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Positron emission tomography (PET) enables robust and reproducible measurements of myocardial blood flow (MBF). However, the relatively limited resolution of PET till recently prohibited distinction between the subendocardial and the subepicardial layers in non-hypertrophied myocardium. Recent developments in hard- and software, however, have enabled to identify a transmural gradient difference in animal experiments. The aim of this study is to determine the feasibility of subendocardial and subepicardial MBF in normal human hearts assessed with (15)O-labeled water PET.Twenty-seven healthy subjects (mean age 41 ± 13 years; 11 men) were studied with (15)O-labeled water PET to quantify resting and hyperaemic (adenosine) MBF at a subendocardial and subepicardial level. In addition, cardiac magnetic resonance imaging was performed to determine left ventricular (LV) volumes and function.Mean rest MBF was 1.46 ± 0.49 in the subendocardium, and 1.14 ± 0.342 mL · min(-1) · g(-1) in the subepicardium (P .001). MBF during vasodilation was augmented to a greater extent at the subepicardial level (subendocardium vs subepicardium: 3.88 ± 0.86 vs 4.14 ± 0.88 mL · min(-1) · g(-1), P = .013). The endocardial-to-epicardial MBF ratio decreased significantly during hyperaemia (1.35 ± 0.23 to 1.12 ± 0.20, P .001). Hyperaemic transmural MBF was inversely correlated with left ventricular end-diastolic volume index (LVEDVI) (r (2) = 0.41, P = .0003), with greater impact however at the subendocardial level.(15)O-labeled water PET enables MBF measurements with distinction of the subendocardial and subepicardial layers in the normal human heart and correlates with LVEDVI. This PET technique may prove useful in evaluating patients with signs of ischaemia due to coronary artery disease or microvascular dysfunction.

Objective We evaluated the ability of a novel automatic index based on area strain to reliably quantify global and regional left ventricular (LV) function and accurately identify wall motion (WM) abnormalities using three-dimensional speckle tracking echocardiography. Methods A total of 140 consecutive patients underwent two- and three-dimensional echocardiography. Segmental WM assessment by area strain was compared with visual assessment of two-dimensional images by two experienced echocardiographers. For global LV function assessment, area strain was validated against LV ejection fraction (EF) and wall motion score index (WMSI). Observer reliability was assessed in all patients, whereas test–retest reliability was evaluated in a subgroup of 50 randomly selected patients. Normal reference values of area strain were determined in 56 healthy subjects. Results Agreement of WM scores between area strain and visual assessment was found in 94% of normal, 55% of hypokinetic, and 91% of akinetic segments ( κ -coefficient 0.88). Sensitivity, specificity, and accuracy of area strain to distinguish abnormal segments from normal segments were 91%, 96%, and 94%, respectively. In regard to global LV function assessment, area strain was highly correlated with EF and WMSI ( r = 0.91 and 0.88, respectively). Observer and test–retest reliability of area strain for quantitative assessment of global and regional LV function were good to excellent (all intraclass correlation coefficients ≥0.77). Intraobserver and interobserver reliability of semiquantitative segmental WM analysis by area strain ( κ -coefficients 0.87 and 0.73) were comparable to visual assessment by experienced echocardiographers (0.85 and 0.69, respectively). Conclusion Area strain represents a promising novel automatic index that may provide an accurate and reproducible alternative to current echocardiographic standards for quantitative assessment of global and regional LV function. Area strain seems to adequately identify regional wall motion abnormalities compared with the clinical standard of visual assessment by experienced echocardiographers.

Magnetic resonance imaging (MRI) is a non-invasive modality which can be used for direct visualization of coronary artery bypass grafts. Spin-echo and gradient-echo (cine-MRI) techniques are now available on standard MR machines and provide information on graft morphology and graft patency with a 90% accuracy. By combining the standard techniques with MR phase velocity mapping, the flow rate in the graft can be measured, thereby offering a unique non-invasive assessment of the graft function. Newer techniques include MR coronary angiography, pharmacologically induced stress MRI, ultrafast MRI of the first-pass (perfusion) of a paramagnetic contrast agent through the myocardium, and31P MR spectroscopy of high-energy phosphate metabolism of the myocardium. All of these may develop into valuable diagnostic tools for the assessment of functional results after CABG or PTCA, but still require clinical validation. At present, MRI is a useful screening procedure for assessment of graft patency and function in post-operative pain syndromes and in late graft occlusion or stenosis.

Hypertrophic cardiomyopathy (HCM) is a familial disorder characterized by left ventricular hypertrophy in the absence of other cardiac or systemic disease likely to cause this hypertrophy. HCM is considered a disease of the sarcomere as most causal mutations are identified in genes encoding sarcomeric proteins, although several other disorders have also been linked to the HCM phenotype. The clinical course of HCM is characterized by a large inter- and intrafamilial variability, ranging from severe symptomatic HCM to asymptomatic individuals. The general picture emerges that the underlying pathophysiology of HCM is complex and still scarcely clarified. Recent findings indicated that both functional and morphological (macroscopic and microscopic) changes of the HCM muscle are present before the occurrence of HCM phenotype. This review aims to provide an overview of the myocardial alterations that occur during the gradual process of wall thickening in HCM on a myofilament level, as well as the structural and functional abnormalities that can be observed in genetically affected individuals prior to the development of HCM with state of the art imaging techniques, such as tissue Doppler echocardiography and cardiovascular magnetic resonance imaging. Additionally, present and future therapeutic options will be briefly discussed.

In the present substudy of the Hebe trial, we investigated the effect of intracoronary bone marrow mononuclear cell (BMMC) and peripheral blood mononuclear cell (PBMC) therapy on the recovery of microcirculation in patients with reperfused ST-segment elevation myocardial infarction (STEMI).Several studies have suggested that cell therapy enhances neovascularization after STEMI.Paired Doppler flow measurements were available for 23 patients in the BMMC group, 18 in the PBMC group, and 19 in the control group. Coronary flow was assessed at 3 to 8 days after primary percutaneous coronary intervention (PCI) and repeated at 4-month follow-up, with intracoronary Doppler flow measurements.At baseline, the coronary flow velocity reserve was reduced in the infarct-related artery and improved over 4 months in all 3 groups. The increase of coronary flow velocity reserve did not significantly differ between the 2 treatment groups and the control group (BMMC group: 2.0 ± 0.5 to 3.1 ± 0.7; PBMC group: 2.2 ± 0.6 to 3.2 ± 0.8; control group: 2.0 ± 0.5 to 3.4 ± 0.9). Additionally, the decrease in hyperemic microvascular resistance index from baseline to 4-month follow-up was not statistically different between the 2 treatment groups and the control group.In STEMI patients treated with primary PCI in the Hebe trial, adjuvant therapy with BMMCs or PBMCs does not improve the recovery of microcirculation. Therefore, our data do not support the hypothesis of enhanced neovascularization after this mode of cell therapy. (Multicenter, randomised trial of intracoronary infusion of autologous mononuclear bone marrow cells or peripheral mononuclear blood cells after primary percutaneous coronary intervention [PCI]; ISRCTN95796863).

