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Shibata S, Wakeham DJ, Thomas JD, Abdullah SM, Platts S, Bungo MW, Levine BD. Cardiac Effects of Long-Duration Space Flight. J Am Coll Cardiol 2023; 82:674-684. [PMID: 37587578 DOI: 10.1016/j.jacc.2023.05.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/17/2023] [Accepted: 05/24/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Ventricular mass responds to changes in physical activity and loading, with cardiac hypertrophy after exercise training, and cardiac atrophy after sustained inactivity. Ventricular wall stress (ie, loading) decreases during microgravity. Cardiac atrophy does not plateau during 12 weeks of simulated microgravity but is mitigated by concurrent exercise training. OBJECTIVES The goal of this study was to determine whether the current exercise countermeasures on the International Space Station (ISS) offset cardiac atrophy during prolonged space flight. METHODS We measured left ventricular (LV) and right ventricular (RV) mass and volumes (via magnetic resonance imaging) in 13 astronauts (4 females; age 49 ± 4 years), between 75 and 60 days before and 3 days after 155 ± 31 days aboard the ISS. Furthermore, we assessed total cardiac work between 21 and 7 days before space flight and 15 days before the end of the mission. Data were compared via paired-samples t-tests. RESULTS Total cardiac work was lower during space flight (P = 0.008); however, we observed no meaningful difference in LV mass postflight (pre: 115 ± 30 g vs post: 118 ± 29 g; P = 0.053), with marginally higher LV stroke volume (P = 0.074) and ejection fraction postflight (P = 0.075). RV mass (P = 0.999), RV ejection fraction (P = 0.147), and ventricular end-diastolic (P = 0.934) and end-systolic volumes (P = 0.145) were not different postflight. There were strong positive correlations between the relative change in LV mass with the relative changes in total cardiac output (r = 0.73; P = 0.015) and total cardiac work (r = 0.53; P = 0.112). CONCLUSIONS The current exercise countermeasures used on the ISS appear effective in offsetting reductions in cardiac mass and volume, despite overall reductions in total cardiac work, during prolonged space flight.
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Affiliation(s)
- Shigeki Shibata
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas, USA; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Denis J Wakeham
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas, USA; University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | | | - Michael W Bungo
- University of Texas Health Science Center, Houston, Texas, USA
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, Texas, USA; University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Thut T, Valsangiacomo Büchel E, Geiger J, Kellenberger CJ, Rücker B, Burkhardt BEU. Signal Thresholding Segmentation of Ventricular Volumes in Young Patients with Various Diseases-Can We Trust the Numbers? Diagnostics (Basel) 2023; 13:diagnostics13020180. [PMID: 36672990 PMCID: PMC9857934 DOI: 10.3390/diagnostics13020180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/14/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
In many cardiac diseases, right and left ventricular volumes in systole and diastole are diagnostically and prognostically relevant. Measurements are made by segmentation of the myocardial borders on cardiac magnetic resonance (CMR) images. Automatic detection of myocardial contours is possible by signal thresholding techniques, but must be validated before use in clinical settings. Biventricular volumes were measured in end-diastole (EDVi) and in end-systole (ESVi) both manually and with the MassK application, with signal thresholds at 30%, 50%, and 70%. Stroke volumes (SV) and cardiac indices (CI) were calculated from volumetric measurements and from flow measured in the ascending aorta and the main pulmonary artery, and both methods were compared. Reproducibility of volumetric measurements was tested in 20 patients. Measurements were acquired in 94 patients aged 15 ± 9 years referred for various conditions. EDVi and ESVi of both ventricles were largest with manual segmentation and inversely proportional to the MassK threshold. Manual and k30 SV and CI corresponded best to flow measurements. Interobserver variability was low for all volumes manually and with MassK. In conclusion, manual and 30% threshold-based biventricular volume segmentation agree best with two-dimensional, phantom-corrected phase contrast flow measurements in a young cardiac referral population and are well reproducible.
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Affiliation(s)
- Titus Thut
- Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 3032 Zurich, Switzerland
| | - Emanuela Valsangiacomo Büchel
- Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 3032 Zurich, Switzerland
| | - Julia Geiger
- Children’s Research Center, University Children’s Hospital Zurich, 3032 Zurich, Switzerland
- Department of Diagnostic Imaging, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Christian Johannes Kellenberger
- Children’s Research Center, University Children’s Hospital Zurich, 3032 Zurich, Switzerland
- Department of Diagnostic Imaging, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Beate Rücker
- Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 3032 Zurich, Switzerland
| | - Barbara Elisabeth Ursula Burkhardt
- Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, 3032 Zurich, Switzerland
- Correspondence:
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Yano K, Toyama Y, Iida T, Hayashi K, Takahashi K, Kanda H. Comparison of Right Ventricular Function Between Three-Dimensional Transesophageal Echocardiography and Pulmonary Artery Catheter. J Cardiothorac Vasc Anesth 2020; 35:1663-1669. [PMID: 33268041 DOI: 10.1053/j.jvca.2020.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aimed to compare measurements of right ventricular function using three-dimensional transesophageal echocardiography (3D TEE), and pulmonary artery catheters (PACs) in patients undergoing cardiac surgery. The authors examined the practicality of using the 3D TEE. DESIGN Prospective observational. SETTING Cardiac operating room at a single university hospital. PARTICIPANTS All adult patients undergoing elective cardiac surgery at a single tertiary care university hospital over two years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), stroke volume (SV), and right ventricular ejection fraction (RVEF) were measured with both 3D TEE and PACs. Assessments were performed using correlation coefficients, paired t tests, and Bland-Altman plots. Thirty-one patients participated in this study. Each measurement showed good agreement. RVEDV and RVESV were slightly lower on 3D TEE than on PAC (205.9 mL v 220.2 mL, p = 0.0018; 143.0 mL v 155.5 mL, p = 0.0143, respectively), whereas no significant differences were observed for SV and RVEF (31.0% v 31.1%, p = 0.0569; 61.6 mL v 66.9 mL, p = 0.92, respectively). Linear regression analysis showed high correlation between 3D TEE and PAC for RVEDV (r = 0.87) and RVESV (r = 0.81), and moderate correlation for SV (r = 0.67) and RVEF (r = 0.67). In the Bland-Altman plot, most patients were within the 95% limits of the agreement throughout all measurements. CONCLUSION A high correlation was found between measurements made with a PAC and with 3D TEE in the assessment of right ventricular function. Three-dimensional TEE would be a potential alternative to PAC for assessment of right ventricular function during intraoperative periods.
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Affiliation(s)
- Kiichi Yano
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan.
| | - Yuki Toyama
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Takafumi Iida
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Kentaro Hayashi
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Keiya Takahashi
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
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Abstract
Cardiac magnetic resonance (CMR) imaging is an effective method for noninvasively imaging the heart which in the last two decades impressively enhanced spatial and temporal resolution and imaging speed, broadening its spectrum of applications in cardiovascular disease. CMR imaging techniques are designed to noninvasively assess cardiovascular morphology, ventricular function, myocardial perfusion, tissue characterization, flow quantification and coronary artery disease. These intrinsic features yield CMR suitable for diagnosis, follow-up and longitudinal monitoring after treatment of cardiovascular diseases. The aim of this paper is to review the technical basis of CMR, from cardiac imaging planes to cardiac imaging sequences.
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Abstract
The purpose of this study was to evaluate a semi-automatic right ventricle segmentation method on short-axis cardiac cine MR images which segment all right ventricle contours in a cardiac phase using one seed contour. Twenty-eight consecutive short-axis, four-chamber, and tricuspid valve view cardiac cine MRI examinations of healthy volunteers were used. Two independent observers performed the manual and automatic segmentations of the right ventricles. Analyses were based on the ventricular volume and ejection fraction of the right heart chamber. Reproducibility of the manual and semi-automatic segmentations was assessed using intra- and inter-observer variability. Validity of the semi-automatic segmentations was analyzed with reference to the manual segmentations. The inter- and intra-observer variability of manual segmentations were between 0.8 and 3.2%. The semi-automatic segmentations were highly correlated with the manual segmentations (R2 0.79-0.98), with median difference of 0.9-4.8% and of 3.3% for volume and ejection fraction parameters, respectively. In comparison to the manual segmentation, the semi-automatic segmentation produced contours with median dice metrics of 0.95 and 0.87 and median Hausdorff distance of 5.05 and 7.35 mm for contours at end-diastolic and end-systolic phases, respectively. The inter- and intra-observer variability of the semi-automatic segmentations were lower than observed in the manual segmentations. Both manual and semi-automatic segmentations performed better at the end-diastolic phase than at the end-systolic phase. The investigated semi-automatic segmentation method managed to produce a valid and reproducible alternative to manual right ventricle segmentation.
