It is shown that there exist background phase distributions yielding an optimized pMRI reconstruction.

Purpose: To compare the usefulness of gadofluorine M with that of Gadomer in assessment of dysferlin-deficient muscular dystrophy at 7.0-T magnetic resonance (MR) imaging., Materials and Methods: All experiments were approved by local review boards. SJL/J mice (n = 24) with dysferlin-deficient muscular dystrophy and C57BL/6 control mice (n = 24) were imaged at 12-15 weeks (young) or older than 30 weeks (old) by using dynamic contrast material-enhanced imaging with inversion-prepared steady-state free-precession sequence before, during, and after administration of gadofluorine M at 2 micromol or Gadomer at 4 micromol intravenously. After imaging, regions of interest were determined from the upper extremity and left ventricular chamber; fractional extravascular extracellular volume, v(e), and permeability surface tissue density product, PS rho, were measured by using a two-compartment pharmacokinetic model. The natural history of muscular dystrophy was assessed histologically in 70 mice (seven five-mouse groups each of SJL/J mice and of control mice) at 4-week intervals from 8 to 32 weeks. In addition, three SJL/J mice and three control mice at age 33 weeks were sacrificed, and fluorescence microscopy was performed for visualization of intravenously administered carbocyanine-labeled gadofluorine M in muscle cells. Statistical analysis was performed by using the t test., Results: Gadofluorine M enhancement was significantly greater in skeletal muscle of 30-week-old mice with dysferlin-deficient muscular dystrophy, compared with control mice. Gadofluorine M demonstrated both increased rate of enhancement (PS rho sec(-1) +/- standard error of the mean: 0.004 e(-)(4) +/- 3 vs 0.002 e(-)(4) +/- 3; P < .05) and increased level of enhancement (v(e) +/- standard error of the mean: 0.035 +/- 0.004 vs 0.019 +/- 0.004; P < .05). Gadomer showed no differential enhancement in the two mouse groups. Histologic examination confirmed the presence of labeled gadofluorine M in muscle cells., Conclusion: Gadofluorine M-enhanced MR imaging may be of value in monitoring dysferlin-deficient muscular dystrophy disease progression in this animal model and could prove to be a useful tool in following the course of chronic muscle diseases in humans., ((c) RSNA, 2008.)

Complications after acute myocardial infarction (AMI) concerning the wall structure may be a true aneurysm, intramyocardial dissection, rupture of the free left ventricular wall covered by pericardium or formation of pseudoaneurysm. Differentiation between these complications of AMI may be difficult as shown by the following case report but is of paramount importance because of the different management.

Aims: The apical ballooning syndrome (ABS) is a new diagnostic entity which is increasingly recognized. Precise magnetic resonance imaging (MRI) data are not yet available and there is little evidence for the differential diagnosis of ABS assessed by MRI., Methods and Results: Between January 2005 and January 2008, 6100 consecutive patients with diagnosis of acute coronary syndrome underwent left heart catheterization. In 59 patients (1.0%), coronary angiography revealed normal coronary arteries, but left ventriculography showed left ventricular dysfunction with apical ballooning. These 59 patients underwent cardiac MRI using a 1.5 T MRI scanner. In 13 patients (22.0%), MRI revealed diagnosis of myocardial infarction, in eight patients (13.6%) diagnosis of myocarditis. In all other 38 (64.4%) patients (36 female, age 73 +/- 10 years) with suspected ABS, no delayed enhancement or signs of inflammation were detected. Follow-up MRI after 3 months showed a completely normalized left ventricular ejection in all patients with suspected ABS. Similarly, the end-diastolic volume and end-systolic volume improved at follow-up., Conclusion: Cardiac MRI allows differentiating ABS from other rare causes with unobstructed coronary vessels such as myocarditis and coronary emboli with spontaneous lysis. Therefore, cardiac MRI can add valuable information in all patients with suspected ABS for further differential diagnosis.

