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Rodríguez-González E, Martínez-Legazpi P, González-Mansilla A, Espinosa MÁ, Mombiela T, Guzmán De-Villoria JA, Borja MG, Díaz-Otero F, Gómez de Antonio R, Fernández-García P, Fernández-Ávila AI, Pascual-Izquierdo C, Del Álamo JC, Bermejo J. Cardiac stasis imaging, stroke, and silent brain infarcts in patients with nonischemic dilated cardiomyopathy. Am J Physiol Heart Circ Physiol 2024; 327:H446-H453. [PMID: 38847759 DOI: 10.1152/ajpheart.00245.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/23/2024] [Accepted: 05/31/2024] [Indexed: 07/17/2024]
Abstract
Cardioembolic stroke is one of the most devastating complications of nonischemic dilated cardiomyopathy (NIDCM). However, in clinical trials of primary prevention, the benefits of anticoagulation are hampered by the risk of bleeding. Indices of cardiac blood stasis may account for the risk of stroke and be useful to individualize primary prevention treatments. We performed a cross-sectional study in patients with NIDCM and no history of atrial fibrillation (AF) from two sources: 1) a prospective enrollment of unselected patients with left ventricular (LV) ejection fraction <45% and 2) a retrospective identification of patients with a history of previous cardioembolic neurological event. The primary end point integrated a history of ischemic stroke or the presence intraventricular thrombus, or a silent brain infarction (SBI) by imaging. From echocardiography, we calculated blood flow inside the LV, its residence time (TR) maps, and its derived stasis indices. Of the 89 recruited patients, 18 showed a positive end point, 9 had a history of stroke or transient ischemic attack (TIA) and 9 were diagnosed with SBIs in the brain imaging. Averaged TR, [Formula: see text] performed well to identify the primary end point [AUC (95% CI) = 0.75 (0.61-0.89), P = 0.001]. When accounting only for identifying a history of stroke or TIA, AUC for [Formula: see text] was 0.92 (0.85-1.00) with odds ratio = 7.2 (2.3-22.3) per cycle, P < 0.001. These results suggest that in patients with NIDCM in sinus rhythm, stasis imaging derived from echocardiography may account for the burden of stroke.NEW & NOTEWORTHY Patients with nonischemic dilated cardiomyopathy (NIDCM) are at higher risk of stroke than their age-matched population. However, the risk of bleeding neutralizes the benefit of preventive oral anticoagulation. In this work, we show that in patients in sinus rhythm, the burden of stroke is related to intraventricular stasis metrics derived from echocardiography. Therefore, stasis metrics may be useful to personalize primary prevention anticoagulation in these patients.
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Affiliation(s)
- Elena Rodríguez-González
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Medicine, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Pablo Martínez-Legazpi
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
- Department of Mathematical Physics and Fluids, Facultad de Ciencias, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | - Ana González-Mansilla
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Medicine, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - M Ángeles Espinosa
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Medicine, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Teresa Mombiela
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Medicine, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Juan A Guzmán De-Villoria
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Radiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
| | - Maria Guadalupe Borja
- Department of Mechanical and Aerospace Engineering, University of California San Diego, La Jolla, California, United States
| | - Fernando Díaz-Otero
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Neurology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rubén Gómez de Antonio
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Pilar Fernández-García
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
| | - Ana I Fernández-Ávila
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Medicine, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Cristina Pascual-Izquierdo
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Department of Hematology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Juan C Del Álamo
- Division of Cardiology, Department of Mechanical Engineering, Center for Cardiovascular Biology, University of Washington, Seattle, Washington, United States
| | - Javier Bermejo
- Department of Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Department of Medicine, Facultad de Medicina, Universidad Complutense, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
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Papapostolou S, Kearns J, Costello BT, O'Brien J, Rudman M, Thompson MC, Cloud G, Stub D, Taylor AJ. Assessing atrial myopathy with cardiac magnetic resonance imaging in embolic stroke of undetermined source. Int J Cardiol 2023; 389:131215. [PMID: 37499949 DOI: 10.1016/j.ijcard.2023.131215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/27/2023] [Accepted: 07/24/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Left atrial myopathy has been implicated in atrial fibrillation (AF)-related stroke and embolic stroke of undetermined source (ESUS). OBJECTIVE To use advanced cardiac magnetic resonance (CMR) imaging techniques, including left atrial (LA) strain and 4D flow CMR, to identify atrial myopathy in patients with ESUS. METHODS 20 patients with ESUS and no AF or other cause for stroke, and 20 age and sex-matched controls underwent CMR with 4D flow analysis. Markers of LA myopathy were assessed including LA size, volume, ejection fraction, and strain. 4D flow CMR was performed to measure novel markers of LA stasis such as LA velocities and the LA residence time distribution time constant (RTDtc). These markers of LA myopathy were compared between the two groups. RESULTS There was no significant difference in: CMR-calculated LA velocities or LA total, passive or active ejection fractions between the groups. There was no significant difference in CMR-derived reservoir, conduit or contractile average longitudinal strain between the ESUS and control groups (22.9 vs 22.6%, p=0.379, 11.2 ± 3.5 vs 12.4 ± 2.6% p=0.224, 10.8 ± 3.2 vs 10.4 ± 2.3%, p=0.625 respectively). Similarly, RTDtc was not significantly longer in ESUS patients compared to controls (1.3 ± 0.2 vs 1.2 ± 0.2, p=0.1). CONCLUSIONS There were no significant differences in any CMR marker of atrial myopathy in ESUS patients compared to healthy controls, likely reflecting the multiple possible aetiologies of ESUS suggesting that the role LA myopathy plays in ESUS is smaller than previously thought.
