Search

To investigate the feasibility of high-dose dobutamine stress (HDDS) imaging using SSFP sequences at 3 T employing patient-adaptive local RF-shimming using a dual-source RF transmission system.13 Patients underwent a HDDS protocol on a 3 T MRI scanner (Achieva 3.0T-TX, Philips Healthcare), equipped with a dual-source RF transmission system. SSFP cine sequences using patient-adaptive local RF-shimming (RF-S) were compared to cine images acquired without additional shimming. Image quality was evaluated on a 4-point grading scale and number of non-diagnostic segments assessed. Contrast (CN) between myocardium (SIM) and blood pool (SIB) was calculated [(SIB-SIM)/(SIB+SIM)].Image quality both at rest and maximum stress was significantly improved with RF-S (ED:3.56±0.5 vs. 3.23±0.63; ES:3.4±0.5 vs. 3.1±0.7) compared to no RF-S (ED:2.9±0.72 vs. 2.15±0.78; ES:2.64±0.74 vs. 1.95±0.76; p0.01). The amount of non-diagnostic segments was significantly reduced when using RF-S at rest and stress (3 vs. 39; 19 vs. 78, p0.05). All HDDS studies were diagnostic if performed with RF-S (n=13/13) in comparison to conventional shimming (n=5/13). Image contrast was improved for SSFP sequences with RF-S (0.53±0.08) compared to conventional images (0.46±0.09, p=0.06).Patient-adaptive local RF-shimming using a dual-source RF transmission system allows for reliable SSFP imaging in a clinical high-dose dobutamine stress protocol at 3 T. RF-S significantly improves image quality and reduces the number of non-diagnostic myocardial segments.

To the Editor: Chloroquine (CQ) has been used for the treatment and prophylaxis of malaria since World War II. Ten years later, the administration of CQ and hydroxychloroquine (HCQ) was introduced for the longterm therapy of rheumatic diseases. Although no reliable statistical data are available, HCQ, which differs from CQ only in a hydroxyl group at the end of the side chain, but not in pharmacokinetics or metabolism, is described in the literature as less toxic and has been staging a comeback, particularly in the treatment of systemic lupus erythematosus (SLE)1. CQ and HCQ induce a dysfunction of the lysosomal enzymes, leading to the impairment of intracellular degradation processes in conjunction with the accumulation of pathological metabolic products (glycogen and phospholipids). These appear histologically as granulovacuolar cell mutations and ultrastructurally as lamellar inclusion bodies (“myeloid bodies”) and as “curvilinear bodies” in cytoplasm (remnants of poorly digested membranes)2,3. Their pharmacokinetics are characterized by a long half-life and a high volume of distribution; they follow a multicompartment model with very slow distribution between plasma and tissue, leading to sustained organ sequestration and sometimes irreversible organ damage4. Severe toxicity in the form of irreversible retinopathy5 is well known under longterm treatment with these substances. In contrast, neuromyopathy6 and especially cardiac damage7 receive scant mention in the literature. Cardiac complications comprise conduction disturbances [bundle-branch block, atrioventricular (AV) block] and cardiomyopathy — often with hypertrophy, restrictive physiology, and congestive heart failure (literature reviews are found in Nord, et al 8 and Costedoat-Chalumeau, et al 9). Because the clinical features of cardiotoxicity are unspecific, the followup of potentially affected patients is of utmost importance. We report a case of a patient with rheumatoid arthritis (RA) and heart disease who was treated with CQ. A … Address correspondence to Dr. E. Tonnesmann, Kaiser-Karl-Klinik, Graurheindorfer Str. 137, D-53117 Bonn, Germany. E-mail: e.toennesmann{at}t-online.de

To evaluate the effect of dual-source parallel radiofrequency (RF) transmission with patient-adaptive local RF shimming on image quality, image contrast, and diagnostic confidence at routine clinical cardiac magnetic resonance (MR) imaging with use of a 3.0-T dual-channel transmit whole-body MR system.Written informed consent was obtained from all patients, and the study protocol was approved by the local institutional review board. Cardiac MR imaging was performed in 28 patients by using a 3.0-T MR unit equipped with a dual-source RF transmission system. The effect of conventional versus dual-source RF transmission on steady-state free precession (SSFP) cine sequences and turbo spin-echo (TSE) black-blood (BB) sequences was evaluated. The homogeneity of the B1 field and contrast-to-noise ratios (CNRs) were measured and tested for statistical significance with the paired t test. Images were analyzed qualitatively for homogeneity, the presence of off-resonance artifacts, and diagnostic confidence independently by two readers. Statistical significance was assessed with the Wilcoxon signed rank test. Inter- and intraobserver agreement was assessed with κ statistics.Quantitative image analysis revealed that B1 homogeneity and CNR were significantly improved for images acquired with dual-source RF transmission compared with conventional RF transmission (P = .005). The quality of SSFP and TSE BB images of the left and the right ventricles showed a significant improvement with respect to image homogeneity and diagnostic confidence as evaluated by the readers (P = .0001, κ0.74). As a side effect, off-resonance artifacts were significantly reduced on SSFP images (P = .0001, κ0.76).Dual-source parallel RF transmission significantly improves image homogeneity, image contrast, and diagnostic confidence compared with conventional RF transmission of cardiac SSFP and TSE BB sequences.

