Clinical recommendations for cardiovascular magnetic resonance mapping of T1, T2, T2* and extracellular volume: A consensus statement by the Society for Cardiovascular Magnetic Resonance (SCMR) endorsed by the European Association for Cardiovascular Imaging (EACVI)

Society for Cardiovascular Magnetic Resonance recommendations toward environmentally sustainable cardiovascular magnetic resonance

Delivery of health care, including medical imaging, generates substantial global greenhouse gas emissions. The cardiovascular magnetic resonance (CMR) community has an opportunity to decrease our carbon footprint, mitigate the effects of the climate crisis, and develop resiliency to current and future impacts of climate change. The goal of this document is to review and recommend actions and strategies to allow for CMR operation with improved sustainability, including efficient CMR protocols and CMR imaging workflow strategies for reducing greenhouse gas emissions, energy, and waste, and to decrease reliance on finite resources, including helium and waterbody contamination by gadolinium-based contrast agents. The article also highlights the potential of artificial intelligence and new hardware concepts, such as low-helium and low-field CMR, in achieving these aims. Specific actions include powering down magnetic resonance imaging scanners overnight and when not in use, reducing low-value CMR, and implementing efficient, non-contrast, and abbreviated CMR protocols when feasible. Data on estimated energy and greenhouse gas savings are provided where it is available, and areas of future research are highlighted.

Normal variations of myocardial T1, T2 and T2* values at 1.5 T cardiac MRI in sex-matched healthy volunteers

PURPOSE

The purpose of this study was to determine the normal variations of myocardial T1, T2, and T2* relaxation times on cardiac MRI obtained at 1.5 T in healthy, sex-balanced volunteers aged between 18 and 69 years.

MATERIAL AND METHODS

A total of 172 healthy volunteers were recruited prospectively. They were further divided into seven sex-balanced age groups (18-19 years, 20-24 years, 25-29 years, 30-39 years, 40-49 years, 50-59 years, and 60-69 years). T1, T2, and T2* mapping were acquired in a single short-axis slice at the mid-level of the left ventricle. Global T1, T2, and T2* values were the mean of all segments. Comparisons between females and males were performed in each age group using independent samples t-test or Wilcoxon rank sum test, as appropriate. Multivariable linear effects models were used to analyze the effect of heart rate, body mass index, left ventricular mass, age, and sex on T1, T2, and T2* values. Inter- and intra-observer correlation (ICC) was evaluated.

RESULTS

A total of 172 healthy participants were included. There were 83 males and 89 females, with a mean age of 37.3 ± 15.6 (standard deviation [SD]) years. Females had greater T1 values (980.9 ± 26.2 [SD] ms) compared to males (949.7 ± 18.3 [SD] ms) (P < 0.001). T1 values decreased with age (974.3 ± 26.97 [SD] ms when ≤ 39 years vs. 954.4 ± 24.12 [SD] ms when > 39 years; P < 0.001), with smaller sex-related differences in older participants. Male sex and age were independently associated with lower values of T1 mapping. Age in females was independently associated with lower T1, T2, and T2* values. Moderate to good inter- and intra-observer agreement was found for T1, T2, and T2* (ICC ranging from 0.72 to 0.89).

CONCLUSION

T1, T2, and T2* values are influenced by age and sex, emphasizing the need to read and calibrate MRI values with respect to patient characteristics to avoid misdiagnosis.

Longitudinal cardiac imaging for assessment of myocardial injury in non-hospitalised community-dwelling individuals after COVID-19 infection: the Rotterdam Study

BACKGROUND

The aim of this study was to assess the presence of myocardial injury after COVID-19 infection and to evaluate the relation between persistent cardiac symptoms after COVID-19 and myocardial function in participants with known cardiovascular health status before infection.

METHODS

In the prospective population-based Rotterdam Study cohort, echocardiography and cardiovascular magnetic resonance (CMR) were performed among participants who recovered from COVID-19 at home within 2 years prior to inclusion in the current study. Persistent cardiac symptoms comprised only self-reported symptoms of chest pain, dyspnoea or palpitations lasting >4 weeks after COVID-19 infection. We used linear regression and linear mixed models to estimate and test age-adjusted and sex-adjusted mean differences (95% CIs) of (1) post-COVID-19 CMR-derived and echocardiographic-derived parameters among participants with and without persistent post-COVID-19 symptoms and (2) pre-COVID-19 and post-COVID-19 echocardiographic assessments.

RESULTS

92 participants were included, with a mean age of 59±8 years of whom 52% were male. Normal post-COVID-19 CMR-derived left ventricular (LV) function and right ventricular ejection fraction were observed in 92% and 98% of participants, respectively. We observed normal native T1 relaxation times in 100%, normal extracellular volume in 98% and normal T2 relaxation times in 98% of the participants. Comparison of pre-COVID-19 and post-COVID-19 echocardiography revealed a significant but small decline in left ventricular ejection fraction (adjusted mean change -1.37% (95% CI -2.57%, -0.17%)) and global longitudinal strain (1.32% (95% CI 0.50%, 2.15%)). Comparing participants with and without persistent symptoms, there were no significant differences in adjusted CMR-derived ventricular volumes, LV function or presence of myocardial injury.

CONCLUSIONS

Almost all recovered non-hospitalised COVID-19 participants had normal CMR-derived ventricular volumes and function, without relevant myocardial injury.

Multiparametric cardiovascular magnetic resonance in patients with myocarditis with consecutive follow-up and a comparison between non-COVID-19 and COVID-19-associated myocarditis

Background

The pattern of myocardial injury and dysfunction development during follow-up is unclear in patients with myocarditis. This study aims to explore the developmental pattern of myocardial injury and cardiac dysfunction during the follow-up of myocarditis by cardiac magnetic resonance (CMR) and differences in short-term follow-up CMR performance between patients with coronavirus disease 2019 (COVID-19)-associated myocarditis (CAM) and non-COVID-19-associated myocarditis (NCAM).

Methods

Data of patients with clinically diagnosed myocarditis who underwent follow-up CMR were retrospectively collected. Patients were divided into the NCAM follow-up and CAM follow-up groups. A portion of patients with normal CMR and volunteers was categorized as control. Qualitative and quantitative assessments of CMR images were used to analyze cardiac structure, function and myocardial damage; compare the differences between the groups; and reveal the developmental pattern in the consecutive follow-up for patients with myocarditis.

Results

This study included 75 patients with NCAM, 25 patients with CAM and 75 cases as control group. Compared with the control group, there was an increase in left ventricular volume, right ventricular volume, extracellular volume in the NCAM follow-up (the last time) group, left ventricular volume, right ventricular ejection fraction, global radial strain (GRS), global circumferential strain, global longitudinal strain (GLS), post-contrast T1 value were decreased. The area under the curve of the GLS was the best (0.836) in discriminating between the two groups, with 78.7% sensitivity and 84.0% specificity. The discriminatory efficacy of the combined right ventricular ejection fraction, GRS, and GLS multiparameter showed the best area under the curve at 0.847, with 80.0% sensitivity and 85.3% specificity. Between the CMR parameter of short- (3 months), medium-, and long-term follow-up (>6 months) for patients with NCAM, a decrease in native T1 (1,256.50±18.63 vs. 1,248.30±17.87 ms, P=0.007) and T2 (49.00±1.34 vs. 47.50±0.97 ms, P=0.015) values was noted in the short-term follow-up group. The short-term follow-up group showed increased ventricular volume, decreased ejection fraction, and impaired myocardial strain in CAM and NCAM compared with the control group. The CAM short-term follow-up group showed an increased T2 value (52.56±3.64 vs. 49.08±3.84 ms, P=0.008) compared with the NCAM short-term follow-up group, and the T2 value was identified with an area under the curve of 0.772, 76% sensitivity, and 83% specificity for the discrimination.

Conclusions

This study revealed that myocarditis led to myocardial damage, cardiac remodeling, and dysfunction during follow-up. An improvement in myocardial edema in the medium- and long-term follow-up groups was observed. In the short-term follow-up, CAM showed more severe myocardial edema. These findings may contribute to the clinical assessment and management of post-myocarditis status.

Artifacts at Cardiac MRI: Imaging Appearances and Solutions

Cardiac MRI (CMR) is an important imaging modality in the evaluation of cardiovascular diseases. CMR image acquisition is technically challenging, which in some circumstances is associated with artifacts, both general as well as sequence specific. Recognizing imaging artifacts, understanding their causes, and applying effective approaches for artifact mitigation are critical for successful CMR. Balanced steady-state free precession (bSSFP), the most common CMR sequence, is associated with band and flow artifacts, which are amplified at 3-T imaging. This can be mitigated by targeted shimming, by short repetition time, or by using a frequency-scout sequence. In patients with cardiac arrhythmias or poor breath hold, the quality of cine imaging can be improved with a non-electrocardiographically gated free-breathing real-time sequence. Motion artifacts on late gadolinium enhancement (LGE) images can be mitigated by using single-shot technique with motion compensation and signal averaging. LGE images are also prone to partial-volume averaging and incomplete myocardial nulling. In phase-contrast imaging, aliasing artifact is seen when the velocity of blood is higher than the encoded velocity. Aliasing can be mitigated by increasing the encoded velocity or using postprocessing software. In first-pass perfusion imaging, a dark rim artifact due to Gibbs ringing can be distinguished from a true perfusion defect based on earlier appearance and fading after a few cardiac cycles. With implanted cardiac devices, artifactual high signal intensity mimicking scar is seen on LGE images, which can be mitigated using a wide-band sequence. With devices and metallic artifacts, traditional gradient-recalled echo sequence has fewer artifacts than bSSFP. CMR at 3 T requires adaptation of sequences to minimize artifacts. ©RSNA, 2025 Supplemental material is available for this article.

