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Background CIEDs have historically restricted the use of MRI due to the potential clinical and configurational risks associated with electromagnetic interference. In this study, the authors investigated the impact of Magnetic Resonance Imaging (MRI) on the functional integrity of non-conditional cardiovascular implantable electronic devices (CIEDs) and their clinical correlates. Methods In this prospective, observational single-center study, we enrolled patients undergoing MRI over a 5-year period. Prior to assessing the impact of MRI on CIEDs, we performed interrogations in sequential duplication to assess the intrinsic variability of devices. Subsequently, we performed interrogations immediately after MRI, and monitored changes in device parameters and clinical events. Results We completed 492 MRI studies, 58% in patients with permanent pacemakers (PPMs) and 42% with implantable cardioverter defibrillators (ICDs). Subsequent MRI exposures occurred in 15% encounters. Accounting for intrinsic variability in CIED leads, there were no significant changes in RA, RV, or LV parameters after MRI, regardless of the region imaged (thoracic vs non-thoracic), type of CIED (PPMs vs ICDs) and among those with serial MRIs. When ranked for % change pre- to post-MRI, the majority of RA, RV and LV metrics for thresholds, sensing, and impedance conformed to ≤20% change from baseline. No significant clinical adverse cardiac events or effect on device microcircuitry occurred during the study. Conclusion Incorporating a novel reproducibility tactic, there were neither clinically meaningful device parameter changes nor adverse clinical events during or following MRIs, suggesting the effects of MRI on non-conditional CIED integrity are far less than previously perceived. This article is protected by copyright. All rights reserved.

Background In patients with conventional pacemakers or ICD's, MRI is infrequently performed due to safety concerns. Recent reports have allayed many of these concerns. However, the additive clinical value of scanning patients with cardiac implants has not been established. Objective Assessing the additive value of thoracic and non-thoracic MRI in patients with implantable cardiac devices. Methods and results Prospective data were analyzed in 500 patients with implanted cardiac devices that underwent MRI over a 12 year period at a single institution (Allegheny General Hospital, Pittsburgh, PA). A set of three questions were answered following scan interpretation by both the MRI technologist and interpreting MRI physician(s): 1) Did the primary diagnosis change? 2) Did MRI provide additional information to the existing diagnosis? 3) Did patient management change? If ‘Yes’ was answered to any of the above questions, it was considered that the MRI scan was of value to patient diagnosis and/or guiding therapy. Scans encountered were neurological/neurosurgical 354 (70.8%), cardiac 98 (19.6%) and orthopedic 48 (9.6%) in nature. In 431 (86%) MRI added additional information to the primary diagnosis and in 277 (55.4%) MRI changed the primary diagnosis. In 304 (60.8%) cases management changed, 265 (53%) due to a change in diagnosis and in 39 (7.8%) due to providing additional information. No safety issues were encountered and no adverse effects of MRI scan were noted. Conclusions MRI in patients with implanted cardiac devices was of additive value to diagnosis and management thereby informing risk-benefit considerations. Condensed abstract 500 patients with implanted cardiac devices who underwent a MRI examination over a 12 year period were followed prospectively. Imaging primarily focus on three anatomical regions (neurological/neurosurgical, cardiac and orthopedic) providing added information to the primary diagnosis in 431 (86%) cases and changing the primary diagnosis in 277 (55.4%) cases. In 304 (60.8%) cases management changed with 265 (53%) being due to a change of diagnosis and in 39 (7.8%) due to providing additional information. No safety issues were encountered using a defined protocol. Conclusions: MR imaging retains its diagnostic yield in patients with implanted devices.

Cardiac imaging is the cornerstone of defining the etiology, quantification and management of mitral regurgitation (MR). This continues to be even more so the case with emerging trans-catheter techniques to manage MR. Transthoracic echocardiography remains the first line imaging modality to assess MR but has limitations. Cardiac MRI(CMR) provides the advantages of quantitative non-visual estimation, 3D volumetric data, late gadolinium, T1 and extracellular volume measurements to comprehensively assess mitral valvular pathology, cardiac remodeling and the prognostic impact of therapies. This review describes the superiority, technical aspects and growing evidence behind CMR, and lays the roadmap for the future of CMR in MR.

Cardiac imaging is the cornerstone of defining the etiology, quantification, and management of mitral regurgitation (MR). This continues to be even more so the case with emerging transcatheter techniques to manage MR. Transthoracic echocardiography remains the first-line imaging modality to assess MR but has limitations. Cardiac MRI(CMR) provides the advantages of quantitative nonvisual estimation, 3D volumetric data, late gadolinium, T1, and extracellular volume measurements to comprehensively assess mitral valvular pathology, cardiac remodeling, and the prognostic impact of therapies. This review describes the superiority, technical aspects and growing evidence behind CMR, and lays the roadmap for the future of CMR in MR.

Objectives The objective of this study was to assess the diagnostic usefulness of thoracic and nonthoracic magnetic resonance imaging (MRI) imaging in patients with implantable cardiac devices (permanent pacemaker or implantable cardioverter-defibrillators [ICDs]) to determine if there was a substantial benefit to patients with regard to diagnosis and/or management. Background MRI is infrequently performed on patients with conventional pacemakers or ICDs. Multiple studies have documented the safety of MRI scans in patients with implanted devices, yet the diagnostic value of this approach has not been established. Methods Evaluation data were acquired in 136 patients with implanted cardiac devices who underwent MRIs during a 10-year period at a single institution. Specific criteria were followed for all patients to objectively define if the diagnosis by MRI enhanced patient care; 4 questions were answered after scan interpretation by both MRI technologists and MRI physicians who performed the scan. 1) Did the primary diagnosis change? 2) Did the MRI provide additional information to the existing diagnosis? 3) Was the pre-MRI (tentative) diagnosis confirmed? 4) Did patient management change? Results If “Yes” was answered to any of the preceding questions, the MRI scan was considered to be of value to patient diagnosis and/or therapy. In 97% (n = 132) of patients, MR added value to patient diagnosis and management. In 49% (n = 67) of patients, MRI added additional valuable information to the primary diagnosis, and in 30% (n = 41) of patients, MRI changed the principle diagnosis and subsequent management of the patient. No safety issues were encountered, and no adverse effects of undergoing the MRI scan were noted in any patient. Conclusions MRI in patients with implanted pacemakers and defibrillators added value to patient diagnosis and management, which justified the risk of the procedure.