Management of life-threatening postsurgical bleeding is complex. If conservative or surgical therapy is demanding, an endovascular treatment can be considered. The goal of this study was to evaluate the outcome of endovascular approaches in the diagnosis and therapy of otherwise intractable postoperative haemorrhages with a study design of outcomes research. Charts of all patients with postsurgical bleedings receiving endovascular treatment were reviewed for clinical outcome, complications, and demographic data. 15 patients were identified. They had rhinosurgery (12/15), tonsillectomy (2/15) or transoral tumour debulking (1/15) prior to the endovascular procedure. In more than 70%, the source of bleeding was directly located angiographically and subsequently superselectively embolized. The remaining patients suffered from post-rhinosurgical epistaxis and underwent a bilateral embolization of the sphenopalatine artery. All bleedings were successfully controlled and no procedure-related complication was noted. In conclusion, endovascular treatment of life-threatening postsurgical haemorrhages should be considered if the source of bleeding is unknown or if surgery is difficult and may result in devastating postoperative complications.

Recent studies suggest that magnetic resonance (MR) imaging of the brain and spine may safely be performed in patients with pacemakers (PMs) and implantable cardioverter/defibrillators (ICDs), when taking adequate precautions. The aim of this study was to investigate safety, feasibility, and diagnostic value (DV) of MR imaging in cardiac applications (cardiac MR [CMR]) in patients with PMs and ICDs for the first time.Thirty-two PM/ICD patients with a clinical need for CMR were examined. The specific absorption rate was limited to 1.5 W/kg. Devices were reprogrammed pre-CMR to minimize interference with the electromagnetic fields. Devices were interrogated pre-CMR and post-CMR and after 3 months. Troponin I levels were measured pre-CMR and post-CMR; image quality (IQ) and DV of CMR were assessed.All devices could be reprogrammed normally post-CMR. No significant changes of pacing capture threshold, lead impedance, and troponin I were observed. Image quality in patients with right-sided devices (RSD) was better compared with that in patients with left-sided devices (LSD) (P.05), and less myocardial segments were affected by device-related artefacts (P.05). Diagnostic value was rated as sufficiently high, allowing for diagnosis, or better in 12 (100%) of 12 patients with RSD, and only in 7 (35%) of 20 patients with LSD.Cardiac MR may be performed safely when limiting specific absorption rate, appropriately monitoring patients, and following device reprogramming. Cardiac MR delivers good IQ and DV in patients with RSD. Cardiac MR in patients with RSD may therefore be performed with an acceptable risk/benefit ratio, whereas the risk/benefit ratio is rather unfavorable in patients with LSD.

Epistaxis is a common clinical problem, and the majority of bleedings can be managed conservatively. However, due to extensive and sometimes life-threatening bleeding, further treatment, such as superselective embolization, may be required. We report our experience with endovascular treatment of life-threatening epistaxis. All patients presenting with excessive epistaxis, which received endovascular treatment at a German tertiary care facility between January 2001 and December 2009, were retrospectively identified. Demographic data, etiology, origin and clinical relevance of bleeding, interventional approach, therapy-associated complications, and outcome were assessed. A total of 48 patients required 53 embolizations. Depending on the etiology of bleeding, patients were assigned to three groups: 1) idiopathic epistaxis (31/48), 2) traumatic or iatrogenic epistaxis (12/48), and 3) hereditary hemorrhagic telangiectasia (HHT) (5/48). Eleven of 48 patients required blood transfusions, and 9 of these 11 patients (82%) were termed clinically unstable. The sphenopalatine artery was embolized unilaterally in 10 of 53 (18.9%) and bilaterally in 41 of 53 (77.4%) procedures. During the same procedure, additional vessels were embolized in three patients (3/53; 5.7%). In 2 of 53(3.8%) cases, the internal carotid artery (ICA) was occluded. Long-term success rates of embolization were 29 of 31 (93.5%) for group 1 and 11 of 12 (91.7%) for group 2 patients. Embolization of patients with HHT offered at least a temporary relief in three of five (60%) cases. Two major complications (necrosis of nasal tip and transient hemiparesis) occurred after embolization. Endovascular treatment proves to be effective for prolonged and life-threatening epistaxis. It is easily repeatable if the first procedure is not successful and offers a good risk–benefit profile.