Challenges in clinical translation of cardiac magnetic resonance imaging radiomics in non-ischemic cardiomyopathy: a narrative review

Background and Objective

Radiomics is an emerging technology that facilitates the quantitative analysis of multi-modal cardiac magnetic resonance imaging (MRI). This study aims to introduce a standardized workflow for applying radiomics to non-ischemic cardiomyopathies, enabling clinicians to comprehensively understand and implement this technology in clinical practice.

Methods

A computerized literature search (up to August 1, 2024) was conducted using PubMed to identify relevant studies on the roles and workflows of radiomics in non-ischemic cardiomyopathy. Expert discussions were also held to ensure the accuracy and relevance of the findings. Only English-language publications were reviewed.

Key Content and Findings

The paper details the essential processes of radiomics, including feature extraction, feature engineering, model construction, and data analysis. It emphasizes the role of MRI in assessing cardiac structure and function and demonstrates how MRI-based radiomics can aid in diagnosing and differentiating non-ischemic cardiomyopathies such as hypertrophic cardiomyopathy, dilated cardiomyopathy, and myocarditis. The study also investigates various cardiac MRI sequences to enhance the clinical application of radiomics.

Conclusions

The standardized radiomics workflow presented in this study aims to assist clinicians in effectively utilizing MRI-based radiomics for the diagnosis and management of non-ischemic cardiomyopathies, thereby improving clinical decision-making.

Additional value of cardiac magnetic resonance parametric mapping in tissue characterization of common benign paediatric cardiac tumours

AIMS

Cardiac magnetic resonance (CMR) parametric mapping is underexplored in cardiac tumours. To evaluate the contribution of mapping sequences on the characterization of paediatric tumours.

METHODS AND RESULTS

All paediatric patients referred for cardiac tumours at Bambino Gesù Children's Hospital from June 2017 to November 2023, who underwent CMR with mapping sequences, were included. The diagnosis of tumour type was performed according to signal characteristics on different sequences. Mass parametric mapping for each subtype and interobserver variability was assessed. Sixteen patients were enrolled. The mean age at CMR was 7 ± 5 years. 'Traditional' mass type assessment diagnosed haemangioma (Group A) in three patients (19%), fibroma (Group B) in four patients (25%), rhabdomyoma (Group C) in six patients (37%), and lipoma (Group D) in three patients (19%). The analysis of variance analysis revealed significant differences in mass native T1 and mass extracellular volume (ECV) values among the four subgroups (P < 0.001 for both comparisons). The mean native T1 and ECV values were respectively 1465 ± 158 ms and 54 ± 4% for Group A, 860 ± 118 ms and 93 ± 4% for Group B, 1007 ± 57 ms and 23 ± 5% for Group C, and 215 ± 13 ms and 0 ± 0% for Group D.

CONCLUSION

Mass mapping analysis is feasible and reproducible in children. ECV values provide the most accurate differentiation. Mass ECV consistently resembles normal myocardium in rhabdomyoma, is extremely high (approaching 100%) in fibroma, equals to zero in lipoma, and matches blood pool ECV (1-Hct) in haemangioma.

Baseline and Follow-Up Cardiac Magnetic Resonance Imaging Findings in Children with Acute Myocarditis and Factors Associated with Late Gadolinium Enhancement

Objectives: Cardiac magnetic resonance (CMR) plays a central role in the diagnosis and follow-up of acute myocarditis (AM). In this study, we aimed to evaluate baseline and follow-up CMR findings and associated factors in children with AM. Methods: A retrospective analysis of CMR in pediatric patients with clinical presentations suggestive of myocarditis was performed. Patients' demographic characteristics, clinical data, and diagnostic test results, as well as CMR imaging results, were evaluated. Results: All 28 pediatric patients with acute myocarditis included in this study had late gadolinium enhancement (LGE) on initial CMR imaging. Additionally, 14 (50%) patients had increased extracellular volume (ECV), 4 (50%) patients had focal high-intensity areas on T2 STIR images, 15 (53.6%) patients had increased T1 relaxation time, and 17 (60.7%) patients had increased T2 relaxation time. At a median follow-up CMR of 6 months, 24 (85.7%) patients had LGE, 5 (17.9%) patients had increased ECV, and 7 (25%) patients had increased T1 relaxation time, while other parameters showed complete recovery. Baseline troponin and CRP levels, T1 relaxation time, T2 relaxation time, and increased ECV were found to be factors associated with the resolution of LGE. Conclusions: Baseline troponin and CRP levels, as well as T1 relaxation time, T2 relaxation time, and increased ECV, were effective parameters that seemed to predict the resolution of LGE. Larger and multicenter experiences would confirm these hypotheses.

Renal T1 Times on Cardiac Magnetic Resonance Reflect Renal Dysfunction and Are Associated with Adverse Outcomes: Insights from an All-Comer Cohort

Background: Renal disease is common in patients with cardiovascular disease (CVD) and is associated with adverse outcomes. Cardiac magnetic resonance (CMR) with advanced mapping techniques is the gold standard for characterizing myocardial tissue, and renal tissue is often visualized on these maps. However, it remains unclear whether renal T1 times accurately reflect renal dysfunction or predict adverse outcomes. Aim: To analyze the relationship between renal T1 times, renal dysfunction, and adverse outcomes. Adverse outcomes were defined as all-cause and cardiovascular death. Methods: Renal T1 times were measured in the native short-axis view in an all-comers cohort undergoing CMR. Renal function parameters were assessed at the time of CMR. Results: A total of 506 patients (mean age 60 ± 15 years, 53% male) were included in the analysis. A significant correlation was observed between log10 renal cortical T1 times and eGFR (r = -0.701, p < 0.001) and creatinine (r = 0.615, p < 0.001). Kaplan-Meier analysis showed an increased risk of all-cause (p < 0.001 by log-rank test) and cardiovascular mortality (p = 0.004 by log-rank test) in patients with renal cortical T1 times above the median. In the univariable Cox regression analysis, there was a significant association between renal cortical T1 times and increased risk of all-cause (HR = 1.73 [95% CI, 1.42-2.11] per every 100 ms increase p < 0.001) and cardiovascular mortality (HR = 1.41 [95% CI, 1.05-1.90] per every 100 ms increase, p = 0.021). This association remained statistically significant after adjustment for prespecified clinical factors (adjusted HR for all-cause death = 1.49 [95% CI, 1.10-2.02] per every 100 ms increase, p = 0.01; adjusted HR for cardiovascular death = 1.42 [95% CI, 1.05-1.90] per every 100 ms increase, p = 0.021). Conclusions: Our results indicate that there is a significant association between increased renal cortical T1 times and impaired renal function, as well as an increased risk of all-cause and cardiovascular mortality, although it should be noted that our results are preliminary and need to be validated in external cohorts performing renal biopsies.

Multiparametric cardiovascular magnetic resonance is associated with outcomes in pediatric heart transplant recipients

BACKGROUND

Multiparametric cardiovascular magnetic resonance (CMR) has an emerging role in non-invasive surveillance of pediatric heart transplant recipients (PHTR). Higher myocardial T2, higher extracellular volume fraction (ECV), and late gadolinium enhancement (LGE) have been associated with adverse clinical outcomes in adult heart transplant recipients. The purpose of this study was to investigate the prognostic value of CMR-derived T1 and T2 mapping, ECV, and LGE for clinical outcomes in PHTR.

METHODS

We performed a single-center, retrospective chart review of consecutive, gadolinium-enhanced CMR studies in PHTR over a 7.5-year period, excluding follow-up studies. Standard CMR ventricular volume and function analysis, T1 mapping with ECV, T2 mapping, and LGE assessment were performed. The composite outcome included cardiac death, non-cardiac death, re-transplantation, and cardiac hospitalization.

RESULTS

Among 113 PHTR, mean age was 13.0 ± 5.1 years, with 6.0 ± 4.0 years since transplant. The indication for CMR was surveillance in 79%. Mean native T1 was 1050 ± 48 ms, T2 49.2 ± 3.9 ms, and ECV 29.7 ± 4.5%. Left ventricular LGE was present in 37% (42/113) and right ventricular LGE in 3.5% (4/113). The mean follow-up time was 2.3 years and median was 1.4 years. Cardiac death occurred in 2% (2/113), re-transplantation in 4% (4/113), and cardiac hospitalization in 22% (25/113). Non-cardiac death did not occur. Using Kaplan-Meier analysis, high T1 (≥1061 ms), T2 (≥50.0 ms), and ECV (≥31.4%) were each associated with decreased freedom from the composite outcome in follow-up. In univariable Cox regression analyses, high T1 was associated with increased risk of the composite outcome (hazard ratios [HR] 4.0, 95% confidence interval [CI] 1.7-9.2, p = 0.001), as were high T2 (HR 2.8, 95% CI 1.1-7.1, p = 0.026), and high ECV (HR 3.5, 95% CI 1.5-8.1, p = 0.004).

CONCLUSION

T1 and T2 mapping are associated with early differences in adverse cardiac events in PHTR. These data suggest a role for a multicenter study with a longer follow-up duration.

Cardiac thrombus: can T1 and T2 mapping replace contrast enhanced images?

AIM

The aim of the study was to evaluate and compare contrast-to-noise ratios (CNRs) and signal-to-noise ratios (SNRs) of pre- and postcontrast T1 maps, T2 maps, early and late gadolinium images in terms of visual assessment of cardiac thrombus, to see if maps can replace contrast-enhanced images for detection of cardiac thrombus.