Background: While left ventricular ejection fraction (LVEF) has been shown to have prognostic value in ischemic cardiomyopathy (ICMX) patients, right ventricular ejection fraction (RVEF) has not been systematically evaluated in either ICMX or non-ischemic cardiomyopathy (NICMX) patients. Moreover, an accurate estimation of RVEF is problematic due to the geometry of the right ventricle (RV). Over the years, there have been improvements in the resolution, image acquisition and post-processing software for cardiac magnetic resonance imaging (CMR), such that CMR has become the “gold standard„ for measuring RV volumetrics and RVEF. We hypothesize that CMR defines RVEF more so than LVEF and might have prognostic capabilities in ischemic and non-ischemic cardiomyopathy patients (ICMX and NICMX). Methods: Patients that underwent CMR at our institution between January 2005 and October 2012 were retrospectively selected if three-dimensional (3D) LVEF < 35%. Patients were further divided into ICMX and NICMX groups. The electronic medical record (EMR) database inquiry determined all-cause mortality and major adverse cardiovascular events (MACE). Additionally, a Social Security Death Index (SSI) database inquiry was performed to determine all-cause mortality in patients who were lost to follow-up. Patients were further sub-grouped on the basis of 3D RVEF ≥ 20%. Separately, patients were sub-grouped by LVEF ≥ 20% in both ICMX and NICMX cases. A cut-off of ≥20% was chosen for the RVEF based on the results of prior studies showing significance based on Kaplan⁻Meier (KM) survival curves. Cumulative event rates were estimated for each subgroup using the KM analysis and were compared using the log-rank test. The 3D RV/LVEFs were compared to all-cause mortality and MACE. ICMX patients were defined using the World Health Organization (WHO) criteria. Results: From a 7000-patient CMR database, 753 heart failure patients were selected. Eighty-seven patients met WHO definition of ICMX and NICMX (43 ICMX and 44 NICMX). The study patients were followed for a median of 3 years (Interquartile range or IQR 1.5⁻6.5 years). The mean age of patients was 58 ± 13 years; 79% were male. In ICMX, mean 3D LVEF was 21% ± 6% and mean 3D RVEF was 38% ± 14%, while for NICMX, mean 3D LVEF was 16% ± 6% and mean 3D RVEF was 30% ± 14% (p < 0.005 for intra- and inter-group comparison). It should be noted that LVEF < RVEF in both groups and the ejection fraction (EF) in NICMX was less than the corresponding EF in ICMX. Overall mortality was higher in ICMX than NICMX (12/40, 30% vs. 7/43, 16%; p < 0.05). Patients were stratified based on both RVEF and LVEF with a threshold of EF ≥ 20% separately. RVEF but not LVEF was a significant predictor of death for NICMX (χ2 = 8; p < 0.005), while LVEF did not predict death in ICMX (χ2 = 2, p = not significant). Similarly, time to MACE was predicted by RVEF for NICMX (χ2 = 9; p < 0.005) but not by LVEF in ICMX (χ2 = 1; p = NS). Importantly, RVEF, while predictive of NICMX MACE, did not emerge as a predictor of survival or MACE in ICMX. Conclusions: Via 3D CMR in non-ischemic CMX patients, RVEF has important value in predicting death and time to first MACE while 3D LVEF is far less predictive.

The maturation of pacemaker/ICD safety in the MRI has catalyzed considerable interest in more routine clinical use. However, limitations to widespread adoption of this seemingly implausible concept just a few years ago remain. Among them is the impact of high magnetic fields, RF and oscillatory

MRI is infrequently performed on patients with conventional pacemakers and ICDs. While many studies have documented MRI safety, the clinical value has not been considered. Yet, the recent CMS-NCD supported more widespread considerations. We propose that MRI in pts with a PM/ICD is crucial to the

In diagnosing cardiac and paracardiac masses, cardiac MRI (CMR) has gained acceptance as the gold standard. CMR has been observed to be superior to echocardiography in characterizing soft-tissue structures and, specifically, in classifying cardiac masses. The aim of our study was to evaluate the association between mortality and cardiac or paracardiac masses initially identified by echocardiography (ECHO) and confirmed by CMR. Between January 2002 and August 2007, a total of 158 patients underwent both ECHO and CMR for the evaluation of cardiac masses that were equivocal or undefined by ECHO. The primary study endpoints were 5-year all-cause mortality and 5-year cardiac mortality. Causes of death as of April 1, 2015 were obtained from medical records or the National Death Index. Patients were analyzed according to mass type determined by CMR using the Kruskal-Wallis test, Kaplan-Meier curves, and the log-rank test. Over a mean duration of follow-up of 10.4 ± 2.9 years (range: 0.01-12 years) post-CMR, the overall all-cause mortality rate was 25.9% (41/158). Median age at death was 76 years and there were 21 females (51.2%). Mortality rates in the different classifications of cardiac masses by CMR were as follows: 20% (1/5) in patients with a Nondiagnostic CMR; 20% (1/5) in Other Diagnoses; 17.9% (7/39) in No Masses (includes Normal Anatomical Variants); 16.7% (3/18) in Benign Masses; 23.8% (15/63) in Fat; 50% (5/10) in Thrombus; and 61.5% (8/13) in Malignant Mass. The mean survival time in patients with No Mass (n = 39) was not significantly longer than patients with any type of cardiac mass (n = 114) (P = .16). No significant difference was found in age at death between patients when grouped by CMR classification (P = .40). However, among CMR-confirmed masses, there were some significant differences by mass classification type (P = .006). During the follow-up period, 26% (41/158) of patients died and 22% (9/41) of the deaths were cardiovascular related; there was no significant difference in mean survival times with respect to cause of mortality (P = .23). In patients with cardiac masses, dually confirmed by ECHO and CMR, significant differences in survival time were observed based upon CMR classified type of mass while CMR was instrumental in obviating invasive biopsy.

