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Objectives We studied in a multicenter setting the accuracy and reproducibility of 3-dimensional echocardiography (3DE)–derived measurements of left atrial volume (LAV) using new, dedicated volumetric software, side by side with 2-dimensional echocardiography (2DE), using cardiac magnetic resonance (CMR) imaging as a reference. Background Increased LAV is associated with adverse cardiovascular outcomes. Although LAV measurements are routinely performed using 2DE, this methodology is limited because it is view dependent and relies on geometric assumptions regarding left atrial shape. Real-time 3DE is free of these limitations and accordingly is an attractive alternative for the evaluation of LAV. However, few studies have validated 3DE-derived LAV measurements against an accepted independent reference standard, such as CMR imaging. Methods We studied 92 patients with a wide range of LAV who underwent CMR (1.5-T) and echocardiographic imaging on the same day. Images were analyzed to obtain maximal and minimal LAV: CMR images using standard commercial tools, 2DE images using a biplane area-length technique, and 3DE images using Tomtec LA Function software. Intertechnique comparisons included linear regression and Bland-Altman analyses. Reproducibility of all 3 techniques was assessed by calculating the percentage of absolute differences in blinded repeated measurements. Kappa statistics were used to compare 2DE and 3DE classification of normal/enlarged against the CMR reference. Results 3DE-derived LAV values showed higher correlation with CMR than 2DE measurements (r = 0.93 vs. r = 0.74 for maximal LAV; r = 0.88 vs. r = 0.82 for minimal LAV). Although 2DE underestimated maximal LAV by 31 ± 25 ml and minimal LAV by 16 ± 32 ml, 3DE resulted in a minimal bias of −1 ± 14 ml for maximal LAV and 0 ± 21 ml for minimal LAV. Interobserver and intraobserver variability of 2DE and 3DE measurements of maximal LAV were similar (7% to 12%) and approximately 2 times higher than CMR (4% to 5%). 3DE classified enlarged atria more accurately than 2DE (kappa: 0.88 vs. 0.71). Conclusions Compared with CMR reference, 3DE-derived LAV measurements are more accurate than 2DE-based analysis, resulting in fewer patients with undetected atrial enlargement.

Journal of cardiovascular magnetic resonance 13(Suppl. 1), P243 (2011). doi:10.1186/1532-429X-13-S1-P243 special issue: "Abstracts of the 2011 SCMR/Euro CMR Joint Scientific Sessions : Nice, France 3-6 February 2011", Published by Elsevier, Amsterdam

ObjectivesThis study evaluated the value of systolic and diastolic deformation indexes determined by strain-encoded imaging to predict persistent severe dysfunction at follow-up in patients after reperfused acute myocardial infarction (AMI) in comparison with late gadolinium enhancement (LGE).BackgroundAnimal studies suggest that regional diastolic function provides information about myocardial viability after AMI. However, data in humans are sparse.MethodsTwenty-six patients underwent magnetic resonance imaging 3 ± 1 days after successfully reperfused ST-segment elevation myocardial infarction and at a follow-up of 6 months. Cine, strain-encoded, and LGE images were acquired. Peak systolic circumferential strain (Ecc) and early diastolic strain rate (Ecc/s) were calculated for each segment at baseline and at follow-up. A cutoff Ecc value of −9% was used to define severe dysfunction at follow-up.ResultsA total of 312 segments were analyzed; 119 segments showed abnormal baseline function. Thirty-five segments showed severe dysfunction at follow-up, which was defined as Ecc at follow-up

Objectives To visualize the coronary sinus using magnetic resonance (MR), and to demonstrate the feasibility of MR-guided intubation of the cardiac venous system (CVS) in swine. Materials and methods A total of 6 pigs were investigated. All experiments were performed using an interventional 1.5-Tesla MRI system. The CVS was visualized using an inversion-recovery navigator-gated whole-heart steady-state free-precession sequence after administration of gadobenate dimeglumine contrast agent. The coronary sinus was then intubated under MR-guidance with a passive MR-compatible guidewire modified by incorporation of iron oxide markers for improved visualization and a nonbraided Cobra-catheter. MR-guided interventions were monitored using a steady-state free-precession real-time imaging sequence. Time needed was measured for MR-guided intubation of the CVS and compared with the time needed for fluoroscopy guided intubation of the CVS. Results Visualization and intubation of the coronary sinus and its site branches was feasible in all cases. Time spent for MR-guided intubation of the CVS was comparable to time spent for fluoroscopy-guided intubation (8.2 +/- 2 minutes vs. 8.3 +/- 1.3 minutes; P = 0.85). Conclusions MR-visualization and MR-guided intubation of the coronary sinus and its side branches is feasible. The feasibility of MR-guided intubation of the CVS might have relevance for procedures like cardiac resynchronization therapy and percutaneous transcatheter mitral annuloplasty, requiring improved 3-dimensional knowledge about cardiac vein anatomy in the near future.

We sought to determine whether the thickness of the non-contrast-enhanced myocardial rim (RIM) predicts recovery of territorial myocardial function after revascularization in chronic ischemic cardiomyopathy (ICM).Non-contrast-enhanced dysfunctional myocardium at late gadolinium-enhanced CMR depicts the presence of viable myocardium.In 29 patients (65 +/- 8 years) with ICM (EF 33 +/- 10), ceCMR and cine images were acquired 5 +/- 10 days before revascularization. Cine images were repeated after 6 months. Regional wall thickness, wall thickening and RIM were determined in each of 12 segments per short-axis slice (4-8/patient), which were assigned to the respective supplying coronary artery (LAD, LCX and RCA). A threshold for normal wall-thickening was derived from a control group (n = 14; 52 +/- 17 years). Functional improvement at follow-up was defined as wall thickening2 mm.Of the 1,896 analyzed segments, 655 segments showed severe dysfunction. At follow-up, 307 segments demonstrated functional improvement. The RIM differed between segments with and without improvement (6.6 +/- 2.4 mm vs. 2.8 +/- 2.0 mm; p0.0001). The area under the receiver operator characteristic (ROC) for predicting overall functional recovery was 0.91 (95%, CI 0.88-0.93, p0.001). A RIM of 4.0 mm predicted functional recovery after revascularization of the supplying coronary artery with a sensitivity and a specificity of 88 and 82% for the LAD, 96 and 86% for the RCA and 88 and 83% for the LCX, respectively.RIM may be a useful marker for predicting territorial functional recovery after revascularization in patients with chronic ICM.

Aims Our aim was to assess the feasibility and safety of real-time (RT) three-dimensional (3D) transoesophageal echocardiography (TEE) for guiding transcatheter closure of interatrial communications and to evaluate its additional benefit over conventional 2D TEE in reducing radiation exposure for the patient. Methods and results Twenty-five patients undergoing device closure of their interatrial defect had the procedure guided by fluoroscopy, 2D TEE, and RT 3D TEE. We retrospectively compared this group with a historical control group in which interventional guidance was performed using fluoroscopy and 2D TEE alone. The application of RT 3D TEE allowed safe device deployment in all patients without any complications, resulting in a reduction of mean fluoroscopy time (10 ± 6 to 6 ± 4 min, P < 0.01), mean dose area product (DAP) (964 ± 628 to 535 ± 464 cGy cm2, P < 0.01), and mean DAP per individual body surface area (494 ± 317 to 273 ± 221 cGy cm2/m2, P < 0.01). Conclusion RT 3D TEE as an adjunct to 2D TEE is a feasible and safe tool to guide transcatheter device closure of interatrial communications, resulting in a reduction of radiation exposure. These data indicate that RT 3D TEE can be used to safely monitor interatrial defect closure in clinical routine.