MATERIALS AND METHODS

T1, T2 maps, and postcontrast images of 22 patients with cardiac thrombus were retrospectively evaluated for SNR and CNR. SNR and CNR values of thrombus, blood pool, and myocardium measured at maps and contrast-enhanced images were compared with each other.

RESULTS

The distinguishability of thrombus from blood pool and myocardium was better on early gadolinium images (EGE) and late gadolinium enhanced (LGE) images than T1 and T2 mapping. The mean CNRs calculated to be the highest on EGE, followed by LGE and then maps.

CONCLUSION

Native mapping sequences may have a potential in detecting cardiac thrombus, but contrast-enhanced images are superior. In future studies, the optimal mapping sequence for evaluation of thrombus in noncontrast images can be determined by using different modified Look-Locker inversion recovery schemes or other T1 and T2 mapping methods.

PRECIS

CNR values of EGE and LGE remained higher than mapping sequences.

Circulating microRNA as promising biomarkers in hypertrophic cardiomyopathy: can advanced cardiac magnetic resonance unlock new insights in research?

Hypertrophic cardiomyopathy (HCM) is a genetic cardiac disorder associated with an increased risk of arrhythmias, heart failure, and sudden cardiac death. Current imaging and clinical markers are not fully sufficient in accurate diagnosis and patient risk stratification. Although known cardiac biomarkers in blood are used, they lack specificity for HCM and primarily stratify for death due to heart failure in overt cases. Non-coding RNAs, particularly microRNAs, have emerged as promising biomarkers due to their role in regulating gene expression in both healthy and pathological hearts. Circulating microRNA signatures may dynamically reflect the progression of HCM, offering potential utility in diagnosis and disease monitoring as well as inform biologic pathways for innovative therapeutic strategies. However, studying microRNAs in cardiovascular diseases is still in its early stages and poses many challenges. This review focuses on emerging research perspectives using advanced cardiac magnetic resonance techniques. We presume, that the search for circulating miR signatures associated with specific adverse myocardial features observed on cardiac magnetic resonance imaging - such as fibrosis, disarray, and microvascular disease - represents a promising direction in HCM research.

Role of advanced CMR features in identifying a positive genotype of hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiovascular disease that affects approximately one in 500 people. Cardiac magnetic resonance (CMR) imaging has emerged as a powerful tool for the non-invasive assessment of HCM. CMR can accurately quantify the extent and distribution of hypertrophy, assess the presence and severity of myocardial fibrosis, and detect associated abnormalities. We will study basic and advanced features of CMR in 2 groups of HCM patients with negative and positive genotype, respectively.

MATERIALS AND METHODS

The study population consisted in consecutive HCM patients referred to Centro Cardiologico Monzino who performed both CMR and genetic testing. Clinical CMR images were acquired at 1.5 T Discovery MR450 scanner (GE Healthcare, Milwaukee, Wisconsin)) using standardized protocols T1 mapping, T2 mapping and late gadolinium enhancement (LGE). Population was divided in 2 groups: group 1 with HCM patients with a negative genotype and group 2 with a positive genotype.

RESULTS

The analytic population consisted of 110 patients: 75 in group 1 and 35 patients in group 2. At CMR evaluation, patients with a positive genotype had higher LV mass (136 vs. 116 g, p = 0.02), LV thickness (17.5 vs. 16.9 mm), right ventricle ejection fraction (63 % vs. 58 %, p = 0.002). Regarding the LGE patients with positive genotype have a higher absolute (33.8 vs 16.7 g, p = 0.0003) and relative LGE mass (31.6 % vs 14.6 %, p = 0.0007). On a segmental analysis all the septum (segments 2, 8, 9, and 14) had a significantly increased native T1 compared to others segments. ECV in the mid antero and infero-septum (segments 8 and 9) have lower values in positive genotype HCM. Interestingly the mean T2 was lower in positive genotype HCM as compared to negative genotype HCM (50,1 ms vs 52,4).

CONCLUSIONS

Our paper identifies the mid septum (segments 8 and 9) as a key to diagnose a positive genotype HCM.

Feasibility of relaxation along a fictitious field in the 2nd rotating frame (TRAFF2) mapping in the human myocardium at 3 T

Purpose

Evaluate the feasibility of quantification of Relaxation Along a Fictitious Field in the 2nd rotating frame (RAFF2) relaxation times in the human myocardium at 3 T.

Methods

T RAFF 2 mapping was performed using a breath-held ECG-gated acquisition of five images: one without preparation, three preceded by RAFF2 trains of varying duration, and one preceded by a saturation prepulse. Pixel-wiseT RAFF 2 maps were obtained after three-parameter exponential fitting. The repeatability ofT RAFF 2 ,T 1 , andT 2 was assessed in phantom via the coefficient of variation (CV) across three repetitions. In seven healthy subjects,T RAFF 2 was tested for precision, reproducibility, inter-subject variability, and image quality (IQ) on a Likert scale (1 = Nondiagnostic, 5 = Excellent). Additionally,T RAFF 2 mapping was performed in three patients with suspected cardiovascular disease, comparing it to late gadolinium enhancement (LGE), nativeT 1 ,T 2 , and ECV mapping.

Results

In phantom,T RAFF 2 showed good repeatability (CV < 1.5%) while showing no ( R 2 = 0.09 ) and high ( R 2 = 0.99 ) correlation withT 1 andT 2 , respectively. MyocardialT RAFF 2 maps exhibited overall acceptable image quality (IQ = 3.0 ± 1.0) with moderate artifact levels, stemming from off-resonances near the coronary sinus. AverageT RAFF 2 time across subjects and repetitions was 79.1 ± 7.3 ms. Good precision (7.6 ± 1.4%), reproducibility (1.0 ± 0.6%), and low inter-subject variability (10.0 ± 1.8%) were obtained. In patients, visual agreement of the infarcted area was observed in theT RAFF 2 map and LGE.

Conclusion

MyocardialT RAFF 2 quantification at 3 T was successfully achieved in a single breath-hold with acceptable image quality, albeit with residual off-resonance artifacts. Nonetheless, preliminary clinical data indicate potential sensitivity ofT RAFF 2 mapping to myocardial infarction detection without the need for contrast agents, but off-resonance artifacts mitigation warrants further investigation.

Recent Progress of Cardiac MRI for Nuclear Medicine Professionals

Recent technical innovation enables faster and more reliable cardiac magnetic resonance (CMR) imaging than before. Artificial intelligence is used in improving image resolution, fast scanning, and automated analysis of CMR. Fast CMR techniques such as compressed sensing technique enable fast cine, perfusion, and late gadolinium-enhanced imaging and improve patient throughput and widening CMR indications. CMR feature-tracking technique gives insight on diastolic function parameters of ventricles and atria with prognostic implications. Myocardial parametric mapping became to be included in the routine CMR protocol. CMR fingerprinting enables simultaneous quantification of myocardial T1 and T2. These parameters may give information on myocardial alteration in the preclinical stages in various myocardial diseases. Four-dimensional flow imaging shows hemodynamic characteristics in or through the cardiovascular structures visually and gives quantitative values of vortex, kinetic energy, and wall-shear stress. In conclusion, CMR is an essential modality in the diagnosis of various cardiovascular diseases, especially myocardial diseases. Recent progress in CMR techniques promotes more widespread use of CMR in clinical practice. This review summarizes recent updates in CMR technologies and clinical research.

Myocardial fibrosis from the perspective of the extracellular matrix: Mechanisms to clinical impact

Fibrosis is defined by the excessive accumulation of extracellular matrix (ECM) and constitutes a central pathophysiological process that underlies tissue dysfunction, across organs, in multiple chronic diseases and during aging. Myocardial fibrosis is a key contributor to dysfunction and failure in numerous diseases of the heart and is a strong predictor of poor clinical outcome and mortality. The excess structural and matricellular ECM proteins deposited by cardiac fibroblasts, is found between cardiomyocytes (interstitial fibrosis), in focal areas where cardiomyocytes have died (replacement fibrosis), and around vessels (perivascular fibrosis). Although myocardial fibrosis has important clinical prognostic value, access to cardiac tissue biopsies for histological evaluation is limited. Despite challenges with sensitivity and specificity, cardiac magnetic resonance imaging (CMR) is the most applicable diagnostic tool in the clinic, and the scientific community is currently actively searching for blood biomarkers reflecting myocardial fibrosis, to complement the imaging techniques. The lack of mechanistic insights into specific pro- and anti-fibrotic molecular pathways has hampered the development of effective treatments to prevent or reverse myocardial fibrosis. Development and implementation of anti-fibrotic therapies is expected to improve patient outcomes and is an urgent medical need. Here, we discuss the importance of the ECM in the heart, the central role of fibrosis in heart disease, and mechanistic pathways likely to impact clinical practice with regards to diagnostics of myocardial fibrosis, risk stratification of patients, and anti-fibrotic therapy.

Cardiovascular imaging in cardio-oncology

Advances in cancer treatment have improved in patient survival rate. On the other hand, management of cardiovascular complications has been increasingly required in cancer patients. Thus, cardio-oncology has attracted the attention by both oncologists and cardiologists. Cardiovascular imaging has played a key role for non-invasive assessment of cardiovascular alterations complimentary to biomarkers and clinical assessment. Suitable imaging selection and interpretation may allow early diagnosis of cardiovascular injury with potential implications for therapeutic management and improved outcomes after cancer therapy. Echocardiography has been commonly used to evaluate cardiac dysfunction in cardio-oncology area. Cardiac CT is valuable for assessing structural abnormalities of the myocardium, coronary arteries, and aorta. Molecular imaging has an important role in the assessment of the pathophysiology and future treatment strategy of cardiovascular dysfunction. Cardiac MRI is valuable for characterization of myocardial tissue. PET and SPECT molecular imaging has potential roles for quantitative assessment of cardiovascular disorders. Particularly, FDG-PET is considered as an elegant approach for simultaneous assessment of tumor response to cancer therapy and early detection of possible cardiovascular involvement as well. This review describes the promising potential of these non-invasive cardiovascular imaging modalities in cardio-oncology.