Objective: The purpose of this study was to evaluate the feasibility and diagnostic accuracy of a combined spoiled gradient-echo (sGRE) andtagged gradient-echo (SPAMM-GRE) protocol for detection of coronary artery disease (CAD) during high-dose dobutamine stress at 3T. Method: The study protocol was approved by the local ethics committee. For stress testing, a standard high-dose dobutamine protocol was employed. Image quality at the highest stress level and diagnostic accuracy of the sGRE and SPAMM-GRE sequences were comparedThe final study population consisted of 37 patients. Results: The mean image quality score was 2.6i0.6 for the sGRE sequence and 2.4i0.6 for the SPAMM-GRE sequence (p.0.05). Sensitivity, specificity and diagnostic accuracy were 0.81, 0.86, 0.84 and 0.88, 0.86, 0.86 for the sGRE and SPAMM-GRE, respectively. In three cases with new wall motion abnormalities (WMAs), detected by sGRE and SPAMM-GRE, WMAs were detected at a lower stress level by tagging. Conclusion: The combined sGRE and SPAMM-GRE high-dose dobutamine protocol at 3T is feasible and delivers good diagnostic accuracy. Tagging increases the sensitivity of high-dose dobutamine stress testing for detection of CAD and may allow for detection of new WMAs at lower stress levels compared with sGRE alone.

History and admission findings Due to a retroperitoneal hematoma after cardiac catheterization a 64 year-old woman received two concentrates of red blood cells. Within two hours after transfusion the patient developed acute dyspnoea, anxiety and shivering. Investigations Computertomography (CT) of the chest revealed a new bilateral, basally accented pulmonary edema. Pulmonary embolism was ruled out. A cardiac cause in terms of cardiogenic shock had been excluded by echocardiography and other non-invasive measurements. Moreover, no circulatory overload (transfusion-associated circulatory overload [TACO]) after transfusion was presented and the stable size of the retroperitoneal hematoma excluded haemorrhagic shock. Hence, the clinical pattern pointed towards a transfusion-related acute lung injury (TRALI). Treatment and course The patient was intubated and a catecholamine medication was initiated. The weaning process proceeded without complications and the patient was extubated after several days. In the following chest x-ray no pulmonary residuals were left. After two weeks the patient was transferred to a rehabilitation unit. Conclusion TRALI is a life-threatening and an often unconsidered complication after transfusion of plasma containing blood products. According to the criteria of the european haemovigilance networks (EHN-criteria), TRALI is diagnosed by clinical and radiological parameters. In case of suspicious TRALI the involved transfusion center has to be informed. By a crossmatch between donor plasma and recipient granulocytes the causal antibodies are detected in most cases. In 17% of cases no antibodies are detected.

Kalbe, Elke Onur, Oezguer A Minnerop, Martina Reimann, Jens Althaus, Astrid Ahmadzadehfar, Hojjat Dodel, Richard Strach, Katharina Clemen, Christoph S Herholz, Karl Haense, Cathleen Fink, Gereon R Schroder, Rolf Letter Research Support, Non-U.S. Gov't Germany Journal of neurology J Neurol. 2011 Mar;258(3):515-8. Epub 2010 Oct 12.

Avascular bone necrosis under immunosuppressive therapy is a well known sequel following solid organ transplantation. Most cases affect hip, knees or shoulders in more than one location and occur in connection with the use of high-dose steroids. In this 50 year old female immunosuppressive therapy consisted of sirolimus and mycophenolate mofetil after a renal transplantation 2 years ago. Steroids had been completely withdrawn after avascular necrosis of the femoral head. Physical examination revealed a reddened and painful left ankle. C-reactive protein was elevated while autoimmune antibodies, rheumatoid factor and screening for reactive arthritis remained negative. Joint fluid examination ruled out infection or gout. Plain radiographs were normal. Under the presumptive diagnosis of erysipelas antibiotic therapy was started, however, without success. Magnetic resonance imaging finally revealed bilateral tibial and tarsal bone necrosis as the underlying cause. In conclusion, avascular bone necrosis should remain an important differential diagnosis in patients with bone or joint pain and a history of organ transplantation, regardless of the present use of steroid therapy.

Aims Left atrial catheter ablation of the pulmonary veins (PV) has evolved as an important therapeutic option for the treatment of atrial fibrillation (AF). We aimed to investigate the incidence and predictors of silent cerebral embolism associated with PV catheter ablation, detected by diffusion-weighted magnetic resonance imaging (DW-MRI). Methods and results We performed a prospective analysis of 53 consecutive patients with persistent or paroxysmal AF that underwent PV ablation and post-procedural cerebral MRI 1 day after lasso catheter-guided ostial PV ablation. Patients were analysed for possible demographical, medical, echocardiographical, and procedural predictors of embolic events. A mean of 3.5 ± 0.5 PVs were ablated per patient. In six patients, DW-MRI depicted new clinically silent microembolism after PV ablation (11%). The number of ineffective medical antiarrhythmic agents prior to ablation procedure was significantly higher in the embolism group (3.3 ± 0.5 vs. 2.2 ± 1.4, P = 0.014). Coronary heart disease (CAD) was more frequent in patients with cerebral embolisms (33 vs. 2%, P = 0.031); left ventricular volume (130 ± 12 vs. 103 ± 26 mL, P = 0.002), and septal wall thickness (13.0 ± 1.4 vs. 7.9 ± 4.8 mm, P = 0.025) were significantly increased. Conclusion This study shows a high incidence of silent micro-embolic events after PV ablation. CAD, left ventricular dilatation, and hypertrophy were potential predictors of this complication.