Background: Several studies have investigated the diagnostic performance of computed tomography coronary angiography (CTCA) for the detection of significant coronary artery disease (CAD). These studies were performed in patients that were already referred for invasive coronary angiography (ICA) and prevalence of significant CAD was high. Although the negative predictive value of CTCA was consistently high, a wide range of positive predictive values (PPVs) was reported. Thus, the PPV of CTCA in patients that undergo CTCA as part of a clinical diagnostic evaluation remains unclear. This study investigated the PPV of CTCA for the detection of significant CAD in clinical practice. Methods: A total of 181 patients with low to intermediate pre-test probability CAD that were referred for non-invasive evaluation of chest pain underwent 64-slice CTCA. CTCA was scored per segment as normal, non-obstructive CAD or obstructive CAD (> 50% diameter stenosis). All patients with obstructive CAD according to CTCA, underwent ICA. Significant CAD was defined as > 50% diameter stenosis on ICA. Results: According to CTCA, 65 (35.9%) patients had obstructive CAD. In 26 (14.4%) patients, significant CAD was found by ICA. The PPV for detection of significant CAD per patient, per vessel and per segment were 40.0% (26/65, 95% CI: 30.6-50.2%), 31.3% (36/115, 95% CI: 24.7-38.8%) and 25.5% (42/165; 95% CI: 20.3-31.4%), respectively. Conclusions: The PPV of CTCA for detection of significant CAD in patients with low to intermediate probability CAD that are clinically referred for non-invasive evaluation of chest pain is markedly lower than generally reported. © 2010 Elsevier Ireland Ltd. All rights reserved.

Cardiovascular magnetic resonance imaging (CMR) is increasingly used in the daily practice of the clinical cardiologist. Technical advances in hardware and development of new software have led to major improvements in image quality, spatial and temporal resolution, and imaging speed, allowing the detailed assessment of the whole spectrum of cardiovascular disease. This article reviews the clinical applications of CMR in patients with acute myocardial infarction (AMI). ### Cine imaging Cine imaging forms the backbone of the CMR examination. It is used for the qualitative and quantitative assessment of myocardial anatomy and function, and, with the use of dobutamine stress, to evaluate ischaemia and viability (box 1). In addition, it may be used as an alternative technique to Doppler echocardiography for the evaluation of valvular heart disease. The standard cine pulse sequence is a breath-hold, steady state free precession (SSFP) sequence that provides optimal contrast between blood and myocardium (figure 1; see also supplemental videos 1 and 2). Current cine sequences use retrospective ECG gating, although prospective gating may be required in patients with irregular heart rhythm. When heart rhythm is notably irregular, as with complex ventricular ectopy, real time imaging without ECG gating will still allow the assessment of regional and global function, albeit at the cost of reduced image quality and spatial and temporal resolution (supplemental video 3). The efficiency of data acquisition may be considerably improved by using parallel imaging, which is based on undersampling of the raw data by using information from multiple receiver coils.1 The improved scan efficiency may be translated into reduced scan time or improved resolution, at the cost of some loss in signal-to-noise. Temporal resolution can also be improved by phase sharing, a …

This chapter describes the currently available expertise and clinical applications of cardiovascular magnetic resonance (CMR) to image coronary artery bypass grafts. There is clear evidence that conventional spin echo and gradient echo CMR are capable of assessing patency of venous aortocoronary grafts. With advances in breath-hold two-dimensional and contrast-enhanced three-dimensional techniques, the accuracy in detecting graft occlusion has further improved. Graft flow patterns and flow reserve can be measured using phase contrast velocity-encoded CMR both at 1.5 T and 3 T. Clinically, these functional measurements may be useful for noninvasive monitoring of bypass graft narrowing progression before and after percutaneous interventions. Limitations are still present in evaluating distal graft segments and sequential grafts as a result of insufficient spatial resolution, low signal-to-noise ratios and motion. Imaging of arterial grafts is complicated by the sternal wire and metallic clip artifacts. A broader role for CMR in the evaluation of patients with aortocoronary bypass grafts may be expected only when improvement of CMR coronary angiography is obtained allowing simultaneous assessment of the native coronary arteries.

To determine the relation between electromechanical endocardial mapping (EEM) and cardiac magnetic resonance (CMR) derived functional and viability parameters in patients with a large myocardial infarction.Forty-two patients with a large ST-elevation myocardial infarction underwent both EEM and CMR four months after primary percutaneous coronary intervention. EEM was performed to assess linear local shortening (LLS), unipolar voltage (UV) and bipolar voltage (BV). CMR cine imaging was performed to determine left ventricular global volumes, ejection fraction and regional function. Late gadolinium enhancement was used to assess size and transmural extent of infarction. Average LLS, UV and BV differed significantly between normal and dysfunctional segments (9.8 vs. 7.3, 11.8 vs. 9.7 and 3.3 vs. 2.8 for LLS, UV and BV respectively; p0.001 for LLS and UV, p=0.006 for BV). In addition, average LLS, UV and BV, differed significantly between non-, subendocardial and transmural enhanced segments (10.8 vs. 8.8 vs. 5.0, 12.3 vs. 10.5 vs. 9.5 and 3.5 vs. 3.0 vs. 2.3 for LLS, UV and BV, respectively, p0.001 for all variables). Although regional EEM data showed reasonable correlation with CMR, specific cut-off values for EEM parameters could not be established.EEM may be helpful in determining both the regional function and the transmural extent of infarction in patients with a large myocardial infarction. However, correlation with CMR parameters was moderate and exact cut-off values for EEM parameters could not be established. Further development of this potentially very useful modality is needed before it can be advocated for exact border-zone endocardial injection.