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Krumm P, Krauß S, Mangold S, Zitzelsberger T, Klumpp BD, Nikolaou K, Nieß AM, Kramer U, Burgstahler C. Mid-term development of the right ventricle in competitive athletes. Acta Radiol 2018; 59:1422-1430. [PMID: 29566549 DOI: 10.1177/0284185118764203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Long-term intensive training induces physiological, morphological, and functional adaption of the athlete's heart. PURPOSE To evaluate the development of athlete's heart during a mid-term follow-up of competitive athletes using cardiac magnetic resonance (CMR). MATERIAL AND METHODS Eighteen competitive long-distance runners and triathletes (age 43 ± 13 years, 3 women) were prospectively examined in a longitudinal follow-up study 5.05 ± 0.6 years after baseline. CMR at 1.5-T was performed for functional and late gadolinium enhancement (LGE) imaging. Left ventricular (LV) and right ventricular (RV) end-diastolic volume (LVEDV, RVEDV) as well as ejection fraction (LVEF, RVEF), LV myocardial mass (LVMM), and atrial sizes were determined and compared to baseline in matched pairs statistics for paired difference. RESULTS LVEDV (197 ± 38 mL vs. 196 ± 38 mL, paired difference -0.9 mL, P = 0.7) and LVEF (62 ± 7% vs. 62 ± 5%, paired difference 0.1%, P = 0.9) did not change during the follow-up period, whereas LVMM increased significantly (149 ± 31 g vs.164 ± 32 g, paired difference 14 g, P < 0.0001). RVEDV significantly increased from 221 ± 47 mL at baseline to 230 ± 52 mL (paired difference 10 mL, P = 0.0033). RVEF decreased from baseline 57 ± 8% to 53 ± 7% (paired difference -3%, P = 0.0234). Left atrial size showed no significant changes (24 ± 5 cm2 vs. 25 ± 6 cm2, paired difference 0.5 cm2, P = 0.17) and right atrial size increased significantly (30 ± 5 cm2 vs. 32 ± 4 cm2, paired difference 2 cm2, P = 0.0054). CONCLUSION This study supports the theory of ongoing remodeling in an athlete's heart. Predominantly the right heart can further enlarge in a mid-term period. This response seems not linearly dependent on a steady, decreased, or increased training volume.
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Affiliation(s)
- Patrick Krumm
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Stefan Krauß
- Department of Internal Medicine V, Sports Medicine, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Stefanie Mangold
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Tanja Zitzelsberger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Bernhard D Klumpp
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Department of Radiology, Rems-Murr-Clinic, Winnenden, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Andreas M Nieß
- Department of Internal Medicine V, Sports Medicine, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Ulrich Kramer
- Department of Diagnostic and Interventional Radiology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Department of Radiology, Rems-Murr-Clinic, Winnenden, Germany
| | - Christof Burgstahler
- Department of Internal Medicine V, Sports Medicine, Eberhard Karls University of Tübingen, Tübingen, Germany
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Konstam MA, Kiernan MS, Bernstein D, Bozkurt B, Jacob M, Kapur NK, Kociol RD, Lewis EF, Mehra MR, Pagani FD, Raval AN, Ward C. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e578-e622. [DOI: 10.1161/cir.0000000000000560] [Citation(s) in RCA: 335] [Impact Index Per Article: 55.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background and Purpose:
The diverse causes of right-sided heart failure (RHF) include, among others, primary cardiomyopathies with right ventricular (RV) involvement, RV ischemia and infarction, volume loading caused by cardiac lesions associated with congenital heart disease and valvular pathologies, and pressure loading resulting from pulmonic stenosis or pulmonary hypertension from a variety of causes, including left-sided heart disease. Progressive RV dysfunction in these disease states is associated with increased morbidity and mortality. The purpose of this scientific statement is to provide guidance on the assessment and management of RHF.
Methods:
The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through September 2017. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or reference to contemporary clinical practice recommendations.
Results:
Chronic RHF is associated with decreased exercise tolerance, poor functional capacity, decreased cardiac output and progressive end-organ damage (caused by a combination of end-organ venous congestion and underperfusion), and cachexia resulting from poor absorption of nutrients, as well as a systemic proinflammatory state. It is the principal cause of death in patients with pulmonary arterial hypertension. Similarly, acute RHF is associated with hemodynamic instability and is the primary cause of death in patients presenting with massive pulmonary embolism, RV myocardial infarction, and postcardiotomy shock associated with cardiac surgery. Functional assessment of the right side of the heart can be hindered by its complex geometry. Multiple hemodynamic and biochemical markers are associated with worsening RHF and can serve to guide clinical assessment and therapeutic decision making. Pharmacological and mechanical interventions targeting isolated acute and chronic RHF have not been well investigated. Specific therapies promoting stabilization and recovery of RV function are lacking.
Conclusions:
RHF is a complex syndrome including diverse causes, pathways, and pathological processes. In this scientific statement, we review the causes and epidemiology of RV dysfunction and the pathophysiology of acute and chronic RHF and provide guidance for the management of the associated conditions leading to and caused by RHF.
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Atlas-Based Computational Analysis of Heart Shape and Function in Congenital Heart Disease. J Cardiovasc Transl Res 2018; 11:123-132. [PMID: 29294215 DOI: 10.1007/s12265-017-9778-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 12/18/2017] [Indexed: 12/18/2022]
Abstract
Approximately 1% of all babies are born with some form of congenital heart defect. Many serious forms of CHD can now be surgically corrected after birth, which has led to improved survival into adulthood. However, many patients require serial monitoring to evaluate progression of heart failure and determine timing of interventions. Accurate multidimensional quantification of regional heart shape and function is required for characterizing these patients. A computational atlas of single ventricle and biventricular heart shape and function enables quantification of remodeling in terms of z scores in relation to specific reference populations. Progression of disease can then be monitored effectively by longitudinal evaluation of z scores. A biomechanical analysis of cardiac function in relation to population variation enables investigation of the underlying mechanisms for developing pathology. Here, we summarize recent progress in this field, with examples in single ventricle and biventricular congenital pathologies.
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Karakus G, Zencirci E, Degirmencioglu A, Güvenc TS, Unal Aksu H, Yildirim A. Easily measurable, noninvasive, and novel finding for pulmonary hypertension: Hypertrophy of the basal segment of septomarginal trabeculation of right ventricle. Echocardiography 2017; 34:290-295. [DOI: 10.1111/echo.13461] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Gultekin Karakus
- Department of Cardiology; Acibadem Maslak Hospital; Istanbul Turkey
| | - Ertugrul Zencirci
- Department of Cardiology; Acibadem University School of Medicine; Istanbul Turkey
| | - Aleks Degirmencioglu
- Department of Cardiology; Acibadem University School of Medicine; Istanbul Turkey
| | - Tolga Sinan Güvenc
- Department of Cardiology; Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Center Training and Research Hospital; Istanbul Turkey
| | - Hale Unal Aksu
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital; Istanbul Turkey
| | - Aydin Yildirim
- Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital; Istanbul Turkey
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10
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Chaturvedi A, Whitnah J, Maki JH, Baran T, Mitsumori LM. Horizontal Long Axis Imaging Plane for Evaluation of Right Ventricular Function on Cardiac Magnetic Resonance Imaging. J Clin Imaging Sci 2017; 6:52. [PMID: 28123842 PMCID: PMC5209858 DOI: 10.4103/2156-7514.197076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 11/14/2016] [Indexed: 11/10/2022] Open
Abstract
Purpose: The purpose of this study was to evaluate a horizontal long axis (HLA) magnetic resonance imaging (MRI) plane aligned to the long axis of the right ventricular (RV) cavity for functional analysis by comparing the measurement variability and time required for the analysis with that using a short-axis (SAX) image orientation. Materials and Methods: Thirty-four cardiac MRI exams with cine balanced steady-state free precession image stacks in both the SAX and the HLA of the RV (RHLA) were evaluated. Two reviewers independently traced RV endocardial borders on each image of the cine stacks. The time required to complete each set of traces was recorded, and the RV end-diastolic volume, end-systolic volume, and ejection fraction were calculated. Analysis times and RV measurements were compared between the two orientations. Results: Analysis time for each reviewer was significantly shorter for the RHLA stack (reviewer 1 = 6.4 ± 1.8 min, reviewer 2 = 6.0 ± 3.3 min) than for the SAX stack (7.5 ± 2.1 and 6.9 ± 3.6 min, respectively; P < 0.002). Bland–Altman analysis revealed lower mean differences, limits of agreement, and coefficients of variation for RV measurements obtained with the RHLA stack. Conclusions: RV functional analysis using a RHLA stack resulted in shorter analysis times and lower measurement variability than for a SAX stack orientation.
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Affiliation(s)
- Abhishek Chaturvedi
- Department of Radiology, University of Washington School of Medicine, 1959 Pacific Street, Seattle, WA, USA; Department of Imaging Sciences, University of Rochester, 601 Elmwood Avenue, Rochester, NY, USA
| | - Joseph Whitnah
- Department of Radiology, University of Washington School of Medicine, 1959 Pacific Street, Seattle, WA, USA
| | - Jeffrey H Maki
- Department of Radiology, University of Washington School of Medicine, 1959 Pacific Street, Seattle, WA, USA
| | - Timothy Baran
- Department of Imaging Sciences, University of Rochester, 601 Elmwood Avenue, Rochester, NY, USA
| | - Lee M Mitsumori
- Department of Radiology, University of Washington School of Medicine, 1959 Pacific Street, Seattle, WA, USA; Department of Radiology, Straub Clinic and Hospital, Honolulu, HI, NY, USA
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Schantz DI, Dragulescu A, Memauri B, Grotenhuis HB, Seed M, Grosse-Wortmann L. Effect of hydration status on atrial and ventricular volumes and function in healthy adult volunteers. Pediatr Radiol 2016; 46:1520-7. [PMID: 27492341 DOI: 10.1007/s00247-016-3656-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/11/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Assessment of cardiac chamber volumes is a fundamental part of cardiac magnetic resonance (CMR) imaging. While the effects of inter- and intraobserver variability have been studied and have a recognized effect on the comparability of serial cardiac MR imaging studies, the effect of differences in hydration status has not been evaluated. OBJECTIVE To evaluate the effects of volume administration on cardiac chamber volumes. MATERIALS AND METHODS Thirteen healthy adults underwent a baseline cardiac MR to evaluate cardiac chamber volumes after an overnight fast. They were then given two saline boluses of 10 ml/kg of body weight and the cardiac MR was repeated immediately after each bolus. RESULTS From the baseline scan to the final scan there was a significant increase in all four cardiac chamber end-diastolic volumes. Right atrial volumes increased 8.0%, from 61.1 to 66.0 ml/m2 (P<0.001), and left atrial volumes increased 10.0%, from 50.0 to 55.0 ml/m2 (P<0.001). Right ventricular volumes increased 6.0%, from 91.1 to 96.5 ml/m2 (P<0.001), and left ventricular volumes increased 3.2%, from 87.0 to 89.8 ml/m2 (P<0.001). CONCLUSION Hydration status has a significant effect on the end-diastolic volumes of all cardiac chambers assessed by cardiac MR. Thus, hydration represents a "variable" that should be taken into account when assessing cardiac chamber volumes, especially when performing serial imaging studies in a patient.
