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Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disorder, more often presenting with asymmetrical septal hypertrophy. Here we report the case of a patient, affected by arterial hypertension, presenting to the emergency department with chest pain, electrocardiographic changes and troponin rise. Further diagnostic work-up ruled out ischemic heart disease and lead to the diagnosis of a rare HCM phenotype affecting the lateral wall of the left ventricle. Cardiac magnetic resonance imaging proved to be a reliable diagnostic test in this case thanks to its tissue characterization ability, allowing the identification of diffuse fibrosis through native T1 mapping, edema through T2 mapping and replacement fibrosis with late gadolinium enhancement, providing us with robust diagnostic and prognostic information. The association of arterial hypertension with atypical HCM forms emerged from multicentric studies, however, further research is needed to fully clarify the complex interactions between arterial hypertension and phenotypic expression of HCM., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Ltd.)

Aims: myocardial oedema is largely represented in takotsubo syndrome (TTS) and may contribute to alter the myocardium morphology and function. The aim of the study is to describe relationships between oedema, mechanical, and electrical abnormalities in TTS., Methods and Results: the study included n = 32 hospitalized TTS patients and n = 23 controls. Cardiac magnetic resonance (CMR) with tissue mapping and feature tracking was performed with concomitant 12-lead electrocardiogram (ECG) recording. Mean age of TTS was 72 ± 12 years old, 94% women. Compared with controls, patients had higher left ventricular (LV) mass, worse systolic function, higher septal native T1 (1116 ± 73 msec vs. 970 ± 23 msec, P < 0.001), T2 (56 ± 5 msec vs. 46 ± 2 msec, P < 0.001), and extracellular volume (ECV) fraction (32 ± 5% vs. 24 ± 1%, P < 0.001). TTS patients had higher apicobasal gradient of T2 values (12 ± 6 msec vs. 2 ± 6 msec, P < 0.001); basal LV wall displayed higher native T1, T2, and ECV (all P < 0.002) but similar circumferential strain against controls (-23 ± 3% vs. -24 ± 4%, P = 0.351). In the TTS cohort, septal T2 values showed significant correlations with native T1 (r = 0.609, P < 0.001), ECV (r = 0.689, P < 0.001), left ventricular ejection fraction (r = -0.459, P = 0.008) and aVR voltage (r = -0.478, P = 0.009). Negative T-wave voltage and QTc length correlated with apicobasal T2 mapping gradient (r = 0.499, P = 0.007 and r = 0.372, P = 0.047, respectively) but not with other tissue mapping measurements., Conclusions: CMR T1 and T2 mapping demonstrated increased myocardial water content conditioning interstitial expansion in acute TTS, detected even outside areas of abnormal wall motion. Oedema burden and distribution associated with mechanical and electrocardiographic changes, making it a potential prognostic marker and therapeutic target in TTS., Competing Interests: Conflict of interest: None declared, (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Tissue characterization by mapping techniques is a recent magnetic resonance imaging (MRI) tool that could aid the tissue characterization of lung parenchyma in coronavirus disease-2019 (COVID-19). The aim of the present study was to compare lung MRI findings, including T1 and T2 mapping, in a group of n = 11 patients with COVID-19 pneumonia who underwent a scheduled cardiac MRI, and a cohort of healthy controls. MRI scout images were used to identify affected and remote lung regions within the patients’ cohort and appropriate regions of interest (ROIs) were drawn accordingly. Both lung native T1 and T2 values were significantly higher in the affected areas of patients with COVID-19 as compared to the controls (1375 ms vs. 1201 ms, p = 0.016 and 70 ms vs. 30 ms, p < 0.001, respectively), whereas no significant differences were detected between the remote lung parenchyma of the COVID-19 patients and the controls (both p > 0.05). When a larger ROI was identified, comprising the whole lung parenchyma within the image irrespective of the affected and remote areas, the COVID-19 patients still retained higher native T1 (1278 ms vs. 1149 ms, p = 0.003) and T2 values (38 ms vs. 34 ms, p = 0.04). According to the receiver operator characteristics curves, the T2 value of the affected region retained the higher accuracy for the differentiation of the COVID-19 patients against the controls (area under the curve 0.934, 95% confidence interval 0.826−0.999). These findings, possibly driven by the ability of MRI tissue mapping to detect ongoing inflammation in the lungs of patients with COVID-19, suggest that T1 and T2 mapping of the lung is a feasible approach in this clinical scenario.