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Affiliation(s)
- Stavroula Papapostolou
- Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - John Kearns
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Victoria, Australia
| | - Benedict T Costello
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia; Western Health, Melbourne, Victoria, Australia
| | - Jessica O'Brien
- Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Murray Rudman
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Victoria, Australia
| | - Mark C Thompson
- Department of Mechanical and Aerospace Engineering, Monash University, Melbourne, Victoria, Australia
| | - Geoffrey Cloud
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Neurology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Dion Stub
- Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Andrew J Taylor
- Heart Centre, The Alfred Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia; Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.
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Roos PR, Rijnberg FM, Westenberg JJM, Lamb HJ. Particle Tracing Based on
4D
Flow Magnetic Resonance Imaging: A Systematic Review into Methods, Applications, and Current Developments. J Magn Reson Imaging 2022; 57:1320-1339. [PMID: 36484213 DOI: 10.1002/jmri.28540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Particle tracing based on 4D Flow MRI has been applied as a quantitative and qualitative postprocessing technique to study temporally evolving blood flow patterns. PURPOSE To systematically review the various methods to perform 4D Flow MRI-based particle tracing, as well as the clinical value, clinical applications, and current developments of the technique. STUDY TYPE The study type is systematic review. SUBJECTS Patients with cardiovascular disease (such as Marfan, Fontan, Tetralogy of Fallot), healthy controls, and cardiovascular phantoms that received 4D Flow MRI with particle tracing. FIELD STRENGTH/SEQUENCE Three-dimensional three-directional cine phase-contrast MRI, at 1.5 T and 3 T. ASSESSMENT Two systematic searches were performed on the PubMed database using Boolean operators and the relevant key terms covering 4D Flow MRI and particle tracing. One systematic search was focused on particle tracing methods, whereas the other on applications. Additional articles from other sources were sought out and included after a similar inspection. Particle tracing methods, clinical applications, clinical value, and current developments were extracted. STATISTICAL TESTS The main results of the included studies are summarized, without additional statistical analysis. RESULTS Of 127 unique articles retrieved from the initial search, 56 were included (28 for methods and 54 for applications). Most articles that described particle tracing methods used an adaptive timestep, a fourth order Runge-Kutta integration method, and linear interpolation in the time dimension. Particle tracing was applied in heart chambers, aorta, venae cavae, Fontan circulation, pulmonary arteries, abdominal vasculature, peripheral arteries, carotid arteries, and cerebral vasculature. Applications were grouped as intravascular, intracardiac, flow stasis, and research. DATA CONCLUSIONS Particle tracing based on 4D Flow MRI gives unique insight into blood flow in several cardiovascular diseases, but the quality depends heavily on the MRI data quality. Further studies are required to evaluate the clinical value of the technique for different cardiovascular diseases. EVIDENCE LEVEL 5. TECHNICAL EFFICACY Stage 1.