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Affiliation(s)
- Daryl I Schantz
- The Labatt Family Heart Centre in the Department of Paediatrics, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada.
- Variety Children's Heart Centre, University of Manitoba, FE241-685 William Avenue, Winnipeg, MB, Canada.
| | - Andreea Dragulescu
- The Labatt Family Heart Centre in the Department of Paediatrics, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada
| | - Brett Memauri
- Department of Radiology, St. Boniface General Hospital, University of Manitoba, Winnipeg, MB, Canada
| | - Heynric B Grotenhuis
- The Labatt Family Heart Centre in the Department of Paediatrics, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada
- Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Mike Seed
- The Labatt Family Heart Centre in the Department of Paediatrics, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lars Grosse-Wortmann
- The Labatt Family Heart Centre in the Department of Paediatrics, The Hospital for Sick Children, 555 University Ave., Toronto, ON, M5G 1X8, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada
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12
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D’Errico L, Lamacie MM, Jimenez Juan L, Deva D, Wald RM, Ley S, Hanneman K, Thavendiranathan P, Wintersperger BJ. Effects of slice orientation on reproducibility of sequential assessment of right ventricular volumes and ejection fraction: short-axis vs transverse SSFP cine cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2016; 18:60. [PMID: 27658396 PMCID: PMC5034656 DOI: 10.1186/s12968-016-0282-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/08/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Test-retest reproducibility is of utmost importance in follow-up of right ventricular (RV) volumes and function; optimal slice orientation though is not yet known. We compared test-retest reproducibility and intra-/inter-observer variability of right ventricular (RV) volumes and function assessed with short-axis and transverse cardiovascular magnetic resonance (CMR). METHODS Eighteen volunteers underwent cine CMR for RV assessment obtaining ventricular coverage in short-axis and transverse slice orientation. Additional 2D phase contrast flow imaging of the main pulmonary artery (MPA) was performed. After complete repositioning repeat acquisitions were performed. Data sets were contoured by two blinded observers. Statistical analysis included Student's t-test, Bland-Altman plots, intra-class correlation coefficient (ICC) and 2-way ANOVA, SEM and minimal detectable difference calculations. RESULTS Heart rates (65.0 ± 7.4 vs. 67.6 ± 9.9 bpm; P = 0.1) and MPA flow (89.8 ± 16.6 vs. 87.2 ± 14.9 mL; P = 0.1) did not differ between imaging sessions. EDV and ESV demonstrated an inter-study bias of 0.4 %[-9.5 %,10.3 %] and 2.1 %[-12.3 %,16.4 %] for short-axis and 1.1 %[-7.3 %,9.4 %] and 0.8 %[-16.0 %,17.6 %] for transverse orientation, respectively. There was no significant interaction between imaging orientation and interstudy reproducibility (p = 0.395-0.824), intra-observer variability (p = 0.726-0.862) or inter-observer variability (p = 0.447-0.706) by 2-way ANOVA. Inter-observer agreement by ICC was greater for short axis versus transverse orientation for all parameters (0.769-0.986 vs. 0.625-0.983, respectively). Minimal detectable differences for short axis and transverse orientations were 10.1 mL/11.5 mL for EDV, 8.3 mL/8.4 mL for ESV and 4.1 % vs. 4.7 % for EF, respectively. CONCLUSION Short-axis and transverse orientation both provide reliable and reproducible measures for follow-up of RV volumes and global function. Therefore, additional transverse SSFP cine CMR may not necessarily be required if performed for the sole purpose of quantitative volumetric RV assessment.
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Affiliation(s)
- Luigia D’Errico
- Department of Medical Imaging, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Mariana M. Lamacie
- Department of Medical Imaging, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Laura Jimenez Juan
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Department of Medical Imaging, Sunnybrook Health Science Centre, Toronto, Canada
| | - Djeven Deva
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Department of Medical Imaging, St. Michaels Hospital, Toronto, Canada
| | - Rachel M. Wald
- Department of Medical Imaging, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Sebastian Ley
- Department of Medical Imaging, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Kate Hanneman
- Department of Medical Imaging, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Paaladinesh Thavendiranathan
- Department of Medical Imaging, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Bernd J. Wintersperger
- Department of Medical Imaging, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
- Department of Medical Imaging, Toronto General Hospital, 1 PMB-273, 585 University Avenue, M5G 2N2 Toronto, ON Canada
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Influence of the short-axis cine acquisition protocol on the cardiac function evaluation: A reproducibility study. Eur J Radiol Open 2016; 3:60-6. [PMID: 27069981 PMCID: PMC4811847 DOI: 10.1016/j.ejro.2016.03.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 03/16/2016] [Accepted: 03/18/2016] [Indexed: 01/20/2023] Open
Abstract
Evaluate several scan protocols for cardiac MRI analysis. Assess inter and intra observer variability for the selection of the best protocol. Consistency in the scan protocol is essential for study comparison. For biventricular studies, short-axis slices should be perpendicular to septum.
Purpose To define the optimal cardiac short-axis cine acquisition protocol for the assessment of the left and rightventricular functions. Materials and methods 20 volunteers were recruited and breath-hold CINE images were acquired on a Siemens Prisma 3T MRI. Four short-axis acquisition planes were defined from the 4-chamber view. AV Junctions: short-axis slices parallel to the plane that cuts through the external right and left atrioventricular junctions. Left AV Junctions: short-axis slices parallel to the plane that cuts through both left atrioventricular junctions. Septum: short-axis slices perpendicular to the septum with one cutting through the septum junction. LongAxis: short-axis slices perpendicular to the long axis with one cutting through the septum junction. Intra and inter reproducibility was assessed using Bland-Altman coefficient of variation (CV) and Lin’s concordance correlation coefficient (CCC). The influence of the protocol on the ejection fraction (EF) and stroke volume (SV) was quantified statistically using pair-wise CV and Pearson’s correlation coefficient R2. Results All protocols led to high reproducibility for the LV EF (mean intra CV = 3.83%, mean inter CV = 4.81%, lowest CV = 4.20% (AV junctions) and highest CV = 5.24% (Left AV Junctions)). Reproducibility of the RV measurements was lower (mean intra CV = 7.84%, mean inter CV = 9.17%). Septum protocol led to significantly lower variability compared to the other 3 protocols for RV EF (CV = 7.62% (Septum), CV = 8.42% (Long Axis), CV = 9.54% (Left AV Junctions) and CV = 11.08% (AV Junctions) with Lin’s CCC varying from 0.4 (AV Junctions) to 0.69 (Septum) for inter-observer reproducibility). No differences in group average for clinical parameters was found for both LV and RV clinical measurements. However, patient-specific RV EF evaluation is dependent on the chosen protocol (CV = 9.95%, R2 = 0.52). Conclusion Based on the results of the study cine mode short-axis acquisitions should be planned perpendicular to the septum in order to guarantee optimal RV and LV measurements.
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Wasemiller S, Earle T, Kashner M, Foster G, Silvet H. Right Ventricular Ejection Fraction in Ischemic Versus Nonischemic Cardiomyopathy. Am J Cardiol 2016; 117:278-81. [PMID: 26684512 DOI: 10.1016/j.amjcard.2015.10.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
Abstract
The relation between the etiology of cardiomyopathy and the function of the right ventricle (RV) has not been well described in the current era of 3-dimensional cardiac imaging. New advances in cardiac imaging with computed tomography (CT) have allowed accurate measurements of ejection fraction (EF), often a challenging task considering the unique RV shape. We evaluated 130 patients at the Loma Linda Veterans Affairs Healthcare System with cardiomyopathy and a left ventricular (LV) EF ≤ 40%. Etiology of cardiomyopathy was determined by CT angiography as ischemic (n = 56) or nonischemic (n = 74). RV volumes and RVEF were calculated based on 3-dimensional data set from CT images. Baseline LVEF was similar with a mean LVEF of 28% (± 6%) in the ischemic group and 28% (± 9%) in the nonischemic group (p = 0.46). RV function and volumes were moderately decreased in both cohorts, without significant difference between the groups (mean RVEF 34 ± 11% in ischemic group and 32 ± 10% in nonischemic group, p = 0.26). In conclusion, most patients with LV dysfunction also have RV dysfunction. The degree of RV dysfunction is not dependent on the etiology of cardiomyopathy.