Objectives Our aim was to establish and evaluate a strategy for safe performance of magnetic resonance imaging (MRI) at 1.5-T in patients with implantable cardioverter-defibrillators (ICDs). Background Expanding indications for ICD placement and MRI becoming the imaging modality of choice for many indications has created a growing demand for MRI in ICD patients, which is still considered an absolute contraindication. Methods Non–pacemaker-dependent ICD patients with a clinical need for MRI were included in the study. To minimize radiofrequency-related lead heating, the specific absorption rate was limited to 2 W/kg. ICDs were reprogrammed pre-MRI to avoid competitive pacing and potential pro-arrhythmia: 1) the lower rate limit was programmed as low as reasonably achievable; and 2) arrhythmia detection was programmed on, but therapy delivery was programmed off. Patients were monitored using electrocardiography and pulse oximetry. All ICDs were interrogated before and after the MRI examination and after 3 months, including measurement of pacing capture threshold, lead impedance, battery voltage, and serum troponin I. Results Eighteen ICD patients underwent a total of 18 MRI examinations at 1.5-T; all examinations were completed safely. All ICDs could be interrogated and reprogrammed normally post-MRI. No significant changes of pacing capture threshold, lead impedance, and serum troponin I were observed. Battery voltage decreased significantly from pre- to post-MRI. In 2 MRI examinations, oversensing of radiofrequency noise as ventricular fibrillation occurred. However, no attempt at therapy delivery was made. Conclusions MRI of non–pacemaker-dependent ICD patients can be performed with an acceptable risk/benefit ratio under controlled conditions by taking both MRI- and pacemaker-related precautions. (Implantable Cardioverter Defibrillators and Magnetic Resonance Imaging of the Heart at 1.5-Tesla; NCT00356239 )

Background— The purpose of the present study was to evaluate a strategy for safe performance of extrathoracic magnetic resonance imaging (MRI) in non–pacemaker-dependent patients with cardiac pacemakers. Methods and Results— Inclusion criteria were presence of a cardiac pacemaker and urgent clinical need for an MRI examination. Pacemaker-dependent patients and those requiring examinations of the thoracic region were excluded. The study group consisted of 82 pacemaker patients who underwent a total of 115 MRI examinations at 1.5T. To minimize radiofrequency-related lead heating, the specific absorption rate was limited to 1.5 W/kg. All pacemakers were reprogrammed before MRI: If heart rate was 60 bpm, sense-only mode was used to avoid MR-induced competitive pacing and potential proarrhythmia. Patients were monitored with ECG and pulse oximetry. All pacemakers were interrogated immediately before and after the MRI examination and after 3 months, including measurement of pacing capture threshold (PCT) and serum troponin I levels. All MR examinations were completed safely. Inhibition of pacemaker output or induction of arrhythmias was not observed. PCT increased significantly from pre- to post-MRI ( P =0.017). In 2 of 195 leads, an increase in PCT was only detected at follow-up. In 4 of 114 examinations, troponin increased from a normal baseline value to above normal after MRI, and in 1 case (troponin pre-MRI 0.02 ng/mL, post-MRI 0.16 ng/mL), this increase was associated with a significant increase in PCT. Conclusions— Extrathoracic MRI of non–pacemaker-dependent patients can be performed with an acceptable risk-benefit ratio under controlled conditions and by taking both MR- and pacemaker-related precautions.

Stress testing for detection of ischemia-induced wall-motion abnormalities has become a mainstay for noninvasive diagnosis and risk stratification of patients with suspected coronary artery disease (CAD). Recent technical developments in magnetic resonance imaging (MRI), including the adoption of balanced steady-state free precession (b-SSFP) sequences-preferentially in combination with parallel imaging techniques-have led to a significant reduction of imaging time and improved patient safety. The stress protocol includes application of high-dose dobutamine (up to 40 microg/kg/min) combined with fractionated atropine (up to a maximal dose of 1.0 mg). High-dose dobutamine stress MRI revealed good sensitivity (83-96%) and specificity (80-100%) for detection of significant CAD. Myocardial tagging methods have been shown to further increase sensitivity for CAD detection. Severe complications (sustained tachycardia, ventricular fibrillation, myocardial infarction, cardiogenic shock) are rare but may be expected in 0.1-0.3% of patients. Dobutamine stress MRI has emerged as a reliable and safe clinical alternative for noninvasive assessment of CAD. New pulse sequences, such as real-time imaging, might obviate the need for breath holding and electrocardiogram (ECG) triggering in patients with severe dyspnoea and cardiac arrhythmias, which may further improve the clinical impact and acceptance of stress MRI in the future.