Aims To evaluate deformation parameters of an endocardial, mid-myocardial, and epicardial myocardial layer in different transmurality of myocardial infarction and assess whether layer-specific deformation analysis allows definition of infarct transmurality. Methods and results Fifty-six patients (mean age 55 ± 9 years, 38 men) with chronic ischaemic left ventricular (LV) dysfunction underwent two-dimensional echocardiography and contrast-enhanced magnetic resonance imaging (ceMRI). The extent of myocardial infarction was determined as relative amount of hyperenhancement by ceMRI in a 16-segment LV model (0%, no infarction; 1–50%, non-transmural infarction; 51–100%, transmural infarction). On the basis of two-dimensional echocardiographic parasternal short-axis views peak systolic circumferential strain was determined for the total wall thickness and for each of three myocardial layers (endocardial, mid-myocardial, and epicardial) using an automatic frame-by-frame tracking system of acoustic echocardiographic markers (EchoPAC, GE Ultrasound). In non-transmural infarction impairment of circumferential strain was greater in the endocardial than the epicardial layer, relative reduction compared with control segments, 45% vs. 28% ( P < 0.001), respectively. In transmural infarction additional impairment of circumferential strain was greater in the epicardial than the endocardial layer, relative reduction compared with non-transmural infarction 29% vs. 7% ( P < 0.001), respectively. Endocardial layer circumferential strain allowed distinction of non-transmural vs. no infarction with higher accuracy than total wall thickness strain [area under the curve (AUC) 0.842 vs. 0.774, respectively, P = 0.001]. Epicardial layer circumferential strain allowed distinction of transmural from non-transmural infarction with higher accuracy than total wall thickness strain (AUC 0.819 vs. 0.762, respectively, P = 0.005). Conclusion Non-transmural infarction results in greater functional impairment of the endocardial than of the epicardial myocardial layer. In transmural infarction both layers are affected similarly compared with controls. A layer-specific analysis of myocardial deformation allows accurate discrimination between different transmurality categories of myocardial infarction.

Identification of the functional severity of intermediate coronary artery lesions is challenging for the interventional cardiologist. Functional severity can be measured invasively using the fractional flow reserve (FFR). However, FFR has the disadvantage of being invasive and associated with radiation exposure. Cardiac MRI (CMR) offers the opportunity to assess myocardial perfusion noninvasively. A semiquantitative index of myocardial perfusion (perfusion reserve index or PRI) can be obtained from the first-pass of a bolus of gadolinium through the myocardium. Studies comparing the invasive FFR to CMR perfusion imaging in patients with coronary artery stenosis of undefined significance have demonstrated that CMR first-pass perfusion imaging may be useful for the assessment of their functional significance. However, in patients with a high prevalence of microvascular dysfunction, the value of this method may be limited because the PRI may be influenced by both the epicardial conductance vessel function as well as microvascular function.

Summary The aim of the study was to validate the accuracy of the exini heart software (exini) package in assessing left ventricular end-diastolic/systolic volumes (EDV, ESV) and ejection fraction (LVEF) from gated 99mTc-MIBI single-photon emission tomography (SPECT). Cardiac magnetic resonance imaging (cMRI) was used as reference. Furthermore, effects of perfusion defects and image quality in SPECT on correlation between gated SPECT and magnetic resonance imaging were investigated. Methods: Seventy patients were examined using gated SPECT (rest study, eight gates per cardiac cycle). EDV, ESV and LVEF were calculated from gated SPECT using exini. Directly before or after SPECT, cMRI (20 gates cardiac per cycle) was performed. EDV, ESV and LVEF were calculated using Simpson’s rule. Perfusion defects were quantified using the summed-rest-score (SRS). Total number of myocardial counts were used to rate image quality. Results: Correlation between results of gated SPECT and cMRI was high for EDV (R = 0·89) and ESV (R = 0·94) and good for LVEF (R = 0·78). ESV (exini 54 ± 31 ml versus cMRI 57 ± 34 ml) and LVEF (exini 62·9 ± 11·7% versus cMRI 60·6 ± 13·9%) did not differ significantly whereas exini overestimated EDV significantly compared with cMRI (exini 144 ± 41 ml versus cMRI 137 ± 36 ml; P

BACKGROUND: Myocardial deformation imaging and contrast-enhanced cardiac magnetic resonance imaging (ceMRI) have been used to define myocardial viability in ischemic left ventricular dysfunction. This study evaluated the incremental predictive value of an integrated analysis of function and tissue structure for functional improvement after revascularization therapy. METHODS: In 59 patients with ischemic left ventricular dysfunction, myocardial viability was defined by pixel-tracking-derived myocardial deformation imaging and ceMRI to predict recovery of function at 9+/-2 months follow-up after revascularization. For each left ventricular segment in a 16-segment model, peak systolic radial strain was determined from parasternal two-dimensional echocardiographic views using an automatic frame-by-frame tracking system of natural acoustic echocardiographic markers, and extent of hyperenhancement using ceMRI. Five categories were generated for each parameter, allowing subsequent combination. The predictive power for segmental improvement in function was determined for each of the modalities as well as the combination of both. RESULTS: From 512 dysfunctional segments at baseline, 251 segments (49%) demonstrated functional recovery. The accuracy to predict functional recovery was area under curve (AUC)=0.846 for peak systolic radial strain and AUC=0.834 for extent of hyperenhancement. A combination of both parameters improved the predictive accuracy compared with hyperenhancement alone, AUC=0.861, P value of less than 0.001. In sequential Cox models, the predictive power for segmental functional recovery of extent of hyperenhancement alone (chi model 171.0, P

Objectives: We sought to study: 1) the accuracy and reproducibility of real-time 3-dimensional echocardiographic (RT3DE) analysis of left ventricular (LV) volumes in a multicenter setting, 2) interinstitutional differences in relationship with the investigators' specific experience, and 3) potential sources of volume underestimation. Background: Reproducibility and accuracy of RT3DE evaluation of LV volumes has not been validated in multicenter studies, and LV volumes have been reported to be underestimated compared to cardiac magnetic resonance (CMR) standard. Methods: A total of 92 patients with a wide range of ejection fractions underwent CMR and RT3DE imaging at 4 different institutions. Images were analyzed to obtain LV end-systolic volume (ESV) and end-diastolic volume (EDV). Reproducibility was assessed using repeated analyses. The investigation of potential sources of error included: phantom imaging, intermodality analysis-related differences, and differences in LV boundary identification, such as inclusion of endocardial trabeculae and mitral valve plane in the LV volume. Results: The RT3DE-derived LV volumes correlated highly with CMR values (EDV: r = 0.91; ESV: r = 0.93), but were 26% and 29% lower consistently across institutions, with the magnitude of the bias being inversely related to the level of experience. The RT3DE measurements were less reproducible (4% to 13%) than CMR measurements (4% to 7%). Minimal changes in endocardial surface position (1 mm) resulted in significant differences in measured volumes (11%). Exclusion of trabeculae and mitral valve plane from the CMR reference eliminated the intermodality bias. Conclusions: The RT3DE-derived LV volumes are underestimated in most patients because RT3DE imaging cannot differentiate between the myocardium and trabeculae. To minimize this difference, tracing the endocardium to include trabeculae in the LV cavity is recommended. With the understanding of these intermodality differences, RT3DE quantification of LV volume is a reliable tool that provides clinically useful information.

