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IMPORTANCE: Low-flow severe aortic stenosis (AS) has higher mortality than severe AS with normal flow. The conventional definition of low-flow AS is an indexed stroke volume (SVi) by echocardiography less than 35 mL/m(2). Cardiovascular magnetic resonance (CMR) is the reference standard for quantifying left ventricular volumes and function from which SVi by CMR can be derived. OBJECTIVE: To determine the association of left ventricular SVi by CMR with myocardial remodeling and survival among patients with severe AS after valve replacement. DESIGN, SETTING, AND PARTICIPANTS: This multicenter longitudinal cohort study was conducted between January 2003 and May 2015 across 6 UK cardiothoracic centers. Patients with severe AS listed for either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) were included. Patients underwent preprocedural echocardiography and CMR. Patients were stratified by echocardiography-derived aortic valve mean and/or peak gradient and SVi by CMR into 4 AS endotypes: low-flow, low-gradient AS; low-flow, high-gradient AS; normal-flow, low-gradient AS; and normal-flow, high-gradient AS. Patients were observed for a median of 3.6 years. Data were analyzed from September to November 2021. EXPOSURES: SAVR or TAVR. MAIN OUTCOMES AND MEASURES: All-cause and cardiovascular (CV) mortality after aortic valve intervention. RESULTS: Of 674 included patients, 425 (63.1%) were male, and the median (IQR) age was 75 (66-80) years. The median (IQR) aortic valve area index was 0.4 (0.3-0.4) cm(2)/m(2). Patients with low-flow AS endotypes (low gradient and high gradient) had lower left ventricular ejection fraction, mass, and wall thickness and increased all-cause and CV mortality than patients with normal-flow AS (all-cause mortality: hazard ratio [HR], 2.08; 95% CI, 1.37-3.14; P

Background: Late gadolinium enhancement (LGE) imaging is well validated for the diagnosis and quantification of myocardial infarction (MI). 2D LGE imaging involves multiple breath‐holds for acquisition of short‐axis slices to cover the left ventricle (LV). 3D LGE methods cover the LV in a single breath‐hold; however, breath‐hold duration is typically long with images susceptible to motion artifacts. Purpose/Hypothesis: To assess a single breath‐hold 3D mDIXON LGE pulse sequence for image quality and quantitation of MI. Study Type: Prospective. Population: Ninety‐ two patients with prior MI. Field Strength/Sequence: 1.5T cardiac MRI protocol using both conventional 2D phase sensitive inversion recovery and 3D mDIXON LGE imaging 10 minutes following contrast administration in random order to avoid bias. Assessment: Data were analyzed qualitatively for image quality (three observers). Quantitative assessment of myocardial scar mass (full‐width half‐maximum), scar transmurality, and contrast‐to‐noise ratio measurements were performed. Time for 2D and 3D LGE imaging was recorded. Statistical Tests: Paired Student's t‐test, Wilcoxon rank test, Cohen κ statistic, Pearson correlation, linear regression, and Bland–Altman analysis. Results: Image quality scores were comparable between 3D and 2D LGE (1.4 ± 0.6 vs. 1.3 ± 0.5; P = 0.162). 3D LGE was associated with greater scar tissue mass (3D: 18.9 ± 17.5 g vs. 2D: 17.8 ± 16.2 g P = 0.03), although this difference was less pronounced when scar tissue was expressed as %LV mass (3D: 13.4 ± 9.9% vs. 2D: 12.7 ± 9.5% P = 0.07). For 3D vs. 2D scar mass there was a strong and significant positive correlation; Bland–Altman analysis showed mean mass bias of 1.1 g (95% confidence interval [CI]: –5.7 to 7.9). Segmental level agreement of scar transmurality between 3D and 2D LGE at the clinical viability threshold of 50% transmurality was excellent (κ = 0.870). 3D image acquisition (15.6 ± 1.4 sec) was just 5% of time required for 2D images (311.6 ± 43.2 sec) P < 0.0001. Data Conclusion: Single breath‐hold 3D mDIXON LGE imaging allows quantitative assessment of MI mass and transmurality, with comparable image quality, in vastly shorter overall acquisition time compared with standard 2D LGE imaging. Level of Evidence: 1 Technical Efficacy: Stage 2

BACKGROUND: Cardiovascular magnetic resonance (CMR) image acquisition techniques during exercise typically requires either transient cessation of exercise or complex post-processing, potentially compromising clinical utility. We evaluated the feasibility and reproducibility of a navigated image acquisition method for ventricular volumes assessment during continuous physical exercise. METHODS: Ten healthy volunteers underwent supine cycle ergometer (Lode) exercise CMR on two separate occasions using a free-breathing, multi-shot, navigated, balanced steady-state free precession cine pulse sequence. Images were acquired at 3-stages, baseline and during steady-state exercise at 55% and 75% maximal heart rate (HR(max)), based on a prior supine cardiopulmonary exercise test. Intra-and inter-observer variability and inter-scan reproducibility were derived. Clinical feasibility was tested in a separate cohort of patients with severe mitral regurgitation (n=6). RESULTS: End-diastolic volume (EDV) of both LV and RV decreased during exercise at 55% and 75% HR(max), although a reduction in RVEDV index was only observed at 75% HR(max). Ejection fractions (EF) for both ventricles were significantly higher at 75% HR(max) compared to their respective baselines (LVEF 68%±3% vs. 58%±5%, P=0.001; RVEF 66%±4% vs. 58%±7%, P=0.02). Intra-observer and inter-observer reproducibility of LV parameters was excellent at all 3-stages. Although measurements of RVESV were more variable during exercise, the reproducibility of both RVEF and RV cardiac index was excellent (CV

Cardiac magnetic resonance (CMR) is widely used for diagnostic and prognostic determination in patients with suspected/known ischemic heart disease (IHD) ([1][1]). CMR is advocated in international clinical practice guidelines and recent multicenter trials like CE-MARC-2 (Clinical Evaluation of

Background Spironolactone may have prognostic benefit in selected patients with heart failure with preserved ejection fraction. This study assessed the myocardial tissue effects of spironolactone in heart failure with preserved ejection fraction. Methods and Results A 1:1 randomized controlled study of 6 months of spironolactone versus control in heart failure with preserved ejection fraction. The primary outcome was change in myocardial extracellular volume fraction by cardiovascular magnetic resonance as a surrogate of diffuse fibrosis. Of 55 randomized patients, 40 (20 women; age, 75.2±5.9 years) completed follow‐up (19 treatment, 21 control). A significant change in extracellular volume over the study period was not seen (treatment, 28.7±3.7% versus 27.7±3.4% [ P =0.14]; controls, 27.6±3.4% versus 28.3±4.4% [ P =0.14]); however, the rate of extracellular volume expansion was decreased by spironolactone (−1.0±2.4% versus 0.8±2.2%). Indexed left ventricular mass decreased with treatment (104.4±26.6 versus 94.0±20.6 g/m 2 ; P =0.001) but not in controls (101.4±29.4 versus 104.0±32.8 g/m 2 ; P =0.111). Extracellular mass decreased by 13.8% (15.1±4.8 versus 13.0±3.4 g/m 2 ; P =0.003), and cellular mass decreased by 8.3% (37.6±10.0 versus 34.3±7.9 g/m 2 ; P =0.001) with spironolactone, but was static in controls. Conclusions Spironolactone did not lead to significant change in extracellular volume. However, spironolactone did decrease rate of extracellular expansion, with a decrease in the mass of both cellular and extracellular myocardial compartments. These data point to the mechanism of action of spironolactone in heart failure with preserved ejection fraction, including a direct tissue effect with a reduction in rate of myocardial fibrosis.