Clinically indicated magnetic resonance imaging (MRI) of the brain was safely performed at 1.5 T on a patient with an implantable cardioverter defibrillator (ICD). The ICD was reprogrammed to detection only, and imaging hardware and protocols were modified to minimize radiofrequency power deposition to the ICD system. The integrity of the ICD system was verified immediately post-MRI and after 6 weeks, including an ICD test with induction of ventricular fibrillation. This case demonstrates that in exceptional circumstances, in carefully selected patients, and using special precautions, an MRI exam of the brain may be possible in patients with ICDs.

PURPOSE Patients (pts.) with atrial fibrillation (AF) and atrial thrombi are known to have an increased risk for cerebral embolism. However, little is known about the clinical course of atrial thrombi and the incidence of cerebral embolism in those patients during anticoagulation therapy. The high sensitivity of MR imaging (MRI) including diffusion-weighted imaging (DWI) suggests that this technique could provide an improved estimate of cerebral embolism associated with the presence of left atrial thrombi. The aims of this prospective study were to evaluate 1) the prevalence of clinically silent and apparent cerebral embolism in pts. with newly diagnosed AF and atrial thrombi using MRI/DWI, 2) the long-term fate of atrial thrombi under continues anticoagulation therapy and 3) the incidence of cerebral embolism during a follow-up period of 12 months with continuous anticoagulation therapy. MATERIALS AND METHODS The study group consisted of 32 pts. with 1) newly diagnosed AF and evidence of left atrial (LA) thrombi detected by TEE and 2) a new start of anticoagulation therapy [International Normalized Ratio (INR) 2.0 - 3.0]. 19 pts. with 1) newly diagnosed AF and no evidence of atrial thrombi and 2) an equivalent anticoagulation regimen served as the control group. In both groups a) MRI/DWI studies of the brain (weeks 0, 4, 8, 12, 20, 28, 36, 44, and 52), b) transesophageal echocardiographic studies (TEE) for assessment of LA-Thrombi (weeks 0 and 52) and c) clinical neurological assessments (weeks 0, 20 and 52) were performed. RESULTS In the study group (AF and LA-Thrombi) 11 out of 32 pts. (34 %) displayed signs of acute (n = 8) or chronic (n = 3) cerebral embolism in the initial MRI studies. In 4 out of 32 pts. (13 %), MRI/DWI depicted new or additional cerebral emboli (n = 12) during the follow-up period despite continuous anticoagulation therapy. 2 (n = 2/4; 50 %) of these patients had clinically apparent neurological deficits. In the control group 1 out of 19 pts. (5 %) showed evidence of chronic cerebral embolism as assessed by MRI/DWI at the beginning of the study (week 0). No embolic cerebral lesions were detected during the 12-month follow-up. Within 12 months only 63 % (n = 20/32) of LA thrombi in the study group resolved completely under anticoagulation. CONCLUSION 1. The incidence of clinically inapparent cerebral emboli in pts. with newly diagnosed AF and atrial thrombi is much higher than the incidence of clinically apparent emboli and has been underestimated in the past. 2. New cerebral embolism may occur even with continued effective anticoagulation therapy in 13 % of pts. 3. Only 63 % of atrial thrombi resolve completely within 12 months under anticoagulation therapy.

We report on a German family presenting with a predominantly distal myopathy primarily affecting anterior compartments of lower legs in childhood. Proximal lower limb and hip girdle weakness developed later in early adulthood in the female index patient and likewise in her mother. Consecutive muscle biopsy findings were first attributed to a mild congenital myopathy and later on interpreted as neurogenic changes without clear signs of a myopathy. Molecular genetic analysis was performed because of the clinical impression of a distal myopathy combined with dominant inheritance. The heterozygous mutation c.349G>A (p.D117N) in the ZASP gene could be found. This mutation had been previously associated with an adult-onset, isolated, dilated left ventricular non-compaction cardiomyopathy (OMIM*605906.0007), which was not present in our patients. Our data show that this mutation can be associated with an isolated skeletal muscle phenotype. Second, mutation analysis of the ZASP gene is suggested for distal myopathies of any age, even in cases of uncharacteristic muscle biopsy findings on routine analysis.

Fragestellung: Evaluierung der 1) myokardialen „first pass (FP)“ Adenosin Stress Perfusion (ASP) mittels k-t BLAST bei Patient mit V.a. koronare Herzerkrankung (KHK) im Vergleich zu FFR Messungen sowie 2) relativen myokardialen Signalintensitatszunahme (RMS) und Bildqualitat in einem offenen MR System. Methoden: 24 Patienten mit V.a. KHK wurden mit einer Standard ASP (140mg/kg KG fur 4min) in einem offenen Panorama HFO 1,0 Tesla System (Philips Healthcare, Best, NL) untersucht. Die FP Perfusion wurde mittels einer k-Raum segmentierten T1-w Gradientenecho Sequenz (Auflosung 3×3mm2, Schichtdicke 10mm, k-t Faktor 3,5) in Ruhe (R) und unter Adenosin Belastung (140µg/kg BW fur 4min) durchgefuhrt. Ausgewertet wurden die RMS (=maximales Myokardsignal – Ausgangs-Myokardsignal/Ausgangs-Myokardsignal) fur die ASP, die Bildqualitat fur R und ASP (4-Punkte-Skala: 1=nicht-diagnostisch, 4=exzellent) sowie die Sensitivitat und Spezifitat fur die Detektion hamodynamisch relevanter Koronararterienstenosen (Goldstandard: fraktionelle Flussreserve

