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Background There are some limitations using the different sequences of clinical cardiac magnetic resonance (cardiac MR) in detection of edema in patients presenting with acute myocardial injury. The purpose of this study is to evaluate the myocardial segmental agreement between the different edema sequences: T2 mapping and turbo inversion recovery magnitude (TIRM) in detection of acute myocardial edema. Results Thirty-seven patients presented with acute infarction were sent to cardiac MR to assess myocardial edema. All cardiac MR studies were scanned using cine, TIRM, and late gadolinium enhancement (LGE) in short axis views (SAX). Position of the T2 mapping slices were copied from the TIRM. The left ventricle (LV) was divided into apical, mid, and basal segments per visualization of the papillary muscles. Edema mass was assessed separately in each segment as well as the total edema mass in both the TIRM and T2 mapping. Twenty-four patients of whom 12.5% had multi-territorial coronary lesions and edema were assessed. Myocardial edema was not assessed in thirteen patients (35%) due to significant intra myocardial hemorrhage (T2 mapping p = 0.79), nor in the LV basal, mid, and apical segments’ edema (p = 0.69, 0.5, and 0.8 respectively). The upper and lower limits of agreements were tested between the TIRM and the T2 mapping of total edema mass, basal segments, mid, and apical ventricular segments were = 18 and − 7.7 g, 11.3 and − 5.1 g, 12.3 and − 5.2 g, and 15.5 and − 7.8 g respectively. Conclusion This study supports the proof of the principle that there is no statistical significant difference per myocardial segments between the T2 mapping and routine edema’s sequences. Larger studies are recommended to assess the impact in clinical outcome.

Patients with repaired tetralogy of Fallot (TOF) have not uncommonly fragmented QRS complexes (fQRS) on surface electrocardiogram. We suggested that the right heart hemodynamics might be correlated with both the number of leads showing fQRS (fQRS extent) and the QRS duration. A retrospective analysis of the magnetic resonance imaging (MRI) derived data of 30 patients following total correction of TOF was performed. The number of leads showing fragmentation (fQRS extent) as well as the QRS duration were assessed and tested for correlation with the right ventricular volumes and severity of pulmonary regurgitation (PR) as detected by MRI. Twenty-one patients had fQRS in at least 2 consecutive leads. fQRS correlated with larger right ventricular volumes and lower ejection fraction. fQRS in 5 leads was an accurate parameter in identifying an indexed right ventricular end diastolic volume >150 ml/m2 with a sensitivity of 87.5% and a specificity of 85.7%. Moreover, it was the most accurate parameter in detecting a PR fraction > 45%. To conclude, assessment of fQRS extent and duration is a simple, available, and an accurate parameter in identifying patients with significant right ventricular hemodynamic changes in repaired TOF patients.

Funding Acknowledgements Type of funding sources: None. Introduction Ventriculoarterial coupling (VAC) is an important surrogate measurement of global cardiovascular efficiency. However, up till recently, this measurement has been rarely used in clinical practice. This could be due to its invasive nature, and the relatively complex methods required for acquisition and interpretation. We here describe a noninvasive method of measuring VA coupling using cardiac magnetic resonance (CMR) in a cohort of hypertrophic cardiomyopathy (HCM). Methods Cardiac MRI was performed in 61 patients with hypertrophic obstructive cardiomyopathy (HOCM) before and after undergoing extended surgical myectomy. Cardiac MRIs from 15 patients with non-obstructive HCM were also included for comparison. Hypertensive patients were excluded from this study. Vitals signs were recorded during each MRI study. Arterial end-systolic pressure (AESP) was determined non-invasively as previously described (0.9x brachial blood pressure). Left ventricular end-systolic pressure (LVESP) was calculated by adding the echo-derived peak systolic gradient across the left ventricular outflow tract to the arterial end-systolic pressure. Indexed stroke volume (SVI) in the ascending aorta as well as indexed end systolic volume (ESVI) were calculated from CMR. Indexed arterial (Ea) and ventricular (Ev) elastance were calculated as AESP/SVI and LVESP/ESVI. VA coupling was then calculated as Ea/Ev. Results Compared to the baseline measurements, VAC increased significantly post myectomy (mean VAC pre-myectomy and post-myectomy 0.38 vs. versus 0.62 respectively, p= 0.00001). VAC in non-obstructive HCM patients (mean = 0.64) was statistically similar to that in post-myectomy (p = 0.82) and statistically different from pre-myectomy (p = 0.00016). The mean of LVOTO gradients post- and pre-myectomy were significantly different (p = 0.00001). Significant correlation of the delta-VAC with the delta gradient in the LVOTO was found (r= 0.35, p = 0.005). Conclusion Non-invasive assessment of VA coupling using CMR is feasible and could be a useful tool in the evaluation of patients with various cardiovascular disorders. Further studies with larger numbers of patients are required to establish the utility of this method in clinical practice.