To compare coronary computed tomographic (CT) angiography with first-pass magnetic resonance (MR) myocardial perfusion imaging in patients with chest pain and low to intermediate probability of coronary artery disease (CAD).Local ethics committee approval and patient written informed consent were obtained. Patients with chest pain and low to intermediate pretest probability of CAD underwent both coronary CT angiography and MR myocardial perfusion imaging. Coronary CT angiographic and MR myocardial perfusion images were analyzed qualitatively by blinded observers. Obstructive CAD was defined as more than 50% diameter stenosis at coronary CT angiography. Data were expressed with 95% confidence intervals (CIs) calculated from binomial expression.In 145 (94.2%) of 154 eligible patients, both coronary CT angiography and MR myocardial perfusion imaging were performed successfully. Mean age was 57 years +/- 10 (standard deviation), and 45.5% of patients were male. Mean interval between coronary CT angiography and MR myocardial perfusion imaging was 4.6 days +/- 3.0; median was 5.0 days. CT coronary angiography revealed obstructive CAD in 52 (35.9%) patients and 78 (17.9%) coronary arteries. At MR myocardial perfusion imaging, myocardial ischemia was demonstrated in 33 (22.8%) patients and 59 (13.6%) vessel territories. Of patients without CAD at coronary CT angiography, 90.5% (57 of 63; 95% CI: 82.6%, 95.0%) had normal myocardial perfusion at MR myocardial perfusion imaging. Of patients with nonobstructive CAD, 83.3% (25 of 30; 95% CI: 69.5%, 91.6%) had normal myocardial perfusion at MR myocardial perfusion imaging. Myocardial ischemia was detected at MR myocardial perfusion imaging in 42.3% (22 of 52; 95% CI: 29.5%, 56%) of patients with obstructive CAD at coronary CT angiography.MR myocardial perfusion imaging and coronary CT angiography have complementary roles in evaluation of patients who are suspected of having CAD. Coronary CT angiography can be used to reliably rule out CAD, but its capability to demonstrate hemodynamically significant CAD is limited. The combination of both techniques enables the clinician to evaluate morphology and functional relevance of CAD comprehensively and noninvasively.

Background: Clinical data on myocardial function in HCM mutation carriers (carriers) is sparse but suggests that subtle functional abnormalities can be measured with tissue Doppler imaging before the development of overt hypertrophy. We aimed to confirm the presence of functional abnormalities using cardiovascular magnetic resonance (CMR), and to investigate if sensitive functional assessment could be employed to identify carriers. Results: 28 carriers and 28 controls were studied. Global left atrial (LA) and left ventricular (LV) dimensions, segmental peak systolic circumferential strain (SCS) and peak diastolic circumferential strain rate (DCSR), as well as the presence of late Gadolinium enhancement (LGE) were determined with CMR. Septal and lateral myocardial velocities were measured with echocardiographic tissue Doppler imaging. lv mass and volumes were comparable between groups. Maximal septal to lateral wall thickness ratio (SL ratio) was larger in carriers than in controls (1.3 ± 0.2 versus 1.1 ± 0.1, p 1.2 and a peak DCSR 105%.s -1 , yielding a negative predictive value of 90%. With multivariate analysis, HCM mutation carriership was an independent determinant of reduced peak SCS and peak DCSR. Conclusions: HCM mutation carriership is an independent determinant of reduced peak SCS and peak DCSR when LV wall thickness is within normal limits, and is associated with increased LA volumes and SL ratio. Using SL ratio and peak DCSR has a high accuracy to identify carriers. However, since carriers also display structural abnormalities and focal LGE, we advocate to also evaluate morphology and presence of LGE when screening for carriers. Background Hypertrophic cardiomyopathy (HCM) is a relatively common cardiomyopathy with an estimated prevalence of 1:500 in the general population [1]. The clinical course has a large inter- and intrafamilial heterogeneity, ranging from mild symptoms of heart failure late in life to the onset of sudden cardiac death at young age. Over 430 mutations in mainly sarcomeric genes have been identified to cause HCM. It has been suggested that the hypertrophy in HCM is a compensatory mechanism for mutant-induced myocardial dysfunction [2-4]. This hypothesis is supported by experimental data demonstrating that sarcomeric dysfunction precedes hypertrophy in HCM animal models [5-7]. Limited clinical data is available on regional myocardial function in human HCM mutation carriers (carriers) when wall thickness is still within normal limits. Several studies using tissue Doppler imaging with

Next to hypertrophy, hypertrophic cardiomyopathy (HCM) is characterized by alterations in myocardial energetics. A small number of studies have shown that myocardial external efficiency (MEE), defined by external work (EW) in relation to myocardial oxidative metabolism (MVO2), is reduced. The present study was conducted to identify determinants of MEE in patients with HCM by use of dynamic positron emission tomography (PET) and cardiovascular magnetic resonance imaging (CMR). Twenty patients with HCM (12 men, mean age: 55.2 +/- 13.9 years) and 11 healthy controls (7 men, mean age: 48.1 +/- 10 years) were studied with [C-11]acetate PET to assess MVO2. CMR was performed to determine left ventricular (LV) volumes and mass (LVM). Univariate and multivariate analyses were employed to determine independent predictors of myocardial efficiency. Between study groups, MVO2 (controls: 0.12 +/- 0.04 ml center dot min(-1)center dot g(-1), HCM: 0.13 +/- 0.05 ml center dot min(-1)center dot g(-1), p = 0.64) and EW (controls: 9,139 +/- 2,484 mmHg center dot ml, HCM: 9,368 +/- 2,907 mmHg center dot ml, p = 0.83) were comparable, whereas LVM was significantly higher (controls: 99 +/- 21 g, HCM: 200 +/- 76 g, p < 0.001) and MEE was decreased in HCM patients (controls: 35 +/- 8%, HCM: 21 +/- 10%, p < 0.001). MEE was related to stroke volume (SV), LV outflow tract gradient, NH2-terminal pro-brain natriuretic peptide (NT-proBNP) and serum free fatty acid levels (all p < 0.05). Multivariate analysis revealed that SV ( = 0.74, p < 0.001) and LVM ( = -0.43, p = 0.013) were independently related to MEE. HCM is characterized by unaltered MVO2, impaired EW generation per gram of myocardial tissue and subsequent deteriorated myocardial efficiency. Mechanical external efficiency could independently be predicted by SV and LVM.

Purpose: To investigate the incremental diagnostic value of dual-bolus over single-contrast-bolus first pass magnetic resonance myocardial perfusion imaging (MR-MPI) for detection of significant coronary artery disease (CAD). Materials and Methods: Patients (n = 49) with suspected CAD underwent first pass adenosine stress and rest MR-MPI and invasive coronary angiography (CA). Gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) was injected with a prebolus (1 mL) and a large bolus (0.1 mmol/kg). For the single-bolus technique, the arterial input function (AIF) was obtained from the large-contrast bolus. For the dual-bolus technique, the AIF was reconstructed from the prebolus. Absolute myocardial perfusion was calculated by Fermi-model constrained deconvolution. Receiver operating characteristic (ROC) analysis was used to investigate diagnostic accuracy of MR myocardial perfusion imaging for detection of significant CAD on CA at vessel-based analysis. Results: The area under the curve (AUC) of the minimal stress perfusion value for the detection of significant CAD using the single-bolus and dual-bolus technique was 0.85 ± 0.04 (95% confidence interval [CI], 0.77–0.93) and 0.77 ± 0.05 (95% CI, 0.67–0.86), respectively. Conclusion: In this study the dual-bolus technique had no incremental diagnostic value over single-bolus technique for detection of significant CAD with the used contrast concentrations. J. Magn. Reson. Imaging 2010;32:88–93. © 2010 Wiley-Liss, Inc.