Objective: Noninvasive positive-pressure ventilation (NPPV) emerged as an efficient tool for treatment of COVID-19 pneumonia. The factors influencing NPPV failure still are elusive. The aim of the study was to investigate the relationships between semiquantitative chest computed tomography (CT) scoring and NPPV failure and mortality in patients with COVID-19., Design: Observational study., Setting: Nonintensive care setting., Participants: A total of 112 patients consecutively admitted for COVID-19 pneumonia., Interventions: Usual care including various degrees of respiratory support., Measurements and Main Results: The semiquantitative CT score was calculated at hospital admission. Subgroups were identified according to the ventilation strategy used (oxygen delivered by Venturi mask n = 53; NPPV-responder n = 38; NPPV-failure n = 21). The study's primary endpoint was the use of NPPV. The secondary endpoints were NPPV failure and in-hospital death, respectively. CT score progressively increased among groups (six v nine v 14, p < 0.05 among all). CT score was an independent predictor of all study endpoints (primary endpoint: 1.25 [95% confidence interval {CI} 1.1-1.4], p = 0.001; NPPV failure: 1.41 [95% CI 1.18-1.69], p < 0.001; in-hospital mortality: 1.21 [95% CI 1.07-1.38], p = 0.003). According to receiver operator characteristics curve analysis, CT score was the most accurate variable for prediction of NPPV failure (area under the curve 0.862 with p < 0.001; p < 0.05 v other variables)., Conclusions: The authors reported the common and effective use of NPPV in patients with COVID-19 pneumonia. In the authors' population, a semiquantitative chest CT analysis at hospital admission accurately identified those patients responding poorly to NPPV., Competing Interests: Conflict of Interest None, (Copyright © 2021 Elsevier Inc. All rights reserved.)

Cyclic GMP-phosphodiesterase type 5 (PDE5) inhibition has been shown to counteract maladaptive cardiac changes triggered by diabetes in some but not all studies. We performed a single-center, 20-week, double-blind, randomized, placebo-controlled trial (NCT01803828) to assess sex differences in cardiac remodeling after PDE5 inhibition in patients with diabetic cardiomyopathy. A total of 122 men and women (45 to 80 years) with long-duration (>3 years) and well-controlled type 2 diabetes mellitus (T2DM; HbA1c < 86 mmol/mol) were selected according to echocardiographic signs of cardiac remodeling. Patients were randomly assigned (1:1) to placebo or oral tadalafil (20 mg, once daily). The primary outcome was to evaluate sex differences in cardiac torsion change. Secondary outcomes were changes in cardiovascular, metabolic, immune, and renal function. At 20 weeks, the treatment-by-sex interaction documented an improvement in cardiac torsion (-3.40°, -5.96; -0.84, P = 0.011) and fiber shortening (-1.19%, -2.24; -0.14, P = 0.027) in men but not women. The primary outcome could not be explained by differences in cGMP concentrations or tadalafil pharmacodynamics. In both sexes, tadalafil improved hsa-miR-199-5p expression, biomarkers of cardiovascular remodeling, albuminuria, renal artery resistive index, and circulating Klotho concentrations. Immune cell profiling revealed an improvement in low-grade chronic inflammation: Classic CD14 ++ CD16 - monocytes reduced, and Tie2 + monocytes increased. Nine patients (14.5%) had minor adverse reactions after tadalafil administration. Continuous PDE5 inhibition could offer a strategy to target cardiorenal complications of T2DM, with sex- and tissue-specific responses. Further studies are needed to confirm Klotho and hsa-miR-199-5p as markers for T2DM complications.

