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AIMS: To determine the optimal T1 mapping approach to assess myocardial fibrosis at 3T. METHODS AND RESULTS: T1 mapping was performed at 3T using the modified look-locker-inversion sequence in 20 healthy volunteers and 20 patients with aortic stenosis (AS). Pre- and post-contrast myocardial T1, the partition coefficient (λ; ΔRmyocardium/ΔRblood, where ΔR = 1/post-contrast T1 - 1/pre-contrast T1), and extracellular volume fraction [ECV; λ (1 - haematocrit)] were assessed. After establishing the optimal time point and myocardial region for analysis, we compared the reproducibility of these T1 measures and their ability to differentiate asymptomatic patients with AS from healthy volunteers. There was no segmental variation across the ventricle in any of the T1 measures evaluated. λ and ECV did not vary with time, while post-contrast T1 was relatively constant between 15 and 30 min. Thus, mid-cavity myocardium at 20 min was used for subsequent analyses. ECV displayed excellent intra-, inter-observer, and scan-rescan reproducibility [intra-class correlation coefficients (ICC) 1.00, 0.97, and 0.96, respectively], as did λ (ICC 0.99, 0.94, 0.93, respectively). Moreover, ECV and λ were both higher in patients with AS compared with controls (ECV 28.3 ± 1.7 vs. 26.0 ± 1.6%, P < 0.001; λ 0.46 ± 0.03 vs. 0.44 ± 0.03, P = 0.02), with the former offering improved differentiation. In comparison, scan-rescan reproducibilities for pre- and post-contrast myocardial T1 were only modest (ICC 0.72 and 0.56) with no differences in values observed between cases and controls (both P> 0.05).CONCLUSIONS: ECV appears to be the most promising measure of diffuse myocardial fibrosis at 3T based upon its superior reproducibility and ability to differentiate disease from health.

Background— Cardiovascular magnetic resonance is the gold-standard technique for the assessment of ventricular function. Although left ventricular volumes and ejection fraction are strong predictors of outcome in dilated cardiomyopathy (DCM), there are limited data regarding the prognostic significance of right ventricular (RV) systolic dysfunction (RVSD). We investigated whether cardiovascular magnetic resonance assessment of RV function has prognostic value in DCM. Methods and Results— We prospectively studied 250 consecutive DCM patients with the use of cardiovascular magnetic resonance. RVSD, defined by RV ejection fraction ≤45%, was present in 86 (34%) patients. During a median follow-up period of 6.8 years, there were 52 deaths, and 7 patients underwent cardiac transplantation. The primary end point of all-cause mortality or cardiac transplantation was reached by 42 of 86 patients with RVSD and 17 of 164 patients without RVSD (49% versus 10%; hazard ratio, 5.90; 95% confidence interval [CI], 3.35–10.37; P P P P =0.006). Assessment of RVSD improved risk stratification for all-cause mortality or cardiac transplantation (net reclassification improvement, 0.31; 95% CI 0.10–0.53; P =0.001). Conclusions— RVSD is a powerful, independent predictor of transplant-free survival and adverse heart failure outcomes in DCM. Cardiovascular magnetic resonance assessment of RV function is important in the evaluation and risk stratification of DCM patients.

Aims Echocardiographic studies have shown that left atrial volume (LAV) predicts adverse outcome in small heart failure (HF) cohorts of mixed aetiology. However, the prognostic value of LAV in non-ischaemic dilated cardiomyopathy (DCM) is unknown. Cardiovascular magnetic resonance (CMR) allows accurate and reproducible measurement of LAV. We sought to determine the long-term prognostic significance of LAV assessed by CMR in DCM. Methods and results We measured LAV indexed to body surface area (LAVi) in 483 consecutive DCM patients referred for CMR. Patients were prospectively followed up for a primary endpoint of all-cause mortality or cardiac transplantation. During a median follow-up of 5.3 years, 75 patients died and 9 underwent cardiac transplantation. After adjustment for established risk factors, LAVi was an independent predictor of the primary endpoint [hazard ratio (HR) per 10 mL/m2 1.08; 95% confidence interval (CI) 1.01–1.15; P = 0.022]. LAVi was also independently associated with the secondary composite endpoints of cardiovascular mortality or cardiac transplantation (HR per 10 mL/m2 1.11; 95% CI 1.04–1.19; P = 0.003), and HF death, HF hospitalization, or cardiac transplantation (HR per 10 mL/m2 1.11; 95% CI 1.04–1.18; P = 0.001). The optimal LAVi cut-off value for predicting the primary endpoint was 72 mL/m2. Patients with LAVi >72 mL/m2 had a three-fold elevated risk of death or transplantation (HR 3.00; 95% CI 1.92–4.70; P < 0.001). LAVi provided incremental prognostic value for the prediction of transplant-free survival (net reclassification improvement 0.17; 95% CI 0.05–0.29; P = 0.002). Conclusions LAVi is a powerful independent predictor of transplant-free survival and HF outcomes in DCM. Assessment of LAV improves risk stratification in DCM and should be incorporated into routine CMR examination.

BackgroundAortic stenosis is the most common age-related valvular pathology. Patients with aortic stenosis and myocardial fibrosis have worse outcome but the underlying mechanism is unclear. Lipoprotein(a) is associated with adverse cardiovascular risk and is elevated in patients with aortic stenosis. Although mechanistic pathways could link Lipoprotein(a) with myocardial fibrosis, whether the two are related has not been previously explored. In this study, we investigated whether elevated Lipoprotein(a) was associated with the presence of myocardial replacement fibrosis.MethodsA total of 110 patients with mild, moderate and severe aortic stenosis were assessed by late gadolinium enhancement (LGE) cardiovascular magnetic resonance to identify fibrosis. Mann Whitney U tests were used to assess for evidence of an association between Lp(a) and the presence or absence of myocardial fibrosis and aortic stenosis severity and compared to controls. Univariable and multivariable linear regression analysis were undertaken to identify possible predictors of Lp(a).ResultsThirty-six patients (32.7%) had no LGE enhancement, 38 (34.6%) had midwall enhancement suggestive of midwall fibrosis and 36 (32.7%) patients had subendocardial myocardial fibrosis, typical of infarction. The aortic stenosis patients had higher Lp(a) values than controls, however, there was no significant difference between the Lp(a) level in mild, moderate or severe aortic stenosis. No association was observed between midwall or infarction pattern fibrosis and Lipoprotein(a), in the mild/moderate stenosis (p = 0.91) or severe stenosis patients (p = 0.42).ConclusionThere is no evidence to suggest that higher Lipoprotein(a) leads to increased myocardial midwall or infarction pattern fibrosis in patients with aortic stenosis.

