Left ventricular aneurysm: comprehensive assessment of morphology, structure and thrombus using cardiovascular magnetic resonance

Postmyocardial Infarction Ventricular Aneurysm: JACC Focus Seminar 5/5

Ventricular aneurysm represents a rare complication of transmural acute myocardial infarction, although other cardiac, congenital, or metabolic diseases may also predispose to such condition. Ventricular expansion includes all the cardiac layers, usually with a large segment involved. Adverse events include recurrent angina, reduced ventricular stroke volume with congestive heart failure, mitral regurgitation, thromboembolism, and ventricular arrhythmias. Multimodality imaging is paramount to provide comprehensive assessment, allowing for appropriate therapeutic decision-making. When indicated, surgical intervention remains the gold standard, although additional therapy (heart failure, anticoagulation, and advanced antiarrhythmic treatment) might be required. However, the STICH (Surgical Treatment for Ischemic Heart Failure) trial did not show any advantage from adding surgical ventricular reconstruction to coronary artery bypass surgery in terms of survival, rehospitalization or symptoms, compared with revascularization alone. Finally, implantable cardiac defibrillator may reduce the risk of fatal arrhythmias.

A deep learning method for the automated assessment of paradoxical pulsation after myocardial infarction using multicenter cardiac MRI data

OBJECTIVE

The current study aimed to explore a deep convolutional neural network (DCNN) model that integrates multidimensional CMR data to accurately identify LV paradoxical pulsation after reperfusion by primary percutaneous coronary intervention with isolated anterior infarction.

METHODS

A total of 401 participants (311 patients and 90 age-matched volunteers) were recruited for this prospective study. The two-dimensional UNet segmentation model of the LV and classification model for identifying paradoxical pulsation were established using the DCNN model. Features of 2- and 3-chamber images were extracted with 2-dimensional (2D) and 3D ResNets with masks generated by a segmentation model. Next, the accuracy of the segmentation model was evaluated using the Dice score and classification model by receiver operating characteristic (ROC) curve and confusion matrix. The areas under the ROC curve (AUCs) of the physicians in training and DCNN models were compared using the DeLong method.

RESULTS

The DCNN model showed that the AUCs for the detection of paradoxical pulsation were 0.97, 0.91, and 0.83 in the training, internal, and external testing cohorts, respectively (p < 0.001). The 2.5-dimensional model established using the end-systolic and end-diastolic images combined with 2-chamber and 3-chamber images was more efficient than the 3D model. The discrimination performance of the DCNN model was better than that of physicians in training (p < 0.05).

CONCLUSIONS

Compared to the model trained by 2-chamber or 3-chamber images alone or 3D multiview, our 2.5D multiview model can combine the information of 2-chamber and 3-chamber more efficiently and obtain the highest diagnostic sensitivity.

CLINICAL RELEVANCE STATEMENT

A deep convolutional neural network model that integrates 2-chamber and 3-chamber CMR images can identify LV paradoxical pulsation which correlates with LV thrombosis, heart failure, ventricular tachycardia after reperfusion by primary percutaneous coronary intervention with isolated anterior infarction.

KEY POINTS

• The epicardial segmentation model was established using the 2D UNet based on end-diastole 2- and 3-chamber cine images. • The DCNN model proposed in this study had better performance for discriminating LV paradoxical pulsation accurately and objectively using CMR cine images after anterior AMI compared to the diagnosis of physicians in training. • The 2.5-dimensional multiview model combined the information of 2- and 3-chamber efficiently and obtained the highest diagnostic sensitivity.

Myocardial extracellular volume quantified by cardiac magnetic resonance predicts left ventricular aneurysm following acute myocardial infarction

OBJECTIVE

This study aimed to investigate the correlation between increased extracellular matrix estimated by cardiac magnetic resonance (CMR) and left ventricular aneurysm after acute myocardial infarction.

METHODS

A total of 175 patients from 3 centers with an isolated left anterior descending culprit vessel underwent CMR examinations within 1 week and at a 6-month follow-up. Of these, 92 were identified to have left ventricular aneurysms (LVAs): 74 with functional aneurysm and 18 with anatomical aneurysm. The predictive significance of acute extracellular volume (ECV), left gadolinium enhancement (LGE), and other characteristics were analyzed using binary logistic regression analysis.

RESULTS

Patients with LVA were more likely to present with left ventricular adverse remodeling (LVAR) than those without (p = 0.009). With optimal cutoff values of 30.90% for LGE and 33% for ECV to discriminate LVA from non-LVA, the area under the curve (AUC) by receiver operator characteristic curve (ROC) analysis was 0.92 (95% CI: 0.87-0.96; p < 0.001) and 0.93 (95% CI: 0.88-0.96; p < 0.001), respectively. ECV was significantly better than LGE at discriminating between functional and anatomical LVA (p < 0.001). Both acute LGE and ECV were predictors of LVA, with an odds ratio of 1.35 (95% CI: 1.21-1.52, p < 0.001) and 1.23 (95% CI: 1.13-1.33, p < 0.001), respectively, by multivariable logistic regression analysis.

CONCLUSIONS

Acute LGE and ECV of the myocardium provided predictive significance for LVA. The discriminative significance of ECV for functional versus anatomical LVA was better than the discriminative significance of LGE.