Background Patients with newly diagnosed dilated cardiomyopathy (DCM) and advanced heart failure have a very high morbidity and mortality with an unpredictable clinical course. We investigated the role of cardiovascular magnetic resonance (CMR) imaging using late gadolinium enhancement (LGE) in this cohort of high-risk patients. We hypothesized that LGE has high prognostic value in primary DCM patients referred for possible transplantation/left ventricular assist device (LVAD) consideration. Methods Over 49 consecutive months, 61 consecutives DCM patients were referred for standard CMR(1.5T, GE) to interrogate the LV pattern, distribution, and extent of LGE (MultiHance, Princeton, NJ). Inclusion criteria for a primary non-ischaemic DCM and EF

Introduction: CMR has become the leading modality to define the clinical impact of hypertrophic cardiomyopathy (HCM). Late gadolinium enhancement (LGE) accurately identifies regions of myocardial fibrosis. It is well known that myocardial fibrosis can occur in patients with HCM and is independently linked to a poorer prognosis than those without fibrosis by CMR. Hypothesis: We hypothesize that there is significant RV involvement in HCM when incorporates a CMR analysis for RV hypertrophy and fibrosis. Methods: A retrospective review of all patients referred for HCM was performed. SSFP/LGE techniques were used to diagnose patients with HCM, using gadolinium administration (0.15 mmol/kg). Post-injection (10 minutes) LGE images were obtained using manual T1-weighted, IR-preparations. Regions of myocardium with LGE signals were visually designated as fibrotic. LV/RV mass indices (LVMI/RVMI) and ejection fractions were calculated. Results: Via 72 patients referred for HCM, 47(65%) were CMR confirmed. The mean LVMI was 108 ± 44 g/m2 while the mean RVMI was 30 ± 21 g/m2. As well, 34/47 (72%) had evidence of LV fibrosis while 24/47 (51%) had evidence for RV fibrosis. Of the RVH positive patients, 26/34 (76%) patients were LV LGE positive and 18/34 (52%) were RV LGE positive. Conclusion: The high frequency of RVH and RV fibrosis in the setting of HCM is surprising in that this phenomenon is rarely described. However, there is no reason to expect the phenotypic expression should be limited to the LV. Interestingly, as for the LV, the presence or absence of RV fibrosis has little predictive power towards the systolic function.

Objectives Investigate the impact of Right Ventricular (RV) Internal Work (IW), ratio of arterial to ventricular end-systolic elastance (Ea/Emax), and RV Insertion Point (IP) Late Gadolinium Enhancement (LGE) on outcome in Pulmonary Hypertension (PH) patients. Background LGE is well known to be present within the RVIPs and Inter Ventricular Septum (IVS) in PH patients, but its prognostic role remains complex and potentially overestimated via 2D qualitative relative to the 3D quantitative measures now available. However, Ea/Emax, a measure of ventricular-arterial coupling and IW, when added to external cardiac work i.e. the P-V loop area as correlates to the heart's energy demands, might fundamentally improve measures of prognosis as they interrogate physiology beyond just the RV. Methods Cardiac Magnetic Resonance Imaging (CMR) of 124 PH patients (age = 60±13, 85F) referred to a large tertiary PH center, was retrospectively examined for RV volumetric and functional indices and RVIP LGE%. Right Heart Catheterizations (RHC) performed within 1±2 months of the CMR were reviewed. Ea/Emax was derived as RV End-Systolic Volume (ESV/RVSV). IW was estimated as RVESV ×(RV end-systolic pressure-RV diastolic pressure). Patients were followed from date of CMR for up to 5 years for MACE (death, hospitalized RV failure, initiation of parenteral prostacyclin, sustained ventricular arrhythmia or referral for lung transplantation). Results MACE was high; 48/124 (39%) patients had MACE by 1.6±1.3 years. Neither RVIP nor IVS LGE using visual assessment or even 3D quantization predicted MACE. The strongest predictor of MACE was RVIW (OR=1.00013, p

‘Septal bounce’ is a pathognomonic sign of constrictive pericarditis (CP). The objectives of the study are to resolve the etiology of the septal bounce, to generate septal bounce-related diagnostic tools, and to prove that its presence is related to the mechanical interaction between the atrioventricular inflow and the inter-ventricular septum. We compared steady state free precession four-chamber images between 11 CP patients and 11 controls via cardiac magnetic resonance. The septal bounce was composed of two movements observed during every cardiac cycle, simultaneous with the rapid filling and atrial systole respectively. Three parameters (measured at end-systole) were generated: right ventricular (RV) clamp (compression ratio of the RV)—greater in CP (0.88 ± 0.03) than controls (0.85 ± 0.03, p = 0.02), tri-septal angle between the tricuspid valve annulus plane and the interventricular septum (81° ± 9° vs. 91° ± 7°, p = 0.01), and impact angle between the tricuspid inflow vector and septum (8.6° ± 8.7° vs. 0° ± 6.6°, p = 0.01). The accuracy, positive predictive value, sensitivity and specificity of these parameters in differentiating CP from controls ranged from 100 to 82 %. A forth parameter—septal flow ratio, gauging the proportion of tricuspid inflow impacting the septum, was markedly higher in CP than controls (0.38 ± 0.19 vs. 0.01 ± 0.03, p < 0.0001) with 100 % sensitivity, specificity, positive and negative predictive value. The septal bounce consists of two sequential movements during each cardiac cycle, is time-related with the rapid ventricular filling and atrial systole, and likely represents a result of the tricuspid blood inflow impacting the interventricular septum. Four septal bounce-derived parameters have a good accuracy in differentiating CP from volunteers.