Background Hypertrophic cardiomyopathy (HCM) is one of the commonest inheritable cardiac disorders. Being a global disease with diffuse myocardial fibrosis, it has a wide range of adverse outcomes ending with sudden cardiac death. Cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) has become a reference standard for visualization of focal myocardial fibrosis. In the setting of less severe or more diffuse fibrosis, LGE is unlikely to reveal the presence of abnormal tissue given the lack of normal myocardium as a reference. Direct measurement of myocardial T1 time (T1 mapping) may improve these methodologic problems of LGE CMR in the setting of diffuse retention of gadolinium-based contrast material. So, we aim at this study to evaluate the clinical application of CMRI native and post-contrast T1 relaxation in assessing diffuse myocardial fibrosis non-invasively in hypertrophic cardiomyopathy. Results There was a significant difference between the percent of fibrosis detected by measuring the extracellular volume percent compared to that detected by LGE, with the former detecting fibrosis in 45.1% of the examined cardiac segments while the latter showed fibrosis in 20.9% of the cardiac segments. Also, measuring the native T1 values showed evidence of fibrosis in about 32.2% of the cardiac segments superseding the percent of fibrosis detected using the LGE alone. The ejection fraction percent showed a negative correlation with the left ventricular mass with a correlation coefficient value of − 0.139 where both interstitial and replacement fibrosis play an important role in the pathophysiology of diastolic dysfunction as well as impairing the myocardial contractility. Also, in cases of obstruction, the extracellular volume (ECV) is more likely to increase in the basal anterior and antero-septal segments as well as the basal inferior segment with P values 0.015, 0.013, and 0.045, respectively. Conclusion Diffuse fibrosis was found to be difficult to be distinguished using LGE. The unique ability of CMR to use proton relaxation times provides a quantitative measurement to detect increased interstitial volume in diffuse myocardial fibrosis. Moreover, it showed that in cases of obstruction, the segments exposed to the highest pressure are more vulnerable to the fibrotic process denoting a relationship between the pressure gradient and the adverse myocardial remodeling.

The integration of comprehensive genomic and phenotypic data from diverse ethnic populations offers unprecedented opportunities toward advancements in precision medicine and novel diagnostic technologies. Current reference genomic databases are not representative of the global human population, making variant interpretation challenging, especially in underrepresented populations, such as the North African population. To address this, the Egyptian Collaborative Cardiac Genomics (ECCO-GEN) Project launched a study comprising 1000 individuals free of cardiovascular disease (CVD). Here, we present the first 391 Egyptian healthy volunteers recruited to establish a pilot phenotyped control cohort. All individuals underwent detailed clinical investigation, including cardiac magnetic resonance imaging (MRI), and were sequenced using a targeted panel of 174 genes with reported roles in inherited cardiac conditions. We identified 1262 variants in 27 cardiomyopathy genes of which 15.1% were not captured in current global and regional genetic reference databases (here: gnomAD and Great Middle Eastern Variome). The ECCO-GEN project aims at defining the genetic landscape of an understudied population and providing individual-level genetic and phenotypic data to support future studies in CVD and population genetics.