Boys With Duchenne Muscular Dystrophy Have Diastolic Dysfunction Based on CMR

BACKGROUND

Cardiomyopathy is the leading cause of death in boys with Duchenne muscular dystrophy (DMD). While cardiac magnetic resonance (CMR) is routinely used to assess fibrosis and left ventricular (LV) ejection fraction, CMR measures of LV filling and ejection in DMD have not been reported.

METHODS

Patients with DMD (n=179) and healthy controls (n=96) were prospectively enrolled and underwent CMR. The DMD cohort was followed clinically at multiple institutions, and clinical data were recorded. Standard volumes and functions were calculated, and LV filling and ejection curves were measured from baseline CMR. Multivariable linear regressions were used to compare ventricular filling and ejection measures between groups, adjusting for baseline differences. Cox regressions were used to evaluate the relationship between diastolic function measures and mortality in the DMD cohort.

RESULTS

Patients with DMD had significantly smaller stature and ventricular volumes than healthy control patients (P<0.001). They had lower baseline LV ejection fraction (P<0.001), though most had normal systolic function. When adjusted for age, sex, heart rate, body surface area, and LV end-diastolic volume, patients with DMD had slower peak filling rates (P<0.001) and peak ejection rates (P<0.001), as well as slower time to peak ventricular ejection rate (P=0.011). When adjusted for heart rate, a lower peak ventricular ejection rate (P=0.007) and peak filling rate (P=0.033), normalized to LV end-diastolic volume, were associated with mortality in patients with DMD.

CONCLUSIONS

Patients with DMD have significantly different baseline CMR filling and ejection indices compared with controls. Some filling indices are associated with mortality and may be useful prognostic measures. Further research is needed in larger cohorts to determine the prognostic value of these differences.

Role of Cardiovascular Magnetic Resonance in the Assessment of Native Aortic Regurgitation With Insights on Mixed and Multiple Valvular Heart Disease: A Narrative Review

Cardiovascular magnetic resonance imaging (CMR) has received extensive validation for the assessment of valvular heart disease (VHD) and offers an accurate and direct method for the quantification of aortic regurgitation (AR). According to the current guidelines, CMR represents a useful second-line investigation in patients with poor acoustic windows or when echocardiography is inconclusive, for example, in cases of multiple or eccentric aortic jets. Without ionizing radiation exposure, CMR provides in-depth information not only on the severity degree of AR, providing a precise quantification of regurgitant volume and fraction, but also on cardiac structure and function, being recognized as the gold standard for the assessment of heart chamber size and systolic function. CMR allows a free choice of cardiac imaging planes and provides further information on the myocardium, thanks to the tissue characterization ability offered by several sequences, such as the late gadolinium enhancement technique. The possibilities offered by CMR become even more interesting in the context of mixed and multiple VHD, where the echocardiographic assessments often encounter difficulties in the quantification of each single valve lesion. The current scientific data support a greater expansion of CMR in this field, thanks to its additional advantages for the diagnosis, risk stratification, and to guide treatment. This review investigates the current CMR techniques and protocols in AR, with special insights into the evaluation of mixed aortic valve disease and multiple VHD including AR.

Extracellular Volume and Fibrosis Volume of Left Ventricular Myocardium Assessed by Cardiac Magnetic Resonance in Vaccinated and Unvaccinated Patients with a History of SARS-CoV-2 Infection

Cardiac magnetic resonance (CMR) enables the assessment of tissue characteristics of the myocardium. Changes in the extracellular volume (ECV) and fibrosis volume (FV) of the myocardium are sensitive and early pathogenetic markers and have prognostic significance. The aim of the study was to assess ECV and FV of left ventricular myocardium in T1 mapping sequence in patients with a history of SARS-CoV-2 infection, considering vaccination status against COVID-19. The study group consisted of 97 patients (52.54 ± 8.31 years, 53% women and 47% men). The participants were divided into three subgroups: A) patients with a history of symptomatic SARS-CoV-2 infection, unvaccinated against COVID-19 (n = 39), B) patients with a history of symptomatic SARS-CoV-2 infection, with a full vaccination schedule against COVID-19 (n = 22), and C) persons without a history of SARS-CoV-2 infection constituting the control subgroup (C, n = 36). All patients underwent 1.5 T cardiac magnetic resonance. In subgroup A compared to subgroups B and C, both the ECV whole myocardium and ECV segments 2, 5-6, 8, and 10-11 were statistically significantly higher. In addition, the ECV segment 16 was statistically significantly higher in subgroup A than in subgroup C. Also, the FV whole myocardium was statistically significantly higher in subgroup A in comparison to subgroups B and C. There were no significant differences in ECV and FV between subgroups B and C. In summary, unvaccinated against COVID-19 patients with a history of symptomatic SARS-CoV-2 infection have higher myocardial ECV and FV values in the T1 mapping sequence, compared to those without COVID-19 and those suffering from COVID-19, previously vaccinated with the full vaccination schedule.

Early detection of myocardial iron overload in patients with β-thalassemia major using cardiac magnetic resonance T1 mapping

BACKGROUND

The T2* technique, used for quantifying myocardial iron content (MIC), has limitations in detecting early myocardial iron overload (MIO). The in vivo mapping of the myocardial T1 relaxation time is a promising alternative for the early detection and management of MIO.

METHODS

32 β-thalassemia major (βTM) patients aged 11.5 ± 4 years and 32 healthy controls were recruited and underwent thorough clinical and laboratory assessments. The mid-level septal iron overload was measured through T1 mapping using a modified Look-Locker inversion recovery sequence with a 3 (3 s) 3 (3 s) 5 scheme. Septum was divided at the mentioned level into 3 zones corresponding to segments 8 and 9 in the cardiac segmentation model.

RESULTS

21.9 % of βTM had clinical cardiac morbidity. The cut-off of T1 mapping of hepatic and myocardium to differentiate between the patients and control groups was ≤466 and ≥ 923 ms respectively. The T1 technique was able to detect 4 patients with high MIC, two of them were not detected by the T2* technique. There was a statistically significant correlation between the average T1 values of the studied zones in patients with βTM and the liver iron content (LIC), the T1 values within segment 8 of the liver, age of patients, the age at first transfusion, age of splenectomy and serum ferritin value.

CONCLUSION

The addition of the T1 mapping sequence to the conventional T2* technique was able to increase the efficacy of the MIC detection protocol by earlier detection of MIO. This would guide chelation therapy to decrease myocardial morbidity.

Cardiovascular magnetic resonance in β-thalassemia major: beyond T2

Β-thalassemia major (TM) patients underwent regular transfusions to prevent complications of chronic anemia. However, these regular transfusions result in progressive iron accumulation in vital organs, including the heart. Myocardial iron overload can lead to cardiac dysfunction and ultimately to heart failure. Diagnosis of cardiac dysfunction in β-TM patients is usually made through clinical examination, electrocardiogram, and echocardiography. Cardiac magnetic resonance (CMR), through the measurement of T2* relaxation time, represents the diagnostic modality of choice for assessing myocardial iron overload and guiding the iron chelation therapy. Despite a tailored chelation therapy reducing myocardial iron overload, heart failure remains the leading cause of morbidity and mortality even in well-treated β-TM patients. Advances in CMR, including myocardial strain, parametric mapping (T1, T2, and extracellular volume), and late gadolinium enhancement (LGE) measurements, have expanded its role in the diagnosis, prognosis, and follow-up of these patients. This review seeks to offer a thorough overview of the potential uses of CMR in β-TM, extending beyond the established role of T2* measurement in guiding chelation therapy. It delves into the emerging applications of new CMR imaging biomarkers that could improve the overall management of β-TM patients.

Mechanistic insights into intrauterine adhesions

Intrauterine adhesions (IUA), also known as Asherman's syndrome, arise from damage to the basal layer of the endometrium, frequently caused by intrauterine interventions. This damage leads to nonregenerative healing of endometrium resulting in replacement by fibrous connective tissue, which bring about the adherence of opposing endometrium to render the uterine cavity and/or cervical canal partially or completely obliterated. IUA is a common cause of the refractory uterine infertility. Hysteroscopy is the gold standard for diagnosis of IUA. However, the method of accurately predicting the likelihood of achieving a live birth in the future remains established. Classical treatments have shown limited success, particularly in severe cases. Therefore, utilizing new research methods to deepen the understanding of the pathogenesis of IUA will facilitate the new treatment approaches to be found. In this article we briefly described the advances in the pathogenesis of IUA, with focus on inflammation and parenchymal cellular homeostasis disruption, defects in autophagy and the role of ferroptosis, and we also outlined the progress in IUA therapy.

Prognostic utility of exercise cardiovascular magnetic resonance in patients with systemic sclerosis-associated pulmonary arterial hypertension

AIMS

Systemic sclerosis complicated by pulmonary arterial hypertension (SSc-PAH) is a rare condition with poor prognosis. The majority of patients are categorized as intermediate risk of mortality. Cardiovascular magnetic resonance (CMR) is well placed to reproducibly assess right heart size and function, but most patients with SSc-PAH have less overtly abnormal right ventricles than other forms of PAH. The aim of this study was to assess if exercise CMR measures of cardiac size and function could better predict outcome in patients with intermediate risk SSc-PAH compared with resting CMR.