The objective of this study was to assess the diagnostic usefulness of thoracic and nonthoracic magnetic resonance imaging (MRI) imaging in patients with implantable cardiac devices (permanent pacemaker or implantable cardioverter-defibrillators [ICDs]) to determine if there was a substantial benefit to patients with regard to diagnosis and/or management.MRI is infrequently performed on patients with conventional pacemakers or ICDs. Multiple studies have documented the safety of MRI scans in patients with implanted devices, yet the diagnostic value of this approach has not been established.Evaluation data were acquired in 136 patients with implanted cardiac devices who underwent MRIs during a 10-year period at a single institution. Specific criteria were followed for all patients to objectively define if the diagnosis by MRI enhanced patient care; 4 questions were answered after scan interpretation by both MRI technologists and MRI physicians who performed the scan. 1) Did the primary diagnosis change? 2) Did the MRI provide additional information to the existing diagnosis? 3) Was the pre-MRI (tentative) diagnosis confirmed? 4) Did patient management change? If "Yes" was answered to any of the preceding questions, the MRI scan was considered to be of value to patient diagnosis and/or therapy.In 97% (n = 132) of patients, MR added value to patient diagnosis and management. In 49% (n = 67) of patients, MRI added additional valuable information to the primary diagnosis, and in 30% (n = 41) of patients, MRI changed the principle diagnosis and subsequent management of the patient. No safety issues were encountered, and no adverse effects of undergoing the MRI scan were noted in any patient.MRI in patients with implanted pacemakers and defibrillators added value to patient diagnosis and management, which justified the risk of the procedure.

Introduction Scimitar syndrome is described as an abnormal connection between one pulmonary vein and the right atrium or vena cava. Case presentation 40 year old female presented with respiratory failure and septic shock that was unresponsive to pressors and IV fluids. Transthoracic echocardiogram showed severely dilated right ventricle with severe tricuspid regurgitation. Chest computed tomography angiogram (CTA) was negative for pulmonary embolism but showed right upper pulmonary vein connecting to inferior vena cava consistent with Scimitar anomaly. (Figure 1) Invasive hemodynamic evaluation showed mixed venous saturation (SvO2) 14%, cardiac index (CI) 1.89 L/min/m2, systemic vascular resistance (SVR) 754 dynes, severely elevated filling pressures, and pulmonary artery pressure (PAP) 77/44 (57) mmHg. Dialysis, dobutamine and inhaled nitroglycerin (iNO) were added to pressors for RV support. Follow up hemodynamic profile showed SvO2 75%, CI 4.9 L/min/m2, improved filling pressures, SVR 473 dynes, PAP 79/37 (48) mmHg. However, liver/kidney function and lactic acid continued to worsen indicating inadequate organ perfusion. Inaccurate SvO2 and subsequent CI and SVR calculation in the setting of L to R shunt through the anomalous vein was suspected. Subsequently, the decision was made to titrate hemodynamic support using MAP>70 accepting the presence of shunt, after which lactic acid and liver/kidney function started improving. Unfortunately, the patient suffered hypoxemic cardiac arrest. The rate of iNO was decreased as it was thought to increase V/Q mismatch despite its hemodynamic benefit to RV. Initiation of extracorporeal membrane oxygenation was difficult because of severe vasospasm. Vegetative state was noted and care was withdrawn per family request. Discussion The patient's hemodynamic profile was consistent with cardiogenic shock secondary to acute RV failure caused by initial IV fluid administration. RV support in the setting of pulmonary hypertension was achieved with dialysis, dobutamine and iNO. Improving hemodynamic parameters obtained by pulmonary catheter didn't correlate with worsening laboratory perfusion parameters. The availability of chest CTA showing an unexpected pulmonary venous anomaly helped our multidisciplinary team explain the inaccuracy of hemodynamic parameters.

MRI is infrequently performed on pts with conventional PM/ICDs. While many studies have unequivocally documented safety, the clinical value has not been considered. We propose that MRI in pts with PM/ICDs is crucial to the existing diagnosis and many times, substantially alters the diagnosis and

Hypertrophic cardiomyopathy (HCM) is a genetically determined heart muscle disease; characterized by left ventricular hypertrophy (LVH). Spiral HCM is described as having a counterclockwise rotation pattern of hypertrophy along with variable degrees of fibrosis. A 34-year-old female presented with symptoms suggestive of heart failure. Echocardiography showed concentric LVH with normal contractility. Cardiac MRI showed asymmetric septal hypertrophy with mid-cavity obliteration and a spiral pattern of variably increasing wall thickness. Late gadolinium enhancement (LGE) demonstrated several areas of abnormal postgadolinium uptake. We report a case of spiral HCM. We should consider cardiovascular magnetic resonance (CMR) as the reference standard for diagnosing HCM.