The assumption of the presence of diffuse myocardial fibrosis in long-standing cyanotic congenital heart disease (CHD) inspired us to noninvasively determine the myocardial extracellular volume (ECV) using contrast CMR. T1 maps were measured pre and 10 min after the injection of 0.15 mmol/kg of gadolinium in 25 subjects. Seven patients with long-standing cyanotic CHD and no previous cardiac surgery (aged 16-53 years and oxygen saturations of 69-90%), nine normal subjects (aged 14-49 years), and nine patients with previously cyanotic CHD, who had been corrected by open heart surgery (aged 2 months-58 years, mean 9 years). Late gadolinium enhancement was performed to exclude scar areas. The T1 values were measured in the interventricular septum and in the left lateral or inferior ventricular wall, such that same areas were assessed in every patient in the pre- and post-contrast T1 scan. ECV was calculated according to ΔR1myocardium/ΔR1blood * (1 - hematocrit). Cyanotic patients had significantly lower ECV percentage than the previous cyanotic patients (septum: 22 ± 2.7% vs 35 ± 4.6%, p = 0.002; LV wall: 22 ± 2.2% vs 30 ± 3.7%, p = 0.01, respectively). No significant differences were found between cyanotic patients and normal controls (septum: 22 ± 2.7% vs 24 ± 1.4%, p = 0.44; LV wall: 22 ± 2.2% vs 24 ± 2%, p = 0.57, respectively). Long-standing cyanosis in CHD without cardiac surgery does not cause diffuse myocardial fibrosis or expansion of the myocardial ECV.

Our aim was (1) to detect the presence of fibrosis by Cardiac magnetic resonance imaging (CMR) in the pediatric age group. (2) Correlate CMR findings with demographic data, LV function, and other echocardiographic parameters. We studied 40 pediatric patients diagnosed as HCM by echocardiography. All patients were subjected to clinical examination (in which the NYHA classification was determined for each patient), echocardiography, and CMR. CMR was done on a 1.5T Philips Achieva scanner in SSFP with delayed myocardial enhancement (DE-MRI). All demographic and functional parameters as well as pressure gradient across left ventricular outflow tract (LVOT) were correlated with the percentage of myocardial enhancement. We studied 13 female and 27 male patients from 45 days up to 18 years. The mean percentage of DE-MRI was 9.7 ± 9%. We found significant correlation between the NYHA classification and the pressure gradient across the LVOT (P =

INTRODUCTION: Duchenne muscular dystrophy (DMD) is known to impact the subepicardial layer of the myocardium through chronic inflammation. Recent animal studies have shown predominant subendocardial involvement in rats with DMD. The primary outcome parameter was to determine by cardiovascular MRI (CMR) if two differential patterns of myocardial involvements exist in DMD; the secondary outcome parameters were to correlate the observed pattern with metabolic markers such as insulin resistance measures. METHODS: Forty patients with DMD were screened using CMR to determine which of them had predominantly subendocardial dysfunction (SENDO group), or subepicardial/midmyocardial involvement (SEPMI group). Patients were subjected to body mass index measurement, serum creatinine kinase, serum lactate dehydrogenase enzyme, fasting glucose-insulin ratio (FGIR), full lipid profile, left ventricular ejection fraction (LVEF), left ventricle E/E´ ratio (the ratio of early mitral inflow velocity to average early diastolic velocities of the basal septum and mitral annulus) for left ventricle diastolic function, and myocardial layer strain discriminating echocardiography (MLSD-STE). Results: 26 patients displayed SENDO while 34 displayed SEPMI. SENDO group displayed overt insulin resistance; (FGIR (SENDO: 7 ± 1 vs. SEPMI: 5 ± 1, P

Introduction To validate right and left ventricular stroke volume (RVSV & LVSV) measurements by forward flow stroke volume from aortic (AoSV) and pulmonary arterial (MPASV) measurements during routine cardiovascular magnetic resonance (CMR) in congenital heart disease (CHD). Methods Retrospectively studied CMR of 147 consecutive patients (median age 22years, range 0.5–64years) with CHD. Patients with ventricular septal defects, mitral valve regurgitation or severe tricuspid-valve-regurgitation were excluded. 126 LVSV were compared to the AoSV. 99 RVSV were compared to the MPASV. Ventricular SV was determined using a routine standard stack of cine axial slices. Arterial forward flow SV was determined using a routine standard phase-velocity quantitative flow sequence. Results AoSV correlated with LVSV by (r 2 =0.9, p 2 =0.8, p Conclusion Measured ventricular SV correlates closely with SV, assessed by CMR flow measurement in the originating great artery in CMR of CHD.