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Affiliation(s)
| | - Tiffany Earle
- Loma Linda University Health, Loma Linda, California
| | - Michael Kashner
- Loma Linda University Health, Loma Linda, California; Veterans Affairs Loma Linda Healthcare System, Loma Linda, California
| | - Gary Foster
- Loma Linda University Health, Loma Linda, California; Veterans Affairs Loma Linda Healthcare System, Loma Linda, California
| | - Helme Silvet
- Loma Linda University Health, Loma Linda, California; Veterans Affairs Loma Linda Healthcare System, Loma Linda, California
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15
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Trzebiatowska-Krzynska A, Driessen M, Sieswerda GT, Wallby L, Swahn E, Meijboom F. Knowledge-based 3D reconstruction of the right ventricle: comparison with cardiac magnetic resonance in adults with congenital heart disease. Echo Res Pract 2015; 2:109-16. [PMID: 26796613 PMCID: PMC4677647 DOI: 10.1530/erp-15-0029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 11/11/2015] [Indexed: 11/10/2022] Open
Abstract
Aim Assessment of right ventricular (RV) function is a challenge, especially in patients with congenital heart disease (CHD). The aim of the present study is to assess whether knowledge-based RV reconstruction, used in the everyday practice of an echo-lab for adult CHD in a tertiary referral center, is accurate when compared to cardiac magnetic resonance (CMR) examination. Subjects and methods Adult patients who would undergo CMR for assessment of the RV were asked to undergo an echo of the heart for further knowledge-based reconstruction (KBR). Echocardiographic images were acquired in standard views using a predefined imaging protocol. RV volumes and ejection fraction (EF) calculated using knowledge-based technology were compared with the CMR data of the same patient. Results Nineteen consecutive patients with congenital right heart disease were studied. Median age of the patients was 28 years (range 46 years). Reconstruction was possible in 16 out of 19 patients (85%). RV volumes assessed with this new method were smaller than with CMR. Indexed end diastolic volumes were 114±17 ml vs 121±19 ml, P<0.05 and EFs were 45±8% vs 47±9%, P<0.05 respectively. The correlation between the methods was good with an intraclass correlation of 0.84 for EDV and 0.89 for EF, P value <0.001 in both cases. Conclusion KBR enables reliable measurement of RVs in patients with CHDs and can be used in clinical practice for analysis of volumes and EFs.
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Affiliation(s)
- Aleksandra Trzebiatowska-Krzynska
- Department of Cardiology and Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden; Department of Cardiology, AHMazON Center for Adult Congenital Heart Disease, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mieke Driessen
- Department of Cardiology, AHMazON Center for Adult Congenital Heart Disease, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Gertjan Tj Sieswerda
- Department of Cardiology, AHMazON Center for Adult Congenital Heart Disease, University Medical Center Utrecht , Utrecht , The Netherlands
| | - Lars Wallby
- Department of Cardiology and Department of Medicine and Health Sciences, Linköping University , Linköping , Sweden
| | - Eva Swahn
- Department of Cardiology and Department of Medicine and Health Sciences, Linköping University , Linköping , Sweden
| | - Folkert Meijboom
- Department of Cardiology, AHMazON Center for Adult Congenital Heart Disease, University Medical Center Utrecht , Utrecht , The Netherlands
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Evaluation of ventricular dysfunction using semi-automatic longitudinal strain analysis of four-chamber cine MR imaging. Int J Cardiovasc Imaging 2015; 32:283-289. [DOI: 10.1007/s10554-015-0771-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 09/15/2015] [Indexed: 10/23/2022]
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17
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Karakus G, Kammerlander AA, Aschauer S, Marzluf BA, Zotter-Tufaro C, Bachmann A, Degirmencioglu A, Duca F, Babayev J, Pfaffenberger S, Bonderman D, Mascherbauer J. Pulmonary artery to aorta ratio for the detection of pulmonary hypertension: cardiovascular magnetic resonance and invasive hemodynamics in heart failure with preserved ejection fraction. J Cardiovasc Magn Reson 2015; 17:79. [PMID: 26318496 PMCID: PMC4553215 DOI: 10.1186/s12968-015-0184-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 08/16/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Previous work indicates that dilatation of the pulmonary artery (PA) itself or in relation to the ascending aorta (PA:Ao ratio) predicts pulmonary hypertension (PH). Whether these results also apply for heart failure with preserved ejection fraction (HFpEF) is unknown. In the present study we evaluated the diagnostic and prognostic power of PA diameter and PA:Ao ratio on top of right ventricular (RV) size, function, and septomarginal trabeculation (SMT) thickness by cardiovascular magnetic resonance (CMR) in HFpEF. METHODS AND RESULTS 159 consecutive HFpEF patients were prospectively enrolled. Of these, 111 underwent CMR and invasive hemodynamic evaluation. By invasive assessment 64 % of patients suffered from moderate/severe PH (mean pulmonary artery pressure (mPAP) ≥30 mmHg). Significant differences between groups with and without moderate/severe PH were observed with respect to PA diameter (30.9 ± 5.1 mm versus 26 ± 5.1 mm, p < 0.001), PA:Ao ratio (0.93 ± 0.16 versus 0.78 ± 0.14, p < 0.001), and SMT diameter (4.6 ± 1.5 mm versus 3.8 ± 1.2 mm; p = 0.008). The strongest correlation with mPAP was found for PA:Ao ratio (r = 0.421, p < 0.001). By ROC analysis the best cut-off for the detection of moderate/severe PH was found for a PA:Ao ratio of 0.83. Patients were followed for 22.0 ± 14.9 months. By Kaplan Meier analysis event-free survival was significantly worse in patients with a PA:Ao ratio ≥0.83 (log rank, p = 0.004). By multivariable Cox-regression analysis PA:Ao ratio was independently associated with event-free survival (p = 0.003). CONCLUSION PA:Ao ratio is an easily measureable noninvasive indicator for the presence and severity of PH in HFpEF, and it is related with outcome.
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Affiliation(s)
| | - Andreas A Kammerlander
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Aschauer
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | | | - Caroline Zotter-Tufaro
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alina Bachmann
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | | | - Franz Duca
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Jamil Babayev
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Stefan Pfaffenberger
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Diana Bonderman
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Julia Mascherbauer
- Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Free-Breathing 3D Imaging of Right Ventricular Structure and Function Using Respiratory and Cardiac Self-Gated Cine MRI. BIOMED RESEARCH INTERNATIONAL 2015; 2015:819102. [PMID: 26185764 PMCID: PMC4491385 DOI: 10.1155/2015/819102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 09/26/2014] [Accepted: 10/07/2014] [Indexed: 11/20/2022]
Abstract
Providing a movie of the beating heart in a single prescribed plane, cine MRI has been widely used in clinical cardiac diagnosis, especially in the left ventricle (LV). Right ventricular (RV) morphology and function are also important for the diagnosis of cardiopulmonary diseases and serve as predictors for the long term outcome. The purpose of this study is to develop a self-gated free-breathing 3D imaging method for RV quantification and to evaluate its performance by comparing it with breath-hold 2D cine imaging in 7 healthy volunteers. Compared with 2D, the 3D RV functional measurements show a reduction of RV end-diastole volume (RVEDV) by 10%, increase of RV end-systole volume (RVESV) by 1.8%, reduction of RV systole volume (RVSV) by 21%, and reduction of RV ejection fraction (RVEF) by 12%. High correlations between the two techniques were found (RVEDV: 0.94; RVESV: 0.85; RVSV: 0.95; and RVEF: 0.89). Compared with 2D, the 3D image quality measurements show a small reduction in blood SNR, myocardium-blood CNR, myocardium contrast, and image sharpness. In conclusion, the proposed self-gated free-breathing 3D cardiac cine imaging technique provides comparable image quality and correlated functional measurements to those acquired with the multiple breath-hold 2D technique in RV.
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19
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Park EA, Lee W, Kim HK, Chung JW. Effect of papillary muscles and trabeculae on left ventricular measurement using cardiovascular magnetic resonance imaging in patients with hypertrophic cardiomyopathy. Korean J Radiol 2015; 16:4-12. [PMID: 25598670 PMCID: PMC4296277 DOI: 10.3348/kjr.2015.16.1.4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 11/05/2014] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate the influence of papillary muscles and trabeculae on left ventricular (LV) cardiovascular magnetic resonance (CMR) analysis using three methods of cavity delineation (classic or modified inclusion methods, and the exclusion method) in patients with hypertrophic cardiomyopathy (HCM). Materials and Methods This retrospective study included 20 consecutive HCM patients who underwent 1.5-T CMR imaging with short-axis cine stacks of the entire LV. LV measurements were performed using three different methods of manual cavity delineation of the endocardial and epicardial contours: method A, presumed endocardial boundary as seen on short-axis cine images; method B, including solely the cavity and closely adjacent trabeculae; or method C, excluding papillary muscles and trabeculae. Ascending aorta forward flow was measured as reference for LV-stroke volume (SV). Interobserver reproducibility was assessed using intraclass correlation coefficients. Results Method A showed larger end-diastole and end-systole volumes (largest percentage differences of 25% and 68%, respectively, p < 0.05), compared with method C. The ejection fraction was 55.7 ± 6.9% for method A, 68.6 ± 8.4% for B, and 71.7 ± 7.0% for C (p < 0.001). Mean mass was also significantly different: 164.6 ± 47.4 g for A, 176.5 ± 50.5 g for B, and 199.6 ± 53.2 g for C (p < 0.001). LV-SV error was largest with method B (p < 0.001). No difference in interobserver agreement was observed (p > 0.05). Conclusion In HCM patients, LV measurements are strikingly different dependent on whether papillary muscles and trabeculae are included or excluded. Therefore, a consistent method of LV cavity delineation may be crucial during longitudinal follow-up to avoid misinterpretation and erroneous clinical decision-making.