METHODS AND RESULTS

Fifty patients with SSc-PAH categorized as intermediate risk underwent CMR-augmented cardiopulmonary exercise testing. Most patients had normal CMR-defined resting measures of right ventricular (RV) size and function. Nine (18%) patients died during a median follow-up period of 2.1 years (range 0.1-4.6). Peak exercise RV indexed end-systolic volume (ESVi) was the only CMR metric to predict prognosis on stepwise Cox regression analysis, with an optimal threshold < 39 mL/m2 to predict favourable outcome. Intermediate-low risk patients with peak RVESVi < 39 mL/m2 had significantly better survival than all other combinations of intermediate-low/-high risk status and peak RVESVi< or ≥39 mL/m2. In our cohort, ventilatory efficiency and resting oxygen consumption (VO2) were predictive of mortality, but not peak VO2, peak cardiac output, or peak tissue oxygen extraction.

CONCLUSION

Exercise CMR assessment of RV size and function may help identify SSc-PAH patients with poorer prognosis amongst intermediate risk cohorts, even when resting CMR appears reassuring, and could offer added value to clinical PH risk stratification.

Clinical impact of novel cardiovascular magnetic resonance technology on patients with congenital heart disease: a scientific statement of the Association for European Pediatric and Congenital Cardiology and the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular magnetic resonance (CMR) imaging is recommended in patients with congenital heart disease (CHD) in clinical practice guidelines as the imaging standard for a large variety of diseases. As CMR is evolving, novel techniques are becoming available. Some of them are already used clinically, whereas others still need further evaluation. In this statement, the authors give an overview of relevant new CMR techniques for the assessment of CHD. Studies with reference values for these new techniques are listed in the Supplementary data online, supplement.

Assessing Acute Pericarditis with T1 Mapping: A Supportive Contrast-Free CMR Marker

OBJECTIVE

The purpose of this study was to explore the impact of pericardial T1 mapping as a potential supportive non-contrast cardiovascular magnetic resonance (CMR) parameter in the diagnosis of acute pericarditis. Additionally, we investigated the relationship between T1 mapping values in acute pericarditis patients and their demographic data, cardiovascular risk factors, clinical parameters, cardiac biomarkers, and cardiac function.

METHOD

This retrospective study included CMR scans in 35 consecutive patients with acute pericarditis (26 males, 45.54 ± 23.38 years). Moreover, we included 17 sex- and age-matched healthy controls (12 males, mean age 47.78 ±19.38 years). CMR-derived pericardial T1 mapping values, which included all pericardial structures within the pericardial layers-encompassing both pericardial effusion and pericardial layer thickness-were analyzed and compared between acute pericarditis patients and controls.

RESULTS

Compared to the matched control group, acute pericarditis patients demonstrated significantly lower pericardial T1 mapping values (2137 ms ± 519 vs. 3268 ms ± 362, p = 0.001). In the multivariable analysis, the pericardial T1 mapping value was independently associated with the severity of pericardial late gadolinium enhancement (LGE) (β coefficient = -3.271, p = 0.003). The receiver operating characteristic curve analysis showed that the diagnostic performance of pericardial T1 mapping in discriminating acute pericarditis patients was excellent, with an area under the curve of 0.97 (95% CI = 0.94-0.98), using a threshold of 2862.5 ms.

CONCLUSIONS

Pericardial T1 mapping values could serve as an additional non-contrast CMR parameter for identifying patients with acute pericarditis, demonstrating an independent association with the severity of pericardial LGE.

Cardiac risk and myocardial fibrosis assessment with cardiac magnetic resonance in patients with myotonic dystrophy

Introduction

Non-invasive evaluation of myocardial tissue is a major goal of cardiac imaging. This is the case of myocardial fibrosis which is crucial in many myocardial diseases. Cardiac extracellular volume (ECV) was shown to indicate myocardial fibrosis and early cardiac involvement. With this study, our objective is to evaluate ECV measured with cardiac magnetic resonance (CMR) in patients with myotonic dystrophy type 1 (DM1) and 2 (DM2) as potential imaging biomarkers of subclinical cardiac pathology, and its relationship with demographic and clinical parameters, ECG-derived measures of cardiac conduction, and neuromuscular performance status.

Materials and methods

We retrospectively analyzed 18 DM1 patients and 4 DM2 patients without apparent cardiac disease who had CMR at our center. Differences between independent distributions were evaluated using Mann-Whitney U test, while correlations were evaluated using Spearman's ρ.

Results

Global ECV in DM1 patients (median 28.36; IQR 24.81-29.77) was significantly higher (p = 0.0141) than in DM2 patients (median 22.93; IQR 21.25-24.35), and than that reported in literature in healthy subjects (p = 0.0374; median 25.60; IQR 19.90-31.90). Septal ECV was significantly higher (p = 0.0074) in DM1 (median 27.37; IQR 25.97-29.74) than in DM2 patients (median 22.46; 21.57-23.19). Global ECV showed a strong, positive correlation with septal ECV (ρ = 0.9282, p < 0.0001). We observed that DM1 women showed significantly higher global (p = 0.0012) and septal (p < 0.0001) ECV values compared to men.

Discussion

We found a significant increase in global and septal cardiac ECV in patients with DM1. These values might thus suggest that DM1 patients present an increased cardiovascular risk, mainly due to cardiac fibrosis, even in absence of overt cardiac pathology at other common cardiovascular exams. DM1 patients may also be at increased risk of early septal fibrosis, with important implications on the risk for fatal arrhythmias. In addition, our results suggest the presence of gender-related differences, with DM1 women being more prone to myocardial fibrosis. Physicians dealing with DM1 may consider CMR as a screening tool for the early identification of patients with increased cardiovascular risk.

AI-powered contrast-free cardiovascular magnetic resonance imaging for myocardial infarction

Cardiovascular magnetic (CMR) resonance is a versatile tool for diagnosing cardiovascular diseases. While gadolinium-based contrast agents are the gold standard for identifying myocardial infarction (MI), their use is limited in patients with allergies or impaired kidney function, affecting a significant portion of the MI population. This has led to a growing interest in developing artificial intelligence (AI)-powered CMR techniques for MI detection without contrast agents. This mini-review focuses on recent advancements in AI-powered contrast-free CMR for MI detection. We explore various AI models employed in the literature and delve into their strengths and limitations, paving the way for a comprehensive understanding of this evolving field.

Myocardial involvement in end-stage renal disease patients with anemia as assessed by cardiovascular magnetic resonance native T1 mapping: An observational study

Cardiovascular disease has become to the main cause of death in the patients with end-stage renal disease (ESRD), and anemia is associated with increased cardiovascular morbidity and mortality in these patients. This study aimed to explore the impact of anemia on myocardial fibrosis using T1 mapping technique in patients with ESRD. A total of 128 subjects including 98 ESRD patients (65 with anemia, 33 without anemia) and 30 normal controls were enrolled. All subjects were underwent cardiovascular magnetic resonance to obtain cardiac cine and T1 mapping images. As potential markers of fibrosis, native T1 values and global longitudinal strain derived by feature-tracking technique were compared. Differences between 3 groups were analyzed using one-way analysis of variance. Associations between variables were assessed by Pearson and Spearman correlation coefficient appropriately. An independent association was identified by the multiple stepwise linear regression analysis. Intraclass correlation was applied to assess observer variability. In all ESRD patients, native T1 values were significantly longer than those of normal controls (global T1, 1357 ± 42 ms vs 1275 ± 48 ms, P < .001). Global T1 value in ESRD patients with anemia was significantly higher (1375 ± 36 ms) compared to that in ESRD patients without anemia (1322 ± 25 ms) and normal controls (1275 ± 48 ms), respectively (all P < .001). Global T1 correlated with hemoglobin negatively (R= -0.499, P < .001). Multiple stepwise linear regression analysis presented the anemia is independently associated with global T1 (R = 0.607, P < .001). Global longitudinal strain was remarkably reduced in ESRD patients with anemia in comparison to those without anemia (P < .001). Diffuse myocardial fibrosis could be detected by native T1 mapping in ESRD patients with long-term anemia. Anemia is an important factor in myocardial fibrosis in ESRD patients, and the evaluation of myocardial involvement is worth considering for clinical management.

Differences in cardiac mechanics assessed by left ventricular hemodynamic forces in athletes and patients with hypertension

We sought to assess cardiac magnetic resonance derived left ventricular hemodynamic forces (HDF) in athletes compared to patients with hypertension. Sixty athletes and 48 hypertensive patients were studied. HDF were measured during the entire cardiac cycle, the systolic phase, suction, early LV filling, and atrial thrust. Statistical comparisons were made between athletes and hypertensive patients, and between endurance and strength athletes. The slope of the systolic ejection was higher in athletes compared to hypertensive patients (541.5 vs. 435 1/sec; p = 0.033). Athletes showed higher HDF during the first phase of systole (4.53 vs. 3.86; p = 0.047) and the systolic impulse (11.26 vs. 8.76; p = 0.045). Compared to hypertensive patients, the AUC of the elastic rebound in athletes was lower (-0.31 vs. -0.44; p = 0.011). Moreover, hypertensive patients had an abnormal suction as revealed by a divergent direction (apex-to-base) of the HDF. The atrial thrust was higher in hypertensive patients than in athletes (-0.31 vs. -0.05; p < 0.001). Compared to endurance athletes, strength athletes had a shorter duration of the systolic impulse (250 vs. 280 ms; p = 0.019) and higher AUC during the early LV filling (1.65 vs. 0.97; p = 0.016). We conclude that HDF allows distinction between the hemodynamic patterns of athletes and patients with hypertension.

