Characterizing myocardial edema and fibrosis in hypertensive crisis with cardiovascular magnetic resonance imaging

A hypertensive crisis is associated with an increased risk of cardiovascular events. Although altered cardiac structure, function, and myocardial architecture on cardiovascular magnetic resonance (CMR) have been associated with increased adverse events in hypertensive patients, the studies did not include patients with hypertensive crisis. Our study aimed to determine myocardial tissue characteristics in patients with hypertensive crisis using CMR imaging. Participants underwent comprehensive CMR imaging at 1.5T. The imaging protocol included cine-, T2-weighted-, contrasted- and multi-parametric mapping images. Blood and imaging biomarkers were compared in hypertensive emergency and hypertensive urgency. Predictors of myocardial edema was assessed using linear regression. The predictive value of T1- and T2 mapping for identifying hypertensive emergency (from urgency) was assessed with receiver operator characteristics curves. Eighty-two patients (48.5 ± 13.4 years, 57% men) were included. Hypertensive emergency constituted 78%. Native T1 was higher in patients with LVH compared to those without (1056 ± 33 vs. 1013 ± 40, P < 0.001), and tended to be higher in hypertensive emergency than urgency (1051 ± 37 vs. 1033 ± 40, P = 0.077). T2-w signal intensity (SI) ratio and T2 mapping values were higher in hypertensive emergency (1.5 ± 0.2 vs. 1.4 ± 0.1, P = 0.044 and 48 ± 2 vs. 47 ± 2, P = 0.004), and in patients with than without LVH (1.5 ± 0.2 vs. 1.4 ± 0.1, P = 0.045 and P = 0.030). A trend for higher extracellular volume was noted in hypertensive emergency compared to urgency (25 ± 4 vs. 22 ± 3, P = 0.050). Native T1 correlated with T2 mapping (rs = 0.429, P < 0.001), indexed LV mass (rs = 0.493, P < 0.001), cardiac troponin (rs = 0.316, P < 0.001) and NT-proBNP (rs = 0.537, P < 0.001), while T2 correlated with cardiac troponin (rs = 0.390, P < 0.001), and NT-proBNP (rs = 0.348, P < 0.001). Non-ischemic LGE pattern occurred in 59% and was 21% more prevalent in the hypertensive emergency group (P = 0.005). Our findings demonstrate that hypertensive crisis is associated with distinct myocardial tissue alterations, including increased myocardial edema and fibrosis, as detected on CMR. Patients with hypertensive emergency had a higher degree of myocardial oedema than hypertensive urgency. Further research is necessary to explore the prognostic value of these findings.

Strong Diagnostic Performance of Single Energy 256-row Multidetector Computed Tomography with Deep Learning Image Reconstruction in the Assessment of Myocardial Fibrosis

Objective Although magnetic resonance imaging (MRI) is the gold standard for evaluating abnormal myocardial fibrosis and extracellular volume (ECV) of the left ventricular myocardium (LVM), a similar evaluation has recently become possible using computed tomography (CT). In this study, we investigated the diagnostic accuracy of a new 256-row multidetector CT with a low tube-voltage single energy scan and deep-learning-image reconstruction (DLIR) in detecting abnormal late enhancement (LE) in LVM. Methods We evaluated the diagnostic performance of CT for detecting LE in LVM and compared the results with those of MRI as a reference. We also measured the ECV of the LVM on CT and compared the results with those on MRI. Materials We analyzed 50 consecutive patients who underwent cardiac CT, including a late-phase scan and MRI, within three months of suspected cardiomyopathy. All patients underwent 256-slice CT (Revolution APEX; GE Healthcare, Waukesha, USA) with a low tube-voltage (70 kV) single energy scan and DLIR for a late-phase scan. Results In patient- and segment-based analyses, the sensitivity, specificity, and accuracy of detection of LE on CT were 94% and 85%, 100% and 95%, and 96% and 93%, respectively. The ECV of LVM per patient on CT and MRI was 33.0±6.2% and 35.9±6.1%, respectively. These findings were extremely strongly correlated, with a correlation coefficient of 0.87 (p<0.0001). The effective radiation dose on late-phase scanning was 2.4±0.9 mSv. Conclusion The diagnostic performance of 256-row multislice CT with a low tube voltage and DLIR for detecting LE and measuring ECV in LVM is credible.

Advanced myocardial characterization and function with cardiac CT

Non-invasive imaging with characterization and quantification of the myocardium with computed tomography (CT) became feasible owing to recent technical developments in CT technology. Cardiac CT can serve as an alternative modality when cardiac magnetic resonance imaging and/or echocardiography are contraindicated, not feasible, inconclusive, or non-diagnostic. This review summarizes the current and potential future role of cardiac CT for myocardial characterization including a summary of late enhancement techniques, extracellular volume quantification, and strain analysis. In addition, this review highlights potential fields for research about myocardial characterization with CT to possibly include it in clinical routine in the future.

Utility of CT and MRI in Cardiac Electrophysiology

Cardiac electrophysiology involves the diagnosis and management of arrhythmias. CT and MRI play an increasingly important role in cardiac electrophysiology, primarily in preprocedural planning of ablation procedures but also in procedural guidance and postprocedural follow-up. The most common applications include ablation for atrial fibrillation (AF), ablation for ventricular tachycardia (VT), and for planning cardiac resynchronization therapy (CRT). For AF ablation, preprocedural evaluation includes anatomic evaluation and planning using CT or MRI as well as evaluation for left atrial fibrosis using MRI, a marker of poor outcomes following ablation. Procedural guidance during AF ablation is achieved by fusing anatomic data from CT or MRI with electroanatomic mapping to guide the procedure. Postprocedural imaging with CT following AF ablation is commonly used to evaluate for complications such as pulmonary vein stenosis and atrioesophageal fistula. For VT ablation, both MRI and CT are used to identify scar, representing the arrhythmogenic substrate targeted for ablation, and to plan the optimal approach for ablation. CT or MR images may be fused with electroanatomic maps for intraprocedural guidance during VT ablation and may also be used to assess for complications following ablation. Finally, functional information from MRI may be used to identify patients who may benefit from CRT, and cardiac vein mapping with CT or MRI may assist in planning access. ©RSNA, 2024 Supplemental material is available for this article.

Society for Cardiovascular Magnetic Resonance 2023 Cases of SCMR Case Series

"Cases of SCMR" is a case series on the SCMR website (https://www.scmr.org) for the purpose of education. The cases reflect the clinical presentation, and the use of cardiovascular magnetic resonance (CMR) in the diagnosis and management of cardiovascular disease. The 2023 digital collection of cases are presented in this manuscript.

The Feasibility of a Model-Based Iterative Reconstruction Technique Tuned for the Myocardium on Myocardial Computed Tomography Late Enhancement

OBJECTIVES

This study evaluated the feasibility of a model-based iterative reconstruction technique (MBIR) tuned for the myocardium on myocardial computed tomography late enhancement (CT-LE).

METHODS

Twenty-eight patients who underwent myocardial CT-LE and late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) within 1 year were retrospectively enrolled. Myocardial CT-LE was performed using a 320-row CT with low tube voltage (80 kVp). Myocardial CT-LE images were scanned 7 min after CT angiography (CTA) without additional contrast medium. All myocardial CT-LE images were reconstructed with hybrid iterative reconstruction (HIR), conventional MBIR (MBIR_cardiac), and new MBIR tuned for the myocardium (MBIR_myo). Qualitative (5-grade scale) scores and quantitative parameters (signal-to-noise ratio [SNR] and contrast-to-noise ratio [CNR]) were assessed as image quality. The sensitivity, specificity, and accuracy of myocardial CT-LE were evaluated at the segment level using an American Heart Association (AHA) 16-segment model, with LGE-MRI as a reference standard. These results were compared among the different CT image reconstructions.

RESULTS

In 28 patients with 448 segments, 160 segments were diagnosed with positive by LGE-MRI. In the qualitative assessment of myocardial CT-LE, the mean image quality scores were 2.9 ± 1.2 for HIR, 3.0 ± 1.1 for MBIR_cardiac, and 4.0 ± 1.0 for MBIR_myo. MBIR_myo showed a significantly higher score than HIR (P < 0.001) and MBIR_cardiac (P = 0.018). In the quantitative image quality assessment of myocardial CT-LE, the median image SNR was 10.3 (9.1-11.1) for HIR, 10.8 (9.8-12.1) for MBIR_cardiac, and 16.8 (15.7-18.4) for MBIR_myo. The median image CNR was 3.7 (3.0-4.6) for HIR, 3.8 (3.2-5.1) for MBIR_cardiac, and 6.4 (5.0-7.7) for MBIR_myo. MBIR_myo significantly improved the SNR and CNR of CT-LE compared to HIR and MBIR_cardiac (P < 0.001). The sensitivity, specificity, and accuracy for the detection of myocardial CT-LE were 70%, 92%, and 84% for HIR; 71%, 92%, and 85% for MBIR_cardiac; and 84%, 92%, and 89% for MBIR_myo, respectively. MBIR_myo showed significantly higher image quality, sensitivity, and accuracy than the others (P < 0.05).