There were 116 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2015, which is a 14 % increase on the 102 articles published in 2014. The quality of the submissions continues to increase. The 2015 JCMR Impact Factor (which is published in June 2016) rose to 5.75 from 4.72 for 2014 (as published in June 2015), which is the highest impact factor ever recorded for JCMR. The 2015 impact factor means that the JCMR papers that were published in 2013 and 2014 were cited on average 5.75 times in 2015. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, the progress of the journal's impact over the last 5 years has been impressive. Our acceptance rate is < 25 % and has been falling because the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors have felt that it is useful once per calendar year to summarize the papers for the readership into broad areas of interest or theme, so that areas of interest can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality papers to JCMR for publication.

Background: Left and right atrial function show a different pattern in advanced age in order to maintain adequate ventricular filling. It has been shown that left atrial (LA) function has a prognostic value in a number of heart conditions. Cardiovascular magnetic resonance (CMR) provides high quality images of the left and right atria using high temporal resolution steady state free precession (SSFP) cine sequences. We used SSFP cines to characterize atrial function in healthy, normotensive, volunteers. Methods: We measured maximum, preatrial contraction and minimum left and right atrial volumes in 120 healthy subjects after careful exclusion of cardiovascular abnormality (60 men, 60 women; 20 subjects per age decile from 20 to 80 years). Data were generated from 3-dimensional modeling, including tracking of the atrioventricular ring motion and time-volume curves analysis. With those measurements, all the usual parameters for left and right atrial function were calculated. Results: Gender had significant influence on some parameters of left and right atrial conduit and booster pump function. Age significantly influenced the majority of parameters of both left and right atrial function, with typically lower reservoir and conduit functions and higher booster pump function, both in males and females belonging to older age groups. CMR normal ranges were modelled for clinical use with normalization, where appropriate, for body surface area and gender, displaying parameters with respect to age. Conclusions: CMR normal reference ranges for components of left and right atrial function are provided for males and females for a wide age range.

Differential diagnosis of asymmetrical left ventricular hypertrophy may be challenging, particularly in patients with history of hypertension. A middle-aged man underwent an echocardiographic examination during workup for hypertension, which unexpectedly showed significant asymmetrical septal hypertrophy and raised suspicion for hypertrophic cardiomyopathy. Cardiovascular magnetic resonance confirmed the asymmetrical hypertrophy. No myocardial late gadolinium contrast enhancement was seen. However, precontrast T1 mapping revealed a low native myocardial T1 value. This was highly suggestive of Anderson-Fabry disease, which was subsequently proved with very low alpha galactosidase enzyme levels and mutation analysis. The case illustrates clinical usefulness of multimodality imaging and the novel tissue characterization techniques for assessment of left ventricular hypertrophy.

Background: Magnetic resonance imaging (MRI) phantoms are routinely used for quality assurance in MRI centres; however their long term stability for verification of myocardial T1/ extracellular volume fraction (ECV) mapping has never been investigated. Methods: Nickel-chloride agarose gel phantoms were formulated in a reproducible laboratory procedure to mimic blood and myocardial T1 and T2 values, native and late after Gadolinium administration as used in T1/ECV mapping. The phantoms were imaged weekly with an 11 heart beat MOLLI sequence for T1 and long TR spin-echo sequences for T2, in a carefully controlled reproducible manner for 12 months. Results: There were only small relative changes seen in all the native and post gadolinium T1 values (up to 9.0 % maximal relative change in T1 values) or phantom ECV (up to 8.3 % maximal relative change of ECV, up to 2.2 % maximal absolute change in ECV) during this period. All native and post gadolinium T2 values remained stable over time with

1500 Volt Direct Current (DC) supply in Electric Traction was converted into 25 kV Alternate Current (AC) by the end of December 2015 in Mumbai Local Train. This conversion showed the drastic changes in the speed control, time and cost saving. It was impossible without the recent developments in the power electronics. This paper present the complete conversion of present traction electric system into MATLAB Model. This model mainly help in studying the performance of Induction motor at normal and faulty condition, effects of various loads without disturbing the main system. Internal system connected to the pantograph via transformer whose secondary is connected to the rectifier, chopper and inverter to control the Induction Motors. Graphical behavior of system can be used to study the performance of motor by plotting speed, torque graph using MATLAB Simulation.

Dilated cardiomyopathy (DCM) is best understood as the final common response of myocardium to diverse genetic and environmental insults. A rigorous work-up can exclude alternative causes of left ventricular (LV) dilation and dysfunction, identify etiologies that may respond to specific treatments, and guide family screening. A significant proportion of DCM cases have an underlying genetic or inflammatory basis. Measurement of LV size and ejection fraction remain central to diagnosis, risk stratification, and treatment, but other aspects of cardiac remodeling inform prognosis and carry therapeutic implications. Assessment of myocardial fibrosis predicts both risk of sudden cardiac death and likelihood of LV functional recovery, and has significant potential to guide patient selection for cardioverter-defibrillator implantation. Detailed mitral valve assessment is likely to assume increasing importance with the emergence of percutaneous interventions for functional mitral regurgitation. Detection of pre-clinical DCM could substantially reduce morbidity and mortality by allowing early instigation of cardioprotective therapy.