Immune checkpoint inhibitors (ICIs) are a family of anticancer drugs in which the immune response elicited against the tumor may involve other organs, including the heart. Cardiac magnetic resonance (CMR) imaging is increasingly used in the diagnostic work-up of myocardial inflammation; recently, several studies investigated the use of CMR in patients with ICI-myocarditis (ICI-M). The aim of the present systematic review is to summarize the available evidence on CMR findings in ICI-M. We searched electronic databases for relevant publications; after screening, six studies were selected, including 166 patients from five cohorts, and further 86 patients from a sub-analysis that were targeted for a tissue mapping assessment. CMR revealed mostly preserved left ventricular ejection fraction; edema prevalence ranged from 9% to 60%; late gadolinium enhancement (LGE) prevalence ranged from 23% to 83%. T1 and T2 mapping assessment were performed in 108 and 104 patients, respectively. When available, the comparison of CMR with endomyocardial biopsy revealed partial agreement between techniques and was higher for native T1 mapping amongst imaging biomarkers. The prognostic assessment was inconsistently assessed; CMR variables independently associated with the outcome included decreasing LVEF and increasing native T1. In conclusion, CMR findings in ICI-M include myocardial dysfunction, edema and fibrosis, though less evident than in more classic forms of myocarditis; native T1 mapping retained the higher concordance with EMB and significant prognostic value.

Uremic cardiomyopathy (UC) is the cardiac remodelling that occurs in patients with chronic kidney disease (CKD). It is characterised by a left ventricular (LV) hypertrophy phenotype, diastolic dysfunction and generally preserved LV ejection fraction. UC has a major role mediating the increased rate of cardiovascular events, especially heart failure related, observed in patients with CKD. Recently, the use of T 1 and T 2 mapping techniques on cardiac MRI has expanded the ability to characterise cardiac involvement in CKD. Native T 1 mapping effectively tracks the progression of interstitial fibrosis in UC, whereas T 2 mapping analysis suggests the contribution of myocardial oedema, at least in a subgroup of patients. Both T 1 and T 2 increased values were related to worsening clinical status, myocardial injury and B-type natriuretic peptide release. Studies investigating the prognostic relevance and histology validation of mapping techniques in CKD are awaited., Competing Interests: Disclosure: The authors have no conflicts of interest to declare., (Copyright © 2022, Radcliffe Cardiology.)

Lung ultrasound (LUS) and chest computed tomography (chest CT) are largely employed to evaluate coronavirus disease 2019 (COVID-19) pneumonia. We investigated semi-quantitative LUS and CT scoring in hospitalized COVID-19 patients. LUS and chest CT were performed within 24 h upon admission. Both were analyzed according to semi-quantitative scoring systems. Subgroups were identified according to median LUS score. Patients within higher LUS score group were older (79 vs 60 years, p<0.001), had higher C-reactive protein (CRP) (7.2 mg/dl vs 1.3 mg/dl, p<0.001) and chest CT score (10 vs 4, p=0.027) as well as lower PaO2/FiO2 (286 vs 356, p=0.029) as compared to patients within lower scores. We found a significant correlation between scores (r=0.390, p=0.023). Both LUS and CT scores correlated directly with patients age (r=0.586, p<0.001 and r=0.399, p=0.021 respectively) and CRP (r=0.472, p=0.002 and r=0.518, p=0.002 respectively), inversely with PaO2/FiO2 (r=-0.485, p=0.003 and r=-0.440, p=0.017 respectively). LUS score only showed significant correlation with hs-troponin T, NT-pro-BNP, and creatinine (r=0.433, p=0.019; r=0.411, p=0.027, and r=0.497, p=0.001, respectively). Semi-quantitative bedside LUS is related to the severity of COVID-19 pneumonia similarly to chest CT. Correlation of LUS score with markers of cardiac and renal injury suggests that LUS might contribute to a more comprehensive evaluation of this heterogeneous population., Competing Interests: Conflict of InterestThe authors declare no competing interests., (© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2021.)

