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Thong EHE, Kong WKF, Poh KK, Wong R, Chai P, Sia CH. Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review. J Cardiovasc Dev Dis 2023; 11:13. [PMID: 38248883 PMCID: PMC10816708 DOI: 10.3390/jcdd11010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.
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Affiliation(s)
| | - William K. F. Kong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Kian-Keong Poh
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Raymond Wong
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ping Chai
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore 119074, Singapore; (W.K.F.K.); (K.-K.P.); (R.W.); (P.C.)
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Gorecka M, Bissell MM, Higgins DM, Garg P, Plein S, Greenwood JP. Rationale and clinical applications of 4D flow cardiovascular magnetic resonance in assessment of valvular heart disease: a comprehensive review. J Cardiovasc Magn Reson 2022; 24:49. [PMID: 35989320 PMCID: PMC9394062 DOI: 10.1186/s12968-022-00882-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 08/04/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Accurate evaluation of valvular pathology is crucial in the timing of surgical intervention. Whilst transthoracic echocardiography is widely available and routinely used in the assessment of valvular heart disease, it is bound by several limitations. Although cardiovascular magnetic resonance (CMR) imaging can overcome many of the challenges encountered by echocardiography, it also has a number of limitations. MAIN TEXT 4D Flow CMR is a novel technique, which allows time-resolved, 3-dimensional imaging. It enables visualisation and direct quantification of flow and peak velocities of all valves simultaneously in one simple acquisition, without any geometric assumptions. It also has the unique ability to measure advanced haemodynamic parameters such as turbulent kinetic energy, viscous energy loss rate and wall shear stress, which may add further diagnostic and prognostic information. Although 4D Flow CMR acquisition can take 5-10 min, emerging acceleration techniques can significantly reduce scan times, making 4D Flow CMR applicable in contemporary clinical practice. CONCLUSION 4D Flow CMR is an emerging CMR technique, which has the potential to become the new reference-standard method for the evaluation of valvular lesions. In this review, we describe the clinical applications, advantages and disadvantages of 4D Flow CMR in the assessment of valvular heart disease.
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Affiliation(s)
- Miroslawa Gorecka
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Malenka M Bissell
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | | | - Pankaj Garg
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK.
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Vidula MK, Xu Z, Xu Y, Alturki A, Reddy BN, Kini P, Alberto-Delgado AL, Jacob R, Chen T, Ferrari VA, Sierra-Galan LM, Chen Y, Viswamitra S, Han Y. Cardiovascular magnetic resonance characterization of rheumatic mitral stenosis: findings from three worldwide endemic zones. J Cardiovasc Magn Reson 2022; 24:24. [PMID: 35387660 PMCID: PMC8988335 DOI: 10.1186/s12968-022-00853-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/15/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Cardiac remodeling in rheumatic mitral stenosis (MS) is complex and incompletely understood. The objective of this study was to evaluate cardiac structural and functional changes in a cohort of patients with rheumatic MS using cardiovascular magnetic resonance (CMR). METHODS This retrospective study included 40 patients with rheumatic MS, consisting of 19 patients from India, 15 patients from China, and 6 patients from Mexico (median (interquartile range (IQR)) age: 45 years (34-55); 75% women). Twenty patients were included in the control group. CMR variables pertaining to morphology and function were collected. Late gadolinium enhancement (LGE) sequences were acquired for tissue characterization. Statistical analyses were performed using the Kruskal-Wallis test and the chi-square test. RESULTS Compared to the control group, patients with MS had lower left ventricular (LV) ejection fraction (51% (42%-55%) vs 60% (57%-65%), p < 0.001), lower right ventricular (RV) ejection fraction (44% (40%-52%) vs 64% (59%-67%), p < 0.001), higher RV end-diastolic volume (72 (58-87) mL/m2 vs 59 (49-69) mL/m2, p = 0.003), larger left atrial volume (87 (67-108) mL/m2 vs 29 (22-34) mL/m2, p < 0.001), and right atrial areas (20 (16-23) cm2 vs 13 (12-16) cm2, p < 0.001). LGE was prevalent in patients with rheumatic MS (82%), and was commonly located at the RV insertion sites. Furthermore, the patient cohorts from India, China, and Mexico were heterogeneous in terms of baseline characteristics and cardiac remodeling. CONCLUSION Our findings demonstrated that biventricular dysfunction, right and left atrial remodeling, and LGE at the RV insertion sites are underappreciated in contemporary rheumatic MS. Further studies are needed to elucidate the prognostic implications of these findings.