Cardiovascular magnetic resonance is a non-invasive imaging modality which is emerging as important tool for the investigation and management of pediatric cardiovascular disease. In this review we describe the key technical and practical differences between scanning children and adults, and highlight some important considerations that must be taken into account for this patient population. Using case examples commonly seen in clinical practice, we discuss the important clinical applications of cardiovascular magnetic resonance, and briefly highlight key future developments in this field.

Histological validation of a new CMR T1-mappingbased protocol to improve accuracy for fibrosis assessment in patients with aortic stenosis Vassilis Vassiliou, Katharina Wassilew, George Asimakopoulos, Anthony de Souza, Cesare Quarto, Ee Ling Heng, Claire E Raphael, Bruce S Spottiswoode, Andreas Greiser, Evangelia Nyktari, Francisco Alpendurada, David Firmin, Andrew Jabbour, John Pepper, Dudley J Pennell, Peter Gatehouse, Sanjay Prasad

Background Ultrasmall superparamagnetic particles of iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI) can detect tissue-resident macrophage activity and identify cellular inflammation. Clinical studies using this technique are now emerging. We aimed to report a range of normal R2* values at 1.5 and 3 T in the myocardium and other tissues following ferumoxytol administration, outline the methodology used and suggest solutions to commonly encountered analysis problems. Methods Twenty volunteers were recruited: 10 imaged each at 1.5 T and 3 T. T2* and late gadolinium enhanced (LGE) MRI was conducted at baseline with further T2* imaging conducted approximately 24 h after USPIO infusion (ferumoxytol, 4 mg/kg). Regions of interest were selected in the myocardium and compared to other tissues. Results Following administration, USPIO was detected by changes in R2* from baseline (1/T2*) at 24 h in myocardium, skeletal muscle, kidney, liver, spleen and blood at 1.5 T, and myocardium, kidney, liver, spleen, blood and bone at 3 T (p

Long-term high-intensity physical activity is associated with morphological changes, termed as the 'athlete's heart'. The differentiation of physiological cardiac adaptive changes in response to high-level exercise from pathological changes consistent with an inherited cardiomyopathy is imperative. Cardiovascular magnetic resonance (CMR) imaging allows definition of abnormal processes occurring at the tissue level, including, importantly, myocardial fibrosis. It is therefore vital in accurately making this differentiation. In this review, we will review the role of CMR imaging of fibrosis, and detail CMR characterisation of myocardial fibrosis in various cardiomyopathies, and the implications of fibrosis. Additionally, we will outline advances in imaging fibrosis, in particular T1 mapping. Finally we will address the role of CMR in pre-participation screening.

ObjectivesThe aim of this study was to determine whether left ventricular (LV) midwall fibrosis, detected by midwall hyperenhancement (MWHE) on late gadolinium enhancement cardiovascular magnetic resonance (CMR) imaging, predicts mortality and morbidity in patients with dilated cardiomyopathy (DCM) undergoing cardiac resynchronization therapy (CRT).BackgroundMidwall fibrosis predicts mortality and morbidity in patients with DCM.MethodsPatients with DCM with (+) or without (−) MWHE (n = 20 and n = 77, respectively) as well as 161 patients with ischemic cardiomyopathy (ICM) undergoing CRT (n = 258) were followed up for a maximum of 8.7 years.ResultsAmong patients with DCM, +MWHE predicted cardiovascular mortality (hazard ratio [HR]: 18.6; 95% confidence intervals [CI]: 3.51 to 98.5; p = 0.0008), total mortality or hospitalization for major adverse cardiovascular events (HR: 7.57; 95% CI: 2.71 to 21.2; p < 0.0001), and cardiovascular mortality or heart failure hospitalizations (HR: 9.56; 95% CI: 2.72 to 33.6; p = 0.0004), independent of New York Heart Association class, QRS duration, atrial fibrillation, LV volumes, LV ejection fraction, and a CMR-derived measure of dyssynchrony. Among patients with DCM and ICM, the risk of cardiovascular mortality for DCM +MWHE (adjusted HR: 18.5; 95% CI: 3.93 to 87.3; p = 0.0002) was similar to that for ICM (adjusted HR: 21.0; 95% CI: 5.06 to 87.2; p < 0.0001). Both DCM +MWHE and ICM were predictors of pump failure death as well as sudden cardiac death. LV reverse remodeling was observed in DCM −MWHE and in ICM but not in DCM +MWHE.ConclusionsMidwall fibrosis is an independent predictor of mortality and morbidity in patients with DCM undergoing CRT. The outcome of DCM with midwall fibrosis is similar to that of ICM. This relationship is mediated by both pump failure and sudden cardiac death.

Background Hypertrophic cardiomyopathy (HCM) is characterised by increased left ventricular wall thickness leading to exercise intolerance and heart failure. Peak oxygen consumption (peak VO2) on cardiopulmonary exercise testing (CPET) is often used as a functional marker alongside B-type natriuretic peptide (BNP). However, CPET is complex and time-consuming, access may be limited, and peak VO2 can be influenced by physical deconditioning and motivation. Our aims were to determine the association between BNP and submaximal exercise parameters, ventilatory efficiency (VE/VCO2) and anaerobic threshold; and to determine whether f these were effective surrogate markers of functional status in patients with HCM.Methods We retrospectively reviewed data for all patients with HCM in our local cardiomyopathy service. A diagnosis of HCM was based on LV hypertrophy >15 mm as per current ESC guidelines. Patients underwent contemporaneous echocardiography, CPET using maximal treadmill ergometry and BNP measurement at sequential annual clinic visits [1 (18%), 2 (52%), 3 (20%) or ≥4 visits (10%)] yielding data from 252 observations over 8 years for 119 individual patients. Univariable and multivariable linear regression was used to investigate variables associated with the results of CPET. Robust standard errors were used to correct for multiple observations from the same patients.Results In our cohort of 119 patients (mean age 49±17 years, 66% men), mean LVEF was 75±7%, maximal wall thickness was 19±5 mm, and left ventricular outflow tract obstruction was present in 15%. The mean peak V02 was 26±8 L/min, mean VE/VCO2 slope was 30±6 and median BNP was 93.5 ng/L (IQR 43.5–232.5). On univariable analysis, several markers were found to predict peak VO2; age (β²=−4.5; 95% CI −6.1 – −3.0; p