Aim: Autonomic dysfunction (AD) is an early feature of systemic sclerosis (SSc). A regular endothelial function is a prerequisite for normal response of the myocardial blood flow (MBF) to cold pressure test (CPT). The aim of the study was to evaluate the relation between MBF and AD at rest and after CPT in asymptomatic SSc patients., Methods: Twenty SSc patients and 10 age-, sex- and body mass index-matched healthy controls underwent cardiac magnetic resonance at rest and after CPT. All subjects underwent 24 hours ambulatory 3-channel electrocardiogram Holter to evaluate AD by heart rate variability., Results: We did not observe any significant difference in MBF (mL/g/min) at rest and after CPT between SSc patients and healthy controls. Delta of MBF (difference between MBF after CPT and rest MBF) was lower (P = 0.039) in SSc patients than healthy controls (0.28 [0.04-0.40] vs 0.33 [0.24-0.54]). The low frequency/high frequency (LF/HF) was higher (P = 0.002) in SSc patients than healthy controls (3 [1.7-6] vs 1.8 [1.1-2.8]). The high frequencies (HF), modulated mainly by paraympathetic system, was lower (P = 0.003) in SSc patients than healthy controls (30 [16-42] vs 36.5 [24-44]). Sympathetic hyperactivity, due to reduction of parasympathetic activity (HF), is present in SSc patients. A negative correlation was observed between Delta of MBF and LF/HF (r = -0.572, P = 0.0031)., Conclusion: AD, characterized by sympathovagal imbalance due to a reduced parasympathetic tone with high LF/HF ratio, could be responsible for the reduced myocardial vasodilatory response after CPT., (© 2019 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Dynamic contrast-enhanced cardiovascular magnetic resonance imaging can be used to quantitatively assess the myocardial blood flow (MBF), recovering the tissue impulse response function for the transit of a gadolinium bolus through the myocardium. Several deconvolution techniques are available, using various models for the impulse response. The method of choice may influence the results, producing differences that have not been deeply investigated yet. Three methods for quantifying myocardial perfusion have been compared: Fermi function modelling (FFM), the Tofts model (TM) and the gamma function model (GF), with the latter traditionally used in brain perfusion MRI. Thirty human subjects were studied at rest as well as under cold pressor test stress (submerging hands in ice-cold water), and a single bolus of gadolinium weighing 0.1  ±  0.05 mmol kg -1 was injected. Perfusion estimate differences between the methods were analysed by paired comparisons with Student's t-test, linear regression analysis, and Bland-Altman plots, as well as also using the two-way ANOVA, considering the MBF values of all patients grouped according to two categories: calculation method and rest/stress conditions. Perfusion estimates obtained by various methods in both rest and stress conditions were not significantly different, and were in good agreement with the literature. The results obtained during the first-pass transit time (20 s) yielded p-values in the range 0.20-0.28 for Student's t-test, linear regression analysis slopes between 0.98-1.03, and R values between 0.92-1.01. From the Bland-Altman plots, the paired comparisons yielded a bias (and a 95% CI)-expressed as ml/min/g-for FFM versus TM, -0.01 (-0.20, 0.17) or 0.02 (-0.49, 0.52) at rest or under stress respectively, for FFM versus GF, -0.05 (-0.29, 0.20) or  -0.07 (-0.55, 0.41) at rest or under stress, and for TM versus GF, -0.03 (-0.30, 0.24) or  -0.09 (-0.43, 0.26) at rest or under stress. With the two-way ANOVA, the results were p  =  0.20 for the method effect (not significant), p  <  0.0001 for the rest/stress condition effect (highly significant, as expected), whereas no interaction resulted between the rest/stress condition and method (p  =  0.70, not significant). Considering a wider time-frame (60 s), the estimates for both rest and stress conditions were 25%-30% higher (p in the range 0.016-0.025) than those obtained in the 20 s time-frame. MBF estimates obtained by various methods under rest/stress conditions were not significantly different in the first-pass transit time, encouraging quantitative perfusion estimates in DCE-CMRI with the used methods.