Current echocardiographic data reporting the impact of concomitant mitral regurgitation (MR) on outcome in patients who undergo transcatheter aortic valve replacement (TAVR) are conflicting. Using cardiovascular magnetic resonance (CMR) imaging, this study aimed to assess the impact of MR severity on cardiac reverse remodeling and patient outcome. 85 patients undergoing TAVR with CMR pre- and 6 m post-TAVR were evaluated. The CMR protocol included cines for left (LV) and right ventricular (RV) volumes, flow assessment, and myocardial scar assessment by late gadolinium enhancement (LGE). Patients were dichotomised according to CMR severity of MR fraction at baseline (‘non-significant’ vs ‘significant’) and followed up for a median duration of 3 years. Forty-two (49%) patients had ‘significant MR’ at baseline; they had similar LV and RV size and function compared to the ‘non-significant MR’ group but had greater LV mass at baseline. In those with significant MR at baseline, 77% (n = 32) had a reduction in MR post-TAVR, moving them into the ‘non-significant’ category at 6-months, with an overall reduction in MR fraction from 34 to 17% (p

Patients with rheumatoid arthritis (RA) are at greater risk of major cardiovascular (CV) events, predominantly due to accelerated atherosclerosis, underpinned by inflammation and RA disease factors and also heart failure.1 Overall, modest event rate has necessitated the use of surrogate CV abnormalities of increased CV risk including arterial stiffness. Increased arterial stiffness is well recognised in established RA,2 with early, similar reports using comprehensive and reliable cardiac MRI (CMRI) in our treatment-naive, early onset RA cohort.3 Autopsy, histopathological and clinical studies in general population and RA cohorts with and without CV disease (CVD) suggest citrullinated proteins as a mechanism for atherosclerosis, including presence of citrullination within the atherosclerotic plaque of subjects without RA.4 5 We hypothesised that individuals with circulating anti-cyclic citrullinated peptide (CCP) but no systemic inflammation (of RA typically associated with increased CV risk) also demonstrate …

Aims To test the hypothesis that patients with ischaemic cardiomyopathy (ICM) and non-ischaemic cardiomyopathy (NICM) have different torsion and strain parameters, and compare to healthy, age-matched controls. VINDICATE investigated efficacy of high-dose vitamin D on patients with heart failure (HF) secondary to left ventricular (LV) systolic dysfunction of any aetiology. It is important to differentiate ICM and NICM as treatment and prognosis varies significantly. Cardiovascular magnetic resonance (CMR) reliably determines aetiology of HF and tissue tagging techniques are recognized as the reference standard measures of strain and torsion. Methods and results Fifty three patients (31 ICM, 22 NICM) from VINDICATE and 25 controls underwent CMR at 3.0T, including cine imaging in multiple planes and tissue tagging by spatial modulation of magnetization. CMR data were analysed blinded, by quantitatively reporting circumferential strain and torsion from tagged images and global longitudinal strain from feature tracking. HF patients had larger ventricles indexed to body surface area, lower left ventricular ejection fraction (LVEF), LV torsion, twist, and strain parameters compared to controls. There were no significant differences between ICM and NICM in age, blood pressure, heart rhythm, or NYHA status. There was no significant difference in LV dimensions, EF, and strain parameters between ICM and NICM. NICM patients had significantly lower LV twist (6.0 ± 3.7° vs. 8.8 ± 4.3°, P = 0.023) and torsion (5.9 ± 3.5° vs. 8.8 ± 4.7°, P = 0.017) compared to ICM. Conclusion Twist, torsion, and strain are reduced in HF patients compared to controls. Torsion and twist are significantly lower in patients with NICM compared to ICM, despite similar volumetric dimensions, circumferential and longitudinal strain parameters, and LVEF.

BACKGROUND: Late gadolinium enhancement (LGE) imaging was validated for diagnosis and quantification of myocardial infarction (MI). Despite good contrast between scar and normal myocardium, contrast between blood pool and myocardial scar can be limited. Dark blood LGE sequences attempt to overcome this issue. PURPOSE: To evaluate T1 rho (T1 ρ)-prepared dark blood sequence and compare to blood nulled (BN) phase sensitive inversion recovery (PSIR) and standard myocardium nulled (MN) PSIR for detection and quantification of scar. STUDY TYPE: Prospective. POPULATION: Thirty patients with prior MI. FIELD STRENGTH/SEQUENCE: Patients underwent identical 1.5 T MRI protocols. Following routine LGE imaging, a slice with scar, remote myocardium, and blood pool was selected. PSIR LGE was repeated with inversion time set to MN, to BN, and T1 ρ FIDDLE (flow-independent dark-blood delayed enhancement) in random order. ASSESSMENT: Three observers. Qualitative assessment of confidence scores in scar detection and degree of transmurality. Quantitative assessment of myocardial scar mass (grams), and contrast-to-noise ratio (CNR) measurements between scar, blood pool, and myocardium. STATISTICAL TESTS: Repeated-measures analysis of variance (ANOVA) with Bonferroni correction, coefficient of variation, and the Cohen κ statistic. RESULTS: CNRscar-blood was significantly increased for both BN (27.1 ± 10.4) and T1 ρ (30.2 ± 15.1) compared with MN (15.3 ± 8.4 P < 0.001 for both sequences). There was no significant difference in CNRscar-myo between BN (55.9 ± 17.3) and MN (51.1 ± 17.8 P = 0.512); both had significantly higher CNRscar-myo compared with the T1 ρ (42.6 ± 16.9 P = 0.007 and P = 0.014, respectively). No significant difference in scar size between LGE methods: MN (2.28 ± 1.58 g) BN (2.16 ± 1.57 g) and T1 ρ (2.29 ± 2.5 g). Confidence scores were significantly higher for BN (3.87 ± 0.346) compared with MN (3.1 ± 0.76 P < 0.001) and T1 ρ (3.20 ± 0.71 P < 0.001). DATA CONCLUSION: PSIR with inversion time (TI) set for blood nulling and the T1 ρ LGE sequence demonstrated significantly higher scar to blood CNR compared with routine MN. PSIR with TI set for blood nulling demonstrated significantly higher reader confidence scores compared with routine MN and T1 ρ LGE, suggesting routine adoption of a BN PSIR approach might be appropriate for LGE imaging. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2018.

ObjectiveTo compare the incidence of silent cerebral infarction and impact on cognitive function following transcatheter aortic valve implantation (TAVI) with the first-generation CoreValve (Medtronic, Minneapolis, Minnesota, USA) and second-generation Lotus valve (Boston Scientific, Natick Massachusetts, USA).DesignA prospective observational study comprising a 1.5 T cerebral MRI scan, performed preoperatively and immediately following TAVI, and neurocognitive assessments performed at baseline, 30 days and 1 year follow-up.SettingUniversity hospitals of Leeds and Leicester, UK.Patients66 (80.6±8.0 years, 47% male) patients with high-risk severe symptomatic aortic stenosis recruited between April 2012 and May 2015.Main outcome measuresIncidence of new cerebral microinfarction and objective decline in neurocognitive performance.ResultsAll underwent cerebral MRI at baseline and immediately following TAVI, and 49 (25 Lotus, 24 CoreValve) completed neurocognitive assessments at baseline, 30 days and 1 year. There was a significantly greater incidence of new cerebral microinfarction observed following the Lotus TAVI (23 (79%) vs 22 (59%), p=0.025) with a greater number of new infarcts per patient (median 3.5 (IQR 7.0) vs 2.0 (IQR 3.0), p=0.002). The mean volume of infarcted cerebral tissue per patient was equivalent following the two prostheses (p=0.166). More patients suffered new anterior (14 (48%) vs 2 (5%), p=0.001) and vertebrobasilar (15 (52%) vs 7 (19%), p=0.005) lesions following Lotus. Lotus was associated with a decline in verbal memory and psychomotor speed at 30 days. However, performance longitudinally at 1 year was preserved in all neurocognitive domains.ConclusionsThere was a higher incidence of silent cerebral microinfarction and a greater number of lesions per patient following Lotus compared with CoreValve. However, there was no objective decline in neurocognitive function discernible at 1 year following TAVI with either prosthesis.