CONCLUSIONS

MBIR tuned for myocardium improved image quality and diagnostic performance for myocardial CT-LE assessment.

Myocardial Fibrosis in Young and Veteran Athletes: Evidence from a Systematic Review of the Current Literature

Background: Exercise is associated with several cardiac adaptations that can enhance one's cardiac output and allow one to sustain a higher level of oxygen demand for prolonged periods. However, adverse cardiac remodelling, such as myocardial fibrosis, has been identified in athletes engaging in long-term endurance exercise. Cardiac magnetic resonance (CMR) imaging is considered the noninvasive gold standard for its detection and quantification. This review seeks to highlight factors that contribute to the development of myocardial fibrosis in athletes and provide insights into the assessment and interpretation of myocardial fibrosis in athletes. Methods: A literature search was performed using the PubMed/Medline database and Google Scholar for publications that assessed myocardial fibrosis in athletes using CMR. Results: A total of 21 studies involving 1642 endurance athletes were included in the analysis, and myocardial fibrosis was found in 378 of 1595 athletes. A higher prevalence was seen in athletes with cardiac remodelling compared to control subjects (23.7 vs. 3.3%, p < 0.001). Similarly, we found that young endurance athletes had a significantly higher prevalence than veteran athletes (27.7 vs. 19.9%, p < 0.001), while male and female athletes were similar (19.7 vs. 16.4%, p = 0.207). Major myocardial fibrosis (nonischaemic and ischaemic patterns) was predominately observed in veteran athletes, particularly in males and infrequently in young athletes. The right ventricular insertion point was the most common fibrosis location, occurring in the majority of female (96%) and young athletes (84%). Myocardial native T1 values were significantly lower in athletes at 1.5 T (p < 0.001) and 3 T (p = 0.004), although they had similar extracellular volume values to those of control groups. Conclusions: The development of myocardial fibrosis in athletes appears to be a multifactorial process, with genetics, hormones, the exercise dose, and an adverse cardiovascular risk profile playing key roles. Major myocardial fibrosis is not a benign finding and warrants a comprehensive evaluation and follow-up regarding potential cardiac disease.

Cardiac magnetic resonance imaging in the evaluation and management of mitral valve prolapse - a comprehensive review

Mitral valve prolapse is a common valve disorder that usually has a benign prognosis unless there is significant regurgitation or LV impairment. However, a subset of patients are at an increased risk of ventricular arrhythmias and sudden cardiac death, which has led to the recognition of "arrhythmic mitral valve prolapse" as a clinical entity. Emerging risk factors include mitral annular disjunction and myocardial fibrosis. While echocardiography remains the primary method of evaluation, cardiac magnetic resonance has become crucial in managing this condition. Cine magnetic resonance sequences provide accurate characterization of prolapse and annular disjunction, assessment of ventricular volumes and function, identification of early dysfunction and remodeling, and quantitative assessment of mitral regurgitation when integrated with flow imaging. However, the unique strength of magnetic resonance lies in its ability to identify tissue changes. T1 mapping sequences identify diffuse fibrosis, in turn related to early ventricular dysfunction and remodeling. Late gadolinium enhancement sequences detect replacement fibrosis, an independent risk factor for ventricular arrhythmias and sudden cardiac death. There are consensus documents and reviews on the use of cardiac magnetic resonance specifically in arrhythmic mitral valve prolapse. However, in this article, we propose an algorithm for the broader use of cardiac magnetic resonance in managing this condition in various scenarios. Future advancements may involve implementing techniques for tissue characterization and flow analysis, such as 4D flow imaging, to identify patients with ventricular dysfunction and remodeling, increased arrhythmic risk, and more accurate grading of mitral regurgitation, ultimately benefiting patient selection for surgical therapy.

MRI of cardiac involvement in COVID-19

The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has led to a diverse pattern of myocardial injuries, including myocarditis, which is linked to adverse outcomes in patients. Research indicates that myocardial injury is associated with higher mortality in hospitalized severe COVID-19 patients (75.8% vs 9.7%). Cardiovascular Magnetic Resonance (CMR) has emerged as a crucial tool in diagnosing both ischaemic and non-ischaemic myocardial injuries, providing detailed insights into the impact of COVID-19 on myocardial tissue and function. This review synthesizes existing studies on the histopathological findings and CMR imaging patterns of myocardial injuries in COVID-19 patients. CMR imaging has revealed a complex pattern of cardiac damage in these patients, including myocardial inflammation, oedema, fibrosis, and ischaemic injury, due to coronary microthrombi. This review also highlights the role of LLC criteria in diagnosis of COVID-related myocarditis and the importance of CMR in detecting cardiac complications of COVID-19 in specific groups, such as children, manifesting multisystem inflammatory syndrome in children (MIS-C) and athletes, as well as myocardial injuries post-COVID-19 infection or following COVID-19 vaccination. By summarizing existing studies on CMR in COVID-19 patients and highlighting ongoing research, this review contributes to a deeper understanding of the cardiac impacts of COVID-19. It emphasizes the effectiveness of CMR in assessing a broad spectrum of myocardial injuries, thereby enhancing the management and prognosis of patients with COVID-19 related cardiac complications.

Effect of spin-lock frequency on quantitative myocardial T1ρ mapping

OBJECTIVES

To use T1ρ mapping to assess myocardial fibrosis and to provide a reference for future clinical application, it is necessary to understand the factors influencing T1ρ values. This study explored the influence of different spin-locking frequencies on T1ρ values under a 3.0-T MR system.

METHODS

Fifty-seven healthy subjects were prospectively and consecutively included in this study, and T1ρ mapping was performed on them in 3 short-axis slices with three spin-lock frequencies at the amplitude of 300 Hz, 400 Hz, and 500 Hz, then nine T1ρ images were acquired per subject. Four T1ρ-weighted images were acquired using a spin-lock preparation pulse with varying durations (0 msec, 13.3 msec, 26.6 msec, 40 msec). T1ρ relaxation times were quantified for each slice and each myocardial segment. The results were analyzed using Student's t-test and one-way analysis of variance (ANOVA) methods.

RESULTS

Mean T1ρ relaxation times were 43.5 ± 2.8 msec at 300 Hz, 44.9 ± 3.6 msec at 400 Hz, and 46.2 ± 3.1 msec at 500 Hz, showing a significant progressive increase from low to high spin-lock frequency (300 Hz vs. 400 Hz, p = 0.046; 300 Hz vs. 500 Hz, p < 0.001; 400 Hz vs. 500 Hz, p = 0.043). In addition, The T1ρ values of females were significantly higher than those of males (300 Hz, p = 0.049; 400 Hz, p = 0.01; 500 Hz, p = 0.002).

CONCLUSION

In this prospective study, myocardial T1ρ values for the specific CMR setting are provided, and we found that gender and spin-lock frequency can affect the T1ρ values.

CRITICAL RELEVANCE STATEMENT

T1ρ mapping could supersede late gadolinium enhancement for detection of myocardial fibrosis. Establishing reference mean values that take key technical elements into account will facilitate interpretation of data in disease states.

KEY POINTS

This study established myocardial T1ρ reference values for different spin-lock frequencies. T1ρ values increased with spin-lock frequency, but numerical differences were minimal. Females had higher T1ρ values than males at all frequencies.

Non-rigid motion-compensated 3D whole-heart T2 mapping in a hybrid 3T PET-MR system

PURPOSE

Simultaneous PET-MRI improves inflammatory cardiac disease diagnosis. However, challenges persist in respiratory motion and mis-registration between free-breathing 3D PET and 2D breath-held MR images. We propose a free-breathing non-rigid motion-compensated 3D T2 -mapping sequence enabling whole-heart myocardial tissue characterization in a hybrid 3T PET-MR system and provides non-rigid respiratory motion fields to correct also simultaneously acquired PET data.

METHODS

Free-breathing 3D whole-heart T2 -mapping was implemented on a hybrid 3T PET-MRI system. Three datasets were acquired with different T2 -preparation modules (0, 28, 55 ms) using 3-fold undersampled variable-density Cartesian trajectory. Respiratory motion was estimated via virtual 3D image navigators, enabling multi-contrast non-rigid motion-corrected MR reconstruction. T2 -maps were computed using dictionary-matching. Approach was tested in phantom, 8 healthy subjects, 14 MR only and 2 PET-MR patients with suspected cardiac disease and compared with spin echo reference (phantom) and clinical 2D T2 -mapping (in-vivo).