Purpose: Definition of the role of real-time elastography (RTE) in the evaluation of response to treatment of uterine fibroids using MRgFUS in symptomatic patients., Materials and Methods: 28 women with 34 symptomatic fibroids, selected for MRgFUS, were enrolled. The patients were preliminarily studied with MRI and suprapubic and transvaginal ultrasound examination including RTE; the follow-up was performed immediately after treatment, at 3 months and 12 months with the same technique. Each lesion was evaluated by looking for ultrasound parameters (volume, resistance index) and RTE strain ratio (SR). Before and after treatment, all patients completed three questionnaires for symptom evaluation (e.g., uterine fibroids symptoms and quality of life)., Results: Of the 27 treated fibroids, only 14 had an effective treatment with non-perfused volume (NPV) >70 %. After 3 months of treatment, 17/21 patients presented significant decrease of uterine bleeding. A positive correlation between %NVP and percentage of fibroid volume decrease was seen. Reduction of SR value from t0 to t2 was found in 19/27 fibroids, particularly significant in fibroids with NPV > 70 %. A significant positive correlation between the percentage of symptom decrease and %SR decrease was found. At the time of statistical analysis, 12/21 patients reached the 12-month follow-up: they showed a further reduction of SR., Conclusion: RTE is a valid method able to support standard ultrasound examination in the evaluation of uterine fibroids, since it allows demonstrating the decrease of rigidity, which can be quantified with the SR parameter. It could be included in a pre-treatment multiparametric evaluation of patients looking for MRgFUS eligibility and in follow-up when it could assess the response to treatment.

Uterine fibroids are benign neoplasms that can cause distressing symptoms in women during their reproductive age. They are often associated with menorrhagia that can determine anemia or bulk-related symptoms. Different treatment options are available: medical therapy has the goal to treat related symptoms, while semi-invasive or non-invasive uterus-sparing procedures aim to treat symptoms and eventually to determine a reduction in fibroids size. In this review we illustrate the current semi-invasive and totally non-invasive most frequently used uterus sparing procedures available. A review of the literature along with personal experience will offer the readers a panoramic view of these up-to-date treatments to be considered as different possibilities to treat women affected by uterine fibroids looking for uterus conserving non-surgical approach.

Aim: In patients affected by aortic valve stenosis (AS) it is mandatory to rule out coronary artery disease (CAD). The role of retrospectively ECG-gated 64-slice CT angiography (64-SCTA) was assessed in patients with AS referred for surgical valve replacement., Methods: Forty-two patients with AS underwent ECG-gated 64-SCTA of thoracic aorta, including the heart and coronary arteries, before surgical valve replacement. Images were evaluated by two independent readers and compared with surgical findings in terms of aortic valve calcification grading, valvular morphology, aortic valve annulus and sino-tubular junction diameters, and valvular area planimetry. Quantitative evaluation of cusps opening was also performed. Finally, the presence of CAD, thoracic aortic aneurysm and left ventricle hypertrophy were assessed., Results: Visualization of the aortic valve without motion artefacts was possible in 38 patients (90.5%). Valvular morphology was correctly assessed in all cases (100%). 64-SCTA correctly determined aortic valve calcification grading and the aortic valve annulus and sinotubular junction diameters in 100% of cases. The aortic valve planimetric area was assessed in 38 cases (90.5%). Ascending aortic aneurysms requiring surgical replacement were detected in 12 patients (28.6%). Significant left ventricle hypertrophy was found in 30 patients (71%)., Conclusion: Preoperative evaluation of patients undergoing surgical replacement for AS with 64-SCTA is feasible. 64-SCTA can rule out CAD and evaluate the status of the aortic valve and thoracic aorta in the same examination, obtaining relevant information for surgical planning.

Purpose: To assess the feasibility of using an ultra-low dose (0.05 mmol/kg of body weight [BW]) of high relaxivity contrast agent for late gadolinium enhancement (LGE) imaging in patients with acute myocardial infarction (AMI)., Materials and Methods: 17 consecutive patients (mean age, 60.1 ± 10.3 years) with ST-segment elevation AMI underwent two randomized cardiac magnetic resonance studies (exam intervals between 24 and 48h) on a 1.5T unit during the first week after the event using gadobenate dimeglumine (Gd-BOPTA) at the dose of 0.1 mmol/kg BW (standard dose or SD group) and 0.05 mmol/kg BW (half dose or HD group). Image quality was qualitatively assessed. Quantitative analysis of LGE were performed by measuring signal intensity (SI), signal-to-noise ratio (SNR) in the infarcted myocardium (IM), non-infarcted myocardium (N-IM) and left ventricular cavity (LVC) in images acquired at 1, 3, 5, 10, 15 and 20 min after administration of Gd-BOPTA using both contrast media protocol. Contrast-to-noise ratio (CNR) between IM and N-IM (CNR IM/N-IM) and between IM and LVC (CNR IM/LVC) were also quantified for each time point. Moreover the extent of infarcted myocardium was measured., Results: 102 LGE images were evaluated for each dose group. Quality score was significantly higher for SD at 1, 15 and 20 min (0.002