Purpose: To retrospectively compare the diagnostic accuracy of three cardiac magnetic resonance (MR) imaging approaches for the detection of histologic and immunohistologic criteria (reference standard) proved myocardial inflammation in patients clinically suspected of having chronic myocarditis (CMC)., Materials and Methods: Cardiac MR imaging was performed in 83 consecutive patients (55 male, 28 female; mean age, 44.8 years +/- 17.7 [standard deviation]) clinically suspected of having CMC, after written informed consent was obtained according to guidelines of the local ethics committee, which approved the study. T2-weighted triple-inversion-recovery imaging to calculate the edema ratio (ER), T1-weighted imaging before and after contrast agent administration to calculate the myocardial global relative enhancement (gRE), and inversion-recovery gradient-echo imaging to evaluate areas of late gadolinium enhancement (LE) were performed. The MR results were correlated with the endomyocardial biopsy (EMB) findings to detect intramyocardial inflammation and cardiotropic viral genomes analyzed at polymerase chain reaction assay. For statistical analyses, receiver operating characteristic analysis and the Wilcoxon test for unpaired data were used because the Kolomogorov-Smirnov test revealed a distribution of data that was different from normality., Results: Intramyocardial inflammation and cardiotropic viral persistence were confirmed at immunohistologic analysis in 48 and 49 of the 83 patients, respectively. The sensitivity, specificity, and diagnostic accuracy of the MR parameters, as compared with the immunohistologic detection of inflammation, were, respectively, 62%, 86%, and 72% for gRE; 67%, 69%, and 68% for ER; and 27%, 80%, and 49% for LE. Cardiac MR-derived gRE, ER, and LE were not associated with polymerase chain reaction proof of viral genomes., Conclusion: In patients clinically suspected of having CMC, increased gRE and ER indicating inflammation were common findings that could be confirmed at immunohistologic analysis, whereas LE had low sensitivity and accuracy. Cardiac MR imaging may be helpful in detecting intramyocardial inflammation noninvasively, but it fails to depict viral persistence., ((c) RSNA, 2008.)

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.

Background: To present a new method for fully quantitative analysis of myocardial blood flow (MBF) using magnetic resonance imaging. The first pass of an intravascular iron oxide contrast medium can be used to quantify myocardial perfusion. The technique was validated in an animal model using colored microspheres., Materials and Methods: In six pigs, a tracking catheter was positioned in the left anterior descending artery (LAD). Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) was performed on a 1.5-T scanner using a hybrid gradient-echo/echoplanar imaging (GRE-EPI) sequence. Regional myocardial blood flow (rMBF) was altered by either inducing vasodilatation with adenosine or creating coronary artery obstruction. The T(1) effect of a superparamagnetic iron oxide-based contrast medium (Resovist) administered at a dose of 8 micromol/kg was used. Upslope, time-to-peak and peak intensity were calculated from the signal intensity-time curves and absolute rMBF using the Kety-Schmidt equation; results were compared to those obtained using colored microspheres., Results: The mean rMBF calculated by MRI was 1.49 (+/-6.91, quartile width) ml/min/g versus 3.21 (+/-1.61) ml/min/g measured by means of microspheres under resting conditions. rMBF increased to a mean of 6.21 (+/-2.83) ml/min/g versus 4.22 (+/-1.70) ml/min/g under adenosine and was reduced to zero flow in total occlusion. Linear regression showed the best correlation for upslope (R=0.714), time-to-peak (R=0.626) and the Kety-Schmidt equation (R=0.584)., Conclusions: The T(1) effect of an iron oxide-based contrast medium allows determination of rMBF when using the Kety-Schmidt equation. The results are similar to those obtained with the standard of reference, colored micropheres, but not better than the results of the semiquantitative approach.

Aims: We compared in vivo blood flow and pulsatility after different types of Fontan operation using magnetic resonance imaging., Material and Methods: A total of 37 consecutive patients (mean age 19+/-7.9 years, 7.3+/-3.2 years after Fontan operation), 7 with atriopulmonary anastomosis (APC), 18 with intra-atrial lateral tunnel (LTFO) and 12 with extracardiac Fontan (ECFO) were studied using magnetic resonance phase-contrast velocity mapping. Blood flow (volume flow) in the superior vena cava (SVC), inferior vena cava (IVC) and both pulmonary arteries were measured and a pulsatility index was calculated for each vessel., Results: For all modifications, the blood flow distribution between the SVC and IVC was normal (1:2). Patients with APC had a normal pulsatility, a dilated right atrium, partial backward flow in the IVC and physiological blood flow distribution between the pulmonary arteries. LTFO and ECFO patients had no retrograde flow in the IVC, equal blood flow distribution between the pulmonary arteries and very low or absent pulsatility., Conclusions: MRI allows hemodynamic quantification and characterization of various types of Fontan modifications and may be a valuable tool to predict Fontan failure. Despite showing normal pulsatility, patients with APC have right atrial dilatation and partial backward flow in the IVC, demonstrating suboptimal Fontan circulation. LTFO and ECFO both produce unidirectional antegrade flow in the IVC but pulsatility is very low or absent, which may promote poor pulmonary artery growth and increase of pulmonary vascular resistance contributing to late Fontan failure.