RESULTS

Phantom results show a high correlation (R2  = 0.996) between proposed approach and gold standard 2D T2 mapping. In-vivo 3D T2 -mapping average values in healthy subjects (39.0 ± 1.4 ms) and patients (healthy tissue) (39.1 ± 1.4 ms) agree with conventional 2D T2 -mapping (healthy = 38.6 ± 1.2 ms, patients = 40.3 ± 1.7 ms). Bland-Altman analysis reveals bias of 1.8 ms and 95% limits of agreement (LOA) of -2.4-6 ms for healthy subjects, and bias of 1.3 ms and 95% LOA of -1.9 to 4.6 ms for patients.

CONCLUSION

Validated efficient 3D whole-heart T2 -mapping at hybrid 3T PET-MRI provides myocardial inflammation characterization and non-rigid respiratory motion fields for simultaneous PET data correction. Comparable T2 values were achieved with both 3D and 2D methods. Improved image quality was observed in the PET images after MR-based motion correction.

Extracellular Volume Fraction by Computed Tomography Predicts Prognosis After Transcatheter Aortic Valve Replacement

BACKGROUND

Extracellular volume fraction (ECV) on magnetic resonance imaging can predict prognosis after aortic valve replacement in patients with aortic stenosis (AS). However, the usefulness of ECV on computed tomography (CT) for patients who have undergone transcatheter aortic valve replacement (TAVR) is unclear, so we investigated whether ECV analysis on CT is associated with clinical outcomes in TAVR candidates.

METHODS AND RESULTS

We analyzed 127 patients with severe AS who underwent preoperative CT for TAVR. We evaluated the utility of ECV analysis on single-energy CT for predicting patient prognosis after TAVR. The primary outcome was a composite of all-cause death and hospitalization due to heart failure (HF) after TAVR. 15 patients (12%) had composite outcomes: 4 deaths and 11 hospitalizations due to HF. In multivariate survival analysis using the Cox proportional hazard model, atrial fibrillation (AF) (hazard ratio (HR), 7.86; 95% confidence interval (CI), 2.57-24.03; P<0.001), history of congestive HF (HR, 4.91; 95% CI, 1.49-16.2; P=0.009) and ECV ≥32.6% on CT (HR, 6.96; 95% CI, 1.92-25.12; P=0.003) were independent predictors of composite outcomes. On Kaplan-Meier analysis, the higher ECV group (≥32.6%) had a significantly greater number of composite outcomes than the lower ECV group (P<0.001).

CONCLUSIONS

ECV on CT is an independent predictor of prognosis after TAVR.

COVID-19 mRNA vaccine-related myocarditis: A PRISMA systematic review, imaging approach and differential diagnoses

We present a case involving a young individual who developed acute myocarditis on the fourth day following administration of a COVID-19 mRNA vaccine. The patient's condition was managed conservatively, resulting in a favorable outcome. This paper extensively discusses the pathogenesis, clinical manifestations, imaging characteristics of COVID-19 mRNA vaccine-related myocarditis and includes a comprehensive review of pertinent literature. Additionally, a systematic review of COVID-19 mRNA vaccine-related myocarditis, conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) principles, is presented. Healthcare professionals should maintain a clinical suspicion for COVID-19 mRNA vaccine-related myocarditis when encountering patients with confirmed myocarditis who have received recent COVID-19 mRNA vaccination, after ruling out other potential causes. The diagnosis of acute myocarditis primarily relies on adherence to the Lake Louise Criteria (LLC) for cardiac magnetic resonance (CMR). Nevertheless, specific CMR features or distinctive patterns indicative of COVID-19 mRNA vaccine-related myocarditis are currently undefined. Among patients with vaccine-related myocarditis, common CMR findings encompass subepicardial late gadolinium enhancement and T2-based myocardial edema, although these findings lack specificity and may resemble other medical conditions. Supportive care involving a short-term regimen of NSAIDs, colchicine, and steroids represents the cornerstone of treatment for this variant of myocarditis, which tends to be self-limiting with favorable short-term prognoses. Timely diagnosis is paramount for optimizing patient care.

Hypertrophic Cardiomyopathy-Advances in Imaging and Diagnostic Strategies

Hypertrophic cardiomyopathy (HCM) is the most important and prevalent cardiac disease in cats. Due to the highly variable nature of HCM, a multimodal approach including physical examination, genetic evaluation, cardiac biomarkers, and imaging are all essential elements to appropriate and timely diagnosis. These foundational elements are advancing rapidly in veterinary medicine. Newer biomarkers such as galectin-3 are currently being researched and advances in tissue speckle-tracking and contrast-enhanced echocardiography are readily available. Advanced imaging techniques, such as cardiac MRI, are providing previously unavailable information about myocardial fibrosis and paving the way for enhanced diagnostic capabilities and risk-stratification in cats with HCM.

Myocardial Tissue Characterization in Patients with Hypertensive Crisis, Positive Troponin, and Unobstructed Coronary Arteries: A Cardiovascular Magnetic Resonance-Based Study

Hypertensive crisis can present with cardiac troponin elevation and unobstructed coronary arteries. We used cardiac magnetic resonance (CMR) imaging to characterize the myocardial tissue in patients with hypertensive crisis, elevated cardiac troponin, and unobstructed coronary arteries. Patients with hypertensive crisis and elevated cardiac troponin with coronary artery stenosis <50% were enrolled. Patients with troponin-negative hypertensive crisis served as controls. All participants underwent CMR imaging at 1.5 Tesla. Imaging biomarkers and tissue characteristics were compared between the groups. There were 19 patients (63% male) with elevated troponin and 24 (33% male) troponin-negative controls. The troponin-positive group was older (57 ± 11 years vs. 47 ± 14 years, p = 0.015). The groups had similar T2-weighted signal intensity ratios and native T1 times. T2 relaxation times were longer in the troponin-positive group, and the difference remained significant after excluding infarct-pattern late gadolinium enhancement (LGE) from the analysis. Extracellular volume (ECV) was higher in the troponin-positive group (25 ± 4 ms vs. 22 ± 3 ms, p = 0.008) and correlated strongly with T2 relaxation time (rs = 0.701, p = 0.022). Late gadolinium enhancement was 32% more prevalent in the troponin-positive group (82% vs. 50%, p = 0.050), with 29% having infarct-pattern LGE. T2 relaxation time was independently associated with troponin positivity (OR 2.1, p = 0.043), and both T2 relaxation time and ECV predicted troponin positivity (C-statistics: 0.71, p = 0.009; and 0.77, p = 0.006). Left ventricular end-diastolic and left atrial volumes were the strongest predictors of troponin positivity (C-statistics: 0.80, p = 0.001; and 0.82, p < 0.001). The increased T2 relaxation time and ECV and their significant correlation in the troponin-positive group suggest myocardial injury with oedema, while the non-ischaemic LGE could be due to myocardial fibrosis or acute necrosis. These CMR imaging biomarkers provide important clinical indices for risk stratification and prognostication in patients with hypertensive crisis.

Cardiovascular magnetic resonance findings in Danon disease: a case series of a family

Background

Cardiac involvement constitutes the primary cause of mortality in patients with Danon disease (DD). This study aimed to explore the cardiac magnetic resonance (CMR) features and progressions of DD cardiomyopathies in a family with long-term follow-up.

Methods

Seven patients (five females and two males), belonging to the same family and afflicted with DD, were enrolled in this study between 2017 and 2022. The cardiac structure, function, strain, tissue characteristics on CMR and their evolutions during follow-up were analyzed.

Results

Three young female patients (3/7, 42.86%) exhibited normal cardiac morphology. Four patients (4/7, 57.14%) displayed left ventricle hypertrophy (LVH), and mostly with septal thickening (3/4, 75%). A single male case (1/7, 14.3%) showed decreased LV ejection fraction (LVEF). Nonetheless, the global LV strain of the four adult patients decreased in different degree. The global strain of adolescent male patients was decreased compared to the age-appropriate female patients. Five patients (5/7, 71.43%) exhibited late gadolinium enhancement (LGE), with proportion ranging from 31.6% to 59.7% (median value 42.7%). The most common LGE location was the LV free wall (5/5, 100%), followed by right ventricle insertion points (4/5, 80%) and intraventricular septum (2/5, 40%). Segmental radial strain (rs = -0.586), circumferential strain (r = 0.589), and longitudinal strain (r = 0.514) were all moderately correlated with the LGE proportions of corresponding segments (P < 0.001). T2 hyperintense and perfusion defect foci were identified, overlapping with the LGE areas. During follow-up, both the young male patients exhibited notable deterioration of their cardiac symptoms and CMR. The LVEF and strain decreased, and the extent of LGE increased year by year. One patient underwent T1 mapping examination. The native T1 value was sensitively elevated even in regions without LGE.

Conclusions

Left ventricular hypertrophy, LGE with sparing or relatively less involved IVS, and LV dysfunction are prominent CMR features of Danon cardiomyopathy. Strain and T1 mapping may have advantages in detecting early-stage dysfunction and myocardial abnormalities in DD patients, respectively. Multi-parametric CMR can serve as an optimal instrument for detecting DD cardiomyopathies.