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Affiliation(s)
- Eun-Ah Park
- Department of Radiology, Cardiovascular Division, Seoul National University Hospital, Seoul 110-744, Korea
| | - Whal Lee
- Department of Radiology, Cardiovascular Division, Seoul National University Hospital, Seoul 110-744, Korea
| | - Hyung-Kwan Kim
- Department of Internal Medicine, Cardiovascular Division, Seoul National University Hospital, Seoul 110-744, Korea
| | - Jin Wook Chung
- Department of Radiology, Cardiovascular Division, Seoul National University Hospital, Seoul 110-744, Korea
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Quick S, Speiser U, Kury K, Schoen S, Ibrahim K, Strasser R. Evaluation and classification of right ventricular wall motion abnormalities in healthy subjects by 3-tesla cardiovascular magnetic resonance imaging. Neth Heart J 2014; 23:64-9. [PMID: 25339203 PMCID: PMC4268217 DOI: 10.1007/s12471-014-0620-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Right ventricular (RV) shape and function serves as an indicator in several types of heart disease such as arrhythmogenic right ventricular dysplasia (ARVD). However, there is no in-depth knowledge of RV motion, even in healthy subjects. The aim of our study was to provide a quantitative analysis of normal variations in RV wall motion in healthy subjects by cardiac magnetic resonance imaging (CMRI). MATERIAL AND METHODS The study population consisted of 65 consecutive patients referred for the evaluation of cardiac function by 3 Tesla CMR. Balanced steady-state free-precession images were obtained and areas of disordered RV wall motion were evaluated and classified based on a standardised segmental model for the right ventricle. RESULTS In 59 patients (90.8 %) wall motion abnormalities (WMA) of the right ventricle were evident. WMA were predominately detected in the apicolateral segments (72 %) compared with mediolateral (24 %, P < 0.001) and inferolateral segments (4 %, P < 0.001). Dyskinesia was the most frequent wall motion disorder (62.4 %), followed by hypokinesia (20.8 %) and bulging (16.8 %). The mean WMA diameter in the transverse plane (6.4 ± 1.9 mm) was significantly shorter compared with the diameter in the horizontal long-axis (8.1 ± 3.6 mm, P = 0.002) and short-axis plane (10.7 ± 4.6 mm). CONCLUSION WMA of the right ventricle are common. Therefore, one should be aware that these nonpathological wall motion disorders can easily be mistaken for a pathological regional wall motion contraction, particularly in ARVD where to date, clear wall motion criteria are lacking.
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Affiliation(s)
- S Quick
- Department of Internal Medicine and Cardiology, Technische Universitaet Dresden Heart Center University Hospital, Fetscherstr 76, 01307, Dresden, Germany,
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21
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Affiliation(s)
- E E van der Wall
- Holland Heart House/Netherlands Society of Cardiology, Moreelsepark 1, 3511 EP, Utrecht, the Netherlands,
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22
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Quantitative magnetic resonance imaging of pulmonary hypertension: a practical approach to the current state of the art. J Thorac Imaging 2014; 29:68-79. [PMID: 24552882 DOI: 10.1097/rti.0000000000000079] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Pulmonary hypertension is a condition of varied etiology, commonly associated with poor clinical outcome. Patients are categorized on the basis of pathophysiological, clinical, radiologic, and therapeutic similarities. Pulmonary arterial hypertension (PAH) is often diagnosed late in its disease course, with outcome dependent on etiology, disease severity, and response to treatment. Recent advances in quantitative magnetic resonance imaging (MRI) allow for better initial characterization and measurement of the morphologic and flow-related changes that accompany the response of the heart-lung axis to prolonged elevation of pulmonary arterial pressure and resistance and provide a reproducible, comprehensive, and noninvasive means of assessing the course of the disease and response to treatment. Typical features of PAH occur primarily as a result of increased pulmonary vascular resistance and the resultant increased right ventricular (RV) afterload. Several MRI-derived diagnostic markers have emerged, such as ventricular mass index, interventricular septal configuration, and average pulmonary artery velocity, with diagnostic accuracy similar to that of Doppler echocardiography. Furthermore, prognostic markers have been identified with independent predictive value for identification of treatment failure. Such markers include large RV end-diastolic volume index, low left ventricular end-diastolic volume index, low RV ejection fraction, and relative area change of the pulmonary trunk. MRI is ideally suited for longitudinal follow-up of patients with PAH because of its noninvasive nature and high reproducibility and is advantageous over other biomarkers in the study of PAH because of its sensitivity to change in morphologic, functional, and flow-related parameters. Further study on the role of MRI image based biomarkers in the clinical environment is warranted.
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Bourantas CV, Loh HP, Bragadeesh T, Rigby AS, Lukaschuk EI, Garg S, Tweddel AC, Alamgir FM, Nikitin NP, Clark AL, Cleland JG. Relationship between right ventricular volumes measured by cardiac magnetic resonance imaging and prognosis in patients with chronic heart failure. Eur J Heart Fail 2014; 13:52-60. [DOI: 10.1093/eurjhf/hfq161] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Christos V. Bourantas
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Huan P. Loh
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Thanjavur Bragadeesh
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Alan S. Rigby
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Elena I. Lukaschuk
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Scot Garg
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Ann C. Tweddel
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Farqad M. Alamgir
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Nikolay P. Nikitin
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - Andrew L. Clark
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
| | - John G.F. Cleland
- Department of Cardiology, Academic Unit; University of Hull; Kingston-upon-Hull PO Box HU16 5JQ UK
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Widya RL, Hammer S, Boon MR, van der Meer RW, Smit JWA, de Roos A, Rensen PCN, Lamb HJ. Effects of short-term nutritional interventions on right ventricular function in healthy men. PLoS One 2013; 8:e76406. [PMID: 24086738 PMCID: PMC3781057 DOI: 10.1371/journal.pone.0076406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 08/26/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A physiological model of increased plasma nonesterified fatty acid (NEFA) levels result in myocardial triglyceride (TG) accumulation, which is related to cardiac dysfunction. A pathophysiological model of increased plasma NEFA levels result in hepatic steatosis, which has been linked to abnormal myocardial energy metabolism. Hepatic steatosis is accompanied by hepatic inflammation, reflected by plasma cholesteryl ester transfer protein (CETP) levels. The current study aimed to investigate effects of these models via different nutritional interventions on right ventricular (RV) function. METHODS Fifteen men (age 25.0±6.6 years) were included and underwent magnetic resonance imaging and spectroscopy in this prospective crossover intervention study. RV function, myocardial and hepatic TG content, and CETP levels were assessed on three occasions: after normal diet, very low-calorie diet (VLCD, physiological model) and high-fat high-energy (HFHE, pathophysiological model) diet (all 3-days diets, randomly ordered, washout phase at least 14 days). RESULTS VLCD induced a decrease in mean E deceleration by 27%. Myocardial TG content increased by 55%, whereas hepatic TG content decreased by 32%. Plasma CETP levels decreased by 14% (all P<0.05). HFHE diet induced a decrease in E/A by 19% (P<0.05). Myocardial TG content did not change, whereas hepatic TG content increased by 112% (P<0.01). Plasma CETP levels increased by 14% (P<0.05). CONCLUSIONS These findings show that RV diastolic function is impaired after short-term VLCD and HFHE diet in healthy men, respectively a physiological and a pathophysiological model of increased plasma NEFA levels. After short-term VLCD, myocardial lipotoxicity may be of importance in decreased RV diastolic function. RV diastolic dysfunction is accompanied by increased hepatic TG content and plasma CETP levels after short-term HFHE diet, suggesting that systemic inflammation reflecting local macrophage infiltration in the heart may be involved in RV dysfunction.
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Affiliation(s)
- Ralph L. Widya
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, the Netherlands
- * E-mail:
| | - Sebastiaan Hammer
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mariëtte R. Boon
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Johannes W. A. Smit
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert de Roos
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Patrick C. N. Rensen
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J. Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
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Bertaso AG, Richardson JD, Wong DT, Cunnington MS, Nelson AJ, Tayeb H, Williams K, Chew DP, Worthley MI, Teo KS, Worthley SG. Prognostic value of adenosine stress perfusion cardiac MRI with late gadolinium enhancement in an intermediate cardiovascular risk population. Int J Cardiol 2013; 167:2055-60. [DOI: 10.1016/j.ijcard.2012.05.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 02/09/2012] [Accepted: 05/11/2012] [Indexed: 10/28/2022]
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Jaroni J, Meier R, Beer A, Herrmann K, Settles M, Rummeny EJ, Huber A. Three-dimensional magnetic resonance imaging using single breath-hold k-t BLAST for assessment of global left ventricular functional parameters. Acad Radiol 2013; 20:987-94. [PMID: 23830604 DOI: 10.1016/j.acra.2013.03.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 03/04/2013] [Accepted: 03/17/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the accuracy of three-dimensional k-t broad-use linear acquisition speed-up technique (k-t BLAST) accelerated magnetic resonance imaging (MRI) for the assessment of left ventricular (LV) parameters compared to segmented multiple breath-hold cine imaging. METHODS A multislice cine (steady state free precession [SSFP]) sequence was performed with complete ventricular coverage during multiple breath-holds (temporal resolution 47 ms, voxel size 1.25 × 1.25 × 8 mm(3)). In addition, two k-t BLAST sequences with complete coverage were acquired, KT1 (temporal resolution 57 ms, voxel size 1.25 × 1.25 × 4 mm(3)) and k-t2 (temporal resolution 57 ms, voxel size 1.25 × 1.25 × 8 mm(3)), during a single breath-hold. For comparison of SSFP and k-t BLAST, LV parameters were determined: ejection fraction (EF), end-diastolic volume, end-systolic volume, and LV mass. RESULTS EF was underestimated by KT1 (47%) and KT2 (48%) compared to the SSFP sequence (53%). All parameters showed high correlation with the k-t BLAST sequences and the SSFP sequence (r = 0.88-0.98, P < .001). The mean relative difference for KT1/KT2 compared to the SSFP sequence was -0.11/-0.09 for the EF, -0.073/-0.086 for the EDV, 0.044/0.051 for the ESV, and 0.085/0.12 for the LV mass. CONCLUSIONS The use of three-dimensional k-t BLAST enabled a determination of the LV parameters with high correlation compared to the SSFP sequence. EF was slightly underestimated, and LV mass was slightly overestimated.
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Affiliation(s)
- Jennifer Jaroni
- Department of Radiology, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675 Munich, Germany.