Aortic stenosis (AS) is characterized by progressive narrowing of the valve and the hypertrophic response of the left ventricle (LV) that ensues [(1)][1]. Although initially adaptive, the hypertrophic response ultimately decompensates and patients transition from hypertrophy to heart failure

Objective To investigate whether cardiac magnetic resonance (CMR) can assess the progression and regression of myocardial fibrosis in patients with aortic stenosis (AS). Methods Sixty-three patients with aortic stenosis were followed up for 2 years with serial CMR and echocardiography: 28 patients (63±13 years, 68% male, 50% asymptomatic severe AS) did not undergo intervention ( natural history cohort ) and 35 patients (67±8 years, 73% male, 83% symptomatic severe AS) underwent aortic valve replacement (AVR) within the first year ( AVR cohort ). Replacement and diffuse myocardial fibrosis were assessed using the late gadolinium enhancement (LGE) and T1 mapping techniques respectively. Annualised change was calculated for all measures. Results In the natural history cohort, left ventricular mass index (LVMi) increased over time (6%±1%, p The AVR cohort displayed a fall in LVMi following surgery (−15%±2%, p Conclusion Changes in diffuse fibrosis can be tracked using iECV and increase with time in patients with AS alongside LV mass and replacement fibrosis. Following AVR there is a fall in LV mass driven predominantly by regression of cellular hypertrophy with more gradual reduction in diffuse fibrosis burden but no change in replacement fibrosis. Mid-wall LGE is present on baseline scan (white arrow) and new areas are seen on 1 year scan (red arrows). Following AVR there is no change in mid-wall LGE (white arrows). Annualised change in imaging measures is presented below in the natural history (black) and AVR (red) groups.

Left ventricular non-compaction (LVNC) is a genetic cardiomyopathy often familial and autosomal dominant. It is characterized by morphological abnormalities affecting the left ventricular myocardium with prominent trabeculations of the inner surface of the ventricle, often extending deep into the ventricular wall. There are no pathognomonic histological findings with normal myocytes being interspersed with areas of fibrosis. Both familial and sporadic forms of non-compaction have been described, the prevalence being estimated to be between 0.01% and 0.27%.1 The diagnosis of LVNC calls for multimodal imaging. Echocardiography, being the most widely available cardiac imaging modality, may raise the initial suspicion of LVNC and can also provide physiological data. See Table 1. Cardiac Magnetic Resonance Imaging (CMR) offers detailed visualization of the extent of non-compaction and supplemental morphological information.4 It should be noted that the current criteria for this condition may result in over diagnosis. View this table: Table 1 Criteria for the diagnosis of isolated left ventricular non-compaction A correct diagnosis is important both for subsequent treatment and also to enable appropriate genetic counselling and familial screening. It is suggested that first degree relatives should be screened. CMR is the best imaging modality currently, though other techniques in the future may be able to improve on diagnostic accuracy. LVNC is associated with LV systolic dysfunction, due to subendocardial hypoperfusion and microcirculation dysfunction, and at a lesser extent to diastolic dysfunction, ventricular arrhythmias, sudden cardiac death and systemic embolism. There is no specific treatment for LVNC at present, with the …

This study examined the cardiac structure and function of a unique cohort of documented lifelong, competitive endurance veteran athletes (>50 yr). Twelve lifelong veteran male endurance athletes [mean ± SD (range) age: 56 ± 6 yr (50–67)], 20 age-matched veteran controls [60 ± 5 yr; (52–69)], and 17 younger male endurance athletes [31 ± 5 yr (26–40)] without significant comorbidities underwent cardiac magnetic resonance (CMR) imaging to assess cardiac morphology and function, as well as CMR imaging with late gadolinium enhancement (LGE) to assess myocardial fibrosis. Lifelong veteran athletes had smaller left (LV) and right ventricular (RV) end-diastolic and end-systolic volumes ( P < 0.05), but maintained LV and RV systolic function compared with young athletes. However, veteran athletes had a significantly larger absolute and indexed LV and RV end-diastolic and systolic volumes, intraventricular septum thickness during diastole, posterior wall thickness during diastole, and LV and RV stroke volumes ( P < 0.05), together with significantly reduced LV and RV ejection fractions ( P < 0.05), compared with veteran controls. In six (50%) of the veteran athletes, LGE of CMR indicated the presence of myocardial fibrosis (4 veteran athletes with LGE of nonspecific cause, 1 probable previous myocarditis, and 1 probable previous silent myocardial infarction). There was no LGE in the age-matched veteran controls or young athletes. The prevalence of LGE in veteran athletes was not associated with age, height, weight, or body surface area ( P > 0.05), but was significantly associated with the number of years spent training ( P < 0.001), number of competitive marathons ( P < 0.001), and ultraendurance (>50 miles) marathons ( P < 0.007) completed. An unexpectedly high prevalence of myocardial fibrosis (50%) was observed in healthy, asymptomatic, lifelong veteran male athletes, compared with zero cases in age-matched veteran controls and young athletes. These data suggest a link between lifelong endurance exercise and myocardial fibrosis that requires further investigation.