Recently, a new generation of transesophageal echocardiography (TEE) probes with a novel matrix array technique was introduced, allowing three-dimensional (3D) presentation of cardiac structures in real-time. This article aims to describe our first experiences with this new technique in the guidance of percutaneous cardiac interventions in the catheter laboratory. We used a matrix array 3D TEE probe connected to a 3D-capable echocardiographic system. The 3D TEE system provides exact imaging of the pathomorphology of cardiac structures as well as intracardiac catheters and devices in real-time. We applied this innovative technique to monitor percutaneous cardiac interventions in the catheter laboratory, such as atrial septal defect (ASD) or patent foramen ovale (PFO) closures, revalving procedures such as percutaneous transvenous mitral valve annuloplasty (PTMA), aortic valve replacements, and electrophysiological procedures. Our findings demonstrate that real-time 3D TEE provides a novel imaging technique to guide interventions in the catheter laboratory, providing fast and complete information about the underlying pathomorphology, improving spatial orientation, and additionally monitoring online the procedure without loss of image quality. These benefits may accelerate the learning curve and improve confidence of the interventional cardiologist in order to increase safety, accuracy, and efficacy of interventional cardiac procedures.

We sought to define the impact of echocardiographically defined left ventricular (LV) lead position on the efficacy of cardiac resynchronization therapy (CRT) in a serial study using 3-dimensional echocardiography. Fifty-eight consecutive patients (53+/-9 years of age; 37 men) with heart failure were included in the study. Echocardiograms were obtained before CRT, within 7 days after implantation, and at 12+/-2 months of follow-up using a 3-dimensional digital ultrasound scanner (iE33, Philips, Andover, Massachusetts). Analysis of the temporal course of contraction in 16 LV segments was performed offline using a semiautomatic contour tracing software (LV Analysis, TomTec, Unterschleissheim, Germany). Based on the resulting volume/time curves the segment with the latest minimum of systolic volume in each patient was identified preoperatively (segment A). In addition, the temporal difference between the pre- and postoperative (within 7 days) minimum of systolic volume was determined for each segment. The segment with the longest temporal difference was defined to show the greatest effect of CRT. Location of the LV lead tip was assumed to be within this segment (segment B). LV lead position was defined as optimal when segments A and B were equal and as nonoptimal when they were far from each other. Using this definition, 26 patients had a nonoptimal and 32 patients an optimal LV lead position. Before CRT ejection fraction (32+/-4% vs 31+/-6%), LV end-systolic and end-diastolic volumes (242+/-92 vs 246+/-88 ml, 315+/-82 vs 323+/-90 ml), and peak oxygen consumption (14.3+/-1.4 vs 14.6+/-1.5 ml/min/kg) were equal in the 2 groups. At 12+/-2 months of follow-up, patients with an assumed optimal LV lead position showed greater increases of ejection fraction (10+/-2% vs 6+/-3%) and peak oxygen consumption (2.4+/-0.3 vs 1.5+/-0.4 ml/min/kg) and greater decreases of LV end-systolic (32+/-7 vs 21+/-5 ml) and end-diastolic (20+/-7 vs 13+/-6 ml) volumes. In conclusion, correspondence of the segment with the latest preoperative LV contraction with the segment with the greatest effect based on CRT results in a significantly greater benefit of ejection fraction and peak oxygen consumption and a greater improvement in LV remodeling. Thus, there is an optimal LV lead position that should be obtained.

The objective of our study was to determine the accuracy of 16-MDCT for evaluation of stent patency and in-stent stenosis in venous coronary bypass grafts.Fourteen patients who had previous stent placements in stenosed venous coronary bypass grafts underwent contrast-enhanced MDCT of the heart (collimation, 16 x 0.75 mm; 120 kV; 550 mAs(eff)) and invasive coronary angiography. A total of 20 stents were evaluated: Vessel and stent diameters proximal to, distal to, and at various sites inside the stent were measured on both techniques, and Bland-Altman plots and correlations were calculated. Image noise and image quality were also assessed applying a Student's t test for data comparison of image noise.All 20 bypass stents were correctly classified as patent. Vessel diameters outside the stent showed an excellent correlation (r = 0.90) and in-stent diameters showed a good correlation (r = 0.72), with lower values for MDCT due to blooming artifacts. All significant in-stent stenoses were correctly classified.In patients suspected of bypass in-stent stenosis, 16-MDCT may be considered as a valuable alternative to conventional angiography for evaluating bypass patency and in-stent stenosis.

The aim of this study was to investigate the value of a real-time magnetic resonance imaging (MRI) approach for the assessment of left-ventricular-wall motion in patients with insufficient transthoracic echocardiography in terms of accuracy and temporal expenditure. Twenty-five consecutive patients were examined on a 1.5-Tesla whole-body MR system (ACS-NT, Philips Medical Systems, Best, NL) using a real-time and ECG-gated (the current gold standard) steady-state free-precession (SSFP) sequence. Wall motion was analyzed by three observers by consensus interpretation. In addition, the preparation, scanning, and overall examination times were measured. The assessment of the wall motion demonstrated a close agreement between the two modalities resulting in a mean kappa coefficient of 0.8. At the same time, each stage of the examination was significantly shortened using the real-time MR approach. Real-time imaging allows for accurate assessment of left-ventricular-wall motion with the added benefit of decreased examination time. Therefore, it may serve as a cost-efficient alternative in patients with insufficient echocardiography.

In cardiac amyloidosis an interstitial deposition of amyloid fibrils causes concentric thickening of the atrial and ventricular walls. We describe the results of tissue characterization of the myocardium by T1 quantification and MRI findings in a patient with cardiac amyloidosis. The T1 time of the myocardium was elevated compared to that in individuals without amyloidosis. The T1 time of the myocardium was 1387 +/- 63 msec (mean value obtained from four measurements +/- standard deviation [SD]) in the patient with cardiac amyloidosis, while the reference value obtained from the myocardium of 10 individuals without known myocardial disease was 1083 +/- 33 msec (mean value +/- SD). In combination with other MR findings suggestive of amyloidosis, such as homogeneous thickening of the ventricular and atrial walls, thickening of the valve leaflets, restrictive filling pattern, and reduction of systolic function, T1 quantification may increase diagnostic confidence.

We sought to assess the value of non-contrast enhanced transthoracic harmonic echocardiography (TEE) for the visualization of left ventricular thrombi in 34 patients with cardiomyopathy. Results were compared to contrast-enhanced magnetic resonance imaging as reference standard. Maximal thrombus size was quantified with both modalities. Magnetic resonance imaging demonstrated thrombi in 15 patients. In these subjects echocardiography was negative in seven patients. Thrombi were excluded in 19 patients with magnetic resonance while echocardiography was deemed positive in 5 subjects. Thrombus size by ce-CMR was not different for clots visualized or not visualized by echocardiography (P = 0.71). Moreover, observer agreement was superior for ce-CMR (kappa = 0.94) as compared to TTE (kappa= 0.71). Non-contrast-enhanced harmonic TTE has limited value for the visualization of thrombi in patients with cardiomyopathy.

Eine Aortenklappenkalzifikation besteht bei mehr als 25% der Patienten > 65 Jahre und ist mit einem um 50% erhohten Risiko an kardiovaskularen Ereignissen assoziiert. Bisher bestand Unsicherheit uber die klinische Relevanz inzidentell detektierter Aortenklappenkalzifikationen in bildgebenden radiologischen Verfahren, insbesondere auf CT-Aufnahmen des Thorax. Bezuglich der multifaktoriellen Pathogenese der Aortenklappenkalzifikation geben neue Daten Hinweise darauf, dass neben anderen Faktoren auch die humoralen Regulatoren der Kalzifizierung einen zentralen Stellenwert haben. Diese Arbeit soll einen Uberblick uber die Pravalenz und klinische Bedeutung von inzidentell detektierten Aortenklappenkalzifikationen geben. Daruber hinaus wird der Stellenwert von Inhibitoren der Kalzifikation in der Pathogenese der Aortenklappenkalzifikation diskutiert.