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Young AA, Prince JL. Cardiovascular magnetic resonance: deeper insights through bioengineering. Annu Rev Biomed Eng 2013; 15:433-61. [PMID: 23662778 DOI: 10.1146/annurev-bioeng-071812-152346] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Heart disease is the main cause of morbidity and mortality worldwide, with coronary artery disease, diabetes, and obesity being major contributing factors. Cardiovascular magnetic resonance (CMR) can provide a wealth of quantitative information on the performance of the heart, without risk to the patient. Quantitative analyses of these data can substantially augment the diagnostic quality of CMR examinations and can lead to more effective characterization of disease and quantification of treatment benefit. This review provides an overview of the current state of the art in CMR with particular regard to the quantification of motion, both microscopic and macroscopic, and the application of bioengineering analysis for the evaluation of cardiac mechanics. We discuss the current clinical practice and the likely advances in the next 5-10 years, as well as the ways in which clinical examinations can be augmented by bioengineering analysis of strain, compliance, and stress.
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Affiliation(s)
- A A Young
- Department of Anatomy with Radiology, School of Medical Science, Faculty of Medical and Health Sciences, University of Auckland, Auckland 1023, New Zealand.
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Widya RL, van der Meer RW, Smit JWA, Rijzewijk LJ, Diamant M, Bax JJ, de Roos A, Lamb HJ. Right ventricular involvement in diabetic cardiomyopathy. Diabetes Care 2013; 36:457-62. [PMID: 23139371 PMCID: PMC3554276 DOI: 10.2337/dc12-0474] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare magnetic resonance imaging-derived right ventricular (RV) dimensions and function between men with type 2 diabetes and healthy subjects, and to relate these parameters to left ventricular (LV) dimensions and function. RESEARCH DESIGN AND METHODS RV and LV volumes and functions were assessed in 78 men with uncomplicated type 2 diabetes and 28 healthy men within the same range of age using magnetic resonance imaging. Steady-state free precession sequences were used to assess ventricular dimensions. Flow velocity mapping across the pulmonary valve and tricuspid valve was used to assess RV outflow and diastolic filling patterns, respectively. Univariate general linear models were used for statistical analyses. RESULTS RV end-diastolic volume was significantly decreased in patients compared with healthy subjects after adjustment for BMI and pulse pressure (177 ± 28 mL vs. 197 ± 47 mL, P < 0.01). RV systolic function was impaired: peak ejection rate across the pulmonary valve was decreased (433 ± 54 mL/s vs. 463 ± 71 mL/s, P < 0.01) and pulmonary flow acceleration time was longer (124 ± 17 ms vs. 115 ± 25 ms, P < 0.05). Indexes of RV diastolic function were impaired: peak filling rate and peak deceleration gradient of the early filling phase were 315 ± 63 mL/s vs. 356 ± 90 mL/s (P < 0.01) and 2.3 ± 0.8 mL/s(2) × 10(-3) vs. 2.8 ± 0.8 mL/s(2) × 10(-3) (P < 0.01), respectively. All RV parameters were strongly associated with its corresponding LV parameter (P < 0.001). CONCLUSIONS Diabetic cardiomyopathy affects the right ventricle, as demonstrated by RV remodeling and impaired systolic and diastolic functions in men with type 2 diabetes, in a similar manner as changes in LV dimensions and functions. These observations suggest that RV impairment might be a component of the diabetic cardiomyopathy phenotype.
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Affiliation(s)
- Ralph L Widya
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
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Tacke CE, Romeih S, Kuipers IM, Spijkerboer AM, Groenink M, Kuijpers TW. Evaluation of cardiac function by magnetic resonance imaging during the follow-up of patients with Kawasaki disease. Circ Cardiovasc Imaging 2012. [PMID: 23197079 DOI: 10.1161/circimaging.112.976969] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Although histopathologic studies suggest persistent myocardial abnormalities after Kawasaki disease (KD), the long-term effects on cardiac function remain to be revealed. We investigated biventricular volumes, function, and the presence of myocardial fibrosis by cardiac magnetic resonance imaging during long-term follow-up of KD. METHODS AND RESULTS Sixty patients with a history of KD (mean age, 16.9 years; 67% men; median interval after KD onset, 11.6 years) and 20 healthy control subjects (mean age, 17.9 years; 55% men) 12 to 24 years of age underwent cardiac magnetic resonance imaging. Biventricular end-diastolic volume, end-systolic volume, stroke volume, and ejection fraction were determined. Volumetric measurements were indexed for body surface area. Late contrast enhancement was used to detect areas of myocardial fibrosis. Biventricular volumes and function did not differ significantly between patients and control subjects. There were also no significant differences between patients with and without a history of left ventricular dysfunction resulting from KD-associated myocarditis or between patients with and without coronary artery aneurysms. Only those with prior ischemic heart disease had a significantly lower left ventricular ejection fraction compared with unaffected KD cases (left ventricular ejection fraction, 51% versus 57%; P=0.012). Late contrast enhancement was observed in only 2 patients with severe coronary artery aneurysms and was typical for myocardial infarction. CONCLUSIONS In this cardiac magnetic resonance imaging study evaluating the cardiac function of patients with KD at long-term follow-up, we did not observe a difference in cardiac function between KD patients and control subjects, except for a subgroup of patients with ischemic heart disease as a result of severe coronary artery pathology.
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Affiliation(s)
- Carline E Tacke
- Departments of Pediatric Hematology, Immunology, and Infectious Diseases, Academic Medical Center, Amsterdam, Netherlands.
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Oezcan S, Attenhofer Jost CH, Pfyffer M, Kellenberger C, Jenni R, Binggeli C, Faeh-Gunz A, Seifert B, Scharf C, Kretschmar O, Valsangiacomo Buechel ER. Pectus excavatum: echocardiography and cardiac MRI reveal frequent pericardial effusion and right-sided heart anomalies. Eur Heart J Cardiovasc Imaging 2012; 13:673-9. [PMID: 22298154 DOI: 10.1093/ehjci/jer284] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS In patients with pectus excavatum (PEX), echocardiographic assessment can be difficult. There are little data on the impact of the chest deformity on echocardiographic findings and comparison of data obtained by echocardiography (echo) with cardiac magnetic resonance imaging (CMR) in PEX. METHODS AND RESULTS In a prospective study, cardiac anomalies in PEX were analysed by echo and compared with CMR in consecutive patients with PEX referred for echo. If they agreed to participate, the patients were referred for CMR and included if the pectus index was ≥3.0 by CMR. Also, clinical data and electrocardiogram tracings were analysed. There were 18 patients (13 females; 72%), with a mean age of 53±16 years; mean pectus index was 4.7 (range: 3-7.3). Echo showed haemodynamically insignificant pericardial effusion in six patients (33%), tricuspid valve prolapse in five (28%), right ventricular (RV) localized wall motion anomalies (WMA) in five (28%) and diminished RV systolic function in two (11%); no patient had RV dilatation. CMR demonstrated cardiac displacement to the left in 9 patients (50%); minimal pericardial effusion was seen in 10 patients (56%; P value=0.13 compared with echo), RV localized WMA in 6 (44%; P value=1.0), diminished RV systolic function in 8 (44%; P=0.07), and RV dilatation in 5 (28%; P=0.06). A completely normal cardiac examination was found in six patients by echo (33%) and in 2 (11%) using CMR. Although some signs of arrhythmogenic RV cardiomyopathy (ARVC) were present, no patient fulfilled the ARVC criteria. CONCLUSION In severe PEX, haemodynamically insignificant pericardial effusion, tricuspid valve prolapse and other RV anomalies possibly due to RV displacement are frequent as demonstrated by both CMR and echo. The cardiac assessment by echo and CMR did show discrepancies; however, they were not significant.
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Affiliation(s)
- S Oezcan
- Cardiovascular Center Zurich Klinik Im Park, Seestr. 220, 8027 Zurich, Switzerland
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Verhaart IEC, van Duijn RJM, den Adel B, Roest AAW, Verschuuren JJGM, Aartsma-Rus A, van der Weerd L. Assessment of cardiac function in three mouse dystrophinopathies by magnetic resonance imaging. Neuromuscul Disord 2011; 22:418-26. [PMID: 22209498 DOI: 10.1016/j.nmd.2011.10.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 10/30/2011] [Indexed: 11/24/2022]
Abstract
Lack of dystrophin results in skeletal muscle dystrophy and dilated cardiomyopathy in humans and animal models. To achieve a basic understanding of the natural development of cardiomyopathy in different dystrophinopathy mouse models, left and right ventricular heart function was assessed at different ages in three dystrophinopathy mouse models (mdx, mdx/utrn(+/-) model and mdx/utrn(-/-)) using magnetic resonance imaging. Left ventricular function was significantly decreased, already at 2months in the most severely affected mdx/utrn(-/-) mice. Furthermore, whereas heart function was stable in wild-type mice over time, both mdx and mdx/utrn(+/-) showed a clear decrease at 10months of age, most prominently in the right ventricle. Therefore magnetic resonance imaging is an adequate technique to determine heart function in dystrophinopathy mouse models and can be used to assess the effect of potential therapies.
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Affiliation(s)
- Ingrid E C Verhaart
- Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Grapsa J, Dawson D, Nihoyannopoulos P. Assessment of right ventricular structure and function in pulmonary hypertension. J Cardiovasc Ultrasound 2011; 19:115-25. [PMID: 22073320 PMCID: PMC3209589 DOI: 10.4250/jcu.2011.19.3.115] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Revised: 08/12/2011] [Accepted: 08/17/2011] [Indexed: 12/02/2022] Open
Abstract
Right ventricular function plays an important role in determining cardiac symptoms and exercise capacity in chronic heart failure. It is known that right ventricle has complex anatomy and physiology. The purpose of this review paper is to demonstrate the best assessment of the right ventricle with current echocardiography. Echocardiography can assess sufficiently right ventricular structure and function and also suggest prognosis in pulmonary hypertension patients, especially with the use of modern imaging techniques. Finally, the new imaging modality of real time three dimensional echocardiography is interchangeable to cardiac magnetic resonance in reproducibility and accuracy.