Objectives We sought to evaluate the relation between atrial fibrillation (AF) and the extent of myocardial scarring together with left ventricular (LV) and atrial parameters assessed by late gadolinium-enhancement (LGE) cardiovascular magnetic resonance (CMR) in patients with hypertrophic cardiomyopathy (HCM). Background AF is the most common arrhythmia in HCM. Myocardial scarring is also identified frequently in HCM. However, the impact of myocardial scarring assessed by LGE CMR on the presence of AF has not been evaluated yet. Methods 87 HCM patients underwent LGE CMR, echocardiography and regular ECG recordings. LV function, volumes, myocardial thickness, left atrial (LA) volume and the extent of LGE, were assessed using CMR and correlated to AF. Additionally, the presence of diastolic dysfunction and mitral regurgitation were obtained by echocardiography and also correlated to AF. Results Episodes of AF were documented in 37 patients (42%). Indexed LV volumes and mass were comparable between HCM patients with and without AF. However, indexed LA volume was significantly higher in HCM patients with AF than in HCM patients without AF (68 ± 24 ml·m-2 versus 46 ± 18 ml·m-2, p = 0.0002, respectively). The mean extent of LGE was higher in HCM patients with AF than those without AF (12.4 ± 14.5% versus 6.0 ± 8.6%, p = 0.02). When adjusting for age, gender and LV mass, LGE and indexed LA volume significantly correlated to AF (r = 0.34, p = 0.02 and r = 0.42, p < 0.001 respectively). By echocardiographic examination, LV diastolic dysfunction was evident in 35 (40%) patients. Mitral regurgitation greater than II was observed in 12 patients (14%). Multivariate analysis demonstrated that LA volume and presence of diastolic dysfunction were the only independent determinant of AF in HCM patients (p = 0.006, p = 0.01 respectively). Receiver operating characteristic curve analysis indicated good predictive performance of LA volume and LGE (AUC = 0.74 and 0.64 respectively) with respect to AF. Conclusion HCM patients with AF display significantly more LGE than HCM patients without AF. However, the extent of LGE is inferior to the LA size for predicting AF prevalence. LA dilation is the strongest determinant of AF in HCM patients, and is related to the extent of LGE in the LV, irrespective of LV mass.

During its German pilot phase, the EuroCMR (European Cardiovascular Magnetic Resonance) registry sought to evaluate indications, image quality, safety, and impact on patient management of routine CMR.CMR has a broad range of applications and is increasingly used in clinical practice.This was a multicenter registry with consecutive enrollment of patients in 20 German centers.A total of 11,040 consecutive patients were enrolled. Eighty-eight percent of patients received gadolinium-based contrast agents. Twenty-one percent underwent adenosine perfusion, and 11% high-dose dobutamine-stress CMR. The most important indications were workup of myocarditis/cardiomyopathies (32%), risk stratification in suspected coronary artery disease/ischemia (31%), as well as assessment of viability (15%). Image quality was good in 90.1%, moderate in 8.1%, and inadequate in 1.8% of cases. Severe complications occurred in 0.05%, and were all associated with stress testing. No patient died during or due to CMR. In nearly two-thirds of patients, CMR findings impacted patient management. Importantly, in 16% of cases the final diagnosis based on CMR was different from the diagnosis before CMR, leading to a complete change in management. In more than 86% of cases, CMR was capable of satisfying all imaging needs so that no further imaging was required.CMR is frequently performed in clinical practice in many participating centers. The most important indications are workup of myocarditis/cardiomyopathies, risk stratification in suspected coronary artery disease/ischemia, and assessment of viability. CMR imaging as used in the centers of the pilot registry is a safe procedure, has diagnostic image quality in 98% of cases, and its results have strong impact on patient management.

Cardiovascular magnetic resonance imaging (CMR) with delayed contrast enhancement (DCE) using Gadolinium (Gd)-based magnetic contrastagents, is a technique which visualizes myocardial infarction (MI) as regions of bright signal (hyperenhancement) compared to normal myocardium. The prognostic value of DCE in patients with ischemic cardiomyopathy has not been fully characterized.All patients with a history of coronary artery disease (CAD) who underwent DCE-CMR imaging between September 1999 and July 2004 were included. CMR-variables were: left ventricular ejection fraction (LVEF), wall motion, mitral regurgitation (MR) and DCE scores. The patient's clinical status was assessed using the New York Heart Association-classification (NYHA).One hundred and ninety-three patients (age 63+/-11, 42 women), including 160 with prior MI, were studied. The mean LVEF was 40+/-14%. Most patients (88%) were in NYHA-class I or II, and 8% had moderate or severe MR. Thirteen patients died during follow-up. Patients who died had a lower baseline LVEF and more significant MR compared to survivors (P=0.04). A higher DCE score was associated with more significant MR (P=0.01). No significant association was demonstrated between NYHA-class and DCE (P=0.34) or between DCE score andmortality (P=0. 8).The study reinforces the important prognostic value of resting LVEF and MR severity in patients with CAD and is the first to demonstrate an association between the degree of DCE and MR severity in these patients. Further investigations including a larger number of patients are needed to fully assess the prognostic value of DCE-CMR in ischemic cardiomyopathy.

These reporting guidelines are recommended by the Society for Cardiovascular Magnetic Resonance (SCMR) to provide a framework for healthcare delivery systems to disseminate cardiac and vascular imaging findings related to the performance of cardiovascular magnetic resonance (CMR) examinations.