Aims: QRS prolongation is a negative prognostic factor for the development of ventricular arrhythmia after repair of tetralogy of Fallot (TOF). In this MRI study, we performed a multivariate analysis to determine the influence of volumetric and functional parameters as well as time factors on QRS duration., Methods and Results: Sixty-seven patients after surgical repair of TOF were studied using a 1.5T MRI. Measurement of the ventricles was performed with a multislice-multiphase sequence. Left and right ventricular volumes, ejection fractions (EF) and myocardial masses were determined. Pulmonary regurgitant fraction (PRF) was quantified by velocity encoded flow measurement in the main pulmonary artery. Maximum QRS duration was taken from a 12-channel ECG. Mean maximum QRS duration was 132 ms (+/- 29 ms). Mean PRF was 29.2% (+/- 13.4%). QRS duration correlated significantly with PRF (r = 0.49; p < 0.01; n = 54) and with right ventricular enddiastolic volume index (RVEDVI) (r = 0.29; p < 0.05; n = 67). Multivariate analysis revealed that the combination of PRF, postoperative period, age at surgical repair, and left ventricular (LV) enddiastolic volume are correlated with QRS prolongation., Conclusion: In patients after repair of TOF, pulmonary regurgitation is related to QRS prolongation. Furthermore, even LV size plays a role in the enlargement of the QRS complex.

In patients with Ewing sarcoma, precise staging is not only crucial for the therapeutic regimen but also for a reliable evaluation of response to therapy. We report on a 15-year-old girl with metastatic spread of a Ewing sarcoma who, apart from conventional staging by bone scan, chest X-ray and CT, was subsidiary examined by FDG-PET and whole-body MRI before and after chemotherapy. Both modalities detected more bone lesions than the bone scan, which led to an altered strategy for radiotherapy. Both examinations might be a great asset to stage-adjusted therapy regimens, ultimately influencing patient outcome., (Copyright (c) 2005 Wiley-Liss, Inc.)

Purpose: Thermotherapy using magnetic nanoparticles (nano cancer therapy) is a new concept of local tumour therapy, which is based on controlled heating of intra-tumoural injected magnetic nanoparticles. The aim of this study was to evaluate the usefulness of PET with a recently introduced amino acid tracer O-(2-[18F]fluoroethyl)-]L-tyrosine (FET) for targeting the nanoparticles implantation., Materials and Methods: Eleven patients with glioblastoma recurrences underwent MR and FET-PET imaging for planning of the nano cancer therapy. Thereafter, the gross tumour volumes (GTV) were defined, taking into consideration the results of both imaging tools., Results: The MRI-based mean GTV was 24.3 cm3 (range 2.5-59.7) and the PET-based mean GTV 31.9 cm3 (range 5.2-77.9). On the average the MRI identified an additional 8.9 +/- 4.7 cm3 and the FET-PET scan-an additional 16.5 +/- 15.2 cm3 outside of the common GTV (15.4 +/- 11.0 cm3). The mean final GTV accounted to 33.8 cm3 (range, 5.2-77.9). The additional information of FET-PET led to an increase in GTV by 22-286% in eight patients and to a decrease of 23% and 26%, respectively, in two patients. In one patient, the final GTV was defined on the basis of MRI data only., Conclusions: FET-PET adds important information on the actual tumour volume in recurrent glioblastomas and is highly valuable for defining the target volume for the nano cancer therapy.