Intravenous iron therapy results in rapid and sustained rise in myocardial iron content through a novel pathway

BACKGROUND AND AIMS

Intravenous iron therapies contain iron-carbohydrate complexes, designed to ensure iron becomes bioavailable via the intermediary of spleen and liver reticuloendothelial macrophages. How other tissues obtain and handle this iron remains unknown. This study addresses this question in the context of the heart.

METHODS

A prospective observational study was conducted in 12 patients receiving ferric carboxymaltose (FCM) for iron deficiency. Myocardial, spleen, and liver magnetic resonance relaxation times and plasma iron markers were collected longitudinally. To examine the handling of iron taken up by the myocardium, intracellular labile iron pool (LIP) was imaged in FCM-treated mice and cells.

RESULTS

In patients, myocardial relaxation time T1 dropped maximally 3 h post-FCM, remaining low 42 days later, while splenic T1 dropped maximally at 14 days, recovering by 42 days. In plasma, non-transferrin-bound iron (NTBI) peaked at 3 h, while ferritin peaked at 14 days. Changes in liver T1 diverged among patients. In mice, myocardial LIP rose 1 h and remained elevated 42 days after FCM. In cardiomyocytes, FCM exposure raised LIP rapidly. This was prevented by inhibitors of NTBI transporters T-type and L-type calcium channels and divalent metal transporter 1.

CONCLUSIONS

Intravenous iron therapy with FCM delivers iron to the myocardium rapidly through NTBI transporters, independently of reticuloendothelial macrophages. This iron remains labile for weeks, reflecting the myocardium's limited iron storage capacity. These findings challenge current notions of how the heart obtains iron from these therapies and highlight the potential for long-term dosing to cause cumulative iron build-up in the heart.

Myocardial Injury in Peritoneal Dialysis Patients Assessed by Multiparametric MRI: Relationship With Left Ventricular Phenotypes

BACKGROUND

Myocardial injury is common in end-stage renal disease (ESRD) patients, but the presence and severity of myocardial injury in different left ventricular (LV) phenotypes were still not fully explored.

PURPOSE

To evaluate myocardial tissue characteristics and deformation in ESRD patients on peritoneal dialysis separated into normal geometry, concentric remodeling, concentric left ventricular hypertrophy (LVH) and eccentric LVH patterns by multiparametric cardiac MRI.

STUDY TYPE

Prospective.

POPULATION

A total of 142 subjects, including 102 on peritoneal dialysis (69 males) and 40 healthy controls (27 males).

FIELD STRENGTH/SEQUENCE

At 3.0 T, cine sequence, T1 mapping and T2 mapping.

ASSESSMENT

LV mass index and LV remodeling index were used to create four subgroups with normal geometry, concentric remodeling, concentric LVH, and eccentric LVH. LV function, strain and strain rate, myocardial native T1 and T2 were measured.

STATISTICAL TESTS

Descriptive statistics, analysis of variance and analysis of covariance, Pearson/Spearman correlation, stepwise regression, and intraclass correlation coefficient. P-value <0.05 was considered statistically significant.

RESULTS

Even in normal geometry, LV strain parameters still diminished compared with the controls (global radial strain: 30.5 ± 7.7% vs. 37.1 ± 7.9%; global circumferential strain: -18.2 ± 2.6% vs. -20.6 ± 2.2%; global longitudinal strain: -13.3 ± 2.5% vs. -16.0 ± 2.8%). Eccentric LVH had significantly lower global circumferential systolic strain rate than concentric LVH (-0.82 ± 0.21%/-second vs. -0.96 ± 0.20%/-second). Compared with the controls, the four subgroups all revealed elevated native T1 and T2, especially in eccentric LVH, while concentric remodeling had the least changes including native T1, T2, and LV ejection fraction. After adjusting for covariates, there was no statistically significant difference in T2 between the four subgroups (P = 0.359).

DATA CONCLUSIONS

Eccentric LVH is associated with the most pronounced evidence of myocardial tissue characteristics and function impairment, while as a benign remodeling, the concentric remodeling subgroup had the least increase in native T1. This study further confirms that native T1 and strain indicators can reflect the severity of myocardial injury in ESRD, providing better histological and functional basis for future grouping treatments.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 3.

The Impact of Bariatric Surgery on Coronary Microvascular Function Assessed Using Automated Quantitative Perfusion CMR

BACKGROUND

Coronary microvascular function is impaired in patients with obesity, contributing to myocardial dysfunction and heart failure. Bariatric surgery decreases cardiovascular mortality and heart failure, but the mechanisms are unclear.

OBJECTIVES

The authors studied the impact of bariatric surgery on coronary microvascular function in patients with obesity and its relationship with metabolic syndrome.

METHODS

Fully automated quantitative perfusion cardiac magnetic resonance and metabolic markers were performed before and 6 months after bariatric surgery.

RESULTS

Compared with age- and sex-matched healthy volunteers, 38 patients living with obesity had lower stress myocardial blood flow (MBF) (P = 0.001) and lower myocardial perfusion reserve (P < 0.001). A total of 27 participants underwent paired follow-up 6 months post-surgery. Metabolic abnormalities reduced significantly at follow-up including mean body mass index by 11 ± 3 kg/m2 (P < 0.001), glycated hemoglobin by 9 mmol/mol (Q1-Q3: 4-19 mmol/mol; P < 0.001), fasting insulin by 142 ± 131 pmol/L (P < 0.001), and hepatic fat fraction by 5.6% (Q1-Q3: 2.6%-15.0%; P < 0.001). Stress MBF increased by 0.28 mL/g/min (Q1-Q3: -0.02 to 0.75 mL/g/min; P = 0.003) and myocardial perfusion reserve by 0.13 (Q1-Q3: -0.25 to 1.10; P = 0.036). The increase in stress MBF was lower in those with preoperative type 2 diabetes mellitus (0.1 mL/g/min [Q1-Q3: -0.09 to 0.46 mL/g/min] vs 0.75 mL/g/min [Q1-Q3: 0.31-1.25 mL/g/min]; P = 0.002). Improvement in stress MBF was associated with reduction in fasting insulin (beta = -0.45 [95% CI: -0.05 to 0.90]; P = 0.03).

CONCLUSIONS

Coronary microvascular function is impaired in patients with obesity, but can be improved significantly with bariatric surgery. Improvements in microvascular function are associated with improvements in insulin resistance but are attenuated in those with preoperative type 2 diabetes mellitus.

Photon-counting detector computed tomography in cardiac imaging

Photon-counting detector computed tomography (PCD-CT) has emerged as a revolutionary technology in CT imaging. PCD-CT offers significant advancements over conventional energy-integrating detector CT, including increased spatial resolution, artefact reduction and inherent spectral imaging capabilities. In cardiac imaging, PCD-CT can offer a more accurate assessment of coronary artery disease, plaque characterisation and the in-stent lumen. Additionally, it might improve the visualisation of myocardial fibrosis through qualitative late enhancement imaging and quantitative extracellular volume measurements. The use of PCD-CT in cardiac imaging holds significant potential, positioning itself as a valuable modality that could serve as a one-stop-shop by integrating both angiography and tissue characterisation into a single examination. Despite its potential, large-scale clinical trials, standardisation of protocols and cost-effectiveness considerations are required for its broader integration into clinical practice. This narrative review provides an overview of the current literature on PCD-CT regarding the possibilities and limitations of cardiac imaging.

Cardiac MRI in Rheumatic Disease

Immune-mediated systemic inflammatory disorders present a latent threat for cardiovascular disease. Early involvement may be associated with constitutional symptoms, while clinical evidence of disease may manifest later in an insidious manner. Multimodality imaging is crucial to detect myocardial involvement, with transthoracic echocardiogram as a first-line imaging modality; however, cardiac MRI (CMRI) has the potential to significantly impact our diagnostic and therapeutic approaches through high-fidelity chamber quantification and parametric mapping techniques. Novel imaging techniques are currently under investigation, including stress CMRI, feature tracking CMR, late gadolinium enhancement (LGE) entropy, and 4 dimensional flow CMRI.

Association Between Myocardial Oxygenation and Fibrosis in Duchenne Muscular Dystrophy: Analysis by Rest Oxygenation-Sensitive Magnetic Resonance Imaging

BACKGROUND

Myocardial hypoxia has been demonstrated in many cardiomyopathies and is related to development of myocardial fibrosis. However, myocardial hypoxia and its association with myocardial fibrosis are understudied in Duchenne muscular dystrophy (DMD)-associated cardiomyopathy.

PURPOSE

To evaluate myocardial hypoxia by oxygenation-sensitive (OS) cardiac magnetic resonance imaging, and further explore its association with fibrosis.

STUDY TYPE

Prospective.

SUBJECTS

Ninety-one DMD boys (8.78 ± 2.32) and 30 healthy boys (9.07 ± 2.30).

FIELD STRENGTH/SEQUENCE

3 T, Balanced steady-state free procession, Modified Look-Locker inversion recovery sequence and Single-shot phase-sensitive inversion recovery sequence.

ASSESSMENT

Cardiac MRI data, including left ventricular functional, segmental native T1, and oxygenation signal-intensity (SI) according to AHA 17-segment model, were acquired. Patients were divided into LGE+ and LGE- groups. In patients with LGE, all segments were further classified as positive or negative segments by segmentally presence/absence of LGE.