Purpose: The use of high-field MRI scanners has introduced new challenges for cardiac imaging, associated with B1- and B0-field inhomogeneities. A dual – source RF transmission system may help reduce dielectric effects, thus improving image contrast and reducing local SAR peaks of cardiac TSE and SSFP sequences, thereby allowing a shorter minimum TR and TE of SSFP sequences. Thus, the aim of our study was to evaluate the impact of dual – source parallel RF transmission with patient adaptive RF-shimming on image quality and diagnostic confidence for routine clinical CMR using a 3.0 T dual – channel transmit whole – body MRI system. Materials and Methods: A clinical 3.0 T MRI system (Achieva 3.0T-TX, Philips Healthcare, Best, Netherlands), equipped with a dual-source RF transmission system was used. The effect of parallel RF transmission with patient adaptive B1 shimming (multi transmit=MTx) vs. conventional (single transmit=STx) RF transmission on SSFP sequences and TSE Black-Blood (TSE BB) sequences was evaluated. Images were analyzed independently by two experienced readers for homogeneity and diagnostic confidence on a 4-point grading-scale. Also, the presence of off-resonance artefacts in the SSFP images was rated on a 4-point grading scale. CNR between interventricular septum and blood pool was determined. Results: A total of 21 patients were included into the study. For both, TSE BB and SSFP -images, the use of MTx resulted in a significant improvement of image homogeneity and diagnostic confidence in the left and right ventricle. As a side effect, off-resonance artefacts were significantly reduced in the acquired SSFP images. Interrater agreement for all ratings was very good. The quantitative measurements revealed a significant increase of CNR in the RF shimmed images using MTx compared to the images acquired with STx.((BR))Conclusions: Patient adaptive local RF-shimming using parallel dual source RF-transmission significantly improves image homogeneity, diagnostic confidence and contrast of cardiac SSFP and TSE BB sequences.

Due to a retroperitoneal hematoma after cardiac catheterization a 64 year-old woman received two concentrates of red blood cells. Within two hours after transfusion the patient developed acute dyspnoea, anxiety and shivering.Computertomography (CT) of the chest revealed a new bilateral, basally accented pulmonary edema. Pulmonary embolism was ruled out. A cardiac cause in terms of cardiogenic shock had been excluded by echocardiography and other non-invasive measurements. Moreover, no circulatory overload (transfusion-associated circulatory overload [TACO]) after transfusion was presented and the stable size of the retroperitoneal hematoma excluded haemorrhagic shock. Hence, the clinical pattern pointed towards a transfusion-related acute lung injury (TRALI).The patient was intubated and a catecholamine medication was initiated. The weaning process proceeded without complications and the patient was extubated after several days. In the following chest x-ray no pulmonary residuals were left. After two weeks the patient was transferred to a rehabilitation unit.TRALI is a life-threatening and an often unconsidered complication after transfusion of plasma containing blood products. According to the criteria of the european haemovigilance networks (EHN-criteria), TRALI is diagnosed by clinical and radiological parameters. In case of suspicious TRALI the involved transfusion center has to be informed. By a crossmatch between donor plasma and recipient granulocytes the causal antibodies are detected in most cases. In 17% of cases no antibodies are detected.

Avascular bone necrosis under immunosuppressive therapy is a well known sequel following solid organ transplantation. Most cases affect hip, knees or shoulders in more than one location and occur in connection with the use of high-dose steroids. In this 50 year old female immunosuppressive therapy consisted of sirolimus and mycophenolate mofetil after a renal transplantation 2 years ago. Steroids had been completely withdrawn after avascular necrosis of the femoral head. Physical examination revealed a reddened and painful left ankle. C-reactive protein was elevated while autoimmune antibodies, rheumatoid factor and screening for reactive arthritis remained negative. Joint fluid examination ruled out infection or gout. Plain radiographs were normal. Under the presumptive diagnosis of erysipelas antibiotic therapy was started, however, without success. Magnetic resonance imaging finally revealed bilateral tibial and tarsal bone necrosis as the underlying cause. In conclusion, avascular bone necrosis should remain an important differential diagnosis in patients with bone or joint pain and a history of organ transplantation, regardless of the present use of steroid therapy.