Immunoglobulin G4-Related Myocarditis with Eosinophilic Infiltration: A Case Report

Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a fibroinflammatory disorder that can involve any organ system; however, myocarditis is extremely rare. A 52-year-old male with dyspnea and chest discomfort underwent cardiac MRI that revealed edema and nodular, patchy, mesocardial and subendoardial delayed enhancement of left ventricle, suggesting myocarditis. Laboratory findings revealed elevated serum IgG4 and eosinophilia. Cardiac biopsy confirmed eosinophilic myocarditis with IgG4-positive cells. Here, we present an unusual case of IgG4-RD manifesting as eosinophilic myocarditis.

Hypertrophic cardiomyopathy - phenotypic variations beyond wall thickness

Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy (LVH) in the absence of another causal disease. Several morphologic and histologic changes have been described. Given the morbidity and mortality associated with HCM, understanding these anatomic variations is key to interpreting imaging. This is especially important since many patients exhibit these associated findings in the absence of LVH and prompt early detection of these variations may lead to early diagnosis and treatment. This article describes the appearance of morphologic variations seen in HCM beyond myocardial thickening including: papillary muscle and mitral valve variants, myocardial crypts, left ventricular myocardial bands, and dystrophic calcification related to increased wall tension.

Myocardial injury after major non-cardiac surgery evaluated with advanced cardiac imaging: a pilot study

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) is a frequent complication caused by cardiac and non-cardiac pathophysiological mechanisms, but often it is subclinical. MINS is associated with increased morbidity and mortality, justifying the need to its diagnose and the investigation of their causes for its potential prevention.

METHODS

Prospective, observational, pilot study, aiming to detect MINS, its relationship with silent coronary artery disease and its effect on future adverse outcomes in patients undergoing major non-cardiac surgery and without postoperative signs or symptoms of myocardial ischemia. MINS was defined by a high-sensitive cardiac troponin T (hs-cTnT) concentration > 14 ng/L at 48-72 h after surgery and exceeding by 50% the preoperative value; controls were the operated patients without MINS. Within 1-month after discharge, cardiac computed tomography angiography (CCTA) and magnetic resonance imaging (MRI) studies were performed in MINS and control subjects. Significant coronary artery disease (CAD) was defined by a CAD-RADS category ≥ 3. The primary outcomes were prevalence of CAD among MINS and controls and incidence of major cardiovascular events (MACE) at 1-year after surgery. Secondary outcomes were the incidence of individual MACE components and mortality.

RESULTS

We included 52 MINS and 12 controls. The small number of included patients could be attributed to the study design complexity and the dates of later follow-ups (amid COVID-19 waves). Significant CAD by CCTA was equally found in 20 MINS and controls (30% vs 33%, respectively). Ischemic patterns (n = 5) and ischemic segments (n = 2) depicted by cardiac MRI were only observed in patients with MINS. One-year MACE were also only observed in MINS patients (15.4%).

CONCLUSION

This study with advanced imaging methods found a similar CAD frequency in MINS and control patients, but that cardiac ischemic findings by MRI and worse prognosis were only observed in MINS patients. Our results, obtained in a pilot study, suggest the need of further, extended studies that screened systematically MINS and evaluated its relationship with cardiac ischemia and poor outcomes. Trial registration Clinicaltrials.gov identifier: NCT03438448 (19/02/2018).

Evaluation of extracellular volume by computed tomography is useful for prediction of prognosis in dilated cardiomyopathy

Cardiac computed tomography (CT) is useful for the screening of coronary artery stenosis, and extracellular volume fraction (ECV) analysis by CT using new dedicated software is now available. Here, we evaluated the utility of ECV analysis using cardiac CT to predict patient prognosis in cases with dilated cardiomyopathy (DCM). We analyzed 70 cases with DCM and cardiac computed tomography (CT) with available late-phase images. We evaluated the ECV of the left ventricular myocardium (LVM) using commercially available software (Ziostation 2, Ziosoft Inc, Japan). ECV on LVM was 33.96 ± 5.04%. Major adverse cardiac events (MACE) occurred in 21 cases (30%). ECV of the LVM on CT, endo-systolic volume, and rate of significant valvular disease were significantly higher in cases with MACE than in those without (37.16 ± 5.91% vs. 32.59 ± 3.95%, 194 ± 109 vs. 138 ± 78 ml and 57% vs. 20%, all P values < 0.05). LVEF was significantly lower in cases with MACE than in those without (23 ± 8 vs. 31 ± 11%, P = 0.0024). The best cut-off value of ECV on LVM for prediction of MACE was 32.26% based on receiver operating characteristics analysis. Cases with ECV ≥ 32.26% had significantly higher MACE based on Kaplan-Meier analysis (P = 0.0032). Only ECV on LVM was an independent predictor of MACE based on a multivariate Cox proportional hazards model (P = 0.0354). Evaluation of ECV on LVM by CT is useful for predicting MACE in patients with DCM.

A new composite indicator consisting of left ventricular extracellular volume, N-terminal fragment of B-type natriuretic peptide, and left ventricular end-diastolic volume is useful for predicting reverse remodeling after catheter ablation for atrial fibrillation

Recently, myocardial extracellular volume (ECV) analysis has been measurable on computed tomography (CT) using new software. We evaluated the use of cardiac CT to estimate the myocardial ECV of left ventricular (LV) myocardium (LVM) to predict reverse remodeling (RR) in cases of atrial fibrillation (AF) after catheter ablation (CA). Four hundred and seven patients underwent CA for AF in our institution from April 2014 to Feb 2021. Of these, 33 patients (8%) with an LVEF ≤ 50% and who had undergone CT were included in our study. We estimated the LVM ECV using commercial software to analyze the CT data. RR was defined as an improvement in LVEF to > 50% after CA. LVEF increased to > 50% in 24 patients (73%) after CA. In all 24 patients, LVM ECV, LV end-diastolic and end-systolic volumes (LVEDV and LVESV), and the n-terminal fragment of pro-B-type natriuretic peptide (NT-proBNP) were significantly lower than in the other nine patients (P = 0.0037, 0.0273, 0.0443, and < 0.0001). On receiver operating characteristic curve analysis, the best cut-off of ECV, LVEDV, LVESV and NT-proBNP for the prediction of RR were 37.73%, 120 mL, 82 mL, and 1267 pg/mL, respectively. We newly defined the ENL (ECV, NT-proBNP, and LVEDV) score as the summed score for the presence or absence (1 or 0; maximum score = 3) of ECV, NT-proBNP, and LVEDV values less than or equal to each best cut-off value, and found that this score gave the highest area under the curve for the prediction of RR (0.9583, P < 0.0001). The ENL score may be useful for predicting RR in patients with AF undergoing CA.

Noninvasive diagnostic modalities for the diagnosis of coronary artery disease: A guide for acute care NPs

ABSTRACT

Selecting noninvasive diagnostic tests for coronary artery disease can be a daunting task to acute care NPs. This article provides an overview of the pathophysiology of coronary artery disease, relevant noninvasive diagnostic imaging modalities, and an evidence-based approach to guide subsequent diagnostic and therapeutic interventions.

Role of advanced imaging with cardiac computed tomography and MRI in atrial and ventricular ablation

PURPOSE OF REVIEW

Increasing evidence supports the use of advanced imaging with cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR) in the work-up of patients with arrythmias being considered for ablation.

RECENT FINDINGS

Advances in imaging technology and postprocessing are facilitating the use of advanced imaging before, during and after ablation in patients with both atrial and ventricular arrhythmias.In atrial arrythmias, quantitative assessment of left atrial wall thickness on CCT and quantification of late gadolinium enhancement (LGE) on CMR identify patients more likely to develop recurrent atrial arrythmias following ablation. In addition, in patients with recurrent arrythmia post ablation, LGE CMR can potentially identify targets for repeat ablation.In ventricular arrythmias, qualitative assessment of LGE can aide in determining the optimal ablation approach and predicts likelihood of ventricular arrythmias inducibility. Quantitative assessment of LGE can identify conduction channels that can be targeted for ablation. On CCT, quantitative assessment of left ventricular wall thickness can demonstrate myocardial ridges associated with re-entrant circuits for ablation.

SUMMARY

This review focuses on the utility of CCT and CMR in identifying key anatomical components and arrhythmogenic substrate contributing to both atrial and ventricular arrhythmias in patients being considered for ablation. Advanced imaging has the potential to improve procedural outcomes, decrease complications and shorten procedural time.