STATISTICAL TESTS

Variables were compared using Student's t, Wilcoxon, Kruskal-Wallis test and one-way analysis of variance. Bivariate Pearson or Spearman correlation were calculated to determine association between oxygenation SI and native T1. Variables with P < 0.10 in the univariable analysis were included in multivariable model. Receiver operating characteristic analysis was used to assess the performance of OS in diagnosing myocardial hypoxia.

RESULTS

The myocardial oxygenation SI of DMD was significantly decreased in all segments compared with normal controls, and more obvious in the LGE+ segments (0.46 ± 0.03 vs. 0.52 ± 0.03). For patients with and without LGE, myocardial oxygenation SI were significantly negatively correlated with native T1 in all segments (r = -0.23 to -0.42). The inferolateral oxygenation SI was a significant independent associator of LGE presence (adjusted OR = 0.900).

DATA CONCLUSION

Myocardial hypoxia evaluated by the OS-Cardiac-MRI indeed occurs in DMD and associate with myocardial fibrosis, which might be used as a biomarker in assessing myocardial damage in DMD.

EVIDENCE LEVEL

1 TECHNICAL EFFICACY: Stage 1.

Native skeletal muscle T1-time on cardiac magnetic resonance: A predictor of outcome in patients with heart failure with preserved ejection fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is associated with heart failure (HF) hospitalizations and death. Previous studies have shown that altered muscle composition is associated with higher risk of adverse outcome in HFpEF patients.

AIM

The purpose of our study was to investigate the association between skeletal muscle composition, as measured by skeletal muscle T1-times on cardiac magnetic resonance (CMR) imaging, and adverse outcome.

METHODS

We measured skeletal muscle T1-times of the back muscles on standard CMR images in a prospective cohort of HFpEF patients. Cox regression models were used to test the association of skeletal muscle T1-times and adverse outcome defined as hospitalization for HF and/or cardiovascular death.

RESULTS

We included 101 patients (mean age 72±7 years, 71 % female) in our study. The median skeletal muscle T1-times were 842 ms (IQR 806-881 ms). In univariate analysis high muscle T1-time was associated with adverse outcome (HR=1.96 [95 % CI, 1.31-2.94] per every 100 ms increase; p=.001). After adjustment for age, sex, body mass index, left- and right ventricular ejection fraction, N-terminal pro-brain natriuretic peptide and myocardial native T1-times, native skeletal muscle T1-time remained an independent predictor for adverse outcome (HR=1.94 [95 % CI, 1.24-3.03] per every 100 ms increase; p=.004).

CONCLUSION

In patients with HFpEF, high skeletal muscle T1-times on standard CMR scans are associated with higher rates of HF hospitalizations and cardiovascular death.

CONDENSED ABSTRACT

Skeletal muscle abnormalities are common in patients with heart failure with preserved ejection fraction (HFpEF). The present study evaluates skeletal muscle composition, as quantified by native skeletal muscle T1-times of the back muscles on standard cardiac magnetic resonance imaging, and assessed the association with adverse outcome, defined as hospitalization for heart failure and/or cardiovascular death. In a prospective cohort of 101 patients with HFpEF, we found that high native skeletal muscle T1-times are associated with an increased risk for adverse outcome. These findings suggest that native skeletal muscle T1-time may serve as marker for improved risk prediction.

Quantification of Replacement Fibrosis in Aortic Stenosis: A Narrative Review on the Utility of Cardiovascular Magnetic Resonance Imaging

Aortic stenosis (AS) is associated with the development of replacement myocardial fibrosis/scar. Given the dose-dependent relationship between scar and clinical outcomes after aortic valve replacement (AVR) surgery, scar quantity may serve as an important risk-stratification tool to aid decision-making on the optimal timing of AVR. Scar is non-invasively assessed and quantified by cardiovascular magnetic resonance (CMR) imaging. Several quantification techniques exist, and consensus on the optimal technique is lacking. These techniques range from a visual manual method to fully automated ones. This review describes the different scar quantification techniques used and highlights their strengths and shortfalls within the context of AS. The two most commonly used techniques in AS include the semi-automated signal threshold versus reference mean (STRM) and full-width half-maximum (FWHM) techniques. The accuracy and reproducibility of these techniques may be hindered in AS by the coexistence of diffuse interstitial fibrosis and the presence of relatively small, non-bright scars. The validation of these techniques against histology, which is the current gold standard for scar quantification in AS, is limited. Based on the best current evidence, the STRM method using a threshold of three standard deviations above the mean signal intensity of remote myocardium is recommended. The high reproducibility of the FWHM technique in non-AS cohorts has been shown and merits further evaluation within the context of AS. Future directions include the use of quantitative T1 mapping for the detection and quantification of scar, as well as the development of serum biomarkers that reflect the fibrotic status of the myocardium in AS.

CMR to characterize myocardial structure and function in heart failure with preserved left ventricular ejection fraction

Despite remarkable progress in therapeutic drugs, morbidity, and mortality for heart failure (HF) remains high in developed countries. HF with preserved ejection fraction (HFpEF) now accounts for around half of all HF cases. It is a heterogeneous disease, with multiple aetiologies, and as such poses a significant diagnostic challenge. Cardiac magnetic resonance (CMR) has become a valuable non-invasive modality to assess cardiac morphology and function, but beyond that, the multi-parametric nature of CMR allows novel approaches to characterize haemodynamics and with magnetic resonance spectroscopy (MRS), the study of metabolism. Furthermore, exercise CMR, when combined with lung water imaging provides an in-depth understanding of the underlying pathophysiological and mechanistic processes in HFpEF. Thus, CMR provides a comprehensive phenotyping tool for HFpEF, which points towards a targeted and personalized therapy with improved diagnostics and prevention.

Recent advances in positron emission tomography for detecting early fibrosis after myocardial infarction

Cardiac remodeling after myocardial infarction is one of the key factors affecting patient prognosis. Myocardial fibrosis is an important pathological link of adverse ventricular remodeling after myocardial infarction, and early fibrosis is reversible. Timely detection and intervention can effectively prevent its progression to irreversible ventricular remodeling. Although imaging modalities such as CMR and echocardiography can identify fibrosis, their sensitivity and specificity are limited, and they cannot detect early fibrosis or its activity level. Positron emission tomography (PET) allows non-invasive visualization of cellular and subcellular processes and can monitor and quantify molecules and proteins in the fibrotic pathway. It is valuable in assessing the extent of early myocardial fibrosis progression, selecting appropriate treatments, evaluating response to therapy, and determining the prognosis. In this article, we present a brief overview of mechanisms underlying myocardial fibrosis following myocardial infarction and several routine imaging techniques currently available for assessing fibrosis. Then, we focus on the application of PET molecular imaging in detecting fibrosis after myocardial infarction.

[Effect of Pulse Wave Synchronization on T1 Value in Cardiac T1 Mapping: Is Pulse Wave Synchronization a Substitute for Electrocardiogram Gating?]

PURPOSE

We investigated whether peripheral pulse synchronization (PPUS) can be an alternate method for electrocardiographic synchronization (ECGS) in measuring myocardial T1 values in cardiac magnetic resonance imaging (CMRI).

METHODS

T1 map imaging was performed on 49 patients undergoing CMRI using the 5s (3s) 3s modified Look-Locker inversion recovery (MOLLI) method for both ECGS and PPUS. The short-axis images of basal, mid, and apical segments were obtained. The T1 map images were analyzed using an image processing system, and T1 values were obtained for each cardiac segment. To assess the degree of agreement between T1 values obtained from ECGS and PPUS, the Bland-Altman analysis and the estimating intraclass correlation coefficient (ICC) were performed for the average T1 value of the entire myocardium and T1 values of each cardiac segment. Also, to evaluate whether PPUS imaging is possible in the diastole phase, we measured the length of systole in the electrocardiogram and the length of transmission (R-R') from R in the electrocardiogram to R (R') in the pulse waveform.

RESULTS

From the comparison of T1 values, a good agreement of ICC was confirmed between the ECGS and PPUS (whole myocardium: 0.97, apical: 0.93, mid: 0.98, and basal: 0.97). The results of the Bland-Altman analysis also indicated good agreement. Moreover, it was shown that the heart was imaged in the diastole phase even with the default scan parameters of PPUS.

CONCLUSION

Our results indicated that PPUS can be an alternate method for ECGS.

Usefulness of Native T1 in Cardiac Magnetic Resonance Imaging and Echocardiographic Strain Parameters for Detecting Early Cardiac Involvement in Fabry Cardiomyopathy

Background

Non-invasive diagnosis of disease stage in Fabry cardiomyopathy with multimodality imaging is pivotal when deciding on the appropriate time to initiate enzyme replacement therapy. However, this approach has not been well established.

Methods and Results

We enrolled 14 patients with Fabry disease. All patients were evaluated using echocardiography and contrast cardiac magnetic resonance (CMR), and were divided into either an early-stage group without left ventricular hypertrophy (LVH; wall thickness >12 mm) or late gadolinium enhancement (LGE; n=7; median age 37 years; 4 female), or an advanced-stage group with LVH and/or LGE (n=7; median age 66 years; 7 female). Strain data from echocardiography and T1 mapping on CMR were compared between the groups. In the advanced-stage group, all strain data were impaired. In the early-stage group, localized longitudinal strain in the basal posterolateral segment was already reduced but both localized and global circumferential strain remained preserved. On CMR analysis, global and localized native T1 shortening were observed in the early-stage group, but were pseudo-normalized in the advanced-stage group. In logistic regression analysis, localized circumferential strain had significant diagnostic value for differentiating between early- and advanced stage (P=0.037) and significantly improved the predictive power of the model containing localized native T1 in CMR.