Background Non-invasive assessment of myocardial ischaemia is a cornerstone of the diagnosis of coronary artery disease. Measurement of myocardial blood flow (MBF) using positron emission tomography (PET) is the current reference standard for non-invasive quantification of myocardial ischaemia. Dynamic myocardial perfusion cardiovascular magnetic resonance (CMR) offers an alternative to PET and a recently developed method with automated inline perfusion mapping has shown good correlation of MBF values between CMR and PET. This study assessed the repeatability of myocardial perfusion mapping by CMR in healthy subjects. Methods Forty-two healthy subjects were recruited and underwent adenosine stress and rest perfusion CMR on two visits. Scans were repeated with a minimum interval of 7 days. Intrastudy rest and stress MBF repeatability were assessed with a 15-min interval between acquisitions. Interstudy rest and stress MBF and myocardial perfusion reserve (MPR) were measured for global myocardium and regionally for coronary territories and slices. Results There was no significant difference in intrastudy repeated global rest MBF (0.65 ± 0.13 ml/g/min vs 0.62 ± 0.12 ml/g/min, p = 0.24, repeatability coefficient (RC) =24%) or stress (2.89 ± 0.56 ml/g/min vs 2.83 ± 0.64 ml/g/min, p = 0.41, RC = 29%) MBF. No significant difference was seen in interstudy repeatability for global rest MBF (0.64 ± 0.13 ml/g/min vs 0.64 ± 0.15 ml/g/min, p = 0.80, RC = 32%), stress MBF (2.71 ± 0.61 ml/g/min vs 2.55 ± 0.57 ml/g/min, p = 0.12, RC = 33%) or MPR (4.24 ± 0.69 vs 3.73 ± 0.76, p = 0.25, RC = 36%). Regional repeatability was good for stress (RC = 30–37%) and rest MBF (RC = 32–36%) but poorer for MPR (RC = 35–43%). Within subject coefficient of variation was 8% for rest and 11% for stress within the same study, and 11% for rest and 12% for stress between studies. Conclusions Fully automated, inline, myocardial perfusion mapping by CMR shows good repeatability that is similar to the published PET literature. Both rest and stress MBF show better repeatability than MPR, particularly in regional analysis. Electronic supplementary material The online version of this article (10.1186/s12968-018-0462-y) contains supplementary material, which is available to authorized users.

Background Left ventricular systolic dysfunction (LVSD) is associated with reduced myocardial perfusion reserve (MPR) even in the absence of proven ischaemic heart disease and patients may have typical angina symptoms, despite the lack of obstructive coronary artery disease. The severity of MPR reduction has been suggested as a prognostic marker in both ischaemic and non-ischaemic cardiomyopathy. We hypothesised that reduction in MPR was associated with worsening symptomatology (NYHA class) and systolic dysfunction (ejection fraction, EF). Methods 40 patients referred from cardiology clinics with LVSD of unknown cause underwent adenosine stress perfusion CMR (Siemens 3T). First pass stress and rest myocardial perfusion CMR data were acquired in three short axis slices with 0.05 mmol/kg intravenous Gadovist using a recently reported free-breathing motion corrected Method with in-line quantification of perfusion maps. For stress, adenosine was administered at 140 mcg/kg/min over 5 min. Segments showing regional perfusion defects or containing scar were excluded from further quantitative analysis. Myocardial blood flow (MBF) was calculated globally for the remaining left ventricle. Patients with no evidence of LVSD (EF-55%) were excluded from analysis. NYHA class was recorded at the time of CMR scan. EF was calculated from a short axis cine data set and classified as: mild (45%), moderate (35­44%) and severe (34%) impairment. ANOVA with post hoc Bonferroni correction was used to compare means of the three groups. Results Patients were grouped both by NYHA class and by EF severity, comparisons of these groups are shown in Table 1. No significant difference was seen between groups with respect to age, resting heart rate and resting MBF. MPR was associated with NYHA class (figure 1). A greater reduction in MPR was associated with a higher NYHA class and there was a significant decrease in MPR between asymptomatic patients and those with exercise limitation (Mean MPR 2.90±0.96, 2.05±0.61, 1.45±0.45 for classes I, II and III respectively, p No significant difference was seen between NYHA II and III (2.05 vs 1.45, p=0.32) although a trend to decreasing MPR was observed. Myocardial perfusion reserve did not correlate with severity of LV dysfunction (figure 2). Conclusion A reduction in MPR is associated with NYHA class in systolic heart failure, independent of ejection fraction. These findings suggest potential therapeutic targets for symptomatic improvement, including use of vasodilators, even in the absence of coronary disease.

Background CMR image acquisition techniques during exercise typically require transient cessation of exercise or complex post-processing analysis, potentially compromising its clinical utility. We evaluated the feasibility and reproducibility of a novel image acquisition Method for the assessment of biventricular physiological response during continuous physical exercise. Methods 10 healthy volunteers (80% men, age 25±2 years) underwent supine cycle ergometer (Lode) induced exercise CMR (Philips 1.5T Ingenia) on two separate occasions using a free-breathing, multi-shot, navigated, balanced steady-state free precession cine pulse sequence. Individual target heart rates (HR) for both moderate and high-intensity exercise were prescribed based on a prior supine cardiopulmonary exercise test (CPET). The scan protocol included a short axis ventricular volume stack and a 40 phase 4-chamber cine. Images were acquired at baseline, and during steady-state moderate and high-intensity exercise (55% and 75% maximal heart rate, respectively). Data were analysed by two independent observers and left and right ventricular (LV, RV) indices calculated. Results End-diastolic volume (EDV) of both LV and RV decreased during moderate and high-intensity exercise, although the reduction in indexed RVEDV (RVEDVi) was only observed during maximal exercise (table 1). Similarly, a significant reduction in end-systolic volumes (ESV) was seen in both ventricles, whilst the reduction in indexed LVESV (LVESVi) was only evident during high-intensity exercise. Ejection fraction (EF) increased from rest to moderate and high intensity exercise in the LV (LVEF 58±5% vs 61±8% vs 68±3%, respectively; p Intra-observer reproducibility of LV parameters was excellent at all three stages (Table 2), although measurements of RVESV were more variable. The reproducibility of both RVEF and RV cardiac indexes was however excellent. Similarly, inter-observer reproducibility of LV volumes, EF and cardiac indexes was excellent. Inter-scan LV and RV ejection fraction were highly reproducible at all 3 stages; RVESVi reproducibility was suboptimal. Conclusion This exercise CMR protocol using a novel free-breathing, multi-shot, navigated imaging Method allows simultaneous assessment of the left and right ventricular response to continuous exercise. Intra and inter-observer reproducibility were excellent. Clinical feasibility and utility now needs to be established.

Objectives: We sought to compare using serial CMR, the quantity of AR and associated valve hemodynamics, following the first‐generation CoreValve (Medtronic, Minneapolis, MN) and the second‐generation Lotus valve (Boston Scientific, Natick, MA).\ud \ud \ud \ud Background: Aortic regurgitation (AR) following Transcatheter Aortic Valve Replacement (TAVR) confers a worse prognosis and can be accurately quantified using cardiovascular magnetic resonance (CMR). Second generation valves have been specifically designed to reduce paravalvular AR and improve clinical outcomes.\ud \ud \ud \ud Methods: Fifty‐one patients (79.0 ± 7.7 years, 57% male) were recruited and imaged at three time points: immediately pre‐ and post‐TAVR, and at 6 months.\ud \ud \ud \ud Results: CMR‐derived AR fraction immediately post‐TAVR was greater in the CoreValve compared to Lotus group (11.7 ± 8.4 vs. 4.3 ± 3.4%, P = 0.001), as was the frequency of ≥moderate AR (9/24 (37.5%) versus 0/27, P

Introduction Myocardial infraction (MI) leads to complex changes in left ventricular (LV) haemodynamics. It remains unknown how four-dimensional (4D) acute changes in LV-cavity blood flow kinetic energy (KE) affect LV remodelling. We hypothesised that LV blood flow energetics is independently associated with adverse LV-remodelling. Methods We recruited 69 revascularised ST-elevation MI patients. All patients underwent cardiovascular magnetic resonance (CMR) at 1.5 T within 48 hours and at 3 months. CMR included cines, early/late gadolinium enhancement and whole-heart 4D flow. CMR analysis included: LV volumes, infarct size (IS,%), microvascular obstruction (MVO,%), two-dimensional, retrospective valve tracking derived mitral inflow metrics and 4D KE components. KE was derived using novel, semi-automated method by using endocardial contours on short-axis cines to extract intra-cavity velocity profile. Adverse LV-remodelling was defined as increase in LV end-diastolic volume by 15%. Results Thirteen (19%) patients developed adverse LV-remodelling. Demographics were comparable between patients with/without remodelling. Baseline CMR in adverse LV-remodelling-group showed significantly lower EF, LV KE, Systolic, A-wave, in-plane KEs and increased MVO (p Conclusion LV haemodynamic assessment by novel, semi-automated, 4D KE mapping adds incremental value to predict adverse LV-remodelling. A-wave KE and MVO size early after acute MI are independently associated with adverse LV-remodelling.