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Affiliation(s)
- Julia Grapsa
- Department of Cardiovascular Sciences, Imperial College of London, National Heart and Lung Institute, Hammersmith Hospital, London, UK
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Bonnemains L, Mandry D, Marie PY, Micard E, Chen B, Vuissoz PA. Assessment of right ventricle volumes and function by cardiac MRI: quantification of the regional and global interobserver variability. Magn Reson Med 2011; 67:1740-6. [PMID: 22135141 DOI: 10.1002/mrm.23143] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/11/2011] [Accepted: 07/18/2011] [Indexed: 01/13/2023]
Abstract
Reproducibility of the manual assessment of right ventricle volumes by short-axis cine-MRI remains low and is often attributed to the difficulty in separating the right atrium from the ventricle. This study was designed to evaluate the regional interobserver variability of the right ventricle volume assessment to identify segmentation zones with the highest interobserver variability. Short-axis views of 90 right ventricles (30 hypertrophic, 30 dilated, and 30 normal) were acquired with 2D steady-state free precession sequences at 1.5 T and were manually segmented by two observers. The two segmentations were compared and the variations were quantified with a variation score based on the Hausdorff distance between the two segmentations and the interobserver 95% limits of concordance of the global volumes. The right ventricles were semiautomatically split into four subregions: apex, mid-ventricle, tricuspid zone, and infundibulum. These four subregions represented 11%, 34%, 36%, and 19% of the volume but, respectively, yielded variation scores of 8%, 16%, 42%, and 34%. The infundibulum yielded the highest interobserver regional variability although its variation score remained comparable to the tricuspid zone due to its lower volume. These results emphasize the importance of standardizing the segmentation of the infundibulum and the tricuspid zone to improve reproducibility.
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Jorstig SH, Kähäri A, Emilsson K, Thunberg P. Calculation of right ventricular stroke volume in short-axis MR images using the equation of the tricuspid plane. Clin Physiol Funct Imaging 2011; 32:5-11. [DOI: 10.1111/j.1475-097x.2011.01047.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Walsh R, Salem Y, Shah A, Lai WW, Nielsen JC. Repeatability of cardiac-MRI-measured right ventricular size and function in congenital heart disease. Pediatr Radiol 2011; 41:1000-7. [PMID: 21437608 DOI: 10.1007/s00247-011-2033-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 02/04/2011] [Accepted: 02/07/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The measurement error for right ventricular (RV) size and function assessed by cardiac MRI (CMRI) in congenital heart disease has not been fully characterized. As CMRI parameters are being increasingly utilized to make clinical decisions, defining error in the clinical setting is critical. OBJECTIVE This investigation examines the repeatability of CMRI for RV size and function. MATERIALS AND METHODS Forty consecutive people with congenital heart disease involving the RV were retrospectively identified. Contouring of RV volumes was performed by two expert CMRI clinicians. The coefficient of variability and repeatability coefficients were calculated. Repeatability coefficients were multiplied by the mean value for each group studied to define a threshold beyond which measurement error was unlikely to be responsible. RESULTS The variability for indexed RV end-diastolic volume = 3.2% and 3.3% for intra- and interobserver comparisons, respectively. The repeatability coefficients were 13.2% and 14.9% for intra- and interobserver comparisons, which yielded threshold values of 15.1 ml/m^2 and 20.2 ml/m^2, respectively. For RV ejection fraction (EF), the repeatability coefficients for intra- and interobserver comparisons were 5.0% and 6.0%, which resulted in threshold values of 2.6 EF% and 3.0 EF%. CONCLUSION The threshold values generated can be used during serial assessment of RV size and function.
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Affiliation(s)
- Rowan Walsh
- Division of Pediatric Cardiology, Mount Sinai School of Medicine, New York, NY, USA
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Ley S, Grünig E, Kiely DG, van Beek E, Wild J. Computed tomography and magnetic resonance imaging of pulmonary hypertension: Pulmonary vessels and right ventricle. J Magn Reson Imaging 2011; 32:1313-24. [PMID: 21105137 DOI: 10.1002/jmri.22373] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Pulmonary hypertension (PH) is very heterogeneous and the classification identifies five major groups including many associated disease processes. The treatment of PH depends on the underlying cause and accurate classification is paramount. A comprehensive assessment to identify the cause and severity of PH is therefore needed. Furthermore, follow-up assessments are required to monitor changes in disease status and response to therapy. Traditionally, the diagnostic imaging work-up of PH comprised mainly echocardiography, invasive right heart catheterization, and ventilation/perfusion scintigraphy. Due to technical advances, multidetector row computed tomography (CT) and magnetic resonance imaging (MRI) have become important and complementary investigations in the evaluation of patients with suspected PH. Both modalities are reviewed and recommendations for clinical use are given.
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Affiliation(s)
- Sebastian Ley
- Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
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Feuchtner GM, Spoeck A, Lessick J, Dichtl W, Plass A, Leschka S, Mueller S, Klauser A, Scheffel H, Wolf F, Jaschke W, Alkadhi H. Quantification of aortic regurgitant fraction and volume with multi-detector computed tomography comparison with echocardiography. Acad Radiol 2011; 18:334-42. [PMID: 21295735 DOI: 10.1016/j.acra.2010.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 11/02/2010] [Accepted: 11/03/2010] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES Evaluate quantification of the aortic regurgitant fraction and volume with computed tomography (CT). MATERIALS AND METHODS Fifty-three patients with aortic regurgitation (AR) and 29 controls were examined with 64-multi-detector CT coronary angiography and transthoracic echocardiography (TTE). A dedicated software algorithm employing three-dimensional segmentation of left ventricle (LV) and right ventricle (RV) volumes and LV mass was applied. AR volume and fraction was calculated based on RV and LV stroke volumes (SV) and compared with echocardiography. The aortic regurgitant orifice area (ROA) was measured by CT. RESULTS A good correlation of the AR fraction and AR volume determined by CT compared to echocardiography was found for mild, moderate, and severe AR with 14.2% ± 9, 28.8% ± 8, and 57.9% ± 9 (r = 0.95, P < .001) for AR fraction, and 15.7 mL ± 11.33 mL ± 14, and 98.9 mL ± 36 for AR volume (r = 0.92, P < .0001), respectively. CT correctly classified severity of AR in 93% of patients based of AR-fraction, and in 89% based on AR volume. The sensitivity and specificity of CT were 98% and specificity 90.3%. The specificity improved to 97%, if the ROA by CT was added as diagnostic criterion. CONCLUSION Aortic regurgitation fraction and volume can be accurately quantified from CT coronary angiography datasets. These parameters can assist clinical management, e.g. in case of pending cardiac surgery decision.
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Aneq MÅ, Nylander E, Ebbers T, Engvall J. Determination of right ventricular volume and function using multiple axially rotated MRI slices. Clin Physiol Funct Imaging 2011; 31:233-9. [DOI: 10.1111/j.1475-097x.2011.01006.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The Role of Three-Dimensional Echocardiography in the Assessment of Right Ventricular Dysfunction after a Half Marathon: Comparison with Cardiac Magnetic Resonance Imaging. J Am Soc Echocardiogr 2011; 24:207-13. [DOI: 10.1016/j.echo.2010.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Indexed: 11/18/2022]
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Grothoff M, Hoffmann J, Lehmkuhl L, Abdul-Khaliq H, Nitzsche S, Mahler A, Dähnert I, Berger F, Gutberlet M. Time course of right ventricular functional parameters after surgical correction of tetralogy of Fallot determined by cardiac magnetic resonance. Clin Res Cardiol 2010; 100:343-50. [DOI: 10.1007/s00392-010-0252-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Accepted: 11/03/2010] [Indexed: 11/28/2022]
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Geva T, Gauvreau K, Powell AJ, Cecchin F, Rhodes J, Geva J, del Nido P. Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery. Circulation 2010; 122:S201-8. [PMID: 20837914 DOI: 10.1161/circulationaha.110.951178] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although pulmonary valve replacement (PVR) is effective in reducing right ventricular (RV) volume overload in patients with chronic pulmonary regurgitation, persistent RV dysfunction and subsequent adverse clinical outcomes have been reported. This trial was conducted to investigate whether the addition of surgical RV remodeling with exclusion of scar tissue to PVR would result in improved RV function and laboratory and clinical parameters, as compared with PVR alone. METHODS AND RESULTS Between February 2004 and October 2008, 64 patients who underwent RV outflow tract procedures in early childhood had more than or equal to moderate pulmonary regurgitation, and fulfilled defined criteria for PVR were randomly assigned to undergo either PVR alone (n=34) or PVR with surgical RV remodeling (n=30). No significant difference was observed in the primary outcome (change in RV ejection fraction, -2±7% in the PVR alone group and -1±7% in the PVR with RV remodeling group; P=0.38) or in any of the secondary outcomes at 6-month postoperative follow-up. Multivariable analysis of the entire cohort identified preoperative RV end-systolic volume index <90 mL/m(2) and QRS duration <140 ms to be associated with optimal postoperative outcome (normal RV size and function), and RV ejection fraction <45% and QRS duration ≥160 ms to be associated with suboptimal postoperative outcome (RV dilatation and dysfunction). CONCLUSIONS The addition of surgical remodeling of the RV to PVR in patients with chronic pulmonary regurgitation did not result in a measurable early benefit. Referral to PVR based on QRS duration, RV end-systolic volume, or RV ejection fraction may be beneficial. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00112320.
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Affiliation(s)
- Tal Geva
- Department of Cardiology, Children's Hospital Boston, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.