In patients with cyanosis from congenital heart disease, erythropoiesis is governed by many factors that can alter the expected relation between the oxygen saturation (O(2sat)) and hemoglobin concentration. We sought to define the relation between the O(2sat) and hemoglobin in such patients and to predict an ideal hemoglobin concentration for a given O(2sat). Adults with congenital heart defects and cyanosis were studied prospectively using blood tests and exercise testing. Nonoptimal hemoglobin was defined as any evidence of inadequate erythropoiesis (i.e., iron, folate, or vitamin B(12) deficiency, increased erythropoietin, reticulocytosis, or a right-shifted oxygen-hemoglobin curve). For patients without these factors, a linear regression equation of hemoglobin versus O(2sat) was used to predict the optimal hemoglobin for all patients. Of the 65 patients studied, 21 met all the prestudy criteria for an optimal hemoglobin. For all patients, no correlation was found between O(2sat) and hemoglobin (r = -0.22). However, a strong linear correlation was found for those meeting the criteria for optimal hemoglobin (r = -0.865, p0.001). The optimal hemoglobin regression equation was as follows: predicted hemoglobin = 57.5 - (0.444 × O(2sat)). A negative correlation was found between the hemoglobin difference (predicted minus measured) and exercise duration on cardiopulmonary exercise testing (r = -0.396, p = 0.005) and the 6-minute walk distance (r = -0.468, p0.001). In conclusion, a strong relation between O(2sat) and hemoglobin concentration can be shown in stable cyanotic patients and used to predict an optimal hemoglobin. This relation might be useful in defining functional anemia in this group.

Chronic heart failure is a common disease placing significant burdens on patients and health-care services. Noninvasive imaging plays a key role in accurate diagnosis, determination of etiology and prognosis, and in monitoring of therapy. Cardiovascular magnetic resonance (CMR) allows both a valuable clinical and research toll for a comprehensive assessment of heart failure patients. Currently, CMR constitutes the gold standard imaging technique for accurate and reproducible measurement of myocardial anatomy, regional and global function, perfusion and viability. In addition, it allows evaluation of acute

Objectives This study aimed to characterize myocardial infarction after percutaneous coronary intervention (PCI) based on cardiac marker elevation as recommended by the new universal definition and on the detection of late gadolinium enhancement (LGE) by cardiovascular magnetic resonance (CMR). It is also assessed whether baseline inflammatory biomarkers are higher in patients developing myocardial injury. Background Cardiovascular magnetic resonance accurately assesses infarct size. Baseline C-reactive protein (CRP) and neopterin predict prognosis after stent implantation. Methods Consecutive patients with baseline troponin (Tn) I within normal limits and no LGE in the target vessel underwent baseline and post-PCI CMR. The Tn-I was measured until 24 h after PCI. Serum high-sensitivity CRP and neopterin were assessed before coronary angiography. Results Of 45 patients, 64 (53 to 72) years of age, 33% developed LGE with infarct size of 0.83 g (interquartile range: 0.32 to 1.30 g). A Tn-I elevation >99% upper reference limit (i.e., myocardial necrosis) (median Tn-I: 0.51 μg/l, interquartile range: 0.16 to 1.23) and Tn-I >3× upper reference limit (i.e., type 4a myocardial infarction [MI]) occurred in 58% and 47% patients, respectively. LGE was undetectable in 42% and 43% of patients with periprocedural myocardial necrosis and type 4a MI, respectively. Agreement between LGE and type 4a MI was moderate (kappa = 0.45). The levels of CRP or neopterin did not significantly differ between patients with or without myocardial injury, detected by CMR or according to the new definition (p = NS). Conclusions This study reports the lack of substantial agreement between the new universal definition and CMR for the diagnosis of small-size periprocedural myocardial damage after complex PCI. Baseline levels of CRP or neopterin were not predictive for the development of periprocedural myocardial damage.

Defining sex differences in dilated cardiomyopathy (DCM) is important in improving disease understanding and management. We used proportional hazard modelling to examine the association between sex and outcome in consecutive patients referred with DCM. Overall, 881 patients (290 women, median left

Data on the association between the extent of mid-wall late gadolinium enhancement (LGE) and heart failure (HF) outcomes is lacking. We used proportional hazard modelling to examine the association between mid-wall LGE extent and a HF composite end-point (HF death, unplanned HF hospitalisation and

Accurate epidemiological data on acute myocarditis is lacking due to heterogeneity in clinical presentation, diagnostic limitations and regional variation. Studies based on patient cohorts with post-mortem or biopsy confirmation are subject to considerable bias and few studies have assessed the true

We present the case of a 55-year-old male who presented with symptoms of dyspnoea and pre-syncope. A 12 lead electrocardiogram demonstrated extensive conduction abnormalities with 2:1 heart block, right bundle branch block and a small Q wave in lead V(1.) This indicated significant myocardial and septal involvement. Echocardiography confirmed the presence of right ventricular infiltration and dysfunction whilst cardiac magnetic resonance showed the infiltration to be nodular in nature. Although a diagnosis of cardiac sarcoidosis and lymphoma were initially considered, sarcoidosis was eventually confirmed following a cervical lymph node biopsy. This case firstly demonstrates the usefulness of the 12-lead electrocardiogram in determining the likely anatomical locality of significant bradyarrhythmias. Secondly it highlights the difficulties in diagnosing cardiac sarcoidosis when cardiac dysfunction is the sole manifestation of the disease.

Cardiomyopathies are a heterogeneous group of diseases of the myocardium associated with architectural abnormalities and mechanical dysfunction. Recent advances in our understanding of the genetics, pathophysiology, and natural history of these conditions has resulted in better diagnosis and management, leading to improvements in mortality. Major developments in imaging techniques, in particular contrast-enhanced MRI, now permit in vivo tissue characterization of the myocardium. Through defining disease severity, etiology, and to some extent in risk stratification, routine cardiovascular magnetic resonance evaluation of this group of patients provides essential information required in everyday clinical practice.