Purpose: To evaluate which cardiac magnetic resonance (MR) imaging technique for detection of microvascular obstruction (MVO) best predicts left ventricular (LV) remodeling after acute myocardial infarction (MI). Materials and Methods: This study had local ethics committee approval; all patients gave written informed consent. Sixty-three patients with first acute MI, treated with primary stent placement and optimal medical therapy, underwent cine MR imaging at 4-7 days and at 4 months after MI. Presence of MVO was qualitatively evaluated at baseline by using three techniques: (a) a single-shot saturation-recovery gradient-echo first-pass perfusion sequence (early hypoenhancement), mean time, 1.09 minutes +/- 0.07 (standard deviation) after contrast material administration; (b) a three-dimensional segmented saturation-recovery gradient-echo sequence (intermediate hypoenhancement), mean time, 2.17 minutes +/- 0.26; and (c) a two-dimensional segmented inversion-recovery gradient-echo late gadolinium enhancement sequence (late hypoenhancement), mean time, 13.32 minutes +/- 1.26. Contrast-to-noise ratios (CNRs) were calculated from the signal-to-noise ratios of the infarcted myocardium and MVO areas. Univariable linear regression analysis was used to identify the predictive value of each MR imaging technique. Results: Early hypoenhancement was detected in 44 (70%) of 63 patients; intermediate hypoenhancement, in 39 (62%); and late hypoenhancement, in 37 (59%). Late hypoenhancement was the strongest predictor of change in LV end-diastolic and end-systolic volumes over time (beta = 14.3 , r = 0.40, P = .001 and beta = 11.3, r = 0.44, P

As computed tomography coronary angiography (CTCA) has a reported excellent negative predictive value for detection of significant coronary artery disease (CAD), it is increasingly used as first line technique in the evaluation of patients with suspected CAD. However, positive predictive value is low and CTCA lacks information about myocardial perfusion. As first pass magnetic resonance myocardial perfusion imaging (MRMPI) can accurately assess myocardial perfusion and does not involve ionizing radiation, it may be a valuable additional technique to CTCA in the evaluation of patients with suspected CAD. Subsequently, their combined use may lower the number of unnecessary, costly invasive coronary angiographies (CAG).

We studied the comparability of left ventricular (LV) mechanical dyssynchrony assessment by tissue Doppler imaging (TDI) and real-time three-dimensional echocardiography (RT3DE) in patients with a wide range of LV ejection fractions and different causes of cardiomyopathy. In addition, we evaluated the ability of both techniques to predict response to cardiac resynchronization therapy (CRT).A total of 90 patients and 30 healthy volunteers underwent both TDI and RT3DE. A subgroup of 27 patients underwent CRT and were evaluated before and 6 months after implantation. Mechanical dyssynchrony was measured with TDI using the standard deviation of time to peak systolic tissue velocity of 12 LV myocardial segments. With RT3DE, the standard deviation of time from QRS onset to minimal volume of 16 LV subvolumes was assessed. Indicators of response to CRT were a clinical improvement ofor= 1 New York Heart Association functional class, and reverse remodeling defined as a reduction ofor= 15% in LV end-systolic volume at 6 months.A moderate correlation (r = 0.581, P.001) was observed between TDI and RT3DE. No significant difference in the presence of mechanical dyssynchrony by TDI and RT3DE was observed (53% vs 48%, respectively). Agreement between techniques was comparable between patients with ischemic and nonischemic cardiomyopathy. However, up to 30% nonagreement between the 2 techniques was found, depending on the severity of LV dysfunction. Of the 27 patients undergoing CRT, clinical response was observed in 70% of patients, whereas reverse remodeling occurred in 63% of patients. All baseline characteristics were similar between responders and nonresponders, except for mechanical dyssynchrony assessed by RT3DE, which was significantly higher in responders compared with nonresponders (10.1% +/- 2.6% vs 5.1% +/- 1.2% for clinical response, P.001; 10.0% +/- 2.8% vs 6.3% +/- 2.3% for reverse remodeling, P = .001). By applying previously defined cutoff values, receiver operating characteristic curve analysis demonstrated a sensitivity of 58% with a specificity of 50% for TDI and a sensitivity of 95% with a specificity of 87% for RT3DE to predict clinical response to CRT. For prediction of reverse remodeling after CRT, sensitivity and specificity were 59% and 50% for TDI, and 88% and 60% for RT3DE, respectively. The optimal cutoff value for systolic dyssynchrony index by RT3DE of 6.7% yielded a sensitivity of 90% with a specificity of 87% to predict clinical response, and a sensitivity of 88% with a specificity of 70% to predict reverse remodeling.Marked differences between techniques are found for the presence of mechanical dyssynchrony when current cutoff values are applied, making interchangeability of these techniques uncertain. Assessment of mechanical dyssynchrony by RT3DE might be an appropriate alternative to TDI for accurate prediction of response to CRT.

Background Normal left ventricular (LV) torsion is caused by opposite basal and apical rotation. Opposite rotation can be lost in heart failure, but might be restored by pacing; therefore, the predictive value of the loss of opposite base-apex rotation in heart failure patients for the response to cardiac resynchronization therapy (CRT) was studied. Methods and Results In 34 CRT candidates and 12 controls, basal and apical LV rotations were calculated using magnetic resonance image tagging. Loss of opposite rotation was quantified by the correlation between both rotation curves: a negative correlation indicates normal, opposite rotation and a positive correlation indicates that base and apex rotate in the same direction. In patients, LV pressure was measured invasively during biventricular stimulation. Acute response to CRT was defined by >10% increase in dP/dt max relative to baseline. LV volume was determined at baseline and 8 months follow-up using echocardiography. The base-apex rotation correlation (BARC) was significantly higher in acute responders (n=22) than in nonresponders (n=12) and controls (0.64±0.51, –0.23±0.67, and –0.68±0.22, respectively; P =.001). The sensitivity and specificity for prediction of acute response were 82% and 83%, respectively, at a cutoff value of 0.5. At follow-up, volumes could be analyzed in 18 patients. In the group with BARC >0.5, end-diastolic volume decreased by 7% (NS), end-systolic volume by 16%, and ejection fraction increased by 28% (both P =.02), whereas in the group with BARC Conclusions The loss of opposite base-apex rotation in patients eligible for CRT is an excellent predictor of acute response and is associated with LV reverse remodeling.

During left ventricular (LV) torsion, the base rotates in an overall clockwise direction and the apex rotates in a counterclockwise direction when viewed from apex to base. LV torsion is followed by rapid untwisting, which contributes to ventricular filling. Because LV torsion is directly related to fiber orientation, it might depict subclinical abnormalities in heart function. Recently, ultrasound speckle tracking was introduced for quantification of LV torsion. This fast, widely available technique may contribute to a more rapid introduction of LV torsion as a clinical tool for detection of myocardial dysfunction. However, knowledge of the exact function and structure of the heart is fundamental for understanding the value of LV torsion. LV torsion has been investigated with different measurement methods during the past 2 decades, using cardiac magnetic resonance as the gold standard. The results obtained over the years are helpful for developing a standardized method to quantify LV torsion and have facilitated the interpretation and value of LV torsion before it can be used as a clinical tool.

Background Hypertrophic Cardiomyopathy (HCM) is characterized by asymmetric hypertrophy of the left ventricle (LV). While over 400 HCM mutations have been identified, increasing number of HCM mutation carriers without hypertrophy have been detected. No data on regional functional and structural abnormalities in HCM mutation carriers before the development of hypertrophy are yet available. With cardiac magnetic resonance imaging (CMR), both regional function and structure can accurately be evaluated.