State-of-the-Art Multimodality Imaging in Sudden Cardiac Arrest with Focus on Idiopathic Ventricular Fibrillation: A Review

Idiopathic ventricular fibrillation is a rare cause of sudden cardiac arrest and a diagnosis by exclusion. Unraveling the mechanism of ventricular fibrillation is important for targeted management, and potentially for initiating family screening. Sudden cardiac arrest survivors undergo extensive clinical testing, with a growing role for multimodality imaging, before diagnosing "idiopathic" ventricular fibrillation. Multimodality imaging, considered as using multiple imaging modalities as diagnostics, is important for revealing structural myocardial abnormalities in patients with cardiac arrest. This review focuses on combining imaging modalities (echocardiography, cardiac magnetic resonance and computed tomography) and the electrocardiographic characterization of sudden cardiac arrest survivors and discusses the surplus value of multimodality imaging in the diagnostic routing of these patients. We focus on novel insights obtained through electrostructural and/or electromechanical imaging in apparently idiopathic ventricular fibrillation patients, with special attention to non-invasive electrocardiographic imaging.

Cardiovascular Magnetic Resonance Imaging in the Early Detection of Cardiotoxicity Induced by Cancer Therapies

The significant progress in cancer treatment, including chemotherapy, immunotherapy, radiotherapy, and combination therapies, has led to higher long-term survival rates in cancer patients, while the cardiotoxicity caused by cancer treatment has become increasingly prominent. Cardiovascular magnetic resonance (CMR) is a non-invasive comprehensive imaging modality that provides not only anatomical information, but also tissue characteristics and cardiometabolic and energetic assessment, leading to its increased use in the early identification of cardiotoxicity, and is of major importance in improving the survival rate of cancer patients. This review focused on CMR techniques, including myocardial strain analysis, T1 mapping, T2 mapping, and extracellular volume fraction (ECV) calculation in the detection of early myocardial injury induced by cancer therapies. We summarized the existing studies and ongoing clinical trials using CMR for the assessment of subclinical ventricular dysfunction and myocardial changes at the tissue level. The main focus was to explore the potential of clinical and preclinical CMR techniques for continuous non-invasive monitoring of myocardial toxicity associated with cancer therapy.

Deep Learning-based Post Hoc CT Denoising for Myocardial Delayed Enhancement

Background To improve myocardial delayed enhancement (MDE) CT, a deep learning (DL)-based post hoc denoising method supervised with averaged MDE CT data was developed. Purpose To assess the image quality of denoised MDE CT images and evaluate their diagnostic performance by using late gadolinium enhancement (LGE) MRI as a reference. Materials and methods MDE CT data obtained by averaging three acquisitions with a single breath hold 5 minutes after the contrast material injection in patients from July 2020 to October 2021 were retrospectively reviewed. Preaveraged images obtained in 100 patients as inputs and averaged images as ground truths were used to supervise a residual dense network (RDN). The original single-shot image, standard averaged image, RDN-denoised original (DL_original) image, and RDN-denoised averaged (DL_ave) image of holdout cases were compared. In 40 patients, the CT value and image noise in the left ventricular cavity and myocardium were assessed. The segmental presence of MDE in the remaining 40 patients who underwent reference LGE MRI was evaluated. The sensitivity, specificity, and accuracy of each type of CT image and the improvement in accuracy achieved with the RDN were assessed using odds ratios (ORs) estimated with the generalized estimation equation. Results Overall, 180 patients (median age, 66 years [IQR, 53-74 years]; 107 men) were included. The RDN reduced image noise to 28% of the original level while maintaining equivalence in the CT values (P < .001 for all). The sensitivity, specificity, and accuracy of the original images were 77.9%, 84.4%, and 82.3%, of the averaged images were 89.7%, 87.9%, and 88.5%, of the DL_original images were 93.1%, 87.5%, and 89.3%, and of the DL_ave images were 95.1%, 93.1%, and 93.8%, respectively. DL_original images showed improved accuracy compared with the original images (OR, 1.8 [95% CI: 1.2, 2.9]; P = .011) and DL_ave images showed improved accuracy compared with the averaged images (OR, 2.0 [95% CI: 1.2, 3.5]; P = .009). Conclusion The proposed denoising network supervised with averaged CT images reduced image noise and improved the diagnostic performance for myocardial delayed enhancement CT. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Vannier and Wang in this issue.

The role of inflammation in the pathogenesis and treatment of arrhythmias

The pathogenesis of arrhythmias is complex and multifactorial. The role of inflammation in the pathogenesis of both atrial and ventricular arrhythmias (VA) has been explored. However, developing successful pharmacotherapy regimens based on those pathways has proven more of a challenge. This narrative review provides an overview of five common arrhythmias impacted by inflammation, including atrial fibrillation (AF), myocardial infarction, arrhythmogenic cardiomyopathy, cardiac sarcoidosis, and QT prolongation, and the potential role for anti-inflammatory therapy in their management. We identified arrhythmias and arrhythmogenic disease states with the most evidence linking pathogenesis to inflammation and conducted comprehensive searches of United States National Library of Medicine MEDLINE^® and PubMed databases. Although a variety of agents have been studied for the management of AF, primarily in an effort to reduce postoperative AF following cardiac surgery, no standard anti-inflammatory agents are used in clinical practice at this time. Although inflammation following myocardial infarction may contribute to the development of VA, there is no clear benefit with the use of anti-inflammatory agents at this time. Similarly, although inflammation is clearly linked to the development of arrhythmias in arrhythmogenic cardiomyopathy, data demonstrating a benefit with anti-inflammatory agents are limited. Cardiac sarcoidosis, an infiltrative disease eliciting an immune response, is primarily treated by immunosuppressive therapy and steroids, despite a lack of primary literature to support such regimens. In this case, anti-inflammatory agents are frequently used in clinical practice. The pathophysiology of arrhythmias is complex, and inflammation likely plays a role in both onset and duration, however, for most arrhythmias the role of pharmacotherapy targeting inflammation remains unclear.

Complete resolution of severe secondary mitral regurgitation accompanying eosinophilic myocarditis due to immunosuppressive treatment

Eosinophilic myocarditis (EM) is an under-diagnosed inflammatory heart disease that often leads to severe left ventricular (LV) dysfunction. Meanwhile, severe secondary mitral regurgitation (MR) with valve disruption, possibly requiring mitral valve repair, is rarely concomitant with EM. We present the case of a 64-year-old female diagnosed with heart failure with severe LV dysfunction and localized asynergy. Echocardiography revealed severe secondary MR with mitral valve disruption. Cardiac magnetic resonance imaging (CMR) showed transmural late-gadolinium enhancement localized in the anterior wall and diffuse high-signal areas on T2-weighted images, suggesting non-ischemic and inflammatory heart disease. Although the peripheral eosinophil count was not elevated on admission, it gradually increased during hospitalization. These findings encouraged us to perform endomyocardial biopsy, which confirmed myocardial eosinophilic infiltration with mild fibrosis and necrosis, leading to the diagnosis of EM. Immunosuppressive treatment with oral corticosteroids improved LV dysfunction and completely resolved severe secondary MR. The current case highlighted that comprehensive assessment of laboratory, imaging, and pathological examinations including CMR is crucial to develop the appropriate therapeutic strategy for refractory heart failure. Immunosuppressive treatment should be considered as the first therapeutic option even in EM cases with severe secondary MR, possibly requiring mitral valve repair.

<Learning objective:The gradual increase in peripheral eosinophils during hospitalization, without significant peripheral eosinophilia on admission, is crucial for the diagnosis of eosinophilic myocarditis. Comprehensive assessment of laboratory, imaging, and pathological examinations including cardiac magnetic resonance imaging is mandatory when building an appropriate therapeutic strategy for refractory heart failure. Severe secondary mitral regurgitation with mitral valve disruption can be completely resolved via immunosuppressive treatment in cases of eosinophilic myocarditis.>

Quantitative analysis of late iodine enhancement using dual-layer spectral detector computed tomography: comparison with magnetic resonance imaging

BACKGROUND

To evaluate the segmental myocardial extracellular volume (ECV) fraction and to define a threshold ECV value that can be used to distinguish positive late gadolinium enhancement (LGE) segments from negative myocardial segments using dual-layer spectral detector computed tomography (SDCT), with magnetic resonance imaging (MRI) as a reference.

METHODS

Fifty-six subjects with cardiac disease or suspected cardiac disease, underwent both late iodine enhancement on CT (CT-LIE) scanning and late gadolinium enhancement on MRI (MRI-LGE) scanning. Each procedure occurred within a week of the other. Global and segmental ECVs of the left ventricle were measured by CT and MRI images. According to the location and pattern of delayed enhancement on MRI image, myocardial segments were classified into 3 groups: ischemic LGE segments (group 1), nonischemic LGE segments (group 2) and negative LGE segments (group 3). The correlation and agreement between CT-ECV and MRI-ECV were compared on a per-segment basis. Receiver operating characteristic (ROC) curve analysis was performed to establish a threshold for LIE detection.