Objective: The objective of this study was to examine the applicability of high magnetic field strengths for comprehensive functional and structural cardiac magnetic resonance imaging (MRI)., Subjects and Methods: Eighteen subjects underwent comprehensive cardiac MRI at 1.5 T and 3.0 T. The following imaging techniques were implemented: double and triple inversion prepared FSE for anatomic imaging, 4 different sets of echocardiographic-gated CINE strategies for functional and flow imaging, inversion prepared gradient echo for delayed enhancement imaging, T1-weighted segmented EPI for perfusion imaging and 2-dimensional (2-D) spiral, and volumetric SSFP for coronary artery imaging., Results: : Use of 3 Tesla as opposed to 1.5 Tesla provided substantial baseline signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) improvements for anatomic (T1-weighted double IR: DeltaSNR = 29%, DeltaCNR = 20%, T2-weighted double IR: DeltaSNR = 39%, DeltaCNR = 33%, triple IR: DeltaSNR = 74%, DeltaCNR = 60%), functional (conventional CINE: DeltaSNR = 123%, DeltaCNR = 74%, accelerated CINE: DeltaSNR = 161%, DeltaCNR = 86%), myocardial tagging (DeltaSNRsystole = 54%, DeltaCNRsystole = 176%), phase contrast flow measurements (DeltaSNR = 79%), viability (DeltaSNR = 48%, DeltaCNR = 40%), perfusion (DeltaSNR = 109%, DeltaCNR = 87%), and breathhold coronary imaging (2-D spiral: DeltaSNRRCA = 54%, DeltaCNRRCA = 69%, 3-D SSFP: DeltaSNRRCA = 60%, DeltaCNRRCA = 126%), but also revealed image quality issues, which were successfully tackled by adiabatic radiofrequency pulses and parallel imaging., Conclusions: Cardiac MRI at 3.0 T is feasible for the comprehensive assessment of cardiac morphology and function, although SAR limitations and susceptibility effects remain a concern. The need for speed together with the SNR benefit at 3.0 T will motivate further advances in routine cardiac MRI while providing an image-quality advantage over imaging at 1.5 Tesla.

Purpose: Before locally ablative treatment of colorectal liver metastases, patients have to be carefully evaluated to decide whether this is the adequate therapy. In this study we determined the value of FDG-PET in comparison to conventional staging procedures., Patients, Methods: In 68 consecutive patients referred for laser induced thermotherapy (LITT) of liver metastases from colorectal cancer, pretherapeutic staging with conventional imaging (thoracic and abdominal CT, liver MRI, chest X-ray) and FDG-PET was performed. The examinations were analysed separately and blinded. Based on the staging information, therapeutic decisions were made by an interdisciplinary review board according to a standardized algorithm. The results were compared between conventional imaging and FDG-PET, and were validated by clinical follow up data and histopathology, respectively., Results: On FDG-PET 210 lesions were interpreted as tumour manifestations. 48 of these were not seen on conventional imaging (true positive, n = 46). In contrast, 24 lesions were visualized by conventional imaging only (true positive, n = 12). Compared to conventional imaging, discrepant findings on FDG-PET led to treatment modifications in 25 patients (37%); these were correct in 20/25 patients. According to the actual treatment course, the inadequate treatment modifications in the remaining 5 patients were avoided by further diagnostic procedures (i.e. biopsies)., Conclusion: In the evaluation of patients with known liver metastases from colorectal cancer before LITT, FDG-PET depicts relevant findings subsidiary to conventional imaging and thus is of high value for therapeutic decision making.

Aim: Comparison of two gated SPECT analysis tools -- gated SPECT quantification (GSQ) and emory cardiac toolbox (ECT) -- in patients with coronary artery disease (CAD) and severely impaired left ventricular function (preoperative: EF <35% by cardiac catheter)., Patients, Methods: A total of 56 gated SPECT examinations (one-day hybrid-protocol with (201)Tl-chloride for rest and (99m)Tc-sestamibi for stress applied during low-dose dobutamine stress MR-examination; temporal resolution; 8 phases per cardiac cycle) were performed in 36 patients (31 preoperatively, 25 postoperatively) and compared with MRI in 48 cases. Left ventricular end-diastolic (LV-EDV) and end-systolic (LV-ESV) volumes as well as the left ventricular ejection fraction (LV-EF) were calculated., Results: The total volumetric assessment by both analysis algorithms (n = 56) showed good intraclass correlation coefficients preoperatively (n = 31), but even better postoperatively (n = 25). The mean reconstruction time was approximately 3 minutes ( +/- 2 SD) for GSQ and 15 minutes ( +/- 5 SD) for ECT. In comparison to MRI the results of both analysis tools also correlated well, but the agreement decreased in the presence of scared tissue. The mean LV-EF (MRI) preoperatively was 30.4%, in 6/36 patients above the values calculated from cardiac catheter, postoperatively 34.6%., Conclusion: Both gated SPECT analysis tools showed reliable volumetric assessments in high-risk patients with CAD and severely reduced LV-EF in comparison to MRI, with advantages for GSQ in terms of postprocessing time. However, for the calculation of LV-EF a markedly lower concordance with MR-results was observed for both methods depending on the presence of myocardial scars.