Introduction Athletes who train regularly can develop left ventricular (LV) hypertrophy, which can be difficult to differentiate from hypertrophic cardiomyopathy. We aimed to use cardiovascular magnetic resonance (CMR) tissue characterisation to assess the cardiac effects of complete detraining. Methods Athletes (n=26) with a limb fracture that prohibited training for >1 month had identical CMR protocol including volumetric analysis and T1 mapping on Philips Acheiva 3.0 T Results Athletes exercised for 7.7±2.3 hours per week and were predominantly male (21/26). LV mass at baseline was 131±27 g, decreasing to 120±23 g after one month detraining (p=0.003). It did not decrease further by three months 122±21 g (p=NS). Reduction in LV mass after one month was mediated by regression of the cardiac myocyte compartment (100±22 g to 90±18 g, p 10% decrease in LV mass (n=9) after one month detraining (AUC 0.90, 95% CI: 0.71 to 0.98, p 54 g/m2 (67% sensitivity, 94% specificity). Conclusion Regression of LV hypertrophy occurs within one month of complete detraining and is mediated by regression of cardiac myocyte mass rather than extracellular compartment. In the athlete with unexplained LV hypertrophy increased myocyte mass has the potential to diagnose physiological remodelling without the need for detraining.

Introduction Late gadolinium enhancement (LGE) imaging is well validated for diagnosis and quantification of myocardial infarction (MI). 2D LGE imaging involves multiple breath-holds for acquisition of each short axis slice to cover the left ventricle (LV). 3D LGE methods cover the LV in a single breath hold; breath-hold duration is typically long with images susceptible to motion artefacts. We evaluated a rapid 3D mDIXON pulse sequence for image quality and quantitation of MI. Methods 92 patients with prior MI underwent identical 1.5 T CMR protocols. Patients underwent conventional 2D PSIR and 3D mDIXON LGE imaging 10 min following contrast administration in random order. Qualitative image assessment and quantitative assessment of myocardial scar mass, scar transmurality were performed. Results Image quality was comparable between 3D and 2D LGE (1.4±0.6 vs 1.3±0.5; p=0.162). 3D LGE demonstrated greater scar mass (3D: 18.9±17.5 g vs 2D: 17.8±16.2 g p=0.03); this was not statistically significantly different when expressed as %LV mass (3D: 13.4±9.9% vs 2D: 12.7%±9.5% p=0.07). There was significant positive correlation for 3D vs 2D scar mass; Bland-Altman showed mean mass bias of 1.1 g (95% CI: −5.7 to 7.9). Excellent agreement (κ=0.870) between 3D and 2D LGE was seen at segmental analysis of scar transmurality (at threshold of 50% transmural extent). 3D image acquisition was 5% of acquisition time for 2D: 3D (15.6±1.4 s) to 2D (311.6±43.2 s) p Conclusion Single breath-hold 3D mDIXON LGE imaging allows quantitative assessment of MI and transmurality with comparable image quality in vastly shorter overall acquisition time compared to 2D LGE imaging.

Late gadolinium enhancement (LGE) imaging is well validated for the diagnosis and quantification of myocardial infarction (MI). 2D LGE imaging involves multiple breath-holds for acquisition of short-axis slices to cover the left ventricle (LV). 3D LGE methods cover the LV in a single breath-hold; however, breath-hold duration is typically long with images susceptible to motion artifacts.To assess a single breath-hold 3D mDIXON LGE pulse sequence for image quality and quantitation of MI.Prospective.Ninety- two patients with prior MI.1.5T cardiac MRI protocol using both conventional 2D phase sensitive inversion recovery and 3D mDIXON LGE imaging 10 minutes following contrast administration in random order to avoid bias.Data were analyzed qualitatively for image quality (three observers). Quantitative assessment of myocardial scar mass (full-width half-maximum), scar transmurality, and contrast-to-noise ratio measurements were performed. Time for 2D and 3D LGE imaging was recorded.Paired Student's t-test, Wilcoxon rank test, Cohen κ statistic, Pearson correlation, linear regression, and Bland-Altman analysis.Image quality scores were comparable between 3D and 2D LGE (1.4 ± 0.6 vs. 1.3 ± 0.5; P = 0.162). 3D LGE was associated with greater scar tissue mass (3D: 18.9 ± 17.5 g vs. 2D: 17.8 ± 16.2 g P = 0.03), although this difference was less pronounced when scar tissue was expressed as %LV mass (3D: 13.4 ± 9.9% vs. 2D: 12.7 ± 9.5% P = 0.07). For 3D vs. 2D scar mass there was a strong and significant positive correlation; Bland-Altman analysis showed mean mass bias of 1.1 g (95% confidence interval [CI]: -5.7 to 7.9). Segmental level agreement of scar transmurality between 3D and 2D LGE at the clinical viability threshold of 50% transmurality was excellent (κ = 0.870). 3D image acquisition (15.6 ± 1.4 sec) was just 5% of time required for 2D images (311.6 ± 43.2 sec) P0.0001.Single breath-hold 3D mDIXON LGE imaging allows quantitative assessment of MI mass and transmurality, with comparable image quality, in vastly shorter overall acquisition time compared with standard 2D LGE imaging.1 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1437-1445.

Two-dimensional (2D) methods of assessing mitral inflow velocities are pre-load dependent, limiting their reliability for evaluating diastolic function. Left ventricular (LV) blood flow kinetic energy (KE) derived from four-dimensional flow cardiovascular magnetic resonance imaging (4D flow CMR) may offer improvements. It remains unclear whether 4D LV blood flow KE parameters are associated with physiological factors, such as age when compared to 2D mitral inflow velocities. Fifty-three healthy volunteers underwent standard CMR, plus 4D flow acquisition. LV blood flow KE parameters demonstrated good reproducibility with mean coefficient of variation of 6 ± 2% and an accuracy of 99% with a precision of 97%. The LV blood flow KEi

Background Myocardial infarction (MI) leads to complex changes in left ventricular (LV) haemodynamics that are linked to clinical outcomes. We hypothesize that LV blood flow kinetic energy (KE) is altered in MI and is associated with LV function and infarct characteristics. This study aimed to investigate the intra-cavity LV blood flow KE in controls and MI patients, using cardiovascular magnetic resonance (CMR) four-dimensional (4D) flow assessment. Methods Forty-eight patients with MI (acute-22; chronic-26) and 20 age/gender-matched healthy controls underwent CMR which included cines and whole-heart 4D flow. Patients also received late gadolinium enhancement imaging for infarct assessment. LV blood flow KE parameters were indexed to LV end-diastolic volume and include: averaged LV, minimal, systolic, diastolic, peak E-wave and peak A-wave KEiEDV. In addition, we investigated the in-plane proportion of LV KE (%) and the time difference (TD) to peak E-wave KE propagation from base to mid-ventricle was computed. Association of LV blood flow KE parameters to LV function and infarct size were investigated in all groups. Results LV KEiEDV was higher in controls than in MI patients (8.5 ± 3 μJ/ml versus 6.5 ± 3 μJ/ml, P = 0.02). Additionally, systolic, minimal and diastolic peak E-wave KEiEDV were lower in MI (P