KEY POINTS

• Patients with LVA were more likely to present with LVAR. • Acute LGE and ECV of the myocardium provided the strongest predictive significance for LVA. • The discriminative significance of ECV for functional versus anatomical LVA was better than that of LGE.

Cardiac MRI Detection of Left Ventricular Aneurysm in Children After Ventricular Assist Device Explantation

Consensus is lacking regarding screening for complications such as ventricular aneurysms after ventricular assist device explant. We report two pediatric patients, status-post explantation, who developed true left ventricular apical aneurysms diagnosed by cardiac magnetic resonance imaging. Imaging also suggested laminated thrombus versus postoperative changes which were treated with antiplatelet therapy.

Cardiac magnetic resonance imaging in heart failure: where the alphabet begins!

Cardiac Magnetic Resonance Imaging has become a cornerstone in the evaluation of heart failure. It provides a comprehensive evaluation by answering all the pertinent clinical questions across the full pathological spectrum of heart failure. Nowadays, CMR is considered the gold standard in evaluation of ventricular volumes, wall motion and systolic function. Through its unique ability of tissue characterization, it provides incremental diagnostic and prognostic information and thus has emerged as a comprehensive imaging modality in heart failure. This review outlines the role of main conventional CMR sequences in the evaluation of heart failure and their impact in the management and prognosis.

Geriatric Presentation of Idiopathic Left Ventricular Aneurysm

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Idiopathic left ventricular aneurysm is a rare diagnosis.

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Management and prognosis of idiopathic left ventricular aneurysms remain unknown.

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We describe a conservative management of an idiopathic left ventricular aneurysm in a geriatric patient.

Overview of left ventricular outpouchings on cardiac magnetic resonance imaging

Left ventricular outpouchings commonly include aneurysm, pseudoaneurysm, and diverticulum and are now being increasingly detected on imaging. Distinction between these entities is of prime importance to guide proper management as outcomes for these entities differ substantially. Chest radiograph is usually nonspecific in their diagnosis. Echocardiography, multi-detector computed tomography evaluation and angiography are helpful in the diagnosis with their inherit limitations. Cardiac magnetic resonance imaging (MRI) is emerging as a very useful tool that allows simultaneous anatomical and functional evaluation along with tissue characterization, which has diagnostic, theraputic and prognostic implications. This article gives an overview of left ventricular outpouchings with special emphasis on their differentiation using cardiac MRI.

Imaging of vascular pseudoaneurysms in the thorax and abdomen

INTRODUCTION

This review article illustrates a spectrum of arterial pseudoaneurysms that may occur in various locations throughout the thoracoabdominal region. This article discusses the common etiologies and typical clinical presentations of arterial pseudoaneurysms as well as the imaging modalities employed in their diagnosis and potential treatment options.

OBJECTIVE

The goal of this review article is to familiarize radiologists with the diagnosis of thoracoabdominal arterial pseudoaneurysms, the prompt identification and treatment of which are crucial in this patient population.

CONCLUSION

In summary, a thorough understanding of the etiologies, imaging characteristics, and clinical implications of pseudoaneurysms can help optimize identification and management of this spectrum of disease.

MR imaging of myocardial infarction

Magnetic resonance (MR) imaging plays an important role in evaluation of various aspects of myocardial infarction (MI). MR imaging is useful in establishing the diagnosis of acute MI, particularly in patients who present with symptoms of MI but outside the diagnostic time frame of altered cardiac enzyme levels or with clinical features of acute MI but without an angiographic culprit lesion. MR imaging is valuable in establishing a diagnosis of chronic MI and distinguishing this condition from nonischemic cardiomyopathies, mainly through use of delayed-enhancement patterns. MR imaging also provides clinicians with several prognostic indicators that enable risk stratification, such as scar burden, microvascular obstruction, hemorrhage, and peri-infarct ischemia. The extent and transmurality of scar burden have been shown to have independent and incremental prognostic power over a range of left ventricular function. The extent of scarring at MR imaging is an important predictor of successful outcome after revascularization procedures, and extensive scarring in the lateral wall indicates poor outcome after cardiac resynchronization therapy. Scar size at MR imaging is also a useful surrogate end point in clinical trials. Finally, MR imaging can be used to detect complications of MI, such as aneurysms, pericarditis, ventricular septal defect, thrombus, and mitral regurgitation. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.335125722/-/DC1.

Left ventricular false-pseudo and pseudo aneurysm: serial observations by cardiac magnetic resonance imaging

A case of extensive inferior myocardial infarction complicated by a large ventricular aneurysm is presented. Magnetic resonance (MR) imaging 4 days after the onset showed a small protrusion from the necrotic inferior myocardium, which expanded 10 days after onset with a marked pericardial effusion. The follow-up examination by MR and CT imaging 6 months after the onset revealed a large ventricular aneurysm from the inferior cardiac wall. After the aneurysmectomy, the histological study revealed that the aneurysm wall was made up of 2 different types of walls; the peripheral part was a false-pseudo aneurysm and the central part was a pseudo aneurysm. From the serial MR imaging, it is considered that such an aneurysm is primarily formed from a small discontinuation of the LV wall followed by oozing type rupture. Finally, the ruptured central part of the LV wall, which was covered by the pericardium, formed a pseudo aneurysm and the stretched peripheral area, which contains myocardium, formed a false-pseudo aneurysm afterward and then they extended together. Thus, MR imaging provided the important information for the understanding of the formation process of the pseudo and false pseudo LV aneurysm.