Ischemic stroke currently represents one of the leading causes of severe disability and mortality in the Western World. Until now, angiography was the most used imaging technique for the detection of the extra-cranial and intracranial vessel pathology. Currently, however, non-invasive imaging tool like ultrasound (US), magnetic resonance (MR) and computed tomography (CT) have proven capable of offering a detailed analysis of the vascular system. CT in particular represents an advanced system to explore the pathology of carotid arteries and intracranial vessels and also offers tools like CT perfusion (CTP) that provides valuable information of the brain's vascular physiology by increasing the stroke diagnostic. In this review, our purpose is to discuss stroke risk prediction and detection using CT.

The concept of ideal tumor surgery is to remove the neoplastic tissue without damaging adjacent normal structures. High-intensity focused ultrasound (HIFU) was developed in the 1940s as a viable thermal tissue ablation approach. In clinical practice, HIFU has been applied to treat a variety of solid benign and malignant lesions, including pancreas, liver, prostate, and breast carcinomas, soft tissue sarcomas, and uterine fibroids. More recently, magnetic resonance guidance has been applied for treatment monitoring during focused ultrasound procedures (magnetic resonance-guided focused ultrasound, MRgFUS). Intraoperative magnetic resonance imaging provides the best possible tumor extension and dynamic control of energy deposition using real-time magnetic resonance imaging thermometry. We introduce the fundamental principles and clinical indications of the MRgFUS technique; we also report different treatment options and personal outcomes.

An 84-year-old woman with left flank pain presented to our institution. Contrast-enhanced computed tomography demonstrated a large spherical adrenal mass (diameter 13 cm) showing features of a benign lesion. Histologic examination revealed a giant adrenal hemangioma. Surgical resection was curative, with no recurrence at 2 years of follow-up. Surgery is usually recommended for symptomatic patients or in the case of a large lesion (>6 cm) because of the possibility of the coexistence of a malignancy or potential complications (ie, hemorrhage, rupture)., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: The objectives of this study were to evaluate the efficacy in pain management of magnetic resonance (MR)-guided focused ultrasound for the primary treatment of painful bone metastases and to assess its potential for local control of bone metastases., Materials and Methods: This was a prospective, single-arm research study with approval from the institutional review board. Eighteen consecutive patients (female, 8; male, 10; mean [SD] age, 62.7 [11.5] years) with painful bone metastases were enrolled. The patients were examined clinically for pain severity and pain interference in accordance with the Brief Pain Inventory-Quality of Life criteria before and at each follow-up visit. Computed tomography and MR imaging were performed before and at 1 and 3 months after the magnetic resonance-guided focused ultrasound treatment. The nonperfused volume (NPV) was calculated to correlate the extension of the ablated pathological tissue in the responder and nonresponder patients., Results: No treatment-related adverse events were recorded during the study. The evaluation of pain palliation revealed a statistically significant difference between baseline and follow-up values for pain severity and pain interference (P = 0.001, both evaluations). In the evaluation of local tumor control, we observed increased bone density with restoration of cortical borders in 5 of the 18 patients (27.7%). In accordance with the MD Anderson criteria, complete and partial responses were obtained in 2 of the 18 patients (11.1%) and 4 of the 18 patients (22.2%), respectively. Nonperfused volume values ranged between 20% and 93%. Mean NPV values remained substantially stable after the treatment (P = 0.08). There was no difference in the NPV values between the responder and nonresponder patients (46.7% [24.2%] [25%-90%] versus 45% [24.9%] [20%-93%]; P = 0.7)., Conclusions: Magnetic resonance-guided focused ultrasound can be safely and effectively used as the primary treatment of pain palliation in patients with bone metastases and has a potential role in local tumor control.