Atrial septal defects (ASDs) account for approximately 6%-10% of congenital heart defects. The well-known types of atrial septal communications are the ostium secundum, ostium primum, sinus venosus types, and coronary sinus defects. A 50-year-old female was referred for TEE for better assessment of MR severity and mechanism. 2D/3D-TEE showed a rare combination of different abnormalities; bi-leaflet mitral valve prolapse, cleft P2, cor triatriatum sinister, and a tunnel-shaped IAS communication. To the best of our knowledge, this is a very rare case with a rare form of atrial septal defect that was not described before. We named this defect an interatrial tunnel.

Objectives To evaluate a systolic ECG-gated high-pitch aortoiliac computed tomography (CT) angiography for planning transcatheter aortic valve implantation (TAVI). Methods Patients referred for TAVI underwent a combined CT imaging with retrospective, multiphasic ECG-gating of the heart and systolic ECG-gated high-pitch aortoiliac CT angiography. Consecutive patients were retrospectively included in this study group. Heart rate (HR) and heart rate variability (HRV) were assessed during the high-pitch ECG prediction phase. Aortic annulus area (AAA) was planimetrically quantified on both datasets. While only one moment of cardiac cycle was available for measurements in the high-pitch CT, the point of time in the multiphasic CT was chosen, where AAA yielded maximum size. Hypothetical prosthesis sizing was compared between multiphasic vs. high-pitch CT. Results Among 61 patients (44.2 % men, mean age: 83.3 ± 5.5 years) average heart rate and HRV were 71.0 ± 13.4 bpm and 7.3 ± 8.5 bpm. 20 patients (32.7 %) had atrial fibrillation at the time of image acquisition. There was a strong correlation of AAA as derived from multiphasic vs. the high-pitch CT (r = 0.98). The difference in AAA was 10.5 ± 17.1mm2 (455.1 ± 83.0 mm2 for multiphasic vs. 444.5 ± 87.2 mm2 for high-pitch CT) and did not reach statistical significance (p = 0.08). Hypothetical prosthesis sizing showed an agreement in 55 of 61 patients (90.2 %). A sizing based on the high-pitch CT resulted in smaller prosthesis choice in 6 patients, all of them suffering from atrial fibrillation. Mean effective radiation dose was 10.9 ± 6.1 mSv for cardiac CTA and 4.1 ± 1.0 mSv for high-pitch CTA. Conclusion For patients with sinus rhythm, systolic high-pitch aortoiliac CTA provides adequate prosthesis size selection as compared with multiphasic ECG-gated cardiac CTA and may result in significantly reduced radiation exposition.

Loeffler’s endocarditis and cardiac manifestations of the hypereosinophilic syndrome (HES) are rare and difficult to diagnose. We report a case of in a 36year-old female with a history of rheumatoid arthritis with disabling dyspnea. The transthoracic echocardiogram demonstrated normal systolic cardiac functions and a left ventricular apical thrombus. However, using cardiovascular magnetic resonance (CMR) with inversion-recovery (IR) delayed enhancement, and cine steady-state free precession (SSFP) sequences, we were able to clearly demonstrate endocardial fibrosis, tissue inflammation, apical ventricular hypertrophy, and LV thrombus that correlate with clinical findings. We believe cardiac MRI is more useful than transthoracic echocardiography in the diagnosis and management of HES and ultimately it obviated the need for biopsy to confirm the diagnosis.

The advancement that took place in assessing fractional flow reserve (FFR) using various competing modalities led to numerous research trials to evaluate the clinical impact of each. Among those trials is the recently published PLATFORM study. The data was designed to compare two clinical scenarios; a combination of computed fluid dynamics with computed tomographic angiography (CTA-guided strategy) in non-obstructive coronary artery disease (CAD) on one arm, compared to the standard practice representing the other clinical arm. The study’s results were evaluated for further evidence and clinical insights.