Background Assessment of left main stem (LMS) stenosis has prognostic and therapeutic implications. Data on assessment of LMS disease by cardiovascular magnetic resonance (CMR) and single photon emission computed tomography (SPECT) are limited. CE-MARC is the largest prospective comparison of CMR and SPECT against quantitative invasive coronary angiography (QCA) for detection of coronary artery disease (CAD), and provided the framework for this evaluation. The aims of this study were to compare diagnostic accuracy of visual and quantitative perfusion CMR to SPECT in patients with LMS stable CAD. Methods Fifty-four patients from the CE-MARC study were included: 27 (4%) with significant LMS or LMS-equivalent disease on QCA, and 27 age/sex-matched patients with no flow-limiting CAD. All patients underwent multi-parametric CMR, SPECT and QCA. Performance of visual and quantitative perfusion CMR by Fermi-constrained deconvolution to detect LMS disease was compared with SPECT. Results Of 27 patients in the LMS group, 22 (81%) had abnormal CMR and 16 (59%) had abnormal SPECT. All patients with abnormal CMR had abnormal perfusion by visual analysis. CMR demonstrated significantly higher area under the curve (AUC) for detection of disease (0.95; 0.85–0.99) over SPECT (0.63; 0.49–0.76) (p = 0.0001). Global mean stress myocardial blood flow (MBF) by CMR in LMS patients was significantly lower than controls (1.77 ± 0.72 ml/g/min vs. 3.28 ± 1.20 ml/g/min, p

Prior myocardial infarction (MI) is associated with increased mortality and is prevalent in certain high risk patient groups. Electrocardiogram may be used in diagnosis, however, sensitivity is limited, thus non-invasive imaging techniques may improve diagnosis. We investigated whether global longitudinal strain (GLS) and longitudinal strain parameters are reduced in patients with prior MI but preserved left ventricular ejection fraction (LVEF). The study included 40 clinical patients with prior MI occurring >3 months previously (defined as subendocardial hyperenhancement on late Gadolinium enhancement imaging) with LVEF ≥ 55% and 40 controls matched for age and LVEF. GLS, global longitudinal strain rate (GLSR) and early diastolic longitudinal strain rate (GLSRe) were measured from cine imaging feature tracking analysis. Presence of wall motion abnormality (WMA) and minimum systolic wall thickening (SWT) were calculated from cine imaging. GLS was −17.3 ± 3.7% in prior MI versus −19.3 ± 1.9% in controls (p = 0.012). GLSR was −88.0 ± 33.7%/s in prior MI versus −103.3 ± 26.5%/s in controls (p = 0.005). GLSRe was 76.4 ± 28.4%/s in prior MI versus 95.5 ± 26.0%/s in controls (p = 0.001). GLS accurately identified prior MI [AUC 0.662 (95% CI 0.54–0.785) p = 0.012] whereas WMA [AUC 0.500 (95% CI 0.386–0.614) p = 1.0] and minimum SWT [AUC 0.609 (95% CI 0.483–0.735) p = 0.093] did not. GLS, GLSR and GLSRe are reduced in prior MI with preserved LVEF. Normal LVEF and lack of WMA cannot exclude prior MI. Prior MI should be considered when reduced GLS, GLSR or GLSRe are detected by non-invasive imaging.

Background— Late gadolinium enhancement (LGE) imaging overestimates acute infarct size. The main aim of this study was to investigate whether acute extracellular volume (ECV) maps can reliably quantify myocardial area at risk (AAR) and final infarct size (IS). Methods and Results— Fifty patients underwent cardiovascular magnetic resonance imaging acutely (24–72 hours) and at convalescence (3 months). The cardiovascular magnetic resonance protocol included cines, T2-weighted imaging, native T1 maps, 15-minute post-contrast T1 maps, and LGE. Optimal AAR and IS ECV thresholds were derived in a validation group of 10 cases (160 segments). Eight hundred segments (16 per patient) were analyzed to quantify AAR/IS by ECV maps (ECV thresholds for AAR is 33% and IS is 46%), T2-weighted imaging, T1 maps, and acute LGE. Follow-up LGE imaging was used as the reference standard for final IS and viability assessment. The AAR derived from ECV maps (threshold of >33) demonstrated good agreement with T2-weighted imaging–derived AAR (bias, 0.18; 95% confidence interval [CI], −1.6 to 1.3) and AAR derived from native T1 maps (bias=1; 95% CI, −0.37 to 2.4). ECV demonstrated the best linear correlation to final IS at a threshold of >46% ( R =0.96; 95% CI, 0.92–0.98; P P Conclusions— ECV maps can reliably quantify AAR and final IS in reperfused acute myocardial infarction. Acute ECV maps were superior to acute LGE in terms of agreement with final IS. IS quantified by ECV maps are independently associated with viability at follow-up.

Background Expansion of the myocardial extracellular volume (ECV) is a surrogate measure of focal/diffuse fibrosis and is an independent marker of prognosis in chronic heart disease. Changes in ECV may also occur after myocardial infarction, acutely because of oedema and in convalescence as part of ventricular remodelling. The objective of this study was to investigate changes in the pattern of distribution of regional (normal, infarcted and oedematous segments) and global left ventricular (LV) ECV using semi-automated methods early and late after reperfused ST-elevation myocardial infarction (STEMI). Methods Fifty patients underwent cardiovascular magnetic resonance (CMR) imaging acutely (24 h–72 h) and at convalescence (3 months). The CMR protocol included: cines, T2-weighted (T2 W) imaging, pre−/post-contrast T1-maps and LGE-imaging. Using T2 W and LGE imaging on acute scans, 16-segments of the LV were categorised as normal, oedema and infarct. 800 segments (16 per-patient) were analysed for changes in ECV and wall thickening (WT). Results From the acute studies, 325 (40.6%) segments were classified as normal, 246 (30.8%) segments as oedema and 229 (28.6%) segments as infarct. Segmental change in ECV between acute and follow-up studies (Δ ECV) was significantly different for normal, oedema and infarct segments (0.8 ± 6.5%, −1.78 ± 9%, −2.9 ± 10.9%, respectively; P

In the setting of acute ST-elevation myocardial infarction (STEMI), it remains unclear which strain parameter most strongly correlates with microvascular obstruction (MVO) or intramyocardial haemorrhage (IMH). We aimed to investigate the association of MVO, IMH and convalescent left ventricular (LV) remodelling with strain parameters measured with cardiovascular magnetic resonance (CMR). Forty-three patients with reperfused STEMI and 10 age and gender matched healthy controls underwent CMR within 3-days and at 3-months following reperfused STEMI. Cine, T2-weighted, T2*-imaging and late gadolinium enhancement (LGE) imaging were performed. Infarct size, MVO and IMH were quantified. Peak global longitudinal strain (GLS), global radial strain (GRS), global circumferential strain (GCS) and their strain rates were derived by feature tracking analysis of LV short-axis, 4-chamber and 2-chamber cines. All 43 patients and ten controls completed the baseline scan and 34 patients completed 3-month scans. In multivariate regression, GLS demonstrated the strongest association with MVO or IMH (beta = 0.53, p 20%). Baseline GLS also demonstrated the strongest diagnostic performance in predicting adverse LV remodelling (AUC = 0.79; 95% CI 0.60–0.98; p = 0.03). Post-reperfused STEMI, baseline GLS was most closely associated with the presence of MVO or IMH. Baseline GLS was more strongly associated with adverse LV remodelling than other CMR parameters.

Background: Left bundle branch block (LBBB) is common following trans-catheter aortic valve replacement (TAVR) and has been linked to increased mortality, although whether this is related to less favourable cardiac reverse remodeling is unclear. The aim of the study was to investigate the impact of TAVR induced LBBB on cardiac reverse remodeling. Methods: 48 patients undergoing TAVR for severe aortic stenosis were evaluated. 24 patients with new LBBB (LBBB-T) following TAVR were matched with 24 patients with a narrow post-procedure QRS (nQRS). Patients underwent cardiovascular magnetic resonance (CMR) prior to and 6 m post-TAVR. Measured cardiac reverse remodeling parameters included left ventricular (LV) size, ejection fraction (LVEF) and global longitudinal strain (GLS). Inter- and intra-ventricular dyssynchrony were determined using time to peak radial strain derived from CMR Feature Tracking. Results: In the LBBB-T group there was an increase in QRS duration from 96 ± 14 to 151 ± 12 ms (P