RESULTS

Among the 56 patients, 896 segments were analyzed, and of these, 73 segments were in group 1, 229 segments were in group 2, and 594 segments were in group 3. In segmental analysis, CT-ECV in group 3 (27.0%; 24.9-28.9%) was significantly lower than that in group 1 (33.2%; 30.7-36.3%) and group 2 (34.9%; 32.3-39.8%; all P<0.001). Good correlations were seen between CT-ECV and MRI-ECV for all groups (group 1: r=0.920; group 2: r=0.936; group 3: r=0.799; all P<0.001). Bland-Altman analysis between CT-ECV and MRI-ECV showed a small bias in all 3 groups (group 1: -2.1%, 95% limits of agreement -11.3-7.1%; group 2: -0.6%, 95% limits of agreement -13.1-11.9%; group 3: 1.0%, 95% limits of agreement -12.7-14.7%). CT-ECV could differentiate between LGE-positive and LGE-negative segments with 83.1% sensitivity and 93.3% specificity at a cutoff of 31%.

CONCLUSIONS

ECV values derived from CT imaging showed good correlation and agreement with MR imaging findings, and CT-ECV provided high diagnostic accuracy for discriminating between LGE-positive and LGE-negative segments. Thus, cardiac CT imaging might be a suitable noninvasive imaging technique for myocardial ECV quantification.

Combined simultaneous FDG-PET/MRI with T1 and T2 mapping as an imaging biomarker for the diagnosis and prognosis of suspected cardiac sarcoidosis

PURPOSE

To evaluate the diagnostic and prognostic significance of combined cardiac 18F-fluorodeoxyglucose (FDG) PET/MRI with T1/T2 mapping in the evaluation of suspected cardiac sarcoidosis.

METHODS

Patients with suspected cardiac sarcoidosis were prospectively enrolled for cardiac 18F-FDG PET/MRI, including late gadolinium enhancement (LGE) and T1/T2 mapping with calculation of extracellular volume (ECV). The final diagnosis of cardiac sarcoidosis was established using modified JMHW guidelines. Major adverse cardiac events (MACE) were assessed as a composite of cardiovascular death, ventricular tachyarrhythmia, bradyarrhythmia, cardiac transplantation or heart failure. Statistical analysis included Cox proportional hazard models.

RESULTS

Forty-two patients (53 ± 13 years, 67% male) were evaluated, 13 (31%) with a final diagnosis of cardiac sarcoidosis. Among patients with cardiac sarcoidosis, 100% of patients had at least one abnormality on PET/MRI: FDG uptake in 69%, LGE in 100%, elevated T1 and ECV in 100%, and elevated T2 in 46%. FDG uptake co-localized with LGE in 69% of patients with cardiac sarcoidosis compared to 24% of those without, p = 0.014. Diagnostic specificity for cardiac sarcoidosis was highest for FDG uptake (69%), elevated T2 (79%), and FDG uptake co-localizing with LGE (76%). Diagnostic sensitivity was highest for LGE, elevated T1 and ECV (100%). After median follow-up duration of 634 days, 13 patients experienced MACE. All patients who experienced MACE had LGE, elevated T1 and elevated ECV. FDG uptake (HR 14.7, p = 0.002), elevated T2 (HR 9.0, p = 0.002) and native T1 (HR 1.1 per 10 ms increase, p = 0.044) were significant predictors of MACE even after adjusting for left ventricular ejection fraction and immune suppression treatment. The presence of FDG uptake co-localizing with LGE had the highest diagnostic performance overall (AUC 0.73) and was the best predictor of MACE based on model goodness of fit (HR 14.9, p = 0.001).

CONCLUSIONS

Combined cardiac FDG-PET/MRI with T1/T2 mapping provides complementary diagnostic information and predicts MACE in patients with suspected cardiac sarcoidosis.

Interleukin-1 blockade in cardiac sarcoidosis: study design of the multimodality assessment of granulomas in cardiac sarcoidosis: Anakinra Randomized Trial (MAGiC-ART)

BACKGROUND

Sarcoidosis is an inflammatory disease characterized by the formation of granulomas, which involve the heart in up to 25% of patients. Cardiac sarcoidosis can lead to life threatening arrhythmias and heart failure. While corticosteroids have been used as a treatment for over 50 years, they are associated with hypertension, diabetes, and weight gain, further increasing cardiovascular risk. Interleukin-1 (IL-1) is the prototypical proinflammatory cytokine that works to activate the nuclear transcription factor NF-kB, one of the targets of glucocorticoids. IL-1 also plays an important role also in the pathophysiology of heart disease including atherosclerosis, myocardial infarction, and myocarditis.

METHODS

Building on a network of research collaborators developed in the Cardiac Sarcoidosis Consortium, we will investigate the feasibility and tolerability of treatment of CS with anakinra at two National Institute of Health Clinical and Translational Science Award (CTSA) hubs with expertise in cardiac sarcoidosis. In this pilot study, up to 28 patients with cardiac sarcoidosis will be recruited to compare the administration of an IL-1 blocker, anakinra, 100 mg daily on top of standard of care versus standard of care only for 28 days and followed for 180 days. Utilizing surrogate endpoints of changes in systemic inflammatory biomarkers and cardiac imaging, we aim to determine whether IL-1 blockade with anakinra can combat systemic and cardiac inflammation in patients with cardiac sarcoidosis.

DISCUSSION

The current trial demonstrates an innovative collaborative approach to clinical trial development in a rare, understudied disease that disproportionately affects females and minorities. Trial Registration The trial was registered prospectively with ClinicalTrials.gov on July 12, 2019, identifier NCT04017936.

Amyloidosis: Multisystem Spectrum of Disease with Pathologic Correlation

Amyloidosis is a group of conditions defined by extracellular deposition of insoluble proteins that can lead to multiorgan dysfunction and failure. The systemic form of the disease is often associated with a plasma cell dyscrasia but may also occur in the setting of chronic inflammation, long-term dialysis, malignancy, or multiple hereditary conditions. Localized forms of the disease most often involve the skin, tracheobronchial tree, and urinary tract and typically require tissue sampling for diagnosis, as they may mimic many conditions including malignancy at imaging alone. Advancements in MRI and nuclear medicine have provided greater specificity for the diagnosis of amyloidosis involving the central nervous system and heart, potentially obviating the need for biopsy of the affected organ in certain circumstances. Specifically, a combination of characteristic findings at noninvasive cardiac MRI and skeletal scintigraphy in patients without an underlying plasma cell dyscrasia is diagnostic for cardiac transthyretin amyloidosis. Histologically, the presence of amyloid is denoted by staining with Congo red and a characteristic apple green birefringence under polarized light microscopy. The imaging features of amyloid vary across each organ system but share some common patterns, such as soft-tissue infiltration and calcification, that may suggest the diagnosis in the appropriate clinical context. The availability of novel therapeutics that target amyloid protein fibrils such as transthyretin highlights the importance of early diagnosis. Online supplemental material is available for this article. ^©RSNA, 2021.

Cardiac Magnetic Resonance Imaging Findings in 2954 COVID-19 Adult Survivors: A Comprehensive Systematic Review

Background

Recent studies have utilized MRI to determine the extent to which COVID‐19 survivors may experience cardiac sequels after recovery.

Purpose

To systematically review the main cardiac MRI findings in COVID‐19 adult survivors.

Study type

Systematic review.

Subjects

A total of 2954 COVID‐19 adult survivors from 16 studies.

Field Strength/sequence

Late gadolinium enhancement (LGE), parametric mapping (T1‐native, T2, T1‐post (extracellular volume fraction [ECV]), T2‐weighted sequences (myocardium/pericardium), at 1.5 T and 3  T.

Assessment

A systematic search was performed on PubMed, Embase, and Google scholar databases using Boolean operators and the relevant key terms covering COVID‐19, cardiac injury, CMR, and follow‐up. MRI data, including (if available) T1, T2, extra cellular volume, presence of myocardial or pericardial late gadolinium enhancement (LGE) and left and right ventricular ejection fraction were extracted.

Statistical Tests

The main results of the included studies are summarized. No additional statistical analysis was performed.

Results

Of 1601 articles retrieved from the initial search, 12 cohorts and 10 case series met our eligibility criteria. The rate of raised T1 in COVID‐19 adult survivors varied across studies from 0% to 73%. Raised T2 was detected in none of patients in 4 out of 15 studies, and in the remaining studies, its rate ranged from 2% to 60%. In most studies, LGE (myocardial or pericardial) was observed in COVID‐19 survivors, the rate ranging from 4% to 100%. Myocardial LGE mainly had nonischemic patterns. None of the cohort studies observed myocardial LGE in “healthy” controls. Most studies found that patients who recovered from COVID‐19 had a significantly greater T1 and T2 compared to participants in the corresponding control group.

Data Conclusion

Findings of MRI studies suggest the presence of myocardial and pericardial involvement in a notable number of patients recovered from COVID‐19.