Background Adenosine stress perfusion is very sensitive for detection of coronary artery disease (CAD), and yields good specificity. Standard adenosine cine imaging lacks high sensitivity, but is very specific. Myocardial tagging improves detection of wall motion abnormalities (WMAs). Perfusion and tagging cardiovascular magnetic resonance (CMR) both benefit from high field imaging (improved contrast to noise ratio and tag persistence). We investigated the diagnostic impact of a combined stress perfusion-tagging protocol for detection of CAD at 3 Tesla. Methods Stress perfusion and tagging images were acquired in 3 identical short axis locations (slice thickness 8 mm, FOV 320–380 mm, matrix 2562). A positive finding at coronary angiography was defined as stenosis or flow limiting restenosis > 50% in native and graft vessels. A true positive CMR – finding was defined as ≥ 1 perfusion deficit or new WMA during adenosine-stress in angiographically corresponding regions. Results We included 60 patients (males: 41, females: 19; 21 suspected, 39 known CAD). Myocardial tagging extended stress imaging by 1.5–3 min and was well tolerated by all patients. Sensitivity and specificity for detection of significant CAD by adenosine stress perfusion were 0.93 and 0.84, respectively. The sensitivity of adenosine stress tagging was less (0.64), while the specificity was very high (1.0). The combination of both stress perfusion and stress tagging did not increase sensitivity. Conclusion The combined adenosine stress perfusion-tagging protocol delivers high sensitivity and specificity for detection of significant CAD. While the sensitivity of adenosine stress tagging is poor compared to perfusion imaging, its specificity is very high. This technique should thus prove useful in cases of inconclusive perfusion studies to help avoid false positive results.

Objective: To compare muscle imaging findings in different subtypes of myofibrillar myopathies (MFM) in order to identify characteristic patterns of muscle alterations that may be helpful to separate these genetic heterogeneous muscular disorders. Methods: Muscle imaging and clinical findings of 46 patients with MFM were evaluated (19 desminopathy, 12 myotilinopathy, 11 filaminopathy, 1 αB-crystallinopathy, and 3 ZASPopathy). The data were collected retrospectively in 43 patients and prospectively in 3 patients. Results: In patients with desminopathy, the semitendinosus was at least equally affected as the biceps femoris, and the peroneal muscles were never less involved than the tibialis anterior (sensitivity of these imaging criteria to detect desminopathy in our cohort 100%, specificity 95%). In most of the patients with myotilinopathy, the adductor magnus showed more alterations than the gracilis muscle, and the sartorius was at least equally affected as the semitendinosus (sensitivity 90%, specificity 93%). In filaminopathy, the biceps femoris and semitendinosus were at least equally affected as the sartorius muscle, and the medial gastrocnemius was more affected than the lateral gastrocnemius. The semimembranosus mostly showed more alterations than the adductor magnus (sensitivity 88%, specificity 96%). Early adult onset and cardiac involvement was most often associated with desminopathy. In patients with filaminopathy, muscle weakness typically beginning in the 5th decade of life was mostly pronounced proximally, while late adult onset (>50 years) with distal weakness was more often present in myotilinopathy. Conclusions: Muscle imaging in combination with clinical data may be helpful for separation of distinct myofibrillar myopathy subtypes and in scheduling of genetic analysis.

Ziele: Evaluierung eines Cine-Gradientenecho (Cine-GRE)/Tagging Protokolls im Rahmen eines Hochdosis-Dobutamin-Stress-Protokolls bei 3T bei Patienten mit V.a. eine obstruktive KHK. Methode: 33 Patienten mit Verdacht auf eine KHK wurden an einem 3T-System mittels eines Hochdosis-Dobutamin-Stress-Protokolls bis zum Erreichen der Zielherzfrequenz bzw. bis zum Auftreten stressinduzierter Wandbewegunsstorungen (WBS) belastet. Es wurden jeweils 4 identische Kurzachsenschnitte der Cine-GRE und Tagging Sequenzen (Cine-GRE TR/TE/a: 4,8ms, 2,6ms, 20°, 25 Herzphasen; Tagging TR/TE/a: 3,7ms, 2,2ms, 10°, 16 Herzphasen, 8mm Tag Abstand) in Ruhe und auf jeder Stressstufe akquiriert. Die Bildqualitat wurde bei der hochsten Belastungsstufe fur beide Sequenzen auf einer 5-Punkte-Skala beurteilt (1: exzellent; 5: nicht-diagnostisch). Die Sequenzen wurden im Hinblick auf stressinduzierte neu aufgetretene bzw. sich verschlechternde WBS als Hinweis auf eine hamodynamisch relevante KHK (Goldstandard: Diameterstenose ≥70% in der konventionellen Katheter-Koronarangiographie) analysiert Ergebnis: Die Untersuchung konnte bei allen Patienten (n=33/33) komplikationslos beendet werden. Die durchschnittliche Bildqualitat betrug 2,2 fur das Tagging und 2,4 fur die Cine-GRE Untersuchungen. Alle Cine-GRE Untersuchungen (n=33) und Tagging Untersuchungen (n=33) ergaben eine diagnostische Bildqualitat. Die Sensitivitat/Spezifitat in der Detektion einer obstruktiven KHK betrugen 93%/79% fur das myokardiale Tagging und 79%/84% fur die Cine-GRE Untersuchung. Die Tagging Untersuchungen wiesen einen falsch negativen Befund auf, die Cine-GRE Untersuchungen drei. Die Analyse von 11 sowohl im Tagging als auch in der Cine-GRE Sequenzen richtig positiv befundeten Falle zeigte bei 4 Patienten (n=4/11) eine Detektion der WBS auf einer niedrigeren Dobutamin Belastungsstufe in der Tagging Untersuchung im Vergleich zur Cine-GRE Untersuchung. Schlussfolgerung: 1. Die Kombination einer Cine-GRE Untersuchung mit myokardialem Tagging bei 3T im Rahmen eines Hochdosis-Dobutamin-Atropin-Protokolls ist ein klinisch praktikables Verfahren mit konsistent guter Bildqualitat. Korrespondierender Autor: Meyer C Universitat Bonn, Radiologische Klinik, Sigmund-Freud-Str.25, 53105 Bonn E-Mail: carsten.meyer@ukb.uni-bonn.de