Background: Despite the wealth of data showing the positive effects on cardiac reverse remodelling in the long-term, the immediate effects of transcatheter aortic valve implantation (TAVI) on the left ventricle are yet to be comprehensively described using cardiovascular magnetic resonance imaging. Also, the link between myocardial fibrosis and acute left ventricular (LV) mass regression is unknown. Methods: Fifty-seven patients with severe aortic stenosis awaiting TAVI underwent paired cardiovascular magnetic resonance scans before and early after the procedure (4 [interquartile range, 3-5] days). LV mass, volume, and function were measured. Late gadolinium enhancement (LGE) imaging was performed to assess for the presence of and pattern of myocardial fibrosis. Results: After the procedure, 53 (95%) patients experienced an immediate (10.1 ± 7.1%) reduction in indexed LV mass (LVMi) from 76 ± 15.5 to 68.4 ± 14.7 g/m2 (P < 0.001). Those with no LGE experienced the greatest LVMi regression (13.9 ± 7.1%) compared with those with a midwall/focal fibrosis pattern LGE (7.4 ± 5.8%) and infarct pattern LGE (7.2 ± 7.0%; P = 0.005). There was no overall change in LV ejection fraction (LVEF; 55.1 ± 12.1% to 55.5 ± 10.9%; P = 0.867), however a significant improvement in LVEF was seen in those with abnormal (< 55%; n = 24; 42%) baseline LVEF (43.2 ± 8.9 to 46.7 ± 10.5%; P = 0.027). Baseline LVMi (P = 0.005) and myocardial fibrosis (P < 0.001) were strong independent predictors of early LVMi regression. Conclusions: LV reverse remodelling occurs immediately after TAVI, with significant LV mass regression in the total population and an improvement in LVEF in those with preexisting LV impairment. Those without myocardial fibrosis at baseline experience greater LV mass regression than those with fibrosis.

IMPORTANCE: Among patients with suspected coronary heart disease (CHD), rates of invasive angiography are considered too high. OBJECTIVE: To test the hypothesis that among patients with suspected CHD, cardiovascular magnetic resonance (CMR)-guided care is superior to National Institute for Health and Care Excellence (NICE) guidelines-directed care and myocardial perfusion scintigraphy (MPS)-guided care in reducing unnecessary angiography. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, 3-parallel group, randomized clinical trial using a pragmatic comparative effectiveness design. From 6 UK hospitals, 1202 symptomatic patients with suspected CHD and a CHD pretest likelihood of 10% to 90% were recruited. First randomization was November 23, 2012; last 12-month follow-up was March 12, 2016. INTERVENTIONS: Patients were randomly assigned (240:481:481) to management according to UK NICE guidelines or to guided care based on the results of CMR or MPS testing. MAIN OUTCOMES AND MEASURES: The primary end point was protocol-defined unnecessary coronary angiography (normal fractional flow reserve >0.8 or quantitative coronary angiography [QCA] showing no percentage diameter stenosis ≥70% in 1 view or ≥50% in 2 orthogonal views in all coronary vessels ≥2.5 mm diameter) within 12 months. Secondary end points included positive angiography, major adverse cardiovascular events (MACEs), and procedural complications. RESULTS: Among 1202 symptomatic patients (mean age, 56.3 years [SD, 9.0]; women, 564 [46.9%] ; mean CHD pretest likelihood, 49.5% [SD, 23.8%]), number of patients with invasive coronary angiography after 12 months was 102 in the NICE guidelines group (42.5% [95% CI, 36.2%-49.0%])], 85 in the CMR group (17.7% [95% CI, 14.4%-21.4%]); and 78 in the MPS group (16.2% [95% CI, 13.0%-19.8%]). Study-defined unnecessary angiography occurred in 69 (28.8%) in the NICE guidelines group, 36 (7.5%) in the CMR group, and 34 (7.1%) in the MPS group; adjusted odds ratio of unnecessary angiography: CMR group vs NICE guidelines group, 0.21 (95% CI, 0.12-0.34, P

Coronary artery disease (CAD) is a leading cause of death and disability worldwide. Cardiovascular magnetic resonance (CMR) is established in clinical practice guidelines with a growing evidence base supporting its use to aid the diagnosis and management of patients with suspected or established CAD. CMR is a multi-parametric imaging modality that yields high spatial resolution images that can be acquired in any plane for the assessment of global and regional cardiac function, myocardial perfusion and viability, tissue characterisation and coronary artery anatomy, all within a single study protocol and without exposure to ionising radiation. Advances in technology and acquisition techniques continue to progress the utility of CMR across a wide spectrum of cardiovascular disease, and the publication of large scale clinical trials continues to strengthen the role of CMR in daily cardiology practice. This article aims to review current practice and explore the future directions of multi-parametric CMR imaging in the investigation of stable CAD.

Background Microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH) are associated with adverse prognosis, independently of infarct size after reperfused ST-elevation myocardial infarction (STEMI). Mitral annular plane systolic excursion (MAPSE) is a well-established parameter of longitudinal function on echocardiography. Objective We aimed to investigate how acute MAPSE, assessed by a four-chamber cine-cardiovascular MR (CMR), is associated with MVO, IMH and convalescent left ventricular (LV) remodelling. Methods 54 consecutive patients underwent CMR at 3T (Intera CV, Philips Healthcare, Best, The Netherlands) within 3 days of reperfused STEMI. Cine, T2-weighted, T2* and late gadolinium enhancement (LGE) imaging were performed. Infarct and MVO extent were measured from LGE images. The presence of IMH was investigated by combined analysis of T2w and T2* images. Averaged-MAPSE (medial-MAPSE+lateral-MAPSE/2) was calculated from 4-chamber cine imaging. Results 44 patients completed the baseline scan and 38 patients completed 3-month scans. 26 (59%) patients had MVO and 25 (57%) patients had IMH. Presence of MVO and IMH were associated with lower averaged-MAPSE (11.7±0.4 mm vs 9.3±0.3 mm; p

Introduction Left bundle branch block (LBBB) is common following trans-catheter aortic valve implantation (TAVI) and has been linked to increased mortality, although whether this is due to the development of a TAVI-induced LBBB cardiomyopathy is unclear. Methods 48 patients undergoing TAVI for severe aortic stenosis were evaluated. 24 patients with TAVI-induced LBBB (LBBB-T) were matched with 24 patients with a narrow post-procedure QRS (nQRS). Patients underwent comprehensive Cardiovascular Magnetic Resonance (CMR) imaging prior to and 6m post-TAVI. Measured cardiac reverse remodelling parameters included left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and left sided chamber size. Inter and intraventricular dyssynchrony was determined using time to peak radial strain derived from CMR Feature Tracking. Results In the nQRS group there was no change in QRSd (93 ± 17 to 96 ± 11 ms, p = 0.098). In the LBBB-T group, QRSd increased by a mean of 55 ms from 96 ± 14 to 151 ± 12 (p= 18.6 ± 5.8 mm, p = 0.773). Post-procedure aortic regurgitant fraction was similar between groups (nQRS 5.4 ± 5.7 vs LBBB-T 5.5 ± 3.3%, p = 0.948). There was an inverse correlation between QRS duration and change in LVEF (r=-0.46, p = 0.001) and QRS duration and change in LV GLS (r=-0.37, p = 0.010). Conclusion LBBB-T is associated with less favourable cardiac reverse remodelling at medium term follow up. In view of this, every effort should be made to prevent TAVI-induced LBBB, especially as TAVI is extended to a younger, lower risk population.