Level of Evidence

3

Technical Efficacy Stage

3

The pivotal role of cardiovascular imaging in the identification and risk stratification of non-compaction cardiomyopathy patients

Non-compaction cardiomyopathy (NCM) is a heterogeneous myocardial disease that can finally lead to heart failure, arrhythmias, and/or embolic events. Therefore, early diagnosis and treatment is of paramount importance. Furthermore, genetic assessment and counseling are crucial for individual risk assessment and family planning. Echocardiography is the first-line imaging modality. However, it is hampered by interobserver variability, depends among others on the quality of the acoustic window, cannot assess reliably the right ventricle and the apex, and cannot provide tissue characterization. Cardiovascular magnetic resonance (CMR) provides a 3D approach allowing imaging of the entire heart, including both left and right ventricle, with low operator variability or limitations due to patient's body structure. Furthermore, tissue characterization, using late gadolinium enhancement (LGE), allows the detection of fibrotic areas possibly representing the substrate for potentially lethal arrhythmias, predicts the severity of LV systolic dysfunction, and differentiates apical thrombus from fibrosis. Conversely, besides being associated with high costs, CMR has long acquisition/processing times, lack of expertise among cardiologists/radiologists, and limited availability. Additionally, in cases of respiratory and/or cardiac motion artifacts or arrhythmias, the cine images may be blurred. However, CMR cannot be applied to patients with not CMR-compatible implanted devices and LGE may be not available in patients with severely reduced GFR. Nevertheless, native T1 mapping can provide detailed tissue characterization in such cases. This tremendous potential of CMR makes this modality the ideal tool for better risk stratification of NCM patient, based not only on functional but also on tissue characterization information.

An Unusual Case of Atrial Wall Cardiac Sarcoidosis Detected on Fluorine-18 Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Scan

Isolated cardiac sarcoidosis (ICS) accounts for 5%-10% of patients with sarcoidosis. It can involve atrioventricular node causing heart block, as well as the basal septum, papillary muscles, focal regions in the free wall, and the myocardium being more commonly involved. The diagnosis is achieved on magnetic resonance imaging (MRI) and endomyocardial biopsy. Recently, Fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography (F-18 FDG PET) has been incorporated in the diagnosis as well as management algorithm. We describe an interesting case of ICS detected on F-18 FDG PET and MRI and discuss its role in the management of this rare presentation.

Successful Treatment of Steroid-Refractory Checkpoint Inhibitor Myocarditis with Globulin Derived-Therapy: A case report and literature review

Immune checkpoint inhibitor (ICI) monoclonal antibody drugs are an important interface of immunology and cancer biology with the intended goal to create cancer specific treatments with less systemic toxicity. Recognition of immune-related adverse events is critical and these include significant cardiovascular toxicity and myocarditis. Compared with other immune-related events, ICI associated myocarditis is rare but is associated with high mortality. The majority of cases present early in the course of therapy and patients can rapidly progress to fulminant myocarditis. Initially, the mainstay of treatment in patients with ICI-associated myocarditis is immunosuppressive therapy with glucocorticoids. For those who do not respond to steroids, the optimal treatment is unclear. This review summarizes the potential adjunctive treatment options for patients with steroid-refractory myocarditis by illustrating a case of myocarditis that was treated with Thymoglobulin and immunoglobulin.

Sarcoidosis, the master mimicker

Sarcoidosis is an idiopathic multisystem disorder characterized by noncaseating granulomas. The article focuses on the typical imaging manifestations of sarcoid and the common differentials that need to be included when appropriate. Mistaking a sarcoid-mimicking disease for sarcoid can result in increased patient morbidity and mortality. The pulmonary system is the most common system involved and is typically the best understood by the radiologist, however a deeper knowledge of the pulmonary findings and features of sarcoid in other organ systems is critical. There is a myriad of sarcoid imaging manifestations that can involve every organ system. Often a confidant diagnosis of sarcoid can be made, however a broad differential may need to be considered- differential diagnoses include primary neoplasm, metastatic disease, infectious, and inflammatory etiologies. Radiologist familiarity with the multimodality multisystem imaging findings of sarcoid can help guide clinical management and optimize patient care.

Multimodality cardiac imaging in the 21st century: evolution, advances and future opportunities for innovation

Cardiovascular imaging has significantly evolved since the turn of the century. Progress in the last two decades has been marked by advances in every modality used to image the heart, including echocardiography, cardiac magnetic resonance, cardiac CT and nuclear cardiology. There has also been a dramatic increase in hybrid and fusion modalities that leverage the unique capabilities of two imaging techniques simultaneously, as well as the incorporation of artificial intelligence and machine learning into the clinical workflow. These advances in non-invasive cardiac imaging have guided patient management and improved clinical outcomes. The technological developments of the past 20 years have also given rise to new imaging subspecialities and increased the demand for dedicated cardiac imagers who are cross-trained in multiple modalities. This state-of-the-art review summarizes the evolution of multimodality cardiac imaging in the 21st century and highlights opportunities for future innovation.

LGE-MRI in the Assessment of Left-ventricular Remodelling in Myocarditis

BACKGROUND

The exact morbidity of myocarditis is unknown, as the treatment is generally delayed in virtue of misdiagnosis or missed diagnosis.

AIM

The aim of this study was to identify prognostic factors of left-ventricular remodeling on CMRI performed in patients with pathological proven myocarditis.

METHODS

Sixty-two cases with various presentations of myocarditis (39 cases with heart failure; 23 cases with arrhythmias) were selected. All patients, who underwent coronary angiography, endomyocardial biopsy, were divided into positive-remodeling and negative-remodelling groups to analyse LGE and cardiac cine parameters at presentation and subsequent to 3 months.

RESULTS

Comparison of two subgroups in CMRI is as follows: positive LGE (65.6% vs. 86.7%; p<0.05), LVEF (41.3±14.8% vs. 37.6±10.1%; p=0.62), (25.7±2.0% vs. 24.0±2.5%; p=0.81), (44.5±3.9mm vs. 46.3±5.4mm; p=0.76), (129.1±8.5ml vs. 135.3±12.2ml; p=0.26), (74.8±7.3ml vs. 79.1±10.0ml; p=0.55), (52.0±5.7g vs. 49.6±6.5g; p=0.71), (34.9±3.5ml vs. 32.4±6.2ml; p=0.68), (3.8±0.7L/min vs. 3.1±0.5L/min; p=0.64), (2.9±0.6L/min*m2 vs. 2.7±0.5L/min*m2; p=0.79).

CONCLUSION

LGE-MRI is rewarding as an independent predictor in left-ventricular positive and negative remodelling of myocarditis.

Change of heart: Reverse takotsubo's cardiomyopathy - A case report

Reverse takotsubo's cardiomyopathy is a rare and relatively unknown variant of takotsubo's cardiomyopathy, also known as stress cardiomyopathy or broken heart syndrome. There are significant differences in the patient age and clinical profiles between classic and reverse takotsubo's cardiomyopathy. Classic takotsubo's cardiomyopathy has been extensively described. However, the little described literature related to reverse takotsubo's cardiomyopathy is limited to the cardiology speciality, with a relative paucity described in radiology. We describe a case report of a 73 year-old female who was diagnosed with reverse takotsubo's cardiomyopathy on the basis of Cardiac MRI. Herein, we hope to bring more awareness of this condition and describe its features on MRI.

Improved Diagnostic Performance of New-generation 320-slice Computed Tomography with Forward-projected Model-based Iterative Reconstruction SoluTion for the Assessment of Late Enhancement in Left Ventricular Myocardium

Objective Forward-projected Model-based Iterative Reconstruction SoluTion (FIRST) is a novel reconstruction method. We investigated the improvement in the diagnostic performance for the detection of abnormal late enhancement (LE) in left ventricular myocardium (LVM) using a new-generation 320-slice computed tomography (CT) device with FIRST. Methods This is a retrospective study that included 100 adult patients who underwent cardiac CT including a late phase scan and magnetic resonance imaging (MRI) within 3 months. The first 50 consecutive patients (first-generation group) underwent first-generation 320-slice CT without FIRST, and the next 50 consecutive patients (second-generation group) underwent second-generation 320-slice CT with FIRST. We compared the diagnostic performance of the first- and second-generation 320-slice CT with FIRST with MRI as a reference standard to detect LE in LVM. Results In the patient-based analysis, the sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of detection of LE on CT were 79%, 90%, 92%, 76%, and 84%, respectively, in the first-generation group and 97%, 84%, 91%, 94%, and 92%, respectively, in the second-generation group. The sensitivity was significantly higher in the second-generation group than in the first-generation group (p=0.049). In the segment-based analysis, the sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of detection of LE on CT were 69%, 96%, 83%, 92%, and 90%, respectively, in the first-generation group and 87%, 94%, 84%, 95%, and 92%, respectively, in the second-generation group. The sensitivity and negative predictive value were significantly higher in the second-generation group than in the first-generation group (p<0.001 and p=0.016). The contrast-noise ratio was significantly higher in the second-generation group than in the first-generation group (5.6±1.7 vs. 2.8±1.1, p<0.001), and the radiation dose for the assessment of LE on CT was significantly higher in the first-generation group than in the second-generation group (4.7±2.7 mSv vs. 2.3±0.1 mSv, p<0.001). Conclusion The diagnostic performance for the detection of LE in LVM significantly improved with the use of second-generation 320-slice CT and FIRST.