Aims: We sought to evaluate the relation between long-term functional outcome after revascularization in patients with chronic ischaemic left ventricular (LV) dysfunction and baseline extent of myocardial fibrosis. Methods and results: Thirty-five patients underwent cine and delayed contrast-enhanced cardiovascular magnetic resonance (deCMR) for the quantitative assessment of regional and global LV functions and segmental extent of hyperenhancement (SEH). Function was assessed 1 month before and 3, 6, and 24 ± 12 months after revascularization, and temporal changes were related to baseline extent of hyperenhancement. The likelihood of functional improvement was inversely related to the SEH during the entire follow-up: at the end of the study period, segments with 1-25, 26-50, 51-75, and 76-100% SEH were 2, 5, 11, and 86 times, respectively, less likely to have functional improvement than segments without hyperenhancement (multilevel analysis, P < 0.001). Although improvement continued over the whole study period in all SEH groups, the time course was significantly more delayed in segments with more extensive hyperenhancement at baseline (multilevel analysis, P < 0.001). Conclusion: In patients with chronic ischaemic LV dysfunction, improvement of dysfunctional but viable myocardium can be considerably delayed. Both the likelihood and the time course of long-term functional improvement are related to the baseline amount of scar, as visualized by deCMR. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008.

Objectives: We studied the relation between presence and severity of microvascular obstruction (MO), measured by cardiovascular magnetic resonance (CMR) and intracoronary Doppler flow measurements, for assessment of myocardial reperfusion in patients with acute anterior myocardial infarction (MI) treated by primary percutaneous coronary intervention (PCI). Background: Cardiovascular magnetic resonance has been used to detect and quantify MO in patients after acute MI but has never been compared with coronary blood flow velocity patterns. Methods: Twenty-seven patients with first anterior ST-segment elevation MI successfully treated with primary PCI were included. Coronary blood flow velocity was measured during recatheterization 4 to 8 days after primary PCI. These measurements were related to MO determined by late gadolinium-enhanced (LGE) CMR performed the day before recatheterization. Results: Early systolic retrograde flow was observed in 0 of 8 patients without MO on LGE CMR and in 10 (53%) of 19 patients with MO (p = 0.01). The extent of MO correlated with the diastolic-systolic velocity ratio (r = 0.44; p = 0.02), diastolic deceleration time (r = -0.61; p = 0.001), diastolic deceleration rate (r = 0.75; p < 0.0001), and coronary flow velocity reserve of the infarct-related artery (r = -0.44; p = 0.02). Furthermore, multivariate regression analyses, including extent of MO, infarct size, and transmural necrosis on LGE CMR, revealed that extent of MO was the only independent factor related to early systolic retrograde flow and diastolic deceleration rate. Conclusions: Assessment of microvascular injury by LGE CMR corresponds well to evaluation by intracoronary Doppler flow measurements. By means of CMR, quantification of myocardial function, infarct size, and microvascular injury can accurately be performed with a single noninvasive technique in patients with acute MI.

Background Non-participants can have a considerable influence on the external validity of a study. Therefore, we assessed the socio-demographic, health-related, and lifestyle behavioral differences between participants and non-participants in a comprehensive CVD lifestyle intervention trial, and explored the motives and barriers underlying the decision to participate or not. Methods We collected data on participants (n = 50) and non-participants (n = 50) who were eligible for inclusion in a comprehensive CVD lifestyle interventional trial. Questionnaires and a hospital patient records database were used to assess socio-demographic, health-related and lifestyle behavioral variables. Univariate and multivariate logistic regression was used to describe the relationship between explanatory variables and study participation. Furthermore, motives and barriers that underlie study participation were investigated by means of questionnaires. Results Participants were younger, single, had a higher level of education and were employed. No statistically significant differences were found in health measures and behavioral variables. The motives for participation that were most frequently reported were: the perception of being unhealthy and willingness to change their lifestyle. The main barriers reported by non-participants were financial arguments and time investment. Conclusion The differences between participants and non-participants in a lifestyle intervention trial are in mainly demographic factors. The participants consent in order to alter their lifestyle, and/or because they want to improve their health. To minimize non-participation, it is recommended that access to a lifestyle intervention program should be easy and cause no financial restraints. Trial registration ISRCTN69776211.

Objectives To compare regional left ventricular (LV) volume curves obtained with real time three-dimensional echocardiography (RT3DE) with two-dimensional circumferential strain curves obtained by MRI in cardiac resynchronization therapy candidates. Background Several methods using either ultrasound or MRI are used to quantify mechanical dyssynchrony (MD). Theoretically, LV volume and circumferential strain seem related, since both measures are connected to the radius of the ventricle. Methods In 21 patients with chronic heart failure, RT3DE and tagged MRI were performed subsequently. Regional LV volume was computed from the ultrasound images. From the MR images, regional circumferential strain was calculated. Cross-correlations with time lags of 1% of the cardiac cycle were performed to compare the curves in corresponding LV segments. Furthermore, peak septal to lateral (SL) delays were compared between modalities. Results High correlations were found between the curves (r 2 = 0.65 ± 0.19), but regional differences in time delay between modalities were observed. In the septum, the volume curve was earlier than the strain curve by 1.8 ± 17.0 time-lags (n.s.), while in the lateral wall, the volume curve was earlier by 3.3 ± 12.0 time-lags (P

We examined the relation between angiographic, electrocardiographic, and gadolinium-enhanced cardiovascular magnetic resonance (CMR) characteristics of microvascular obstruction (MVO), and their predictive value on functional recovery after acute myocardial infarction (AMI).Microvascular obstruction on CMR has been shown to predict left ventricular (LV) remodeling, but it is not well known how it compares with commonly used criteria of microvascular injury, and earlier reports have produced conflicting results on the significance and extent of MVO.Thrombolysis In Myocardial Infarction (TIMI) flow grade, myocardial blush grade (MBG), and ST-segment resolution were assessed in 60 patients with AMI treated with primary stenting. Cardiovascular magnetic resonance was performed between 2 and 9 days after revascularization to determine early MVO on first-pass perfusion imaging, late MVO on late gadolinium-enhanced imaging, and infarct size and transmural extent. Cine imaging was used to determine LV volumes and global and regional function at baseline and 4-month follow-up.Early and late MVO were both related to incomplete ST-segment resolution (p = 0.002 and p = 0.01, respectively), but not to TIMI flow grade and MBG. Of all angiographic, electrocardiographic, and CMR variables, late MVO was the strongest parameter to predict changes in end-diastolic volume (beta = 0.53; p = 0.001), end-systolic volume (beta = 8.67; p = 0.001), and ejection fraction (beta = 3.94; p = 0.006) at follow-up. Regional analysis showed that late MVO had incremental diagnostic value to transmural extent of infarction (odds ratio: 0.18; p0.0001).In patients after revascularized AMI, late MVO proved a more powerful predictor of global and regional functional recovery than all of the other characteristics, including transmural extent of infarction.