To evaluate retrospectively the prevalence and grade of aortic valve calcification incidentally detected on chest multi-detector row computed tomographic (CT) scans and to compare the grade of calcification with the severity of aortic valve disease as assessed with echocardiography.Patient informed consent was waived by the institutional board on medical ethics that approved this study. The authors identified 402 patients (231 men and 171 women; mean age, 62.5 years +/- 12.1) of 1820 patients who underwent chest multi-detector row CT between July 2001 and August 2004 and also underwent echocardiography. Aortic valve calcification at multi-detector row CT was visually graded on a scale ranging from 0 to 4 (0 = no calcification, 4 = severe calcification). CT findings were correlated with hemodynamic data obtained at echocardiography. Patients without aortic stenosis were compared with patients with aortic stenosis. The Student t test, Spearman correlation coefficient, chi(2) analysis, and an unweighted kappa test were used to compare results.Aortic valve calcification was noted on multi-detector row CT scans in 72 of the 402 patients (18%). Twelve of 20 patients (60%) with grade 3 or grade 4 calcification on CT scans had aortic stenosis at echocardiography, compared with only nine of 382 patients (2.4%) with grade 0-2 calcification (P.001). Significant correlations were observed between the grade of aortic valve calcification and the echocardiographically determined mean (r = 0.45, P = .03) and peak transvalvular gradient (r = 0.47, P = .03). There was substantial agreement between the grade of valve calcification at multi-detector row CT and the severity of aortic valve disease at echocardiography (kappa = 0.67).Aortic valve calcification was an incidental finding on 18% of multi-detector row CT scans. The grade of aortic valve calcification is correlated with the hemodynamic severity of aortic valve disease as determined with echocardiography.

Multislice spiral computed tomography (MSCT) allows the in vivo detection of valvular calcification. The aim of this study was to validate the quantification of aortic valve calcification (AVC) by MSCT with in vitro measurements by atomic absorption spectroscopy.In 18 patients with severe aortic stenosis, 16 detector row MSCT (SOMATOM Sensation 16, Siemens, Forchheim, Germany with scan parameters as follows: 420 milliseconds tube rotation time, 12 x 0.75 mm collimation, tube voltage 120 KV) was performed before aortic valve replacement. Images were reconstructed at 60% of the RR interval with an effective slice thickness of 3 mm and a reconstruction increment of 2 mm. AVC was assessed using Agatston AVC score, mass AVC score, and volumetric AVC score. After valve replacement, the calcium content of the excised human stenotic aortic valves was determined in vitro using atomic absorption spectroscopy.The mean Agatston AVC score was 3,842 +/- 1,790, the mean volumetric AVC score was 3,061 +/- 1,406, and mass AVC score was 888 +/- 492 as quantified by MSCT. Atomic absorption spectroscopy showed a mean true calcification mass (Ca5(PO4)3OH) of 19 +/- 8 mass%. There was a significant correlation between in vivo AVC scores determined by MSCT and in vitro mean true calcification mass (r = 0.74, P = 0.0004 for mass AVC score, r = 0.79, P = 0.0001 for volumetric AVC score and r = 0.80, P = 0.0001 for Agatston AVC score) determined by atomic absorption spectroscopy. Linear regression analysis showed a significant association between the degree of hydroxyapatite (given in mass%) in the aortic valve and the degree of AVC (R = 0.74, F = 19.6, P = 0.0004 for mass AVC score, R = 0.80, F = 29.3, P = 0.0001 for Agatston AVC score and R = 0.79, F = 27.3, P = 0.0001 for volumetric AVC score) assessed by MSCT.MSCT allows accurate in vivo quantification of aortic valve calcifications.

Rationale and Objectives Three-dimensional high-spatial-resolution angiograms of the coronary arteries were acquired with an electrocardiogram-gated three-dimensional rotational angiography technique on an interventional X-ray system. Materials and Methods During selective injection of contrast material in the left and right coronary artery, projection images were obtained in eight pigs during a continuous rotation of the X-ray gantry over an angular range of 180° within 8 seconds. Results Three-dimensional tomographic reconstruction depicted the proximal, medial, and distal sections of the main arteries as well as the main bifurcations in multiple cardiac phases in all animals. Conclusions For the first time, this feasibility study shows that a three-dimensional angiogram of the coronary arteries can be obtained intraprocedurally in a conventional interventional suite by means of tomographic reconstruction from projection images.

Die exakte Erfassung der Morphologie und die Einschatzung der Funktion einer insuffizienten Mitralklappe sind mit den bisherigen konventionellen dopplerechokardiographischen Methoden eingeschrankt. Alle Methoden der zweidimensionalen Schnittbildtechnik sind bei der Darstellung der Pathomorphologie auf die Fahigkeit des Untersuchers angewiesen, aus den verschiedenen Schnitt ebenen eine mentale Rekonstruktion vorzunehmen. Die Verfahren zur Schweregradbeurteilung einer Mitralinsuffizienz (MI) beruhen entweder auf einer Abschatzung der MI-Jet-Grose oder auf raumlichen Annahmen zur Geometrie, die haufig unzutreffend sind und die Genauigkeit beeintrachtigen. Neuere echokardiographische Techniken wie die 3-D-Echokardiographie erlauben eine umfassendere Darstellung und Beurteilung der Pathomorphologie, was gerade bei raumlich komplexen Veranderungen die Sensitivitat und diagnostische Genauigkeit der Methode steigert. Die Kombination mit der dreidimensionalen Doppler-Information ermoglicht eine zuverlassigere und exakter quantifizierbare Beurteilung des Insuffizienzschweregrades. Andere bildgebende Verfahren wie die Magnetresonanztomographie stellen wegen der ebenso kompletten dreidimensionalen Erfassung der Morphologie und ihres enormen Potentials zur Messung intrakardialer Blutflusse eine vielversprechende Alternative dar.

Stress cardiomyopathy is a novel clinical syndrome affecting predominantly elderly female patients. It is characterized by severe reversible left ventricular dysfunction demonstrating a peculiar pattern of extensive apical wall motion abnormality known as "apical ballooning". The syndrome is typically precipitated by acute severe emotional, psychological or physical stress. It mimics acute coronary syndrome exhibiting typical clinical and electrocardiographic features of acute myocardial infarction. At angiography, however, significant coronary artery disease is invariably excluded. In the acute phase, the syndrome may be complicated by cardiogenic shock or ventricular fibrillation. Clinical data indicate that the disease is associated with an extensive increase of endogenous cathecholamine levels which may exhibit a direct toxic effect on the myocytes causing non-ischemic myocardial "stunning". This mechanism may have important implications for the management of patients in the acute phase of the disease. The prognosis of stress cardiomyopathy, however, seems favorable with recovery of global and regional myocardial function within a few weeks in the vast majority of patients. Yet, long-term outcome data in larger patient populations are lacking. We report the case of a female patient presenting with stress cardiomyopathy and review the current knowledge of the disease.