Objectives We sought to investigate the clinical-genetic profile of left-dominant arrhythmogenic cardiomyopathy (LDAC). Background In the absence of coronary disease and left ventricular (LV) systolic dysfunction, lateral T-wave inversion and arrhythmia of LV origin are often considered benign. Similarly, chest pain with enzyme release might be attributed to viral myocarditis. We hypothesized that these abnormalities might be manifestations of the “left-dominant” subtype of arrhythmogenic right ventricular cardiomyopathy. Methods The 42-patient cohort was established through clinical evaluation of individuals with unexplained (infero)lateral T-wave inversion, arrhythmia of LV origin, and/or proven LDAC/idiopathic myocardial fibrosis in the family. Results Patients presented from adolescence to age >80 years with arrhythmia or chest pain but not heart failure. Desmosomal mutations were identified in 8 of 24 families (15 of 33 patients). Magnetic resonance findings included LV late-enhancement in a subepicardial/midwall distribution, corresponding to fibrofatty replacement and fibrosis on histopathology. Fifty percent had previously been misdiagnosed with viral myocarditis, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy, or idiopathic ventricular tachycardia. Arrhythmic events included presentation with ventricular fibrillatory arrest in 1 patient and 2 instances of sudden cardiac death during follow-up. Conclusions Arrhythmogenic cardiomyopathy is distinguished from DCM by a propensity towards arrhythmia exceeding the degree of ventricular dysfunction. The left-dominant subtype is under-recognized owing to misattribution to other disorders and lack of specific diagnostic criteria. Clinicians are alerted to the possibility of LDAC in patients of any age with unexplained arrhythmia of LV origin, (infero)lateral T-wave inversion, apparent DCM (with arrhythmic presentation), or myocarditis (chest pain and enzyme rise with unobstructed coronary arteries).

A greater understanding of the molecular basis of hibernating myocardium may assist in identifying those patients who would most benefit from revascularization. Paired heart biopsies were taken from hypocontractile and normally-contracting myocardium (identified by cardiovascular magnetic resonance) from 6 patients with chronic stable angina scheduled for bypass grafting. Gene expression profiles of hypocontractile and normally-contracting samples were compared using Affymetrix microarrays. The data for patients with confirmed hibernating myocardium were analysed separately and a different, though overlapping, set (up to 380) of genes was identified which may constitute a molecular fingerprint for hibernating myocardium. The expression of B-type natriuretic peptide (BNP) was increased in hypocontractile relative to normally-contracting myocardium. The expression of BNP correlated most closely with the expression of proenkephalin and follistatin 3, which may constitute additional heart failure markers. Our data illustrate differential gene expression in hypocontractile and/hibernating myocardium relative to normally-contracting myocardium within individual human hearts. Changes in expression of these genes, including increased relative expression of natriuretic and other factors, may constitute a molecular signature for hypocontractile and/or hibernating myocardium.

Background Hypertension causes cardiac morbidity and premature mortality. Accurate evaluation to exclude potentially curable causes is important. Cardiovascular Magnetic Resonance and Magnetic Resonance Angiography (CMR/CE-MRA) provide an integrated approach to the assessment of hypertensive patients — a single study can identify certain secondary causes and assess left ventricular (LV) mass and function. The aim of this study was to prospectively evaluate the feasibility of CMR/CE-MRA to define LV dimensions and exclude some secondary causes in a selected group of hypertensives. Methods and results Fifty-three hypertensives (46±17 years, 18 females) were prospectively studied (early onset hypertension, n =17; drug resistant hypertension, n =23; hypertension with increased creatinine at baseline/after ACEi, n =12; hypertension with peripheral vessel disease, n =1). Study protocol included assessment of LV and aorta, imaging of adrenals and 3D CE-MRA of aorta and renal arteries. Significant abnormalities were found in 13 patients (25%) — renal artery stenosis ( n =8), aortic coarctation ( n =4), adrenal mass ( n =1). Mean LV mass index was increased compared with matched controls. LV systolic dysfunction was found in 9 patients. Conclusions CMR/CE-MRA provides comprehensive evaluation of hypertensive patients and could allow for a unique integrated approach with assessment of LV dimensions as well as detection of some secondary causes.

A previously fit and healthy 30-year-old man reported experiencing palpitations accompanied by nausea, sweating and presyncope. These symptoms were found to be associated with episodes of nonsustained ventricular tachycardia. He was a nonsmoker, did not drink excessively, denied illicit drug use and had no family history of structural cardiac disease or sudden death.Electrocardiography, laboratory tests, electrophysiological studies, echocardiography, coronary angiography, chest radiography, cardiac MRI (with late gadolinium enhancement), chest CT, lymph-node biopsy, Ziehl Nielsen staining, blood and sputum cultures and heaf testing.Tubercular myocarditis.Antituberculous chemotherapy supported by antiarrhythmic and steroid pharmacotherapy and cardioverter-defibrillator implantation. Repeated imaging was performed to monitor disease progression.

Heart failure is a common disorder that is associated with significant morbidity, mortality and financial burden to healthcare services. In the UK, around 900 000 people have been diagnosed with heart failure and the prevalence of the condition increases as the population ages.w1 Population-based studies suggest that heart failure carries a worse prognosis than breast and colon cancer, with estimates suggesting a 1 year mortality of 40% from the time of diagnosis. Heart failure currently accounts for a total of one million inpatient bed days and admissions are projected to rise by 50% over the next 25 years. Heart failure treatment currently absorbs 1.8% of the total National Health Service budget, of which 70% is spent on hospitalisation. Accurate diagnosis, assessment and risk stratification of such patients by imaging modalities is important, particularly with the advent of effective but expensive implantable devices. In the last 5 years, there have been tremendous advances in the ability of cardiovascular magnetic resonance (CMR) to fulfil many of these needs and provide a comprehensive assessment.1 A combination of hardware and software developments means that a modern CMR scanner is able to yield information on myocardial anatomy, function, tissue characterisation, viability, perfusion and flow within a single 45–60 min study. ### Basic principles Understanding the way in which CMR works provides a basis for appreciating its role in evaluating patients with heart failure. CMR yields high contrast and high resolution images of the heart by mapping radio wave signals absorbed and emitted by hydrogen nuclei (protons) in a powerful magnetic field. Most cardiovascular pathologies manifest with an increase in water content which is rich in protons so that CMR is a sensitive guide to early disease states. CMR is currently mainly performed at a magnetic field strength of 1.5 Tesla (T). The two main types of …