Reverse remodeling of the left atrium (LA) following successful pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) has been well documented. However, mitral regurgitation (MR) recovery after successful PVI has never been demonstrated systematically. The objective of our study was to retrospectively analyze the effectiveness of PVI in patients with AF on recovery of MR using cardiac magnetic resonance (CMR) imaging. Prior to PVI, patients underwent a clinically indicated CMR imaging. Post-PVI (6 ± 2 months), patients underwent a follow-up MRI and were classified into two groups—responders (R) and non-responders (NR) to PVI—as assessed by cessation of AF at the end of the prespecified 6-month (14-day “P” sensitive event monitor defined) follow-up period. Furthermore, CMR was used to evaluate the severity of MR (0 to 4+) and to relate changes in MR to LA volumes as well as mitral apparatus geometry. Patients who had mild and higher MR (2+) on baseline CMR and had a post-PVI CMR were selected for final analysis. Out of the consecutive 122 patients with AF who underwent PVI, 74 patients that had mitral regurgitation on initial CMR were included in the study. Of these74 patients with AF with MR, 52 (70 %) were classified as R and 22 (30 %) were classified as NR. Baseline demographics were similar between the groups. In the subgroup with mild to severe MR, pre vs. post in the R group MR severity significantly improved (mean = 2.3, median = 2.0 vs. mean = 1.0, median = 1.0, p

Background The preoperative workup of orthotopic liver transplantation (OLT) patients is practically complex given the need for multiple imaging modalities. We recently demonstrated in our proof-of-concept study the value of a one-stop-shop approach using cardiovascular MRI (CMR) to address this complex problem. However, this approach requires further validation in a larger cohort, as detection of hepatocellular carcinoma (HCC) as well as cardiovascular risk assessment is critically important in these patients. We hypothesized that coronary risk assessment and HCC detectability is acceptable using the one-stop-shop CMR approach. Methods In this observational study, patients underwent CMRI evaluation including cardiac function, stress CMR, thoracoabdominal MRA, and abdominal MRI on a standard MRI scanner in one examination. Results Over 8 years, 252 OLT candidates underwent evaluation in the cardiac MRI suit. The completion rates for each segment of the CMR examination were 99% for function, 95% completed stress CMR, 93% completed LGE for viability, 85% for liver MRI, and 87% for MRA. A negative CMR stress examination had 100% CAD event-free survival at 12 months. A total of 63 (29%) patients proceeded to OLT. Explant pathology confirmed detection/exclusion of HCC. Conclusions This study further defines the population suitable for the one-stop-shop CMR concept for preop evaluation of OLT candidates providing a road map for integrated testing in this complex patient population for evaluation of cardiac risk and detection of HCC lesions.

Today, MRI is infrequently performed in pts with conventional PM/lCDs. While MagnaSafe, published in NEJM for non-thoracic MRI, unequivocally documented safety, the clinical value remains unconsidered. A myopic, potentially prohibitive, focus on safety continues. MRI in PM/lCDs pts is crucial to

Performance of MRI is uncommonly conducted on patients with retained metallic devices/objects. Recent work has suggested with an appropriate protocol, pacemakers/lCD's may be safer than previously thought. However, for other devices and retained leads lacking the ability to be programmed to MR-safe

To establish the clinical validity and accuracy of automatic thresholding and manual trimming (ATMT) by comparing the method with the conventional contouring method for in vivo cardiac volume measurements. CMR was performed on 40 subjects (30 patients and 10 controls) using steady-state free precession cine sequences with slices oriented in the short-axis and acquired contiguously from base to apex. Left ventricular (LV) volumes, end-diastolic volume, end-systolic volume, and stroke volume (SV) were obtained with ATMT and with the conventional contouring method. Additionally, SV was measured independently using CMR phase velocity mapping (PVM) of the aorta for validation. Three methods of calculating SV were compared by applying Bland-Altman analysis. The Bland-Altman standard deviation of variation (SD) and offset bias for LV SV for the three sets of data were: ATMT-PVM (7.65, [Formula: see text]), ATMT-contours (7.85, [Formula: see text]), and contour-PVM (11.01, 4.97), respectively. Equating the observed range to the error contribution of each approach, the error magnitude of ATMT:PVM:contours was in the ratio 1:2.4:2.5. Use of ATMT for measuring ventricular volumes accommodates trabeculae and papillary structures more intuitively than contemporary contouring methods. This results in lower variation when analyzing cardiac structure and function and consequently improved accuracy in assessing chamber volumes.

Background: MRI is infrequently performed on patients with conventional pacemakers/ICD’s. Multiple recent studies and registries (MagnaSafe) have documented the safety of MRI in these patients, yet the diagnostic value of this approach has not been established remaining a critical issue to advance this field in an era of progressive MRI useage. Objective: 1) to examine a protocol to assess the diagnostic utility of thoracic and non-thoracic MRI in patients with implantable devices and 2) to determine if there is substantial benefit to the pt with regard to diagnosis and/or management. Methods: Over 8 years, 134 pts with PM/AICD’s underwent MRI (GE, 1.5T Milwaukee, WI) at a single institution. Specific criteria were followed for all pts to objectively define whether final diagnosis by MRI imaging enhanced patient care. A checklist of three questions was answered following scan interpretation by both the technologist and performing MRI physician(s):1) Did the primary diagnosis change? 2) Did the MRI provide additional information to the existing diagnosis? 3) Did patient management change? If ’Yes’ was answered to any of the above questions, it was considered that the MRI scan was of value to patient diagnosis and/or therapy. Results: All 134 pts underwent MRI/CMR without complications: avg scan time 24±9min including 42 pts with ICD’s, 5 pts with a retained lead and 87 non-MR conditional pacemakers. In 83% (n=112) MR added value to patient diagnosis and management. In 64% (n=86) MRI added additional valuable information to the primary diagnosis and in 19% (n=26) MRI was life-saving, changing the principal diagnosis and subsequent management of the pt. There were no deaths, arrhythmias or power-on-resets encountered and no adverse effects were noted in any pt. No post-procedure revisions or reimplantations of generator/lead were required. Conclusions: MR imaging in patients with implanted cardiac devices adds substantial value to patient diagnosis and management justifying the risk of the procedure. In this real-world patient population, we have shown that MR imaging retains its very high diagnostic yield. Risk-benefit ratios clearly justify the performance of MRI even in this higher risk population, that is, until such time as MR-conditional devices are universal.