PURPOSE: To prospectively assess the effect of including or excluding endocardial trabeculae in left ventricular (LV) measurements and the reproducibility of these measurements at cine cardiovascular magnetic resonance (MR) imaging with true fast imaging with steady-state precession (FISP). MATERIALS AND METHODS: The study was approved by the local ethics committee, and each subject gave informed consent before participating. Twenty healthy subjects and 20 consecutive patients underwent 1.5-T cardiovascular MR imaging. Seven to 12 short-axis views encompassing the entire LV were acquired by using true FISP. Endocardial and epicardial contours were traced manually. The data sets in each patient were analyzed twice: with inclusion of endocardial trabeculae in the LV cavity volume and with exclusion of endocardial trabeculae from the cavity volume. On the basis of these two contour sets, the end-diastolic (ED) and end-systolic (ES) LV volumes, ejection fraction (EF), and LV mass were calculated. Additionally, interobserver and interexamination reproducibility was assessed by using Bland-Altman analysis. RESULTS: Compared with exclusion of trabeculae, inclusion of trabeculae in the LV cavity volume resulted in significantly larger ED and ES LV volumes (mean differences, 21 mL ± 11 [standard deviation] and 19 mL ± 33, respectively; P < .001) and lower EFs (mean difference, -2% ± 2; P < .001). The calculated LV mass was significantly smaller with inclusion than with exclusion of trabeculae (mean difference, -21 g ± 12; P < .001). All interobserver and interexamination limits of agreement based on inclusion of trabeculae, except those for EF measurements, were superior to those based on exclusion of trabeculae. At measurement reproducibility comparisons, differences in interobserver ED LV volume, and LV mass and interexamination LV mass were statistically significant, favoring the inclusion of trabeculae in the LV cavity volume. CONCLUSION: Trabeculae significantly affect quantifications of LV volume and mass. The superior reproducibility of LV measurements with the inclusion of endocardial trabeculae in the cavity volume favors this tracing algorithm for clinical use. © RSNA, 2005.

Objectives The aim of this study was to examine if contrast-enhanced multislice spiral computed tomography (MSCT) is comparable to contrast-enhanced magnetic resonance imaging (MRI) for depiction of acute myocardial infarction (MI). Background Delayed-enhancement MRI of MI is well established, but there are no clinical reports about MSCT for this indication. Early perfusion deficit on MSCT has been reported to correlate with the presence of MI. Methods A total of 28 consecutive patients (23 men; 55.9 ± 11.4 years) with reperfused MI underwent contrast-enhanced cardiac 16-slice MSCT. Images were acquired in the arterial phase and the late phase 15 min after administration of 120 ml contrast material. Within 5 days, patients underwent MRI after administration of 0.2 mmol Gd-dimeglumine/kg/bodyweight. All examinations were completed within two weeks after MI. The area of MI was compared between the different imaging techniques using Bland-Altman method and multivariate analysis. Agreement of the contrast enhancement patterns was evaluated with a weighted kappa test. Results Mean infarct size on MRI was 31.2 ± 22.5% per slice compared with 33.3 ± 23.8% per slice for late-enhancement MSCT and 24.5 ± 18.3% per slice for early-perfusion-deficit MSCT. Bland-Altman data showed a good agreement between late-enhancement MRI and late-enhancement MSCT. Contrast enhancement patterns demonstrated an excellent agreement between late-enhancement MRI and late-enhancement MSCT (kappa = 0.878). The results were worse comparing MRI and early-phase MSCT (kappa = 0.635). Conclusions Multislice spiral computed tomography allows for the assessment of acute MI. Late-enhancement MSCT appears to be as reliable as delayed contrast-enhanced MRI in assessing infarct size and myocardial viability in acute MI.

Purpose. To evaluate a standardized definition of delayed hyperenhancement in the analysis of contrast-enhanced cardiac magnetic resonance (ceCMR) imaging. Patients and Methods. CeCMR was performed in 15 patients with chronic ischemic heart disease. Delayed hyperenhancement was analyzed both by visual analysis by an experienced team of observers, and after thresholding the window setting of the images at 2, 3, 4, 5, and 6 SD above the mean signal intensity of remote, normal myocardium in the same slice. In each patient, total infarct size (TIS) and segmental infarct extent (SIE) were calculated. Results. TIS and SIE were 22.9 ± 12.2 mL and 32 ± 28% after visual analysis. Thresholding the window setting at 2, 3, 4, and 6 SD above signal intensity of remote caused a 40%, 31%, and 17% increase (p < 0.007) and a 7% decrease (p = NS) in TIS, and a 75%, 41%, and 16% increase and 22% decrease in SIE (p < 0.001), respectively. There was no difference between visual analysis and analysis after thresholding at 5 SD. Conclusion. Analyzing ceCMR with a standardized definition of hyperenhancement related to the signal of remote, nonenhanced myocardium may result in considerable overestimation of infarct size at the usual cut-off of 2 SD.

Analysis of diastolic function for assessment of myocardial viability has not been evaluated. Strain rate (SR) analysis allows quantitative segmental analysis of myocardial function and has been used during dobutamine stimulation for assessment of systolic functional reserve. In 37 patients with ischemic left ventricular dysfunction diastolic function was evaluated at rest and during low-dose dobutamine stimulation (10 mug/kg/min) using SR imaging and related to F18-fluorodeoxyglucose positron emission tomography. Analysis of peak early (E waves) and late (A waves) diastolic myocardial SR was performed using apical views. In all, 317 segments had normal function at rest by 2-dimensional echocardiography. A total of 192 segments with dyssynergy at rest were classified by positron emission tomography as viable in 94 cases and nonviable in 98 cases. Dys-synergic segments had lower E and A waves SR compared with normal contracting segments. There were no significant differences in peak E and A waves SR at rest between dys-synergic viable and nonviable segments. With dobutamine stimulation peak E waves SR increased significantly for viable segments (0.89 +/- 0.51-1.06 +/- 0.51 L/s, P.01) whereas it was unchanged for nonviable segments (0.77 +/- 0.49-0.78 +/- 0.48 L/s, P = .835). Peak A waves SR increased for viable (0.71 +/- 0.55-1.00 +/- 0.56 L/s, P.01) and nonviable (0.57 +/- 0.47-0.71 +/- 0.58 L/s, P = .023) segments. However, during dobutamine stimulation peak A waves SR was larger ( P.001) for viable than for nonviable segments. In conclusion, normal contracting segments at rest have higher E and A waves SR compared with dys-synergic segments. Dys-synergic viable myocardial segments demonstrate an increase in E and A waves SR with dobutamine stimulation whereas nonviable segments are less responsive to dobutamine.

This study evaluated the acute and follow-up effectiveness of sirolimus-eluting stents (SESs) and nonpolymer-based paclitaxel-eluting stents (PESs) in comparison will balloon angioplasty for treatment of complex in-stent restenosis (ISR) lesions. Drug-eluting stents have been demonstrated to be highly effective for treatment of de novo lesions. The use of drug-eluting stents for treatment of complex ISR is less well defined. Eighty one lesions with in-stent restenosis (lesion length < 30 mm in a native coronary artery) were treated with either PTCA alone (n = 26 lesions in 25 patients), PES (n = 27 lesions in 24 patients; Achieve, Cook; 3,1 μg paclitaxel/mm2 nonpolymer-based coating), SES (n = 28 lesions in 28 patients; Cypher, Cordis; 140 μg sirolimus/cm2 metal surface area). Nine-month MACE rates were 32%, 8%, and 14% (all due to repeated revascularization procedures, except one death in the SES group) in the PTCA, PES, and SES group, respectively. Postintervention minimal lumen diameter in stent was significantly greater in the SES and the PES group in comparison with the PTCA group (2.37 ± 0.26, 2.54 ± 0.42, 1.78 ± 0.23 mm; P < 0.001). At 6-month angiographic follow-up, late loss in stent was 0.77 ± 0.45, 0.43 ± 0.53, and 0.29 ± 0.52 mm for the PTCA, PES, and SES group, respectively (P = 0.005). In-lesion restenosis rate was 61% for the PTCA group, 20% for the PES group, and 13% for the SES group (P = 0.042). The implantation of SES as well as nonpolymer PES proved to be effective for treatment of ISR. The combination of improved acute gain and reduced late loss results in a significantly improved angiographic follow-up result in comparison with PTCA. Catheter Cardiovasc Interv 2005;64:28–34. © 2004 Wiley-Liss, Inc.