With great interest, we have read the article of Hoedemaekers et al. 1 on linking non-compaction cardiomyopathy to hypertrophic, restrictive, and dilated cardiomyopathies. The authors extensively describe two families in which variable severities of non-compaction of the myocardium segregated with mutations in the cardiac s myosin heavy chain gene (MYH7). Although genetic heterogeneity of traditional cardiomyopathies is well recognized, the identification of non-compaction in patients with dilated, hypertrophic, and restrictive cardiomyopathies suggests that non-compaction may be considered as a …

Right ventricular (RV) volume measurements with cardiovascular magnetic resonance (CMR) is considered the gold standard, but acquisition and analysis remain timeconsuming. The aim of our study was therefore to investigate the accuracy and performance of a semi-quantitative assessment of RV function in CMR, compared to the standard quantitative approach. Seventy-five subjects with pulmonary hypertension (15), anterior myocardial infarction (15), inferior myocardial infarction (15), Brugada syndrome (15) and normal subjects (15) underwent cine CMR. RV end-systolic and enddiastolic volumes were determined to calculate RV ejection fraction (EF). Four-chamber cine images were used to measure tricuspid annular plane systolic excursion (TAPSE). RV fractional shortening (RVFS) was calculated by dividing TAPSE by the RV end-diastolic length. RV EF correlated significantly with TAPSE (r = 0.62, p < 0.01) and RVFS (r = 0.67, p < 0.01). Sensitivity to predict RV dysfunction was comparable between TAPSE and RVFS, with higher specificity for RVFS, but comparable areas under the ROC curve. Intra- and inter-observer variability of RV EF was better than TAPSE (3%/4% versus 7%/15%, respectively). For routine screening in clinical practice, TAPSE and RVFS seem reliable and easy methods to identify patients with RV dysfunction. The 3D volumetric approach is preferred to assess RV function for research purposes or to evaluate treatment response.

PURPOSE: To evaluate safety and image quality of cardiovascular magnetic resonance (CMR) at 3.0 T in patients with coronary stents after myocardial infarction (MI), in comparison to the clinical standard at 1.5 T. METHODS: Twenty-five patients (21 men; 55 +/- 9 years) with first MI treated with primary stenting, underwent 18 scans at 3.0 T and 18 scans at 1.5 T. Twenty-four scans were performed 4 +/- 2 days and 12 scans 125 +/- 23 days after MI. Cine (steady-state free precession) and late gadolinium-enhanced (LGE, segmented inversion-recovery gradient echo) images were acquired. Patient safety and image artifacts were evaluated, and in 16 patients stent position was assessed during repeat catheterization. Additionally, image quality was scored from 1 (poor quality) to 4 (excellent quality). RESULTS: There were no clinical events within 30 days of CMR at 3.0 T or 1.5 T, and no stent migration occurred. At 3.0 T, image quality of cine studies was clinically useful in all, but not sufficient for quantitative analysis in 44% of the scans, due to stent (6/18 scans), flow (7/18 scans) and/or dark band artifacts (8/18 scans). Image quality of LGE images at 3.0 T was not sufficient for quantitative analysis in 53%, and not clinically useful in 12%. At 1.5 T, all cine and LGE images were quantitatively analyzable. CONCLUSION: 3.0 T is safe in the acute and chronic phase after MI treated with primary stenting. Although cine imaging at 3.0 T is suitable for clinical use, quantitative analysis and LGE imaging is less reliable than at 1.5 T. Further optimization of pulse sequences at 3.0 T is essential

In the majority of patients with left ventricular (LV) dysfunction, this condition results from ischaemic cardiomyopathy that is caused by coronary artery disease and subsequent ischaemia and myocardial infarction. However, normal coronary arteries are found in a substantial proportion of patients with LV dysfunction. While a patient is inevitably exposed to a small but considerable risk when performing a coronary angiogram, research has focused on seeking non-invasive methods to differentiate ischaemic from non-ischaemic cardiomyopathy (NICM), which requires an importantly different therapeutic approach than in the case of ischaemic cardiomyopathy. Moreover, NICM has a heterogeneous aetiology resulting from a complex interplay between predisposed genetic constitution and the detrimental effects of infectious and/or toxic agents on the function of myocardium. Consequently, further optimisation of treatment in NICM patients warrants determination of the underlying cause(s) of NICM. In the last decade, important progress has been made in determining the aetiology of cardiomyopathies by using cardiac magnetic resonance imaging (CMR). CMR allows a comprehensive, non-invasive assessment of cardiac function, morphology and tissue characterisation within a 45 min timeframe. Since an introduction to CMR techniques has recently been published in this series, we will restrict the description of CMR techniques to a brief summary of their role in tissue differentiation and determination of the aetiology of cardiomyopathies (table 1). View this table: Table 1 Appearance of tissue involved in ischaemic and non-ischaemic cardiomyopathy in different cardiac magnetic resonance imaging techniques Although a classification based on genetic interrogation of cardiomyopathies has been advocated, we will classify NICM according to the World Health Organization into hypertrophic cardiomyopathy (HCM), restrictive cardiomyopathy (RCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC) and unclassified cardiomyopathy, in order to concur with clinical practice. ### Differentiating physiological from pathological hypertrophy LV hypertrophy is diagnosed when LV mass exceeds the normal range, which is 85–181 g or 46–83 g/m2 for males and 66–114 g or 37–67 g/m2 for females with steady state free precession (SSFP) cine imaging. …

Aims To determine in a multicentre, multivendor trial the diagnostic performance for perfusion-cardiac magnetic resonance (perfusion-CMR) in comparison with coronary X-ray angiography (CXA) and single-photon emission computed tomography (SPECT). Methods and results Of 241 eligible patients from 18 centres, 234 were randomly dosed with 0.01, 0.025, 0.05, 0.075, or 0.1 mmol/kg Gd-DTPA-BMA (Omniscan™, GE-Healthcare) per stress (0.42 mg/kg adenosine) and rest perfusion study. Coronary artery disease (CAD) was defined as diameter stenosis ≥50% on quantitative CXA. Five CMR and eight SPECT studies (of 225 complete studies) were excluded from analyses due to inadequate quality (three blinded readers scored per modality). The comparison of CMR vs. SPECT was based on receiver operating characteristic (ROC) analysis. Perfusion-CMR at the optimal CM dose (0.1 mmol/kg) had similar performance as SPECT, if only the SPECT studies of the 42 patients with this dose were considered [area under ROC curve (AUC): 0.86 ± 0.06 vs. 0.75 ± 0.09 for SPECT, P = 0.12]; however, diagnostic performance of perfusion-CMR was better vs. the entire SPECT population (AUC: 0.67 ± 0.05, n = 212, P = 0.013). Conclusions In this multicentre, multivendor trial, ROC analyses suggest perfusion-CMR as a valuable alternative to SPECT for CAD detection showing equal performance in the head-to-head comparison. Comparing perfusion-CMR with the entire SPECT population suggests CMR superiority over SPECT, which warrants further evaluation in larger trials