Background Pacemaker/AICD use may no longer be prohibitive in the MRI environment. Seminal work by us and others has pointed towards increasing safety and specifically, the marked additive clinical value. Historically, on only extraordinarily high-risk patients with acute diagnoses were imaged. However, over time, we began to note an interesting trend as our understanding, science and comfort level admixed with zero-event rate almost imperceptibly causes us to ‘relax’ the mandate for acuity. We wondered, “Has imaging a patient with a pacemaker that was once considered a last resort procedure started to evolve into a routine study? What have we learned from performing these procedures?

Background Pacemaker/ AICD imaging is currently clincally performed in the MRI environment. A vigilant team consisting of Cardiologist, EP staff, and technologists with close patient monitoring and supervision has evolved this heretofore risky endeavor into a procedure with established safety if done properly. However, once safety is established, does such add valuable irrefutable information to merit that risk?

Methods A total of 48 patients were imaged on a GE CV/i Excite Version 12, 1.5 T system (GE, Milwaukee, WI). 8 patients had an AICD, 7 had an AICD/Pacemaker, 2 had a single pacemaker lead, 2 REVO pacemakers and 29 patients had a traditional dual-chamber pacemaker. A specific criteria was followed for all the patients undergoing this procedure to scrutinize if the final diagnosis provided additional information in patient care. A checklist of three questions were gathered and answered after the final interpretation of the MRI. Does the diagnosis change? Does the MRI provide additional information to the existing diagnosis? Does patient management change? If ‘yes’ was answered any of the above questions it was considered that the MRI scan was of value to patient diagnosis.

Introduction: CMR is considered the ‘gold standard’ for noninvasive LV and RV mass quantitation. This concept is predominantly based on GRE sequences yet never validated in humans undermining its credibility. SSFP offers superior image contrast potentially redefining the CMR gold standard for mass. Objective: To establish correlations between SSFP-CMR LV and RV mass vs. pathology mass using Htx pts. Methods: Over 3 years, 68 pts were evaluated including 48 HTx explants obtained immediately from the OR upon HTx. They were prepared (removed PM/AICD and/or LV/RVAD) and scanned ex vivo via SSFP for CMR LV/RV mass (1.5T GE, WI). Via an A utomatic T hresholding program for segmentation with M anual T rimming (ATMT) of extraneous cardiac tissue a 3D LV model was generated. The weight of total heart including papillary and trabeculae for LV and RV was measured via high-fidelity scale. Correlations were between 3D CMR vs. pathology with B-A plots. A separate cohort of 20 non-Htx pts underwent in vivo validation. Results: Of 48 Htx pts, 3 (6%) were excluded due to poor images (peri-surgical destruction) leaving 45 (94%) for analysis. Correlations: 1) Total CMR 3D mass (448±116g) vs. total pathology mass (444±118g; r=0.99, p Conclusions: SSFP-CMR accurately defines total cardiac, LV and RV mass as compared to explanted hearts (despite variable surgical removal of instrumentation). Thus, while GRE was the original ‘gold standard’ for LV mass, SSFP, despite its universal acceptance as the ‘ de facto gold standard is now formally validated in a first-ever human autopsy study. Further, the regression equation now includes , not excludes papillary and trabecular mass.

Introduction: In cardiac MRI (CMR), heart volumes are traditionally measured using contouring methods applied to contiguous image data. Herein, we introduce a new approach, Automatic Threshold and Manual Trimming (ATMT), which is applied to the same contiguous data set. Potentially, the ATMT method can be applied by seed/region-growing algorithms with minimal user supervision. We sought to establish its clinical validity. Hypothesis: We hypothesize that the ATMT approach is more accurate as compared to conventional 'gold standard', cardiac contouring. Methods: Hearts from two populations (N=74) were evaluated: explanted heart transplant (Tx) and a clinical validation cohort ( in vivo ). The transplanted hearts were imaged ex vivo using CMR and then weighed on a high-fidelity scale. Cardiac volume/mass was compared (N=54) to the patient cohort (N=20) and measured non-invasively with stroke volume, independently measured via CMR phase velocity technique. Bland-Altman was applied in a 3-way manner for each group. Results: Bland-Altman analysis for Standard Deviation (SD), Bias and Correlation (R) are summarized in Table 1. When compared with independent measurements (weight/flow), ATMT has lower Bias (close to zero) and SD. Further, any comparison involving cardiac contours has a substantially larger bias term and a higher SD. From the table below, ATMT has consistently higher correlations with the independent measurement than does the contour method. Conclusions: Based on multiple comparison metrics with independent measures, the ATMT approach is more accurate and reproducible for quantification of cardiac volume (integral for EF determination) as compared to standard contouring. Furthermore, ATMT accommodates trabeculae and papillary structures more intuitively than the contouring method. This intrinsic accuracy coupled with the potential for more rapid analysis gives a valid impetus to further develop the ATMT approach further increasing CMR accuracy.