Die Einfuhrung der transosophagealen Echokardiographie (TEE) vor fast 20 Jahren hat mit beeindruckendem Erfolg einen neuen Zugang zum Herzen ermoglicht. In weniger als 2 Jahrzehnten hat sie sich zu einem wichtigen diagnostischen Instrument sowohl in der Kinder- und Erwachsenkardiologie als auch in der Herzchirurgie und Anasthesie entwickelt. In den letzten Jahren wurde die Anzahl der Indikationen fur eine TEE-Untersuchung kontinuierlich erweitert. Die Kombination aus qualitativ hochwertigen morphologischen und hamodynamischen Informationen sowie die Moglichkeit einer bettseitigen Anwendung der TEE auf der Intensivstation und im Operationssaal garantieren, dass diese Methode neben Magnetresonanztomographie (MRT) und Multislice-Computertomographie (MSCT) einen festen Platz im diagnostischen Instrumentarium der Kardiologen und Anasthesisten behalten wird. Weitere Fortschritte in der Transducer-Technologie sowie die Entwicklung von miniaturisierten Matrix-Transducern versprechen in naher Zukunft eine dreidimensionale Echtzeitdarstellung des Herzens auch vom Osophagus aus, die das diagnostische Potential dieser Technik und deren Einfluss auf die Durchfuhrung therapeutischer Eingriffe erneut ausweiten wird.

The degree of valvular calcification in patients with aortic stenosis was determined with retrospectively ECG-gated 16-MDCT and correlated with the severity of stenosis assessed at cardiac catheterization.We conducted a prospective study of 72 patients (38 men and 34 women; mean age +/- SD, 69.5 +/- 8.8 years) with aortic stenosis who underwent 16-MDCT and cardiac catheterization. Aortic valve calcification was assessed using the aortic Agatston score, aortic mass score, and aortic volume score. Severity of aortic stenosis was classified at cardiac catheterization. Aortic valve area and peak-to-peak and mean transvalvular gradients were correlated with the degree of calcification determined on MDCT.All measured aortic valve calcification scores were significantly higher in patients with severe aortic stenosis (n = 46) than in patients with moderate (n = 15) or mild (n = 11, p0.001) aortic stenosis. Aortic valve calcification scores were inversely related to aortic valve area (r = -0.67, p0.001 for aortic mass score) and correlated significantly with peak-to-peak (r = 0.70, p0.001) and mean transvalvular (r = 0.72, p0.001) gradients. No correlation between the aortic valve calcification and the total coronary calcium scores was observed.Aortic valve calcification assessed on 16-MDCT is associated with severity of aortic stenosis. Thus, aortic valve calcification scores should be calculated routinely in all patients undergoing MDCT for assessment of coronary calcification. High aortic valve calcification scores indicate possibly severe aortic stenosis and should prompt a further functional evaluation.

Objectives We sought to validate high-resolution transthoracic real-time (RT) three-dimensional echocardiography (3DE), in combination with a novel semi-automatic contour detection algorithm, for the assessment of left ventricular (LV) volumes and function in patients. Background Quantitative RT-3DE has been limited by impaired image quality and time-consuming manual data analysis. Methods Twenty-four subjects with abnormal (n = 14) or normal (n = 10) LVs were investigated. The results for end-diastolic volume (EDV), end-systolic volume (ESV), and ejection fraction (EF) obtained by manual tracing were compared with the results determined by the semi-automatic border detection algorithm. Moreover, the results of the semi-automatic method were compared with volumes and EF obtained by cardiac magnetic resonance imaging (CMRI). Results Excellent correlation coefficients (r = 0.98 to 0.99) and low variability (EDV −1.3 ± 8.6 ml; ESV −0.2 ± 5.4 ml; EF −0.1 ± 2.7%; p = NS) were observed between the semi-automatically and manually assessed data. The RT-3DE data correlated highly with CMRI (r = 0.98). However, LV volumes were underestimated by RT-3DE compared with CMRI (EDV −13.6 ± 18.9 ml, p = 0.002; ESV −12.8 ± 20.5 ml, p = 0.005). The difference for EF was not significant between the two methods (EF 0.9 ± 4.4%, p = NS). Observer variability was acceptable, and repeatability of the method was excellent. Conclusions The RT-3DE, in combination with a semi-automatic contour tracing algorithm, allows accurate determination of cardiac volumes and function compared with both manual tracing and CMRI. High repeatability suggests applicability of the method for the serial follow-up of patients with cardiac disease.

The main aim of this study was to validate the accuracy of 4D-MSPECT in the assessment of left ventricular (LV) end-diastolic/end-systolic volumes (EDV, ESV) and ejection fraction (LVEF) from gated technetium-99m methoxyisobutylisonitrile single-photon emission tomography ((99m)Tc-MIBI SPET), using cardiac magnetic resonance imaging (cMRI) as the reference method. By further comparing 4D-MSPECT and QGS with cMRI, the software-specific characteristics were analysed to elucidate clinical applicability. Fifty-four patients with suspected or proven coronary artery disease (CAD) were examined with gated (99m)Tc-MIBI SPET (8 gates/cardiac cycle) about 60 min after tracer injection at rest. LV EDV, ESV and LVEF were calculated from gated (99m)Tc-MIBI SPET using 4D-MSPECT and QGS. On the same day, cMRI (20 gates/cardiac cycle) was performed, with LV EDV, ESV and LVEF calculated using Simpson's rule. Both algorithms worked with all data sets. Correlation between the results of gated (99m)Tc-MIBI SPET and cMRI was high for EDV [ R=0.89 (4D-MSPECT), R=0.92 (QGS)], ESV [ R=0.96 (4D-MSPECT), R=0.96 (QGS)] and LVEF [ R=0.89 (4D-MSPECT), R=0.90 (QGS)]. In contrast to ESV, EDV was significantly underestimated by 4D-MSPECT and QGS compared to cMRI [130+/-45 ml (4D-MSPECT), 122+/-41 ml (QGS), 139+/-36 ml (cMRI)]. For LVEF, 4D-MSPECT and cMRI revealed no significant differences, whereas QGS yielded significantly lower values than cMRI [57.5%+/-13.7% (4D-MSPECT), 52.2%+/-12.4% (QGS), 60.0%+/-15.8% (cMRI)]. In conclusion, agreement between gated (99m)Tc-MIBI SPET and cMRI is good across a wide range of clinically relevant LV volume and LVEF values assessed by 4D-MSPECT and QGS. However, algorithm-varying underestimation of LVEF should be accounted for in the clinical context and limits interchangeable use of software.

To compare a spiral gradient-echo sequence with a radial steady-state free precession sequence and to compare these two interactive real-time cardiac magnetic resonance (MR) imaging examinations with harmonic two-dimensional echocardiography (ECHO) for the evaluation of regional myocardial function.Electrocardiographically triggered breath-hold steady-state free precession (BH-SSFP) MR imaging was the reference standard. Thirty-five nonselected patients scheduled for routine ECHO were included. Data from corresponding two-, three-, and four-chamber long-axis views and a midventricular short-axis view were acquired with each modality. Image quality and depiction of segmental wall motion were scored semiquantitatively by using the 16-segment model of the American Society of Echocardiography. Repeated-measures analysis of variance was performed to assess differences in image quality and wall motion depiction scores among the four imaging methods. Agreement was assessed by using Cohen kappa statistics.Compared with the image quality achieved with BH-SSFP MR imaging, the image quality achieved with radial MR imaging was similar (nonsignificant difference), but that achieved with spiral MR imaging and ECHO was significantly inferior (P.0001). There were no significant differences in the image quality of the long- and short-axis views between the radial and BH-SSFP sequences, while the image quality of the long-axis spiral (P.05) and the short- and long-axis ECHO (P.0001) views was lower than that of the BH-SSFP views. Compared with the mean wall motion score for BH-SSFP MR imaging, the mean wall motion score for radial MR imaging was not significantly different, but those for ECHO (P.05) and spiral MR imaging (P =.0003) were significantly lower. Cohen kappa coefficients for agreement with the BH-SSFP sequence regarding wall motion scoring were 0.47 for ECHO, 0.67 for the spiral sequence, and 0.89 for the radial sequence.The radial sequence enables similar accurate assessment of regional wall motion compared with the BH-SSFP sequence and yields image quality that is superior to that yielded by the spiral sequence and ECHO.