Objectives This study sought to determine what factors are associated with pulmonary artery thrombi in Eisenmenger patients. Background Pulmonary artery thrombosis is common in Eisenmenger syndrome, although its underlying pathophysiology is poorly understood. Methods Adult patients with Eisenmenger syndrome underwent computed tomography pulmonary angiography, cardiac magnetic resonance imaging, and echocardiography. Measurement of ventricular function, pulmonary artery size, and pulmonary artery blood flow were obtained. Hypercoagulability screening and platelet function assays were performed. Results Of 55 consecutive patients, 11 (20%) had a detectable thrombus. These patients were older (p = 0.032), but did not differ in oxygen saturation, hemoglobin, or hematocrit from those without thrombus. Right ventricular ejection fraction by magnetic resonance imaging was lower in those with thrombus (0.41 ± 0.15 vs. 0.53 ± 0.13, p = 0.017), as was left ventricular ejection fraction (0.48 ± 0.12 vs. 0.60 ± 0.09, p = 0.002), a finding corroborated by tissue Doppler and increased brain natriuretic peptide. Those with thrombus also had a larger main pulmonary artery diameter (48 ± 14 mm vs. 38 ± 9 mm, p = 0.007) and a lower peak systolic velocity in the pulmonary artery (p = 0.003). There were no differences in clotting factors, platelet function, or bronchial arteries between groups. Logistic regression showed pulmonary artery velocity to be independently associated with thrombosis. Conclusions Pulmonary arterial thrombosis among adults with Eisenmenger syndrome is common and relates to older age, biventricular dysfunction, and slow pulmonary artery blood flow rather than degree of cyanosis or coagulation abnormalities. Further work to define treatment efficacy is needed.

Aims Troponin measurement is used in the assessment and risk stratification of patients presenting acutely with chest pain when the main cause of elevation is coronary artery disease. However, some patients have no coronary obstruction on angiography, leading to diagnostic uncertainty. We evaluated the incremental diagnostic value of cardiovascular magnetic resonance (CMR) in these patients. Methods and results Sixty consecutive patients (mean age 44 years, 72% male) with a troponin-positive episode of chest pain and unobstructed coronary arteries were recruited within 3 months of initial presentation. All patients underwent CMR with cine imaging, T2-weighted imaging for detection of inflammation, and late gadolinium enhancement imaging for detection of infarction/fibrosis. An identifiable basis for troponin elevation was established in 65% of patients. The commonest underlying cause was myocarditis (50%), followed by myocardial infarction (11.6%) and cardiomyopathy (3.4%). In the 35% of patients where no clear diagnosis was identified by CMR, significant myocardial infarction/fibrosis was excluded. Conclusion CMR is a valuable adjunct to conventional investigations in a diagnostically challenging and important group of patients with troponin-positive chest pain and unobstructed coronary arteries.

There were 102 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2014, which is a 6 % decrease on the 109 articles published in 2013. The quality of the submissions continues to increase. The 2013 JCMR Impact Factor (which is published in June 2014) fell to 4.72 from 5.11 for 2012 (as published in June 2013). The 2013 impact factor means that the JCMR papers that were published in 2011 and 2012 were cited on average 4.72 times in 2013. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, the progress of the journal’s impact over the last 5 years has been impressive. Our acceptance rate is

Introduction: Constrictive pericarditis is characterized by constriction of the heart secondary to pericardial inflammation. Cardiovascular magnetic resonance (CMR) imaging is useful imaging modality for addressing the challenges of confirming this diagnosis. It can be used to exclude other causes of right heart failure, such as pulmonary hypertension or myocardial infarction, determine whether the pericardium is causing constriction and differentiate it from restrictive cardiomyopathy, which also causes impaired cardiac filling. Case Presentation: A 77-year-old man from a country with high incidence of tuberculosis presented with severe dyspnea. Echocardiography revealed a small left ventricle with normal systolic and mildly impaired diastolic function. Left heart catheterization revealed non-obstructive coronary disease, not felt contributory to the dyspnea. Anatomy imaging with cardiovascular magnetic resonance imaging (CMR) showed global, severely thickened pericardium. Short tau inversion recovery (STIR) sequences for detection of oedema/ inflammation showed increased signal intensity and free breathing sequences confirmed septal flattening on inspiration. Late gadolinium imaging confirmed enhancement in the pericardium, with all findings suggestive of pericardial inflammation and constriction. Conclusions: CMR with STIR sequences, free breathing sequences and late gadolinium imaging can prove extremely useful for diagnosing constrictive pericarditis.

Background Although cardiovascular magnetic resonance (CMR) is showing increasingly diagnostic potential in left ventricular non-compaction (LVNC), relatively little research relevant to CMR is conducted in children with LVNC. This study was performed to characterize and compare CMR features and clinical outcomes in children with LVNC with and without late gadolinium enhancement (LGE). Methods A cohort of 40 consecutive children (age, 13.7 ± 3.3 years; 29 boys and 11 girls) with isolated LVNC underwent a baseline CMR scan with subsequent clinical follow-up. Short-axis cine images were used to calculate left ventricular (LV) ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), myocardial mass, ratio of non-compacted-to-compacted myocardial thickness (NC/C ratio), and number of non-compacted segments. The LGE images were analyzed to assess visually presence and patterns of LGE. The primary end point was a composite of cardiac death and heart transplantation. Results The LGE was present in 10 (25 %) children, and 46 (27 %) segments were involved, including 23 non-compacted segments and 23 normal segments. Compared with LGE- cohort, LGE+ cohort had significantly lower LVEF (23.8 ± 10.7 % vs. 42.9 ± 16.7 %, p

AIMS: Magnetic resonance (MR) conditional pacemakers are increasingly implanted into patients who may need cardiovascular MR (CMR) subsequent to device implantation. We assessed the added value of CMR for diagnosis and management in this population. METHODS AND RESULTS: CMR and pacing data from consecutive patients with MR conditional pacemakers were retrospectively reviewed. Images were acquired at 1.5 T (Siemens Magnetom Avanto). The indication for CMR and any resulting change in management was recorded. The quality of CMR was rated by an observer blinded to clinical details, and data on pacemaker and lead parameters were collected pre- and post-CMR. Seventy-two CMR scans on 69 patients performed between 2011 and 2015 were assessed. All scans were completed successfully with no significant change in lead thresholds or pacing parameters. Steady-state free precession (SSFP) cine imaging resulted in a greater frequency of non-diagnostic imaging (22 vs. 1%, P < 0.01) compared with gradient echo sequences (GRE). Right-sided pacemakers were associated with less artefact than left-sided pacemakers. Late gadolinium enhancement imaging was performed in 59 scans with only 2% of segments rated of non-diagnostic quality. The CMR data resulted in a new diagnosis in 27 (38%) of examinations; clinical management was changed in a further 18 (25%). CONCLUSIONS: CMR in patients with MR conditional pacemakers provided diagnostic or management-changing information in the majority (63%) of our cohort. The use of gradient echo cine sequences can reduce rates of non-diagnostic imaging. Right-sided device implantation may be considered in patients likely to require CMR examination.