Background CMR is considered the ‘gold standard’ for non-invasive LV and RV mass quantitation. This information is solely based on gradient-recalled echo (GRE) sequences while contrast dependent on intrinsic T1/T2 characteristics potentially offers superior image contrast between blood and myocardium. This study aims, for the first time in humans, to validate the SSFP approach using explanted hearts obtained from heart transplant recipients. Our objective is establish the correlation between and to validate steady-state free precession (SSFP) derived LV and RV mass vs. autopsy mass of hearts from cardiac transplants patients. Methods Over three-years, 58 explanted cardiomyopathy hearts were obtained immediately upon orthotopic heart transplantation from the OR. They were quickly cleaned, prepared and suspended in a saline-filled container and scanned ex vivo via SSFP-SA slices to define LV/RV mass. Using an automatic thresholding program, segmentation was achieved in combination with manual trimming (ATMT) of extraneous tissue incorporating 3D cardiac modeling performed by independent and blinded readers. The explanted hearts were then dissected with the ventricles surgically separated at the interventricular septum. Weights of the total heart not excluding papillary and trabecular myocardium, LV and RV were measured via high-fidelity scale. Linear regression and Bland-Altman plots were used to analyze the data. The intra-class correlation coefficient was used to assess intra-observer reliability. Results Of the total of 58 explanted hearts, 3 (6%) were excluded due to poor image quality leaving 55 patients (94%) for the final analysis. Significant positive correlations were found between total 3D CMR mass (450 ± 111 g) and total pathology mass (445 ± 116 g; r = 0.99, p < 0.001) as well as 3D CMR measured LV mass (301 ± 93 g) and the pathology measured LV mass (313 ± 96 g; r = 0.95, p < 0.001). Strong positive correlations were demonstrated between the 3D CMR measured RV mass (149 ± 46 g) and the pathology measured RV mass (128 ± 40 g; r = 0.76, p < 0.001). The mean bias between 3D-CMR and pathology measures for total mass, LV mass and RV mass were: 3.0 g, -16 g and 19 g, respectively. Conclusions SSFP-CMR accurately determines total myocardial, LV and RV mass as compared to pathology weighed explanted hearts despite variable surgical removal of instrumentation (left and right ventricular assist devices, AICD and often apical core removals). Thus, this becomes the first-ever human CMR confirmation for SSFP now validating the distinction of ‘gold standard’.

Background We hypothesize that infarct detection by electrocardiogram (EKG) is inaccurate as compared with detection by magnetic resonance imaging and is potentially independent of infarct vs noninfarct status. This might have implications for societies in which initial cardiovascular testing is uniformly EKG. Objective This study aimed to relate EKG-defined scar to cardiovascular magnetic resonance imaging (CMR)–defined scar independent of the underlying myocardial pathology. Methods A total of 235 consecutive patients who underwent CMR-late gadolinium enhancement (LGE) with simultaneous EKG were screened for Q waves and compared with patients with a positive LGE pattern. The patients were divided into 3 groups: (1) patients with a positive infarct LGE pattern (LGE+/+; herein defined as LGE+), (2) patients with a noninfarct LGE pattern (LGE+/−), and (3) patients with a negative LGE pattern (LGE−). Results While 139 of 235 patients (59%) were either LGE+ or LGE+/−, pathological Q waves were present in only 74 of 235 patients (31%). However, of these LGE+ or LGE+/− patients, only 76 (32%) had an infarct LGE pattern representing little overlap between the presence of LGE+ and Q waves. EKG sensitivity and specificity to detect infarct: 66% and 85%, respectively. However, of 24 of 74 patients (32%) with Q waves on the EKG, 66% were LGE+/− and 34% were LGE−. Importantly, 3-dimensional volume of myocardial scar was far more predictive of a Q wave than of scar transmurality. Conclusion EKG-defined scar, while ubiquitous for an infarct, has low sensitivity than CMR-LGE–defined scar. Unexpectedly, a significant number of pathological Q waves had absent infarct etiology, indicating high false positivity. Similarly, underrecognition of bona fide myocardial infarction frequently occurs, while 3-dimensional CMR volume of myocardial scar is far more predictive of a Q wave than of scar transmurality. This suggests that the well-regarded EKG may be a disservice when applied on a population basis, leading to inappropriate over or under downstream testing with wide socioeconomic implications.

Methods Subjects were eligible for entry if they had documented PAH as defined by WHO Criteria and were referred for a clinically indicated CMR exam where routine 3D metrics and LGE were performed. All images were retrospectively reviewed. The data collected as follows: right and left ventricular RV/LV EDVI and ESVI; RVEF and LVEF; RV anterior and inferior hinge point angle measurements (systole and diastole); LV diameters to determine eccentricity index in diastole and systole; RV hinge point LGE and right heart catheterization: RV and pulmonary arterial (PA) pressures. The hinge point angles were measured at the level of the head of the papillary muscles in the short axis. LGE was determined on the SA LGE images as not present, mild, moderate or severe (zero, 1, 2 or 3). All were related to right heart derived pressures. All patients were analyzed using IBM Statistical Package, PASW, version 18 (Formally SPSS).

Background CMR has become the leading modality to define the clinical impact of hypertrophic cardiomyopathy (HCM) providing complete coverage of both ventricles with high spatial resolution. Late gadolinium enhancement (LGE) accurately identifies regions of myocardial fibrosis. Via CMR, innumerable studies have established that LVH and LGE are the predominant phenotypic expressions of HCM. It is well known that myocardial fibrosis can occur in patients with HCM and is independently linked to a poorer prognosis than those without fibrosis by CMR.

Background We test the hypothesis that cardiac magnetic resonance (CMR) imaging-based indices of four-dimensional (4D) (three dimensions (3D) + time) right ventricle (RV) function have predictive values in ascertaining invasive pulmonary arterial systolic pressure (PASP) measurements from right heart catheterization (RHC) in patients with pulmonary arterial hypertension (PAH). Methods We studied five patients with idiopathic PAH and two age and sex-matched controls for RV function using a novel contractility index (CI) for amplitude and phase to peak contraction established from analysis of regional shape variation in the RV endocardium over 20 cardiac phases, segmented from CMR images in multiple orientations. Results The amplitude of RV contractility correlated inversely with RV ejection fraction (RVEF; R2 = 0.64, P = 0.03) and PASP ( R2 = 0.71, P = 0.02). Phase of peak RV contractility also correlated inversely to RVEF ( R2 = 0.499, P = 0.12) and PASP ( R2 = 0.66, P = 0.04). Conclusions RV contractility analyzed from CMR offers promising non-invasive metrics for classification of PAH, which are congruent with invasive pressure measurements.