Methods Twenty patients presented with acute heart failure. Echo and cardiac markers (including Troponin, CK, CK-MB) were performed for every patient. Patient’s age ranged from 2 mo-14years. All patients underwent CMRI study. All CMRI studies were scanned using the routine protocol to fulfill the Lake Louise criteria. The performed sequences include: 1.cine stead state free precession in axial and short axis to calculate cardiac function and volumes, 2.T2 TSE in short axis cuts for cardiac edema, the cut off value of >2.3 obtained from the ratio between myocardial muscle to skeletal muscle signals was used, 3. Short axis T1 TSE before and 5 minutes after contrast injection was used as marker of capillary leakage, and delayed myocardial enhancement (LGE) in short axis and four chamber images to show the LGE pattern. Children under 6 years were sedated with chloral hydrate.

Patients younger than 8 years are usually examined by cardiovascular magnetic resonance (CMR) under general anesthesia (GA) or sedation without intubation. Therefore, we sought to study the feasibility of CMR in patients aged 3 to 8years without GA or sedation.Data sets of 71 consecutive patients aged 3 to 8years were studied retrospectively.The total cohort was divided into 2 groups: a no-GA or sedation without intubation group (no-GA or sedation) and a GA or sedation without intubation group (GA or sedation).The patients' age, scan durations for each group, successfully answered clinical question, and number of sequences per study were compared between both groups.Scan duration in the no-GA or sedation group (n=44) was 35± 20minutes, and that in the GA or sedation group (n=27) was 60± 31minutes (P.001). The percentage of successful reports was 95% (42/44) in the no-GA or sedation group and 89% (24 of 27) in the GA or sedation group (P=.29).CMR in patients aged 3 to 8years is usually successfully feasible without GA or sedation.

Background Theoretically, blood flow in the ascending aorta of patients with helical flow patterns, as in patients with bicuspid aortic valves (BAV), are underestimated by routine two dimensional (2D) phase contrast velocity encoding (PC-VENC). Four dimensional (4D) PC-VENC is theoretically not influenced by flow patterns. Hence, both, 2D PC-VENC and 4D PC VENC should result in similar blood flow measurements in the ascending aorta of subjects without helical flow patterns, as in subjects with tricuspid aortic valves (TAV).

Objective: To assess the value of conventional echocardiographic measurements for quantification of pulmonary regurge and right ventricular function in comparison to Cardiac Magnetic Resonance Imaging (CMR) after surgical repair of Tetralogy Of Fallot (TOF). Methods: Twenty five asymptomatic children after TOF repair (9.2 ± 4 years) were compared to twenty five age matched healthy children. Echocardiographic quantification of pulmonary regurge was assessed by (1) pulmonary regurge jet width/pulmonary artery diameter, (2) pulmonary pressure half time, (3) pulmonary regurge index; pulmonary regurge duration to diastole duration, (4) no flow time; diastole duration - pulmonary regurge duration and (5) diastole/systole velocity time integral ratio. Measurements derived from conventional echocardiography were compared to pulmonary regurgitant fraction, right ventricular volumes and ejection fraction by CMR. Results: On CMR, the pulmonary regurgitant fraction was 28.64 ± 10.2%. By conventional echocardiography, pulmonary regurge index and no flow time were found to offer the best prediction for severity of pulmonary regurge. Pulmonary regurge index of 64 msec has sensitivity of 81% and specificity of 100% (AUC=0.894) in identifying significant pulmonary regurge. Compared to controls, patients after TOF repair showed significantly lower right ventricle myocardial velocities, higher E/ E‘ ratio and prolonged MPI. Among the TOF patients, right ventricular MPI showed significant negative correlation (r=-0.402; P=0.008) with tricuspid valve annulus peak systolic velocity (S‘) and significant positive correlation (r= 0. 413; P=0.04) with right ventricle stroke volume by CMR. Conclusion: Conventional echocardiography can offer a simple, readily available and accurate tool for quantification of pulmonary regurge and right ventricular function during mid- term follow up after surgical repair of tetralogy of Fallot.