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Papavassiliu T, Veltmann C, Doesch C, Haghi D, Germans T, Schoenberg SO, van Rossum AC, Schimpf R, Brade J, Wolpert C, Borggrefe M. Spontaneous type 1 electrocardiographic pattern is associated with cardiovascular magnetic resonance imaging changes in Brugada syndrome. Heart Rhythm 2010; 7:1790-6. [PMID: 20828633 DOI: 10.1016/j.hrthm.2010.09.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Accepted: 09/01/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with Brugada syndrome (BrS) and a spontaneous type 1 ECG are considered to be at greater increased risk for sudden cardiac death than are patients with an abnormal ECG only after administration of sodium channel blockers and therefore represent a more severe phenotype. Thus, it can be hypothesized that in the presence of a more severe electrical phenotype, structural and functional changes are more likely expected because electrical changes can play a causal role in producing structural changes. OBJECTIVE The purpose of this study was to investigate whether the different ECG manifestations in patients with BrS are associated with structural changes detected by cardiovascular magnetic resonance imaging. METHODS Cardiovascular magnetic resonance imaging was performed on 69 consecutive patients with proven BrS and 30 healthy controls. Twenty-six patients had a spontaneous diagnostic type 1 BrS ECG; the remainder had a type 1 response to ajmaline provocation. Left and right ventricular volumes and dimensions were assessed and compared with respect to ECG pattern. RESULTS The right ventricular outflow tract area was significantly enlarged in patients with a spontaneous type 1 ECG compared to patients with a nondiagnostic resting ECG or controls (11 cm(2), 9 cm(2), and 9 cm(2), respectively, P < .05). Patients with a spontaneous type 1 BrS ECG revealed significantly lower left ventricular ejection fraction than did patients with a nondiagnostic resting ECG and controls (56 ± 5 vs 59 ± 5 vs 60 ± 4, respectively, P < .05) and significantly lower right ventricular ejection fraction (54 ± 5 vs 59 ± 5, P = .001) as well as end-systolic volumes compared to controls (34 ± 9 mL/m(2) vs 28 ± 79 mL/m(2), P = .02). CONCLUSION Patients with a spontaneous type 1 BrS ECG reveal significantly functional and morphological alterations in both the left and right ventricles compared to patients with basal nondiagnostic ECG or controls.
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Shimada YJ, Shiota M, Siegel RJ, Shiota T. Accuracy of Right Ventricular Volumes and Function Determined by Three-Dimensional Echocardiography in Comparison with Magnetic Resonance Imaging: A Meta-Analysis Study. J Am Soc Echocardiogr 2010; 23:943-53. [PMID: 20797527 DOI: 10.1016/j.echo.2010.06.029] [Citation(s) in RCA: 173] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Indexed: 10/19/2022]
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Evaluation of left atrial function by multidetector computed tomography before left atrial radiofrequency-catheter ablation: Comparison of a manual and automated 3D volume segmentation method. Eur J Radiol 2010; 75:e141-6. [DOI: 10.1016/j.ejrad.2010.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 03/18/2010] [Accepted: 03/19/2010] [Indexed: 11/20/2022]
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Omoumi P, Métais J, Bertrand P, Alison D. Volumétrie et fraction d’éjection ventriculaires gauches et droites en IRM : critères de contourage et reproductibilité interobservateur. ACTA ACUST UNITED AC 2010; 91:769-78. [DOI: 10.1016/s0221-0363(10)70114-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Leibundgut G, Rohner A, Grize L, Bernheim A, Kessel-Schaefer A, Bremerich J, Zellweger M, Buser P, Handke M. Dynamic assessment of right ventricular volumes and function by real-time three-dimensional echocardiography: a comparison study with magnetic resonance imaging in 100 adult patients. J Am Soc Echocardiogr 2010; 23:116-26. [PMID: 20152692 DOI: 10.1016/j.echo.2009.11.016] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to validate a novel real-time three-dimensional echocardiographic (RT3DE) analysis tool for the determination of right ventricular volumes and function in unselected adult patients. METHODS A total of 100 consecutive adult patients with normal or pathologic right ventricles were enrolled in the study. A dynamic polyhedron model of the right ventricle was generated using dedicated RT3DE software. Volumes and ejection fractions were determined and compared with results obtained on magnetic resonance imaging (MRI) in 88 patients with adequate acquisitions. RESULTS End-diastolic, end-systolic, and stroke volumes were slightly lower on RT3DE imaging than on MRI (124.0 +/- 34.4 vs 134.2 +/- 39.2 mL, P < .001; 65.2 +/- 23.5 vs 69.7 +/- 25.5 mL, P = .02; and 58.8 +/- 18.4 vs 64.5 +/- 24.1 mL, P < .01, respectively), while no significant difference was observed for ejection fraction (47.8 +/- 8.5% vs 48.2 +/- 10.8%, P = .57). Correlation coefficients on Bland-Altman analysis were r = 0.84 (mean difference, 10.2 mL; 95% confidence interval [CI], -31.3 to 51.7 mL) for end-diastolic volume, r = 0.83 (mean difference, 4.5 mL; 95% CI, -23.8 to 32.9 mL) for end-systolic volume, r = 0.77 (mean difference, 5.7 mL; 95% CI, -24.6 to 36.0 mL) for stroke volume, and r = 0.72 (mean difference, 0.4%; 95% CI, -14.2% to 15.1%) for ejection fraction. CONCLUSION Right ventricular volumes and ejection fractions as assessed using RT3DE imaging compare well with MRI measurements. RT3DE imaging may become a time-saving and cost-saving alternative to MRI for the quantitative assessment of right ventricular size and function.
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Affiliation(s)
- Gregor Leibundgut
- Department of Cardiology, University Hospital Basel, Basel, Switzerland.
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Han Y, Osborn EA, Maron MS, Manning WJ, Yeon SB. Impact of papillary and trabecular muscles on quantitative analyses of cardiac function in hypertrophic cardiomyopathy. J Magn Reson Imaging 2010; 30:1197-202. [PMID: 19856455 DOI: 10.1002/jmri.21958] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To examine the impact of cardiovascular magnetic resonance (CMR) partitioning methods on volumetric analysis in hypertrophic cardiomyopathy (HCM) patients. The standard CMR method for partitioning ventricular myocardium from ventricular cavity includes the myocardial papillary and trabecular muscles in the cavity volume. This approach may misrepresent ventricular mass and volume in patients with HCM due to large papillary muscles and extensive trabeculations. MATERIALS AND METHODS Ventricular volume and mass analyses were performed in 30 patients with HCM using the standard method and a detailed method that excluded papillary and trabecular muscles from the left ventricular (LV) volume while including them in LV mass. We also analyzed the degree of mitral regurgitation and compared the results with Doppler echocardiography in a subgroup of 12 patients. Interobserver variability was assessed. RESULTS The detailed method yielded 17% higher indexed LV mass, 20% lower indexed LV diastolic volume, 13% higher LV ejection fraction (EF) (all P < 0.0001). The resultant mitral regurgitant volumes using the detailed method had less discrepancy with Doppler echocardiography results compared with the results from the standard methods. Interobserver variability was similar by both methods. CONCLUSION For patients with HCM, a detailed analysis in which the ventricular papillary and trabecular muscles are excluded from LV volume is preferred.
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Affiliation(s)
- Yuchi Han
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA.
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Grapsa J, O'Regan DP, Pavlopoulos H, Durighel G, Dawson D, Nihoyannopoulos P. Right ventricular remodelling in pulmonary arterial hypertension with three-dimensional echocardiography: comparison with cardiac magnetic resonance imaging. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 11:64-73. [DOI: 10.1093/ejechocard/jep169] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Beerbaum P, Barth P, Kropf S, Sarikouch S, Kelter-Kloepping A, Franke D, Gutberlet M, Kuehne T. Cardiac function by MRI in congenital heart disease: Impact of consensus training on interinstitutional variance. J Magn Reson Imaging 2009; 30:956-66. [DOI: 10.1002/jmri.21948] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Buechel EV, Kaiser T, Jackson C, Schmitz A, Kellenberger CJ. Normal right- and left ventricular volumes and myocardial mass in children measured by steady state free precession cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2009; 11:19. [PMID: 19545393 PMCID: PMC2718870 DOI: 10.1186/1532-429x-11-19] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 06/21/2009] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Quantification of ventricular volume by steady state free precession (SSFP) cardiovascular magnetic resonance is accurate and reproducible. Normal values exist for adults, but are lacking for children.We sought to establish normal values for left and right ventricular volumes, mass and function in healthy children by using SSFP. METHODS AND RESULTS Fifty children (27 females, 23 males) without cardiovascular disease were evaluated. Median age was 11 years (range 7 months - 18 years), weight 35 kg (range 7-77 kg), height 146 cm (range 66-181 cm). Thirty-six examinations were performed with breath holding, 14 in freely breathing sedated children.Ventricular volumes and mass were measured in the end systolic and end diastolic phase on SSFP cine images acquired in a short axis plane as a stack of 12 contiguous slices covering full length of both ventricles. Regression analysis showed an exponential relationship between body surface area (BSA) and ventricular volumes and mass (normal value = a*BSAb). Normative curves for males and females are presented in relation to BSA for the end-diastolic volume, end-systolic volume and mass of both ventricles. Intra- and interobserver variability of the measurements was within the limits of 2% and 7% respectively, except for right ventricular mass (10%). CONCLUSION The exponential equation for calculation of normal values for each ventricular parameter and graphical display of normative curves for data acquired in healthy children by SSFP cardiovascular magnetic resonance are provided.
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Affiliation(s)
| | - Thomas Kaiser
- Division of Pediatric Cardiology, University Children's Hospital, Zurich, Switzerland
| | - Clare Jackson
- Division of Pediatric Cardiology, University Children's Hospital, Zurich, Switzerland
| | - Achim Schmitz
- Division of Anesthesiology, University Children's Hospital, Zurich, Switzerland
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