The response to cardiac resynchronization therapy (CRT), which is applied to patients with heart failure (HF) and left bundle-branch block (LBBB), can be predicted from the mechanical dyssynchrony measured on circumferential strain. Circumferential strain can be assessed by either 2D or 3D strain analysis. In this study was evaluated the difference between 2D and 3D circumferential strain using MR tagging with high temporal resolution (14 ms). Six healthy volunteers and five patients with LBBB were evaluated. We compared the 2D and 3D circumferential strains by computing the mechanical dyssynchrony and the cross correlation (r) between 2D and 3D strain curves, and by quantifying the differences in peak circumferential shortening, time to onset, and time to peak of shortening. The obtained maximum r2 values were 0.97 ± 0.03 and 0.87 ± 0.16 for the healthy and LBBB populations, respectively, and thus showed a good similarity between 2D and 3D strain curves. No significant difference was observed between 2D and 3D in time to onset, time to peak, or peak circumferential shortening. Thus, to measure dyssynchrony, 2D strain analysis will suffice. Since 2D analysis is easier to implement than 3D analysis, this finding brings the application of MRI tagging and strain analysis closer to the clinical routine.

In the setting of primary percutaneous coronary intervention (PPCI), patients with a concurrent chronic total occlusion (CTO) in a non-infarct related artery (IRA) were recently identified as a high-risk subgroup. It is unclear whether ST-elevation myocardial infarction (STEMI) patients with a CTO

Myocarditis can present with acute coronary syndrome-like (ACS) symptoms, new-onset heart failure (NOHF) or life threatening arrhythmias (LTA) with various ECG - and laboratory test abnormalities. Cardiac magnetic resonance (CMR) tissue characterization using Late Gadolinium Enhancement (LGE) and T2

Purpose To discuss differences between displacement encoding with stimulated echoes (DENSE) and the harmonic phase (HARP) in imaging and reconstruction strategies. Materials and Methods HARP and DENSE are presented in their historical context: while the HARP method was developed from the framework of myocardial tagging, DENSE arose from the framework of stimulated echo and displacement encoding using bipolar gradients. Both techniques have evolved since their introduction, thereby becoming more similar over time and losing their distinct features. Newly introduced improvements have successfully been applied in both methods. Differences between both methods are discussed point by point. Results From this discussion it follows that almost all apparent differences are in fact nonexistent. Conclusion In the literature, both techniques are still regarded as distinctly different techniques, where a more general treatment of the technique is justified. Once it is realized that both frameworks are easily merged, the benefits are 1) less confusion about the (dis)advantages of either technique, and 2) understanding of phase-based strain imaging that is more general than HARP or DENSE alone. J. Magn. Reson. Imaging 2006. © 2006 Wiley-Liss, Inc.

Left ventricular (LV) filling results from diastolic suction of the left ventricle and passive left atrial (LA) emptying at early diastole and LA contraction at end-diastole. Effects of aging on LA and LV geometric characteristics and function and its consequences for LV filling are incompletely understood. Insight into these effects may increase the understanding of diastolic function. Cardiac magnetic resonance imaging was used to study effects of aging on left atrioventricular coupling and LV filling. Forty healthy volunteers underwent cardiac magnetic resonance imaging and were subdivided into 2 age groups of 20 to 40 (younger group) and 40 to 65 years (older group). For the older group, LA volumes were larger (p

A 59-year-old man with no relevant medical history was referred to our clinic for analysis of exertional chest pain. He had noticed slowly progressive symptoms approximately 6 months before referral, although they did not prohibit his daily 12-mile cycling exercise routine. During diagnostic 99m-technetium-sestamibi single photon emission computed tomography treadmill stress testing, the ECG showed pathological ST-segment depression, and the patient had anginal chest pain. Three-dimensional reconstructed scintigraphic perfusion images (Figure 1) displayed a substantial reversible defect in the anterolateral myocardium with only a mild resting perfusion defect in the distal segment of the anterior wall, which coincided with a small area of subendocardial fibrosis visualized …

Background Recently, several preliminary reports have demonstrated that cell transplantation after acute myocardial infarction in humans is safe and leads to better preserved left ventricular function and improved myocardial perfusion and coronary flow reserve.Methods The HEBE trial is a multicenter, prospective, randomized, 3-arm open trial with blinded evaluation of end points. Patients with acute large myocardial infarction treated with primary percutaneous coronary intervention (PCI) will undergo magnetic resonance imaging (MRI) and echocardiography. A total of 200 patients are randomized to treatment with (1) intracoronary infusion of autologous mononuclear bone marrow cells, (2) intracoronary infusion of peripheral mononuclear blood cells, or (3) standard therapy. Mononuclear cells are isolated from bone marrow aspirate or venous blood by density gradient centrifugation. Within 7 days after PCI and within 24 hours after bone marrow aspiration or blood collection, a catheterization for. intracoronary infusion of the mononuclear cells in the infarct-related artery is performed. In all patients, follow-up will be obtained at 1, 4, and 12 months. MRI and catheterization are repeated at 4 months, and all images are analyzed by a core laboratory blinded to randomization. The primary end point of the study is the change in regional myocardial function in dysfunctional segments at 4 months relative to baseline, based on segmental analysis as measured by MRI.Implications If intracoronary infusion of autologous mononuclear bone marrow cells or peripheral mononuclear blood cells is proven to be beneficial after primary PCI; it could be a valuable tool in preventing heart failure-related morbidity and mortality after myocardial infarction.

Cardiovascular magnetic resonance imaging (CMR) with delayed contrast enhancement (DCE) using Gadolinium based contrast media is a recently developed technique which allows the direct visualisation of myocardial necrosis or fibrosis as regions of bright signal (hyperenhancement) compared with normal myocardium. The manuscript presents a review of the current clinical application of DCE–CMR for the diagnosis and prognosis of various common cardiac conditions such as ischaemic and non-ischaemic cardiomyopathies, and less common diseases such as cardiac sarcoidosis or Loffler endocarditis (Table 1).