We report the clinical, genetic and cardiac magnetic resonance imaging (MRI) findings in 11 German patients with heterozygous E245D, D339Y, R350P and L377P desmin mutations and without cardiac symptoms. Clinical evaluation revealed a marked variability of skeletal muscle, respiratory and cardiac involvement even between patients with identical mutations, ranging from asymptomatic to severely affected. While echocardiography did not show any pathological findings in all 11 patients, cine MRI revealed focal left ventricular hypertrophy in 2 patients and MR delayed enhancement imaging displayed intramyocardial fibrosis in the left ventricle in 4 patients indicating early myocardial involvement. Our data argue against distinct genotype-phenotype correlations and suggest that comprehensive cardiac MRI is superior to conventional echocardiography for the detection of early and clinically asymptomatic stages of cardiomyopathy in desminopathy patients. Therefore, cardiac MRI may serve as a screening tool to identify patients at risk, which might benefit from early pharmacological and/or interventional (e.g. implantable cardioverter-defibrillator devices) therapy.

To implement a high-resolution first-pass myocardial perfusion imaging protocol (HRPI) at 3 T, and to evaluate the feasibility, image quality and accuracy of this approach prospectively in patients with suspected CAD. We hypothesized that utilizing the gain in SNR at 3 T to increase spatial resolution would reduce partial volume effects and subendocardial dark rim artifacts in comparison to 1.5 T. HRPI studies were performed on 60 patients using a segmented k-space gradient echo sequence (in plane resolution 1.97 x 1.94 mm(2)). Semiquantitative assessment of dark rim artifacts was performed for the stress studies on a slice-by-slice basis. Qualitative visual analysis was compared to quantitative coronary angiography (QCA) results; hemodynamically significant CAD was defined as stenosisor=70% at QCA. Dark rim artifacts appeared in 108 of 180 slices (average extent 1.3 +/- 1.2 mm representing 11.8 +/- 10.8% of the transmural myocardial thickness). Sensitivity, specifity, and test accuracy for the detection of significant CAD were 89%,79%, and 85%. HRPI studies at 3 T are feasible in a clinical setting, providing good image quality and high accuracy for detection of significant CAD. The presence of dark rim artifacts does not appear to represent a diagnostic problem when using a HRPI approach.

The purpose of this study was to evaluate high-resolution (HR) myocardial first-pass perfusion in healthy volunteers at 3 T compared to a typical clinical imaging protocol at 1.5 T, with respect to overall image quality and the presence of subendocardial dark rim artifacts. Myocardial first-pass rest perfusion studies were performed at both field strengths using a T1-weighted saturation-recovery segmented k-space gradient-echo sequence combined with parallel imaging (Gd-DTPA 0.05 mmol/kg). Twenty-six healthy volunteers underwent (1) a HR perfusion scan at 3 T(pixel size 3.78 mm(2)) and (2) a standard perfusion approach at 1.5 T(pixel size 9.86 mm(2)). The contrast enhancement ratio (CER) and overall image quality (4-point grading scale: 4: excellent; 1: non-diagnostic) were assessed, and a semiquantitative analysis of dark rim artifacts was performed for all studies. CER was slightly higher (1.31 +/- 0.32 vs. 1.14 +/- 0.34; p0.01), overall image quality was significantly improved (3.03 +/- 0.43 vs. 2.37 +/- 0.39; p0.01), and the number of dark rim artifacts (139 +/- 2.09 vs. 243 +/- 2.33; p0.01) was significantly reduced for HR perfusion imaging at 3 T compared to the standard approach at 1.5 T. HR myocardial rest perfusion at 3 T is superior to the typical clinical perfusion protocol performed at 1.5 T with respect to the overall image quality and presence of subendocardial dark rim artifacts.