Background Transcatheter aortic valve implantation is an established therapeutic option for patients with severe symptomatic aortic stenosis unsuitable for surgery. CMR has a lower intra-observer and inter-observer variability than echocardiography in the assessment of aortic regurgitation (AR), offering full volumetric quantitation independent of the number or eccentricity of regurgitant jets. Moderate AR following TAVI is an independent predictor of mortality in the postoperative period and has prompted development of novel bioprostheses designed to facilitate precise deployment and minimise paravalvular regurgitation (Figure 1). Aim To compare the degree of early post-procedure aortic regurgitation following implantation of the Medtronic CoreValve and Boston Scientific Lotus Valve systems in patients treated for severe symptomatic aortic stenosis. Methods All patients underwent an identical 1.5T CMR scan (Intera, Phillips Healthcare, Best, Netherlands) post-procedure prior to discharge. Through-plane phase contrast velocity encoded imaging was performed perpendicular to the aortic valve jet at a level above the aortic prosthesis. Aortic flow was subsequently quantified offline (QFlow version 7.2, Medis Medical Imaging Systems, Leiden, The Netherlands) and regurgitant fraction (%) derived. AR was defined as regurgitant fraction of none/trivial ≤ 5%, mild 6 – 15%, moderate 16 – 25%, moderate-severe 26 – 48%, and severe > 48% The invasive AR index derived at the time of TAVI was also recorded ([(Diastolic BP-LVEDP)/Systolic BP] x100). Results 18 Medtronic CoreValve patients (age 79.6 ± 6.3 years, 67% male, EuroSCORE II 4.59 ± 3.59%) and 24 Boston Lotus TAVI patients (age 78.6 ± 8.7years, 54% male, EuroSCORE II 4.07 ± 3.37%) were studied at a median interval of 6 days following implantation. The residual peak aortic pressure gradient observed following Boston Lotus implantation was higher than that following Medtronic CoreValve (25.8 ± 12.1 vs.15.0 ± 5.5mmHg, p = 0.001). The absolute regurgitant fraction was significantly lower following Boston Lotus implantation than following Medtronic CoreValve (Lotus: 4.0 ± 3.5% vs. CoreValve: 11.7 ± 7.2%, p = 0.001). The classification of AR severity is summarised in Figure 2. Overall, 39% of patients with CoreValve had moderate AR compared to no reported cases in the Lotus group. There was a negative correlation between invasive AR index and regurgitant fraction from CMR imaging (Spearman’s coefficient − 0.4, p = 0.016). Conclusions CMR directly quantifies AR following TAVI and there is agreement with invasive AR measurements. There was significantly less aortic regurgitation in the immediate post-implant period using the Boston Lotus valve compared with the Medtronic CoreValve. However the residual peak pressure gradient was lower with the Medtronic CoreValve. Further work is required to assess the longer term differences in AR and whether this translates into a mortality benefit.

Background NICE 2010 guidelines (CG95) proposed investigation according to pre-test likelihood (PTL) of coronary artery disease (CAD) in patients presenting with stable chest pain; low risk patients are referred for CT coronary angiography (CTCA), intermediate risk should have a functional test (stress echocardiography, MPS, CMR) with invasive angiography reserved for high risk patients and those with a PTL>90% having no investigation and treated prospectively as angina. The 2016 update to CG95 now recommends referral for CTCA in all patients with typical or atypical chest pain and in those with non-anginal pain but with ECG changes, with functional imaging reserved for those who have previously documented coronary disease or revascularisation. Our aim was to compare imaging resource utilisation between the 2010 and 2016 guideline recommendations to highlight the potential service implications if followed explicitly. Methods Consecutive patients referred over 4 weeks to the Leeds General Infirmary rapid access chest pain clinic (RACPC) with stable chest pain symptoms were prospectively evaluated. Non identifiable data was collected on demographics, typicality of chest pain symptoms and ECG findings and subsequently requested 1st line investigation. Patient notes were reviewed and PTL for patients was calculated in accordance with CG95 and hypothetical investigative strategies calculated according to both 2010 and 2016 guidelines. Results 157 consecutive patients were evaluated between 17th October and 17th November 2016. Patient demographics are displayed in table 1. 37 (23.5%) patients had typical angina, 55 (35.0%) had atypical angina, 65 (41.4%) had non-anginal symptoms. 16 (10.2%) patients had previous infarction/revascularisation. 25 (15.9%) patients had a PTL 90%. Table 2 shows diagnostic tests requested and hypothetical investigative strategies according to NICE 2010 CG95 and the 2016 update. Conclusion/Implications Our results show that if implemented in proposed 2016 form there will be a significant increase in the referral rate for CTCA with a corresponding decrease in referral for functional imaging and angiography. Furthermore the number of patients that are not investigated would more than double following the introduction of the proposed NICE 2016 guidelines. CTCA has high sensitivity for the diagnosis of CAD but more limited specificity and concerns are that increased usage in intermediate/high risk patients may lead to increased rates of unnecessary angiography due to the overestimation of severity of CAD. The change in guidelines would lead to a significant shift in practice that has implications for both workforce planning and provision of resources.

Introduction Pre-test likelihood models recommended in current UK and US guidelines have been shown to overestimate the probability of coronary artery disease(CAD). We aimed to develop a UK population-based multivariable risk model from CE-MARC(a contemporary study of stable CAD where all patients underwent X-ray coronary angiography) and validate it prospectively in the CE-MARC 2 trial population. Methods CE-MARC (development population) enrolled patients between 2006–9 with suspected angina. Multivariable logistic regression modelled presence of significant stenosis (QCA≥70% in epicardial arteries or ≥50% in Left Main Stem) as a function of baseline demographic and clinical characteristics. The validation population were from the CE-MARC 2 trial (2012–16) that underwent angiography, plus additional low and high-risk patients from Leeds General Infirmary (2014–2016) to ensure adequate numbers across the full risk spectrum. Discrimination and calibration were assessed and compared to existing CAD consortium models(ESC 2013 guidelines) and the Duke Score(NICE CG95 2010 and US 2012 guidelines). Results There were 675 patients in the development population, and 369 patients in the validation population(Table 1). A multivariable model was developed that included age, sex, angina type, smoking, diabetes, dyslipidaemia, hypertension, ECG Q-waves and ST segment abnormalities.The validation population had a similar CV risk profile. The new CE-MARC model discriminated well (c-statistic: 0.78 (95%CI 0.73–0.82)) and was well-calibrated (Table 2, Figure 1). In comparison, the Duke clinical model was very poorly calibrated (−1.016; −1.265 to −0.766; p Conclusion The CE-MARC risk model, developed from a large contemporary UK population undergoing angiography, performed very well in the independent validation sample, without needing any adjustment for different risk prevalence or for miscalibration. In contrast, the earlier Duke risk score substantially over-predicted CAD risk, and remained poorly-calibrated even when this was corrected. The CAD consortium model (ESC 2013 guidelines), slightly under-estimated average CAD risk, but performed well once this was accounted for lower margin presents histogram of number of patients with each predicted risk score

Background Prognosis and treatment of patients with chronic heart failure (CHF) differs according to whether it is ischaemic (ICM) or non-ischaemic cardiomyopathy (NICM). Multi-parametric cardiovascular magnetic resonance (CMR) can distinguish these aetiologies; strain imaging however may confer incremental diagnostic and prognostic information over left ventricular ejection fraction (LVEF). We hypothesised in a prospectively recruited sample of CHF patients, ICM and NICM have different myocardial strain patterns. Methods The VINDICATE trial investigated efficacy of high dose vitamin D in patients with CHF. A subgroup of the trial underwent CMR, blood and cardiopulmonary exercise tests at baseline. 53 patients (31 ICM, 22 NICM) underwent identical 3.0T CMR protocols (Achieva, Philips Healthcare, Best, The Netherlands). Tissue tagging by spatial modulation of magnetization (SPAMM) (spatial resolution 1.51 × 1.57×10mm3, tag separation 7 mm, 18 phases, typical TR/TE 5.8/3.5 ms, flip angle 10°, typical temporal resolution 55 ms) was acquired in short axis slices acquired at the apex, mid-ventricle, and base. Late gadolinium enhancement (LGE) was performed 15 min following administration of 0.15 mmol/kg gadolinium DTPA. CMR data were analysed quantitatively using commercially available software (CVI42, Circle Cardiovascular Imaging Inc. Calgary, Canada and inTag v1.0, CREATIS lab, Lyon, France). Endocardial and epicardial contours were drawn on SPAMM sequences using a semi-automated process. Peak circumferential LV strain (Ecc) was measured at apex, mid-ventricle, and base. LV twist was calculated by subtracting basal from apical rotation. Torsion was determined by: Torsion = Peak Twist x (Apical Radius+Basal Radius)/2xApex to Base length Results The two groups were comparable for baseline demographics (Table 1). The ICM group had significantly more prior revascularisation (CABG/PCI). There was no significant difference between the 2 groups in both LV dimensions and LVEF, however ICM had significantly more LGE (Table 2). There was no significant difference between the 2 groups in Ecc. NICM patients had significantly lower LV twist and torsion compared to the ICM group 6.0±3.68° vs 8.8±4.32° p=0.020 and 6.3±3.79° vs 8.8±4.69° p=0.048 respectively. Conclusion Despite similar EF and Ecc, patients with NICM had significantly less LV torsion than ICM. Myocyte dysfunction in ICM is more sub-endocardial due to the wave-front of ischaemia and more global in NICM. Relative perseveration of LV torsion of ICM over NICM is likely a result of sparing of sub-epicardial fibres and an increased compensatory recruitment of sub-epicardial fibres that are predominantly responsible for LV torsion. Recognition of different torsion patterns of ICM and NICM gives insight into aetiology of CHF, which may assist patient diagnosis and management, especially in those unable to have contrast agents.