Conclusions

A combination of localized native T1 in CMR and echocardiographic strain parameters could be useful for staging Fabry cardiomyopathy.

Native myocardial T1 and right ventricular size by CMR predict outcome in systemic sclerosis-associated pulmonary hypertension

OBJECTIVES

Measures of right heart size and function are prognostic in systemic sclerosis-associated pulmonary hypertension (SSc-PH), but the importance of myocardial tissue characterisation remains unclear. We aimed to investigate the predictive potential and interaction of cardiovascular magnetic resonance (CMR) myocardial tissue characterisation and right heart size and function in SSc-PH.

METHODS

A retrospective, single-centre, observational study of 148 SSc-PH patients confirmed by right heart catheterization who underwent clinically indicated CMR including native myocardial T1 and T2 mapping from 2016 to 2023 was performed.

RESULTS

Sixty-six (45%) patients died during follow-up (median 3.5 years, range 0.1-7.3). Patients who died were older (65 vs 60 years, P = 0.035) with more dilated (P < 0.001), hypertrophied (P = 0.013) and impaired (P < 0.001) right ventricles, more dilated right atria (P = 0.043) and higher native myocardial T1 (P < 0.001).After adjustment for age, indexed right ventricular end-systolic volume (RVESVi, P = 0.0023) and native T1 (P = 0.0024) were independent predictors of all-cause mortality. Both RVESVi and native T1 remained independently predictive after adjusting for age and PH subtype (RVESVi P < 0.001, T1 P = 0.0056). Optimal prognostic thresholds for RVESVi and native T1 were ≤38 mL/m2 and ≤1119 ms, respectively (P < 0.001). Patients with RVESVi ≤ 38 mL/m2 and native T1 ≤ 1119 ms had significantly better outcomes than all other combinations (P < 0.001). Furthermore, patients with RVESVi > 38mL/m2 and native T1 ≤ 1119 ms had significantly better survival than patients with RVESVi > 38mL/m2 and native T1 > 1119ms (P = 0.017).

CONCLUSION

We identified prognostically relevant CMR metrics and thresholds for patients with SSc-PH. Assessing myocardial tissue characterisation alongside right ventricular function confers added value in SSc-PH and may represent an additional treatment target.

Current understanding and management of cardiovascular involvement in rheumatic immune-mediated inflammatory diseases

Immune-mediated inflammatory diseases (IMIDs) are a spectrum of disorders of overlapping immunopathogenesis, with a prevalence of up to 10% in Western populations and increasing incidence in developing countries. Although targeted treatments have revolutionized the management of rheumatic IMIDs, cardiovascular involvement confers an increased risk of mortality and remains clinically under-recognized. Cardiovascular pathology is diverse across rheumatic IMIDs, ranging from premature atherosclerotic cardiovascular disease (ASCVD) to inflammatory cardiomyopathy, which comprises myocardial microvascular dysfunction, vasculitis, myocarditis and pericarditis, and heart failure. Epidemiological and clinical data imply that rheumatic IMIDs and associated cardiovascular disease share common inflammatory mechanisms. This concept is strengthened by emergent trials that indicate improved cardiovascular outcomes with immune modulators in the general population with ASCVD. However, not all disease-modifying therapies that reduce inflammation in IMIDs such as rheumatoid arthritis demonstrate equally beneficial cardiovascular effects, and the evidence base for treatment of inflammatory cardiomyopathy in patients with rheumatic IMIDs is lacking. Specific diagnostic protocols for the early detection and monitoring of cardiovascular involvement in patients with IMIDs are emerging but are in need of ongoing development. This Review summarizes current concepts on the potentially targetable inflammatory mechanisms of cardiovascular pathology in rheumatic IMIDs and discusses how these concepts can be considered for the diagnosis and management of cardiovascular involvement across rheumatic IMIDs, with an emphasis on the potential of cardiovascular imaging for risk stratification, early detection and prognostication.

Cardiac manifestations and outcomes of COVID-19 vaccine-associated myocarditis in the young in the USA: longitudinal results from the Myocarditis After COVID Vaccination (MACiV) multicenter study

Background

We aimed to study the clinical characteristics, myocardial injury, and longitudinal outcomes of COVID-19 vaccine-associated myocarditis (C-VAM).

Methods

In this longitudinal retrospective observational cohort multicenter study across 38 hospitals in the United States, 333 patients with C-VAM were compared with 100 patients with multisystem inflammatory syndrome in children (MIS-C). We included patients ≤30 years of age with a clinical diagnosis of acute myocarditis after COVID-19 vaccination based on clinical presentation, abnormal biomarkers and/or cardiovascular imaging findings. Demographics, past medical history, hospital course, biochemistry results, cardiovascular imaging, and follow-up information from April 2021 to November 2022 were collected. The primary outcome was presence of myocardial injury as evidenced by late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging.

Findings

Patients with C-VAM were predominantly white (67%) adolescent males (91%, 15.7 ± 2.8 years). Their initial clinical course was more likely to be mild (80% vs. 23%, p < 0.001) and cardiac dysfunction was less common (17% vs. 68%, p < 0.0001), compared to MIS-C. In contrast, LGE on CMR was more prevalent in C-VAM (82% vs. 16%, p < 0.001). The probability of LGE was higher in males (OR 3.28 [95% CI: 0.99, 10.6, p = 0.052]), in older patients (>15 years, OR 2.74 [95% CI: 1.28, 5.83, p = 0.009]) and when C-VAM occurred after the first or second dose as compared to the third dose of mRNA vaccine. Mid-term clinical outcomes of C-VAM at a median follow-up of 178 days (IQR 114-285 days) were reassuring. No cardiac deaths or heart transplantations were reported until the time of submission of this report. LGE persisted in 60% of the patients at follow up.

Interpretation

Myocardial injury at initial presentation and its persistence at follow up, despite a mild initial course and favorable mid-term clinical outcome, warrants continued clinical surveillance and long-term studies in affected patients with C-VAM.

Funding

The U.S. Food and Drug Administration.

Cardiovascular Magnetic Resonance Imaging of Takotsubo Syndrome: Evolving Diagnostic and Prognostic Perspectives

Takotsubo syndrome (TS) is a temporary form of left ventricular (LV) dysfunction characterized by a distinct pattern of LV impairment, often triggered by a physical or emotional stressful event. Historically, TS was considered a benign condition due to its prompt restoration of myocardial function and generally excellent outcomes. However, recent studies have shown that complications similar to those seen after myocardial infarction can occur, necessitating careful monitoring of these patients. Among noninvasive imaging techniques, cardiovascular magnetic resonance (CMR) is becoming increasingly important in evaluating patients with TS. CMR offers a unique ability to noninvasively assess myocardial tissue characteristics, allowing for detecting the typical features of TS, such as specific wall motion abnormalities and myocardial edema. Beyond its well-established diagnostic utility in the clinical management of TS, CMR has also proven valuable in prognosis and risk stratification for these patients. Advances in CMR, including myocardial strain and parametric mapping have expanded its role in the diagnosis, prognosis, and follow-up of these patients. This review aims to provide a comprehensive overview of the potential applications of CMR in the diagnostic and prognostic evaluation of TS patients. It explores the emerging use of novel CMR imaging biomarkers that may enhance diagnosis, improve prognostic accuracy, and contribute to the overall management of these patients.

Imaging to Facilitate Ventricular Tachycardia Ablation: Intracardiac Echocardiography, Computed Tomography, Magnetic Resonance, and Positron Emission Tomography

Catheter ablation is a well-established and effective strategy for the management of ventricular tachycardia (VT). However, the identification and characterization of arrhythmogenic substrates for targeted ablation remain challenging. Electrogram abnormalities and responses to pacing during VT provide the classical and most validated methods to identify substrates. However, the 3-dimensional nature of the myocardium, nonconductive tissue, and heterogeneous strands of conductive tissue at the border zones or through the nonconductive zones can prohibit easy electrical sampling and identification of the tissue critical to VT. Intracardiac echocardiography is critical for identification of anatomy, examination of catheter approach and contact, assessment of tissue changes during ablation, and even potential substrates as echogenic regions, but lacks specificity with regard to the latter compared with advanced modalities. In recent decades, cardiac magnetic resonance, computed tomography and positron emission tomography have emerged as valuable tools in the periprocedural evaluation of VT ablation. Cardiac magnetic resonance has unparalleled soft tissue and temporal resolution and excels at identification of expanded interstitial space caused by myocardial infarction, fibrosis, inflammation, or infiltrative myopathies. Computed tomography has excellent spatial resolution and is optimal for identification of anatomic variabilities including wall thickness, thrombus, and lipomatous metaplasia. Positron emission tomography excels at identification of substrates including amyloidosis, sarcoidosis, and other inflammatory substrates. These imaging modalities are vital for assessing arrhythmogenic substrates, guiding optimal access strategy, and assessing ablation efficacy. Although clearly beneficial in specific settings, further clinical trials are needed to enhance generalizability and optimize integration of cardiac imaging for VT ablation.

Visualising myocardial injury after noncardiac surgery: a case series using postoperative cardiovascular MRI

Myocardial injury after noncardiac surgery (MINS) and perioperative myocardial injury are associated with increased morbidity and mortality. Both are diagnosed by a perioperative increase in troponin, yet there is controversy if MINS is a genuine myocardial insult. We applied postoperative cardiovascular magnetic resonance T2 mapping techniques to visualise acute myocardial injury (i.e. oedema) in six patients with multiple cardiovascular risk factors who underwent aortic surgery. The burden of myocardial oedema was substantially higher in four patients with elevated troponin qualifying for MINS, compared with patients without MINS. The data and images suggest that MINS represents genuine myocardial injury.