Purpose To evaluate the value of cine true fast imaging with steady-state free precession (SSFP) for semiquantitative assessment of valvular dysfunction in the heart and to compare the results to that obtained with a standard breath-hold segmented gradient-recalled echo-planar imaging sequence (GE-EPI). Materials and Methods Twenty-three patients with known valvular dysfunction (main component: 16 with aortic valve stenosis, nine with aortic valve insufficiency, three with mitral stenosis, two with mitral regurgitation, two with tricuspidal regurgitation, and one with pulmonary stenosis) and 23 control subjects with normal valvular function underwent MR imaging on a 1.5-T system (ACS-NT, Philips, Best, The Netherlands). Cine SSFP and GE-EPI images were acquired in identical long-axis views. Images were evaluated for the presence and extent of the signal void arising from the valves and for image quality consensus by two experienced radiologists. Results were compared to those obtained by cardiac catheterization (in 16 patients) or color Doppler (in the remaining seven patients). Results On SSPF images, the complex flow pattern in valvular regurgitant or stenotic lesions caused signal void within the bright blood pool of the atria or ventricles, similar to GE-EPI, in all patients. Valvular dysfunction was delineated using SSFP with the same high sensitivity (100%) as using the GE-EPI sequence. Results correlated to those obtained by cardiac catheterization or color Doppler ultrasonography (P < 0.001, r = 0.97). However, the jet phenomenon was slightly more pronounced in five patients on GE-EPI. There was no significant signal void in the 23 control subjects with both sequences. In all 46 subjects, the image quality of SSFP images was rated higher (P < 0.05; 2.6 ± 0.1; using a scale ranging from 0–3) compared to GE-EPI (1.7 ± 0.1). Conclusion The results of this study suggest that valvular dysfunction can be semiquantitatively assessed using SSFP cine MR imaging. J. Magn. Reson. Imaging 2004;19:59–67. © 2003 Wiley-Liss, Inc.

Aims: We sought to evaluate whether left ventricular (LV) mass (M) determined by M-mode echocardiography is overestimated compared with LVM calculated by threedimensional (3D) echocardiography (E) in patients with normal LV shape. Methods and Results: A total of 112 studies in 56 patients (60 � 13 years) with hypertension ðn ¼ 25Þ or aortic stenosis ðn ¼ 31Þ and 30 control subjects (57 � 14 years) evaluated for cardiac sources of embolism were analyzed. LVM by M-mode and 3DE was highly correlated (r ¼ 0:85; p < 0:001). However, there were broad limits of agreement (� 58 to 110 g) demonstrating large variability between the methods. M-mode overestimated 3DE LVM by a mean of 15 � 24% ðp < 0:001Þ with overestimation in controls and the different patient groups. Variability was unrelated to increasing quartiles of LVM values. Using techniquespecific partition values for normal LVM, the agreement between M-mode and 3DE for the detection of LV hypertrophy was 83% (Kappa ¼ 0.59; p < 0:001). Conclusion: Although M-mode and 3DE correlate well for the calculation of LVM, there is a systematic difference between the two techniques leading to overestimation of LVM by the 1D technique. Thus, previously published cutoff values for normal LVM derived from M-mode may not apply for 3DE. However, the use of techniquespecific partition values allows stratification of patients for the presence of LV hypertrophy with reasonable agreement.

OBJECTIVES: We evaluated whether delayed contrast-enhanced magnetic resonance imaging (DCE-MRI) using an extracellular contrast agent could predict improvement of dysfunctional but viable myocardium after acute reperfused myocardial infarction (MI). BACKGROUND: The transmural extent of hyperenhancement at DCE-MRI has been related to improvement of function in reperfused MI. However, evidence is still limited, and earlier reports have produced conflicting results regarding the significance of contrast patterns after infarction. METHODS: Thirty patients (mean age 59 ± 11 years, 27 males) underwent cine MRI and DCE-MRI 7 ± 3 days after a first reperfused acute MI and follow-up cine MRI at 13 ± 3 weeks. Segmental wall thickening and segmental extent of hyperenhancement were scored in 1,689 segments. RESULTS: Of 500 dysfunctional segments, 273 (55%) improved at follow-up. There was no difference in likelihood of improvement or complete functional recovery between segments with 0% and 1% to 25% hyperenhancement. The likelihood of improvement of segments without hyperenhancement was 2.9, 14.3, and 20 times higher than that of segments with 26% to 50%, 51% to 75%, and >75% hyperenhancement, respectively (p < 0.001). The likelihood of complete functional recovery of segments without hyperenhancement was 3.8, 11.1, and 50 times higher than that of segments with 26% to 50%, 51% to 75%, and >75% hyperenhancement, respectively (p < 0.001). CONCLUSIONS: In patients with recent reperfused MI, functional improvement of stunned myocardium is predicted by DCE-MRI.

An interactive real-time spiral gradient-echo and an interactive real-time radial steady-state free precession sequence were investigated for the quantitative assessment of left ventricular function. Data were acquired in 18 patients without electrocardiographic triggering and breath holding. With the interactive real-time spiral gradient-echo sequence, significant underestimation of endocardial and epicardial volumes was demonstrated; with the interactive real-time radial steady-state free precession sequence, excellent agreement was shown with standard cardiac-triggered segmented k-space breath-hold steady-state free precession MR imaging. Interactive real-time radial steady-state free precession imaging allows accurate quantitative assessment of left ventricular volumes.

Rationale and Objectives. Cardiac and respiratory controlled MR-imaging is the gold standard for imaging of cardiac masses. However, this technique may be limited in patients with dyspnoe or arrhythmia. The aim of this study was the evaluation of an interactive MR-approach for the detection and localization of cardiac masses. Methods. Interactive real-time spiral gradient-echo (spiralGE) and radial steady-state-free-precession (radialSSFP) MR-imaging was performed during free-breathing and without cardiac triggering in 15 patients with 14 intracardiac or paracardiac masses. Standard cardiac triggered segmented k-space breath-hold steady-state-free-precession cine MR-imaging was used as the reference MR-imaging technique. Two groups of investigators blinded to clinical data were ask to rank image quality and to identify cardiac masses on real-time MR-images. Results. Image quality was superior using radialSSFP when compared with spiralGE. Using radialSSFP all masses were correctly detected while 6 of 14 masses were missed on spiralGE. Mean real-time MR-imaging time was less than 3 minutes for both techniques. Conclusion. Interactive real-time radialSSFP MR-imaging allows for accurate and fast detection of cardiac masses without the need of cardiac or respiratory triggering.

Objectives: We sought to compare contrast-enhanced magnetic resonance imaging (ceMRI) with nuclear metabolic imaging for the assessment of myocardial viability in patients with chronic isch...

flow velocity in the recanalized artery is related to left ventricular recovery in patients with acute infarction and successful direct balloon angioplasty. J Am Coll Cardiol 1998;32:338–344. 13. French JK, Straznicky IT, Webber BJ, Aylward PE, Frey MJ, Adgey AA, Williams BF, McLaughlin SC, White HD. Angiographic frame counts 90 minutes after streptokinase predict left ventricular function at 48 hours following myocardial infarction. Heart 1999;81:128–133. 14. Manginas A, Gatzov P, Chasikidis C, Voudris V, Pavlides G, Cokkinos DV. Estimation of coronary flow reserve using the Thrombolysis In Myocardial Infarction (TIMI) frame count method. Am J Cardiol 1999;83:1562– 1565.