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Affiliation(s)
- Paul R. Roos
- Department of Radiology Leiden University Medical Center Leiden The Netherlands
| | - Friso M. Rijnberg
- Department of Cardiothoracic Surgery Leiden University Medical Center Leiden The Netherlands
| | | | - Hildo J. Lamb
- Department of Radiology Leiden University Medical Center Leiden The Netherlands
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Evaluation of Left Ventricular Function Using Four-Dimensional Flow Cardiovascular Magnetic Resonance: A Systematic Review. J Cardiovasc Dev Dis 2022; 9:jcdd9090304. [PMID: 36135449 PMCID: PMC9503592 DOI: 10.3390/jcdd9090304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
There is increasing recognition of the value of four-dimensional flow cardiovascular magnetic resonance (4D-flow MRI) as a potential means to detect and measure abnormal flow behaviour that occurs during early left ventricular (LV) dysfunction. We performed a systematic review of current literature on the role of 4D-flow MRI-derived flow parameters in quantification of LV function with a focus on potential clinical applicability. A comprehensive literature search was performed in March 2022 on available databases. A total of 1186 articles were identified, and 30 articles were included in the final analysis. All the included studies were ranked as “highly clinically applicable”. There was considerable variability in the reporting of methodologies and analyses. All the studies were small-scale feasibility or pilot studies investigating a diverse range of flow parameters. The most common primary topics of investigation were energy-related flow parameters, flow components and vortex analysis which demonstrated potentials for quantifying early diastolic dysfunction, whilst other parameters including haemodynamic forces, residence time distribution and turbulent kinetic energy remain in need of further evaluation. Systematic quantitative comparison of study findings was not possible due to this heterogeneity, therefore limiting the collective power of the studies in evaluating clinical applicability of the flow parameters. To achieve broader clinical application of 4D-flow MRI, larger scale investigations are required, together with standardisation of methodologies and analytical approach.
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Costello BT, Voskoboinik A, Qadri AM, Rudman M, Thompson MC, Touma F, La Gerche A, Hare JL, Papapostolou S, Kalman JM, Kistler PM, Taylor AJ. Measuring atrial stasis during sinus rhythm in patients with paroxysmal atrial fibrillation using 4 Dimensional flow imaging: 4D flow imaging of atrial stasis. Int J Cardiol 2020; 315:45-50. [PMID: 32439367 DOI: 10.1016/j.ijcard.2020.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/14/2020] [Accepted: 05/04/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Paroxysmal atrial fibrillation (PAF) is associated with cardioembolic risk, however events may occur during sinus rhythm (SR). 4D-flow cardiac magnetic resonance (CMR) imaging allows visualisation of left atrial blood flow, to determine the residence time distribution (RTD), an assessment of atrial transit time. OBJECTIVE To determine if atrial transit time is prolonged in PAF patients during SR, consistent with underlying atrial stasis. METHOD 91 participants with PAF and 18 healthy volunteers underwent 4D flow analysis in SR. Velocity fields were produced RTDs, calculated by seeding virtual 'particles' at the right upper pulmonary vein and counting them exiting the mitral valve. An exponential decay curve quantified residence time of particles in the left atrium, and atrial stasis was expressed as the derived constant (RTDTC) based on heartbeats. The RTDTC was evaluated within the PAF group, and compared to healthy volunteers. RESULTS Patients with PAF (n = 91) had higher RTDTC compared with gender-matched controls (n = 18) consistent with greater atrial stasis (1.68 ± 0.46 beats vs 1.51 ± 0.20 beats; p = .005). PAF patients with greater thromboembolic risk had greater atrial stasis (median RTDTC of 1.72 beats in CHA₂DS₂-VASc≥2 vs 1.52 beats in CHA₂DS₂-VASc<2; p = .03), only female gender and left ventricular ejection fraction contributed significantly to the atrial RTDTC (p = .006 and p = .023 respectively). CONCLUSIONS Atrial stasis quantified by 4D flow is greater in PAF, correlating with higher CHA₂DS₂-VASc scores. Female gender and systolic dysfunction are associated with atrial stasis. RTD offers an insight into atrial flow that may be developed to provide a personalised assessment of thromboembolic risk.
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Affiliation(s)
- Benedict T Costello
- Baker Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, The Alfred Hospital, Melbourne, Australia; Department of Cardiology, St Vincent's Hospital, Australia
| | - Aleksandr Voskoboinik
- Baker Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, The Alfred Hospital, Melbourne, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Abdul M Qadri
- Department of Mechanical and Aerospace Engineering, Monash University, Australia
| | - Murray Rudman
- Department of Mechanical and Aerospace Engineering, Monash University, Australia
| | - Mark C Thompson
- Department of Mechanical and Aerospace Engineering, Monash University, Australia
| | - Ferris Touma
- Heart Centre, The Alfred Hospital, Melbourne, Australia
| | - Andre La Gerche
- Baker Heart & Diabetes Institute, Melbourne, Australia; Department of Cardiology, St Vincent's Hospital, Australia
| | - James L Hare
- Baker Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, The Alfred Hospital, Melbourne, Australia
| | - Stavroula Papapostolou
- Baker Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, The Alfred Hospital, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Australia
| | - Peter M Kistler
- Baker Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, The Alfred Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Australia
| | - Andrew J Taylor
- Baker Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, The Alfred Hospital, Melbourne, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University.
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