We have read the article “Implications of Early Aortic Stiffening in Patients With Transposition of the Great Arteries After Arterial Switch Operation” by Voges et al,1 with great interest. We congratulate the authors for this study. However, in our opinion there is an aspect that needs clarification. Using cardiac magnetic resonance measurements, Voges et al1 …

Aim To analyze the correspondence of the 17 left ventricular myocardial segments with each coronary artery by using late gadolinium contrast enhanced cardiovascular magnetic resonance (CMR) imaging. Material and methods A total number of 58 patients with known or suspected ischemic heart disease were enrolled in this study. Those patients were scheduled for CMR and conventional coronary angiography. The correspondence between the coronary artery distribution and the supplied myocardium was assessed according to the 17-segment model. Results The segments 1, 2, 3, 7, 8, 13, 14 and 17 were totally specific for LAD, segments 6 and 12 were totally specific for LCX, and segment 10 was specific for RCA. There was overlap between LAD and RCA for segments 9 and 15. There was overlap between LCX and RCA for segments 4, 5 and 11. The segment 16 was shared by the all territories (LAD, LCX and RCA) with slight LCX predominance. Conclusions Our study concluded that the LAD territory on CMR bases is larger than the American Heart Association (AHA) proposed 17-segment model.

Objective The long-term outcome of Tetralogy of Fallot (TOF) surgical repair in developing countries is still unknown. Therefore the aim of the study was the quantification of pulmonary regurgitation (PR) and right ventricular functions using cardiac magnetic resonance (CMR) in order to follow up midterm post transannular patch repair of asymptomatic TOF patients. Methods We prospectively studied 37 asymptomatic corrected TOF patients (aged 18 years or less), aged at surgery was of median, min/max of (19, 8/48 months). Cardiac functions were assessed using routine steady state free precession techniques. PR quantification was performed using the routine velocity encoding phase contrast in the main pulmonary artery. Results Four patients had mild PR, 26 had moderate PR and seven had severe PR, with a median value of PR% in CMR amounting to 29% (max: 75% and min: 13%). Indexed right ventricle end-diastolic volume amounted to (mean ± SD) 130 ± 38 ml, and indexed right ventricle end-systolic volume amounted to 63 ± 26 ml. Conclusion Accurate quantitative assessment of PR in the mid and long-term course of TOF patients is paramount. CMR has to be introduced as a new modality in Egypt in the follow up course of asymptomatic TOF patients.

Background Cardiovascular Magnetic Resonance (CMR) of pediatric patients has become routine clinical practice. Patients under eight years are usually examined under general anesthesia (GA) or sedation without intubation. However, in our clinical experience, CMR may be feasible in patients aged 3 to 8 years without general anesthesia or sedation without intubation. Methods Retrospectively studied datasets of total number of 71 patients aged between 3 and 8 years. The total cohort was divided into two groups, first with no general anesthesia or sedation without intubation (no GA or sedation) and the second group patients with general anesthesia or sedation without intubation (GA or sedation). The patients’ age groups and scan durations for each group, percentage of successfully answering the clinical question in each group, total number of scanned sequences in each group, and number of sequences per study were recorded and compared between both groups. Results Forty-four patients in the no GA or sedation group, 27 in the GA or sedation group. The scan duration was in the no GA or sedation group: 35 minutes ± 20.44 minutes, and in the GA or sedation group: 60 minutes ± 31 minutes (p < 0.001). The percentage of successful reports was 95% (42 of 44) in the no GA or sedation group and 89% (24 of 27) in the patients with GA or sedation group. Conclusions In scope of understanding the CHD hemodynamics, and clinical requests and questions; the decision of using neither general anesthesia with intubation nor sedation with without intubation was favored by our center’s CMR unit over examining the patients under general anesthesia or sedation, to avoid the effect of general anesthesia and sedation on cardiac function during CMR, decrease the CMR scan duration, and increase the feasibility of the CMR in the young age group between three and eight years. Funding