Background Validation of four-dimensional (4D) flow CMR accelerated acquisition methods is needed to make them more robust for clinical applications.1 Our aim was to compare three widely-used acceleration methods in 4D flow CMR: 4D segmented fast-gradient-echo (4D- turbo-field-echo, 4D-TFE), 4D non-segmented gradient-echo with echo-planar imaging (4D- EPI) and 4D-k-t Broad-use Linear Acquisition Speed-up Technique accelerated TFE (4D-k-t BLAST). Methods CMR was performed in two institutions on identical 1.5T systems. Acceleration methods were compared in static/pulsatile phantoms (Figure 1) and 25 volunteers. In volunteers, the CMR protocol included: cines, 2D phase contrast (PC) at the aortic valve (AV) and mitral valve (MV) and three whole-heart free-breathing (no respiratory motion correction) 4D flow CMR pulse sequences. Field-of-view, slices, phases (30), voxel size and VENC were the same for each subject. In volunteers, net acquisition time for each 4D flow sequence was recorded, as well as a visual grading of image quality on a four-point scale: 0, no artefacts to 3, non-evaluable. Results For the pulsatile phantom experiments, the mean error against the reference flow by time beaker measurements for 4D-TFE was 4.9%±1.3%, for 4D-EPI 7.6%±1.3% and for 4D-k-t BLAST 4.4%±1.9%. In vivo, acquisition time was shortest for 4D-EPI at 7 min59s±2 min30s. 4D- EPI and 4D-k-t BLAST had minimal artefacts, while for 4D-TFE, 40% of AV and MV assessments were non-evaluable because of phase dispersion artefacts. Peak velocity assessment using 4D-EPI demonstrated best correlation to 2D PC (AV: r=0.78, p Conclusion Of the three 4D flow CMR methods tested, 4D-EPI demonstrated the least susceptibility to artefacts, good image quality, modest agreement with the current reference standard for peak intra-cardiac velocities and the highest consistency of intra-cardiac flow quantifications. Competing interests The authors declare that they have no competing interests. Acknowledgement We thank Gavin Bainbridge, Caroline Richmond, Margaret Saysell and Petra Bijsterveld for their invaluable assistance in recruiting and collecting data for this study. Funding Sources This work was supported by the British Heart Foundation [FS/10/62/28409 to S.P.] and Dutch ZonMw [Project Number: 104003001 to J.W]. References . Dyverfeldt P, Bissell M, Barker AJ, Bolger AF, et al. 4D flow cardiovascular magnetic resonance consensus statement. J Cardiovasc Magn Reson2015;17:72.

Introduction Aortic stenosis (AS) results in left ventricular hypertrophy, myocyte dysfunction and fibrosis as a physiological response to excessive afterload. Transcatheter Aortic Valve implantation (TAVI) is an effective treatment for severe AS, however controversy exists whether gender predisposes to improved myocardial function post procedure. Feature-tracking cardiovascular magnetic resonance (FT-CMR) is a novel method for quantification of myocardial strain and strain rate that can identify subtle changes in left ventricular (LV) mechanics prior to overt changes in LV ejection fraction (EF). Our aim was to compare the acute impact of TAVI on LV function between males and females defined by strain measurements. Methods 59 patients, 34 males and 25 females matched for age (78.4 ± 7.19 years vs 78.8 ± 9.7 years p = 0.876), EuroSCORE II (5.19 ± 4.33% vs 4.26 ± 2.99% p = 0.788) and presence of baseline myocardial fibrosis (p = 0.829) with severe, symptomatic AS were prospectively enrolled prior to TAVI. All patients underwent an identical 1.5T CMR protocol (Intera or Ingenia, Phillips Healthcare, Best, The Netherlands) at baseline and at a median of 4 days following TAVI. Endocardial and epicardial borders were traced manually on the end-diastolic slice, then strain and strain rate measurements were obtained using commercially available post-processing software (CVI42, Circle Cardiovascular Imaging, Calgary, Alberta, Canada). Results TAVI was associated with a significant and comparable reduction in peak aortic pressure gradient and LV mass index in both men and women (Table 1). There was no significant difference in extent of pressure drop (p = 0.374) or extent of regression of LV mass index (p = 0.095) between men and women. There was no significant change in left ventricular end diastolic volume indexed (LVEDVI) or LVEF observed acutely following TAVI, in men or women (Table 1). Longitudinal strain (Ell), circumferential strain (Ecc) and circumferential strain rate (SRcc) did not change significantly in men or women (Table 2). However, TAVI was associated with a significant increase in longitudinal strain rate (SRll) in males (p = 0.012) that was not observed in females (p = 0.184) (Table 2). Conclusion TAVI was associated with structural reverse remodelling that was comparable between males and females. Functional recovery in LV mechanics following TAVI may occur earlier in males than in females, although this may reflect the higher LVMI that men have at baseline prior to TAVI.

Introduction Refractory angina describes those patients with persistence of symptoms despite revascularisation and routine pharmacotherapy with β-blockers, calcium channel antagonists and nitrates. Ranolazine offers adjunct therapy in such cohorts, by providing anti-ischaemic effects complementary to existing agents. It is thought to be well-tolerated, without significant effects on haemodynamic parameters including heart rate and blood pressure. This prospective study aimed to establish the short-term effectiveness and safety profile of ranolazine in patients with refractory angina. Methods Bradford Royal Infirmary has a specialised cardiology service to manage refractory angina (BRAS). From their database, 50 consecutive patients were selected for inclusion between May 2013 and February 2014. All patients were commenced on ranolazine 375 mg twice daily at initial review, and therapy was continued for 1 month. Those who required up-titration of anti-anginals or revascularisation on clinical grounds were excluded from the study. Results of 6 min walks, Canadian Cardiovascular Society (CCS) grading of angina severity and QTc interval on resting ECG was tabulated, both pre-intervention and at 1 month. Wilcoxon signed rank sum testing was applied to measure differences in outcome. Patients were surveyed to assess for tolerability and adverse events. Results 45 patients were eligible for inclusion. 87% (39/45) were male, with a mean age of 65.2 years (SD 12.3). At 1 month, there was a median increase in 6 min walk of 30 metres (95% CI: 25 – 60; p = 0.0002). CCS grading class for angina severity reduced by 0.5 (95% CI: 0 – 0.86; p Conclusions These findings suggest that ranolazine offers effective additive therapy in patients with persistent anginal symptoms who have been otherwise optimised. Despite our small sample size, results demonstrated a statistically significant improvement in performance on 6 min walk, CCS grading score and usage of GTN spray. Overall, ranolazine was well-tolerated without QTc prolongation or overt side-effects. Further studies are indicated to establish whether effects are maintained in the longer term.

Background Regional contractile dysfunction is a frequent finding in hypertrophic cardiomyopathy (HCM). We aimed to investigate the contribution of different tissue characteristics in HCM to regional contractile dysfunction. Methods We prospectively recruited 50 patients with HCM who underwent cardiovascular magnetic resonance (CMR) studies at 3.0 T including cine imaging, T1 mapping and late gadolinium enhancement (LGE) imaging. For each segment of the American Heart Association model segment thickness, native T1, extracellular volume (ECV), presence of LGE and regional strain (by feature tracking and tissue tagging) were assessed. The relationship of segmental function, hypertrophy and tissue characteristics were determined using a mixed effects model, with random intercept for each patient. Results Individually segment thickness, native T1, ECV and the presence of LGE all had significant associations with regional strain. The first multivariable model (segment thickness, LGE and ECV) demonstrated that all strain parameters were associated with segment thickness (P