Recent advances in a number of surgical and catheter-based therapeutic approaches in cardiology have allowed less invasive treatment with a better prognosis even in complex cases. These techniques include electrophysiological examination and ablation, surgical and transcatheter mitral valve repair as well as transfemoral aortic valve implantation, and percutaneous closure of atrial appendage, septal defects, and paravalvular leaks.

Global left ventricular (LV) function is an important prognostic parameter and is useful for therapeutic decision-making. Since its introduction, two-dimensional (2D) echocardiography has played an important role in the quantitation of LV function.

Aims: To evaluate the ability of tissue tracking for rapid assessment of left ventricular function by determination of the systolic mitral annular displacement. Tissue racking is a new echocardiographic modality based on Doppler Tissue maging allowing rapid visual assessment of the systolic baso-apical displacement of each myocardial segment in apical views by a graded colour display. Methods and Results: We studied 90 patients (69 male, age 60·410·1 years) with different left ventricular function (25 subjects with normal left ventricular function, 25 patients with homogeneous depression of left ventricular function and 40 patients with prior myocardial infarction). Systolic mitral annular displacement was determined by tissue tracking and M-mode echocardiography. Apical two-, three- and four-chamber views were used to determine the mitral annular displacement of six sites. Left ventricular ejection fraction was determined by two-dimensional echocardiography using Simpson’s rule. Tissue tracking was possible in all patients. In the 50 patients with normal left ventricular function or homogeneous depression of left ventricular function, mean mitral annular displacement correlated closely with mitral annular displacement determined by M-mode (r=0·99, P

The goals of this study were to determine regional systolic function of the septum and to relate it to regional wall thickness and wall stress.Wall thickening, a parameter of systolic function, is determined by wall thickness and wall stress. In patients with hypertrophic obstructive cardiomyopathy (HOCM), hypertrophic nonobstructive cardiomyopathy (HNCM), and hypertensive heart disease (HHD), regional systolic function of normal and hypertrophic septal regions has been incompletely characterized by 2-dimensional echocardiography. Thus, multiplane transesophageal echocardiography with 3-dimensional reconstruction of the septum was used.In 49 patients (15 controls, 11 with HOCM, 8 with HNCM, and 15 with HHD) 4 parallel (2 basal and 2 apical) equidistant short-axis cross sections from base to apex were obtained from the reconstructed septum. In each short-axis cross section, 6 wall-thickness measurements were made in 15 degrees intervals at end diastole and end systole, for a total of 48 measurements in each patient. Fractional thickening was calculated as wall thickening divided by end-diastolic wall thickness. Wall thickness of the basal cross sections was significantly thicker (P.001) in HOCM and HNCM than in HHD. However, circumferential wall thickness was more evenly distributed in HNCM and HHD when compared with HOCM. In the basal cross sections, fractional thickening was similarly reduced in all hearts, though basal wall stress was significantly different in all groups (P.001). In the apical cross sections, wall thickness was similar in all diseased hearts, but fractional thickening was better (P.001) and wall stress lower (P.001) in HNCM than in HOCM and HHD.In septal regions without or with only mild hypertrophy, regional systolic function is preserved and appears to be determined by hemodynamic factors such as wall stress. However, in regions with moderate to severe hypertrophy, systolic function is markedly and uniformly impaired in all groups, which seems not to be caused by differences in wall thickness and wall stress but by the degree of the myocardial disease process.

The interpretation of induced wall motion abnormalities during dobutamine stress echocardiography is affected in the case of impaired image quality. In 48 consecutive patients (mean age 62±9 years, 32 males, 16 females) with suspected coronary disease undergoing coronary angiography, the transpulmonary contrast agent BY 963 was given i.v. as bolus during dobutamine stress echocardiography (10–40μgkgmin, plus max. 1mg atropine) to analyze improvements in endocardial border delineation. For each of the 16 segments of the left ventricle, the endocardial border delineation was evaluated. Using BY 963 the average number of non-evaluable segments decreased by 58% from 5.2% to 2.2% at rest (p=0.008) and by 56% from 5.9% to 2.6% at maximal stress (p=0.003) as compared to the non-contrast study for all patients. In patients with impaired image quality, defined as at least 1 non-evaluable segment at rest without contrast enhancement (N=14), the number of non-evaluable segments decreased from 19.2% to 8.2% (p=0.004) at rest and from 19.2% to 9.6% (p=0.006) at maximal stress. The greatest decrease of non-evaluable segments was seen in the lateral and anterior segments of the apical views (maximum of 80%). The improved endocardial border delineation resulted in an improved agreement between two observers in the interpretation of the dobutamine stress echocardiograms as positive or negative (kappa=0.38 without contrast, kappa=0.58 with contrast). Contrast application resulted in a slight improvement of diagnostic accuracy of dobutamine stress echocardiography in the detection of angiographically proven significant coronary artery disease. Conclusion: In patients with impaired endocardial border delineation the use of the echo contrast agent BY 963 reduces the number of non-evaluable segments. Improvement of endocardial delineation is greatest for lateral and anterior segments in the apical views.

Die dreidimensionale Erfassung kardiovaskularer Strukturen mittels Ultraschall eroffnet neue Ansatze fur den klinischen Alltag und die Losung wissenschaftlicher Fragestellungen. Die Datenaufnahme ist auf verschiedene Arten moglich: (1) Die „Realtime-3D-Echokardiographie“ mittels neuentwickelter Matrix-Schallkopfe gilt als zukunftstrachtig, hat aber verschiedene Limitationen; (2) die 3D-Rekonstruktion verwendet eine Vielzahl nacheinander aufgenommener 2D-Schnittebenen (z.B. bei multiplaner TEE), die erst im Nachhinein zusammengefugt werden. Zwei Arten der Auswertung sind moglich

The objective of this study was to assess the accuracy and reproducibility of transesophageal 3-dimensional echocardiography (3DE) in comparison with magnetic resonance imaging (MRI) for the in vivo calculation of left ventricular mass (LVM). In addition, mass values obtained by M-mode echocardiography were compared with those calculated by MRI. Three-dimensional reconstruction of the left ventricle was performed from a transesophageal and transgastric transducer position with a multiplane transducer in 20 patients. Left ventricular mass was calculated from both transducer positions by using slices of various thicknesses, ranging from 5 to 20 mm. Reproducibility was determined by 5 repeated measurements of mass in each of 5 randomly selected left ventricles. M-mode echocardiography was performed according to the method described by Devereux. For MRI, multiple short-axis views with 10-mm slice thickness were acquired in inspiration hold. Correlation was high for mass determined by 3DE and MRI (for 10-mm slice thickness: r = 0.99; y = 0.99 x - 0.7 g; standard error of estimate = 8.5 g; P.001). There was no statistical bias, and the limits of agreement ranged from +/-16.4 g to +/-27.2 g, depending on the slice thickness. Variability was lowest for a slice thickness of 10 mm (SD +/- 8.2 g). The reproducibility of mass determination was excellent (mean width of the 95% CI 12.8 g). Left ventricular mass values calculated from the transgastric and transesophageal transducer position were not different from each other (mean bias 0.6 +/- 9.1 g; P = ns). M-mode-based LVM calculations showed systematic overestimation and large measurement variability (bias 23.7 g; 95% CI +/- 92.8 g). Compared with MRI, transesophageal 3DE is an accurate and reproducible method for the determination of LVM and clearly superior to M-mode echocardiography.