Background CMR is considered the ‘gold standard’ for non-invasive LV and RV mass quantitation. To our knowledge, this information is solely based on GRE sequences, with its dependence on flow conditions having never been prospectively or retrospectively validated in humans undermining its credibility. SSFP, with intrinsic contrast dependent on T1/T2 characteristics, offers superior image contrast between blood and myocardium and might redefine the CMR gold standard for cardiac mass. Herein we validate an SSFP approach using explanted hearts obtained from heart transplant recipients.

A 54-year-old male patient with bilateral metal-on-metal hip prosthesis and recently diagnosed cobalt toxicity presented with gradually worsening symptoms of heart failure. Serum cobalt (120 μg/l; normal

Cardiac magnetic resonance (CMR) imaging generally allows a more accurate and valid quantification of cardiac function, mass and regurgitant volumes than echocardiography. Although recent technological advancements in CMR have made the evaluation of cardiac valves more reliable, no studies have yet been conducted to compare semi-quantitative grading (SQG) using CMR steady-state free precession (SSFP) sequences with quantitative grading (QG) based on stroke volumes and phase-velocity mapping (PVM). It is proposed that the SQG of cardiac valvular regurgitations based on CMR SSFP sequences is feasible, and highly correlative with standard CMR QG methods.CMR data obtained between January 2007 and December 2011 was evaluated prospectively for valvular regurgitant lesions. Patients were included if they had right and left ventricular volumetrics based on CMR SSFP sequences and PVM across the aortic and pulmonic valves with reported regurgitant volumes and fractions. Patients were excluded if they had prosthetic valves, cardiac arrhythmias and intra-cardiac shunts. Regurgitant lesions were semi-quantitatively (visually) graded on a standard scale of 0 to 4 (trace, mild, moderate, moderate to severe, and severe) and compared with quantitative regurgitant fractions. Correlations were evaluated by Spearman's rho formula, and kappa for intra- and inter-observer variabilities were obtained on 30% of the study sample.A total of 97 patients (58 males, 39 females; average age 55 +/- 18 years) representing 134 valvular regurgitations [mitral (MR), aortic (AR), tricuspid (TR), and pulmonary (PR)] were analyzed by semiquantitative and quantitative methods. The regurgitant lesions included 44 mitral, 50 aortic, 29 tricuspid, and 11 pulmonary. The correlation between SQR versus QG yielded the following results: 0.67, p0.001 (MR, r = 0.66, p0.001; AR, r = 0.68, p0.002; TR, r = 0.68, p = 0.001; PR, r = 0.70, p = 0.017). The results for QG versus SQG accounting for clinically significant differences of +/- 1 grade for the group were as follows: 0.95, p0.001 (MR, r = 0.91, p0.001; AR, r = 0.96, p0.001; TR, r = 0.99, p0.001; PR, r = 0.93, p0.001). No discrepancy between surgical regurgitation was present (3+ versus 4+). Weighted kappa results were 0.67 and 0.61 for intra- and inter-observer variabilities.The visual assessment of cardiac regurgitant lesions is reliable, accurate and reproducible when compared to formal quantitative analysis via CMR. This confirms a robust role for CMR in assessing regurgitant lesions, particularly for surgical decision-making. These results were applicable to patients in sinus rhythm at the time of scanning.

Background Preoperative cardiovascular risk stratification in orthotopic liver transplantation candidates has proven challenging due to limitations of current noninvasive modalities. Additionally, the preoperative workup is logistically cumbersome and expensive given the need for separate cardiac, vascular, and abdominal imaging. We evaluated the feasibility of a "one-stop shop" in a magnetic resonance suite, performing assessment of cardiac structure, function, and viability, along with simultaneous evaluation of thoracoabdominal vasculature and liver anatomy. Methods In this pilot study, patients underwent steady-state free precession sequences and stress cardiac magnetic resonance (CMR), thoracoabdominal magnetic resonance angiography, and abdominal magnetic resonance imaging (MRI) on a standard MRI scanner. Pharmacologic stress was performed using regadenoson, adenosine, or dobutamine. Viability was assessed using late gadolinium enhancement. Results Over 2 years, 51 of 77 liver transplant candidates (mean age, 56 years; 35% female; mean Model for End-stage Liver Disease score, 10.8; range, 6-40) underwent MRI. All referred patients completed standard dynamic CMR, 98% completed stress CMR, 82% completed late gadolinium enhancement for viability, 94% completed liver MRI, and 88% completed magnetic resonance angiography. The mean duration of the entire study was 72 min, and 45 patients were able to complete the entire examination. Among all 51 patients, 4 required follow-up coronary angiography (3 for evidence of ischemia on perfusion CMR and 1 for postoperative ischemia), and none had flow-limiting coronary disease. Nine proceeded to orthotopic liver transplantation (mean 74 days to transplantation after MRI). There were six ascertained mortalities in the nontransplant group and one death in the transplanted group. Explant pathology confirmed 100% detection/exclusion of hepatocellular carcinoma. No complications during CMR examination were encountered. Conclusions In this proof-of-concept study, it appears feasible to perform a comprehensive, efficient, and safe preoperative liver transplant imaging in a CMR suite-a one-stop shop, even in seriously ill patients.