Background: In clinical settings an easy and reliable method for following up right ventricular (RV) function in patients after repair of tetralogy of Fallot (TOF) is needed. It is, however, unclear whether the novel modified short axis view from echocardiography is superior to the apical four chamber view in this aspect., Materials and Methods: Thirty postoperative TOF patients with median age 17 years (range 6-45 years) and follow up period of 10 years (range 0.5-40 years) were examined echocardiographically using the apical four chamber view and the novel modified short axis view. RV areas in end-systole (Amin) and end-diastole (Amax) were measured and an area fraction [(Amax - Amin)/Amax * 100%] was calculated from the respective view. RV ejection fraction was assessed through magnetic resonance imaging (MRI). The RV area fractions from echocardiography were compared to the RV ejection fraction., Results: The right ventricular area fraction derived from the modified short axis view was significantly lower than that from the apical four chamber view (34.3+/-9.1% vs. 42.5+/-10.2%, p=0.007). Both the RV area fractions obtained from the modified short axis view (r=0.674, p<0.001) and from the apical four chamber view (r=0.512, p=0.025) correlated significantly with the MRI derived RV ejection fraction., Conclusion: The novel modified short axis view from echocardiography may be superior to the apical four chamber view for routine follow up of patients after TOF repair, in whom the right ventricular outflow tract plays an important role in the right ventricular systolic function.

The role of nuclear medicine imaging in the diagnosis of vascular parkinsonism (VP) has been addressed by only few studies up to now. Most previous reports suggest no or only mild impairment of DAT and D2 receptors in VP. In contrast, in four patients with VP, reported here, the combined DAT and D2 receptor SPECT showed highly unusual changes in the pre- and/or postsynaptic dopaminergic system. The possible value of combined DAT/D2 receptor SPECT imaging should be investigated by future prospective studies.

Introduction: The long-term follow-up of patients with D-transposition of the great arteries after atrial switch operation shows specific problems such as tricuspid valve insufficiency, rhythm disturbances and failure of the morphologic right ventricle in systemic position. Assessment of the myocardial contractility of the subaortic right ventricle by conventional echocardiography is limited. The usage of tissue Doppler echocardiography with strain combined with strain rate imaging provides a new approach for quantitative analysis of longitudinal myocardial function. The aim of this study was to assess patterns of wall motion and regional contractile function of the systemic right ventricle in patients after atrial switch operation for D-transposition of the great arteries and to compare them to those of normal subjects., Patients and Methods: Twenty-four patients with Dtransposition of the great arteries after atrial switch operation with a mean age of 21.3 (range, 13 to 31) years and a postoperative period of 16.9 years were examined and compared to 22 control individuals with a mean age of 21.5 (range, 3 to 43) years. Tissue Doppler studies were obtained from apical 4- chamber view to determine regional systolic (Syst(T)) and diastolic (E(T), A(T)) velocities as well as E(T)/A(T) ratio at the basal free wall. The presystolic isovolumic contraction peak was assessed and the ratio of the presystolic peak velocity to the isovolumic acceleration time as the IVA index was calculated. Strain and peak systolic and diastolic strain rates were assessed on basal, middle and apical segments of the right ventricular free wall. Data obtained from the morphologic right systemic ventricle in patients were compared to those derived from the left and the right ventricle in controls., Results: The right ventricular free wall systolic velocities were significantly reduced in patients compared to velocities obtained from the normal right and left ventricle. On the other hand, the IVA index was only reduced in patients compared to the IVA index in the normal subpulmonary right ventricle. Compared to data obtained from the normal systemic left ventricle, the IVA index in patients was not significantly different. In contrast, strain and strain rate parameters in all analyzed segments mostly showed a highly significant reduction compared to normal right and left ventricular data., Conclusion: Tissue Doppler echocardiography is a promising tool for the evaluation of regional myocardial contractile function of the morphologic right systemic ventricle in patients following atrial switch operation for D-transposition of the great arteries. Presystolic, systolic and diastolic regional ventricular function was reduced in the systemic right ventricle. However, further comparative studies using other quantitative parameters of global and regional myocardial function derived from cardiac catheterization or MRI should be performed in order to evaluate the reliability of tissue Doppler echocardiography for the assessment of global right ventricular function in these patients.