Comparison of 3D and 2D late gadolinium enhancement magnetic resonance imaging in patients with acute and chronic myocarditis

We compared a fast, single breath-hold three dimensional LGE sequence (3D LGE) with an established two dimensional multi breath-hold sequence (2D LGE) and evaluated image quality and the amount of myocardial fibrosis in patients with acute and chronic myocarditis. 3D LGE and 2D LGE (both spatial resolution 1.5 × 1.5 mm², slice-thickness 8 mm, field of view 350 × 350 mm²) were acquired in 25 patients with acute myocarditis (mean age 40 ± 18 years, 7 female) and 27 patients with chronic myocarditis (mean age 44 ± 22 years, 9 female) on a 1.5 T MR system. Image quality was evaluated by two independent, blinded readers using a 5-point Likert scale. Total myocardial mass, fibrotic mass and total fibrotic tissue percentage were quantified for both sequences in both groups. There was no significant difference in image quality between 3D und 2D acquisitions in patients with acute (p = 0.8) and chronic (p = 0.5) myocarditis. No significant differences between 3D and 2D acquisitions could be shown for myocardial mass (acute p = 0.2; chronic p = 0.3), fibrous tissue mass (acute p = 0.7; chronic p = 0.1) and total fibrous percentage (acute p = 0.4 and chronic p = 0.2). Inter-observer agreement was substantial to almost perfect. Acquisition time was significantly shorter for 3D LGE (24 ± 5 s) as compared to 2D LGE (350 ± 58 s, p < 0.001). In patients with acute and chronic myocarditis 3D LGE imaging shows equal diagnostic quality compared to standard 2D LGE imaging but with significantly reduced acquisition time.

Role of Cardiac Computed Tomography for Etiology Evaluation of Newly Diagnosed Heart Failure with Reduced Ejection Fraction

Delayed-enhanced dual-energy computed tomography (DECT) can evaluate the extent and degree of myocardial fibrosis while coronary CT angiography (CCTA) is a widely accepted coronary artery evaluation method. We sought to describe the role of combined cardiac CT for the evaluation of underlying etiology in patients with newly diagnosed heart failure with reduced ejection fraction (HFrEF). Sixty-three consecutive patients (31 men, 63 ± 16 years) with newly diagnosed HFrEF were enrolled in this prospective study. Coronary artery disease and myocardial fibrosis were evaluated on CCTA and DECT, respectively, and the tentative underlying etiologies of heart failure (HF) were determined with combinations of findings from both CTs. Concordance between tentative etiologies from cardiac CT and final etiologies from clinical decisions within a 2-year follow-up was assessed. Eighteen patients were diagnosed with ischemic HF on initial cardiac CT, and the final diagnosis was not changed. Another 45 patients with nonischemic HF included tentative etiologies of dilated cardiomyopathy (n = 32, 71.1%), sarcoidosis or myocarditis (n = 8, 17.8%), amyloidosis (n = 2, 4.4%), noncompaction (n = 2, 4.4%) and arrhythmogenic right ventricular cardiomyopathy (n = 1, 2.2%). Five nonischemic HF patients showed different etiologies between initial cardiac CT and clinical decisions. The concordance between cardiac CT and clinical decisions was 92.1%. A high degree of concordance was achieved between tentative etiologies from cardiac CT and final diagnoses from clinical decisions. Combined cardiac CT is a feasible, safe and effective imaging tool for the initial evaluation of newly diagnosed HFrEF patients.

Cardiovascular Magnetic Resonance Imaging: Identifying the Effects of Cancer Therapy

The era of modern oncology incorporates an ever-evolving personalized approach to hematological malignancies and solid tumors. As a result, patient survival rates have, in part, substantially improved, depending on the specific type of underlying malignancy. However, systemic therapies may come along with potential cardiotoxic effects resulting in heart failure with increased morbidity and mortality. Ultimately, patients may survive their malignancy but die as a result of cancer treatment. Cardiovascular magnetic resonance imaging has long been in use for the assessment of function and tissue characteristics in patients with various nonischemic cardiac diseases. Besides an introductory overview on the general definition of cardiotoxicity including potential underlying mechanisms, this review provides insight into the application of various cardiovascular magnetic resonance imaging techniques in the setting of cancer therapy-related cardiac and vascular toxicity. Early identification of cardiotoxic effects may allow for on-time therapy adjustment and/or cardioprotective measures to avoid subsequent long-term heart failure with increased mortality.

Prognostic value of late gadolinium enhancement in cardiac MRI of non-ischemic dilated cardiomyopathy patients

Background

The role of late gadolinium enhancement (LGE) in cardiac MRI (CMR) as prognostic marker in non-ischemic dilated cardiomyopathy (NIDCM) is evolving.

Objective

To study the effect of LGE in the prognosis of NIDCM patients.

Methods

112 consecutive NIDCM patients, who underwent CMR, were prospectively followed up for 745 ± 320 days. Primary end point was occurrence of MACE {composite of all-cause mortality, resuscitated cardiac arrest, sustained ventricular tachycardia (VT)/appropriate ICD shock, heart failure (HF) hospitalization}.

Results

LGE was present in 44 out of 112 patients (39%). The primary end point (MACE) was significantly higher in LGE + ve group compared to the LGE –ve group (72.7% vs. 29.4%; p < 0.0001). Similarly, cardiac mortality (9.1% vs 2.9%; p < 0.049), VT (13.6% vs. 2.9%; p < 0.031), HF hospitalization (63.6% vs. 30.9%; p < 0.001) were significantly more in LGE + ve group. In univariate model, LGE demonstrated the strongest association with MACE (Hazard ratio [HR] = 2.96 [95% CI 1.685 to 5.201; p < 0.0001). LGE extent of >14% of LV predicted MACE with 90.6% sensitivity and 86% specificity. HR of LGE extent >14% of LV for MACE is 6.12; p < 0.01. LGE was associated with MACE irrespective of its location, pattern or distribution. Multivariate model showed LGE and its extent >14% of LV volume were strongest predictor of MACE.

Conclusion

LGE and its extent >14% predicts adverse cardiac events in NIDCM irrespective of LVEF and LGE location, pattern or distribution. This study emphasises the role of CMR in risk stratification of NIDCM patients and guiding therapy.

Cardiac Sarcoidosis

Approximately 5% of patients with sarcoidosis will have clinically manifest cardiac involvement presenting with one or more of ventricular arrhythmias, conduction abnormalities, and heart failure. It is estimated that another 20 to 25% of pulmonary/systemic sarcoidosis patients have asymptomatic cardiac involvement (clinically silent disease). Cardiac presentations can be the first (and/or an unrecognized) manifestation of sarcoidosis in a variety of circumstances. Immunosuppression therapy (usually with corticosteroids) has been suggested for the treatment of clinically manifest cardiac sarcoidosis (CS) despite minimal data supporting it. Positron emission tomography imaging is often used to detect active disease and guide immunosuppression. Patients with clinically manifest disease often need device therapy, typically with implantable cardioverter defibrillators (ICDs). The extent of left ventricular dysfunction seems to be the most important predictor of prognosis among patients with clinically manifest CS. In the current era of earlier diagnosis, modern heart failure treatment, and use of ICD therapy, the prognosis from CS is much improved. In a recent Finnish nationwide study, 10-year cardiac survival was 92.5% in 102 patients.

Additive prognostic value of red cell distribution width over late gadolinium enhancement on CMR in patients with non-ischemic dilated cardiomyopathy

Elevated red cell distribution width (RDW) and late gadolinium enhancement on cardiac magnetic resonance (LGE-CMR) are both poor prognostic factors. This study examined the relationship between RDW and LGE-CMR characteristics in patients with non-ischemic dilated cardiomyopathy (NICM), and investigated whether the additive prognostic value of RDW as an integrative systemic factor over LGE-CMR exists or not. A total of consecutive 378 patients who underwent CMR at two general hospitals in South Korea were retrospectively analyzed. The primary endpoint was a composite of all-cause death, hospitalizations due to worsening heart failure and major arrhythmic events. During a mean follow-up period of 40.8 months, 151 (39.9%) patients experienced primary endpoints. The RDW value was significantly higher in patients with LGE than in those without LGE (13.7 ± 1.5% vs. 13.3 ± 1.4%, p = 0.034), but it was not associated with the extent or distribution patterns of the LGE. Addition of RDW into the model with clinical risk factors and LGE-CMR characteristics led to a significant improvement in the prediction of worse outcomes (χ² increased from 73 to 82; p = 0.023). RDW could provide incremental predictive value for adverse clinical events beyond LGE-CMR data in NICM patients.