This chapter will discuss how cardiovascular magnetic resonance (CMR) can assess myocardial viability in patients with chronic heart failure and help to identify those who may derive improvement in left ventricular function and (potentially) prognosis from revascularization. The following CMR parameters as markers of viability will also be discussed: end-diastolic wall thickness; dobutamine stress ventriculography; late gadolinium enhancement and transmurality of infarction; and new techniques (including MR spectroscopy and myocardial tagging).

Background Coronary perfusion pressure is a combination of proximal perfusion pressure and distal coronary artery pressure resulting from contraction and relaxation of the myocardium and the consequences on the microcirculation. Wave intensity analysis (WIA) defines dominant waves causing coronary filling during the cardiac cycle and allows separation of proximally and distally originating waves.Reduced myocardial perfusion has been shown to predict mortality in hypertrophic cardiomyopathy (HCM), however no study has assessed the relationship between coronary filling patterns and downstream absolute myocardial perfusion.

The recent discovery of heterozygous human mutations that truncate full-length titin (TTN, an abundant structural, sensory, and signaling filament in muscle) as a common cause of end-stage dilated cardiomyopathy (DCM) promises new prospects for improving heart failure management. However, realization of this opportunity has been hindered by the burden of TTN-truncating variants (TTNtv) in the general population and uncertainty about their consequences in health or disease. To elucidate the effects of TTNtv, we coupled TTN gene sequencing with cardiac phenotyping in 5267 individuals across the spectrum of cardiac physiology and integrated these data with RNA and protein analyses of human heart tissues. We report diversity of TTN isoform expression in the heart, define the relative inclusion of TTN exons in different isoforms (using the TTN transcript annotations available at http://cardiodb.org/titin), and demonstrate that these data, coupled with the position of the TTNtv, provide a robust strategy to discriminate pathogenic from benign TTNtv. We show that TTNtv is the most common genetic cause of DCM in ambulant patients in the community, identify clinically important manifestations of TTNtv-positive DCM, and define the penetrance and outcomes of TTNtv in the general population. By integrating genetic, transcriptome, and protein analyses, we provide evidence for a length-dependent mechanism of disease. These data inform diagnostic criteria and management strategies for TTNtv-positive DCM patients and for TTNtv that are identified as incidental findings.

Background Temporal patterns of coronary blood flow velocity can provide important information on disease state and are currently assessed invasively using a Doppler guidewire. A non-invasive alternative would be beneficial as it would allow study of a wider patient population and serial scanning. Methods A retrospectively-gated breath-hold spiral phase velocity mapping sequence (TR 19 ms) was developed at 3 Tesla. Velocity maps were acquired in 8 proximal right and 15 proximal left coronary arteries of 18 subjects who had previously had a Doppler guidewire study at the time of coronary angiography. Cardiovascular magnetic resonance (CMR) velocity-time curves were processed semi-automatically and compared with corresponding invasive Doppler data. Results When corrected for differences in heart rate between the two studies, CMR mean velocity through the cardiac cycle, peak systolic velocity (PSV) and peak diastolic velocity (PDV) were approximately 40 % of the peak Doppler values with a moderate - good linear relationship between the two techniques (R2: 0.57, 0.64 and 0.79 respectively). CMR values of PDV/PSV showed a strong linear relationship with Doppler values with a slope close to unity (0.89 and 0.90 for right and left arteries respectively). In individual vessels, plots of CMR velocities at all cardiac phases against corresponding Doppler velocities showed a consistent linear relationship between the two with high R2 values (mean +/−SD: 0.79 +/−.13). Conclusions High temporal resolution breath-hold spiral phase velocity mapping underestimates absolute values of coronary flow velocity but allows accurate assessment of the temporal patterns of blood flow.

OBJECTIVES We sought to assess the utility of cardiovascular magnetic resonance (CMR) in the evaluation of arrhythmogenic right ventricular cardiomyopathy (ARVC) in relation to diagnostic criteria and genotype. BACKGROUND Timely diagnosis of ARVC is difficult as clinical findings may be subtle and nonspecific in early disease. The role of CMR is controversial owing to the absence of a standardized protocol, insufficient experience with the modality, and inherent difficulties in imaging the right ventricle. METHODS Comprehensive CMR examination was performed in 232 patients undergoing evaluation for suspected ARVC. CMR outcomes were compared with: 1) prospective clinical diagnosis using Task Force guidelines, with and without the proposed modifications for familial ARVC; and 2) gene-carrier status in 35 individuals from genotyped families. RESULTS CMR studies were positive in all 64 patients who prospectively fulfilled Task Force criteria, resulting in 100% sensitivity. Specificity in relation to Task Force criteria was low (29%). Of the 119 apparent false positives detected by CMR, however, 63 fulfilled modified diagnostic criteria for familial ARVC and 7 were obligate gene carriers, suggesting that CMR frequently identifies individuals with early disease, in whom Task Force criteria are relatively insensitive. This was borne out by evaluation of genotyped individuals (26 gene-positive and 9 gene-negative), in whom CMR had a sensitivity of 96% and a specificity of 78%. CONCLUSIONS CMR is a valuable component of the diagnostic workup for ARVC when performed with a dedicated protocol by specialists with experience in analysis of volumes, right ventricular wall motion, and delayed-enhancement imaging.