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Affiliation(s)
- Mahesh K Vidula
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ziqian Xu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuanwei Xu
- Division of Cardiology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Abdullah Alturki
- Division of Cardiothoracic Imaging, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Bhavana N Reddy
- Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Prayaag Kini
- Department of Cardiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | | | - Ron Jacob
- Division of Cardiovascular Medicine, Lancaster General Hospital, Lancaster, PA, USA
| | - Tiffany Chen
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Victor A Ferrari
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lilia M Sierra-Galan
- Division of Cardiology, American British Cowdray Medical Center, Mexico City, Mexico
| | - Yucheng Chen
- Division of Cardiology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Sanjaya Viswamitra
- Department of Radiology, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, Karnataka, India
| | - Yuchi Han
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
- Division of Cardiothoracic Imaging, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
- Division of Cardiology, Biomedical Research Tower, The Ohio State University, Room 216, 460 W. 12th Avenue, Columbus, OH, 43210, USA.
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Cross B, Stepien KM, Gadepalli C, Kharabish A, Woolfson P, Tol G, Jenkins P. Pre-operative Considerations in Adult Mucopolysaccharidosis Patients Planned for Cardiac Intervention. Front Cardiovasc Med 2022; 9:851016. [PMID: 35445089 PMCID: PMC9013828 DOI: 10.3389/fcvm.2022.851016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Mucopolysaccharidoses (MPS) are rare lysosomal storage diseases characterized by multiorgan involvement and shortened longevity. Due to advances in therapies such as enzyme replacement therapy and haematopoietic stem cell therapy, life expectancy has increased posing newer challenges to patients and health professionals. One such challenge is cardiovascular manifestations of MPS, which can be life limiting and cause reduction in quality of life. Any cardiovascular intervention mandates comprehensive, multi-systemic work-up by specialist teams to optimize outcome. We highlight the importance of multidisciplinary evaluation of adult MPS patients requiring cardiovascular intervention. Clinical assessments and investigations are discussed, with a focus on the cardiac, anesthetic, airway, respiratory, radiological and psychosocial factors.
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Affiliation(s)
- Benjamin Cross
- Adult Congenital Heart Disease Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Karolina M. Stepien
- Adult Inherited Metabolic Diseases Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
- *Correspondence: Karolina M. Stepien
| | - Chaitanya Gadepalli
- Ear Nose and Throat Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Ahmed Kharabish
- Radiology Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Radiology Department, Cairo University, Giza, Egypt
| | - Peter Woolfson
- Cardiology Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Govind Tol
- Anaesthetics Department, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Petra Jenkins
- Adult Congenital Heart Disease Department, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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Meinel TR, Eggimann A, Brignoli K, Wustmann K, Buffle E, Meinel FG, Scheitz JF, Nolte CH, Gräni C, Fischer U, Kaesmacher J, Seiffge DJ, Seiler C, Jung S. Cardiovascular MRI Compared to Echocardiography to Identify Cardioaortic Sources of Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:699838. [PMID: 34393979 PMCID: PMC8362907 DOI: 10.3389/fneur.2021.699838] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/30/2021] [Indexed: 01/21/2023] Open
Abstract
Background: To compare the diagnostic yield of echocardiography and cardiovascular MRI (CMR) to detect structural sources of embolism, in patients with ischemic stroke with a secondary analysis of non-stroke populations. Methods and Results: We searched MEDLINE/Embase (from 01.01.2000 to 24.04.2021) for studies including CMR to assess prespecified sources of embolism. Comparison included transthoracic and/or transesophageal echocardiography. Two authors independently screened studies, extracted data and assessed bias using the QUADAS-2 tool. Estimates of diagnostic yield were reported and pooled. Twenty-seven studies with 2,525 patients were included in a study-level analysis. Most studies had moderate to high risk of bias. Persistent foramen ovale, complex aortic plaques, left ventricular and left atrial thrombus were the most common pathologies. There was no difference in the yield of left ventricular thrombus detection between both modalities for stroke populations (4 studies), but an increased yield of CMR in non-stroke populations (28.1 vs. 16.0%, P < 0.001, 10 studies). The diagnostic yield in stroke patients for detection of persistent foramen ovale was lower in CMR compared to transoesophageal echocardiography (29.3 vs. 53.7%, P < 0.001, 5 studies). For both echocardiography and CMR the clinical impact of the management consequences derived from many of the diagnostic findings remained undetermined in the identified studies. Conclusions: Echocardiography and CMR seem to have similar diagnostic yield for most cardioaortic sources of embolism except persistent foramen ovale and left ventricular thrombus. Randomized controlled diagnostic trials are necessary to understand the impact on the management and potential clinical benefits of the assessment of structural cardioaortic stroke sources. Registration: PROSPERO: CRD42020158787.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Angela Eggimann
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Kristina Brignoli
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Kerstin Wustmann
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eric Buffle
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Jan F Scheitz
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research, Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Klinik für Neurologie, Berlin Institute of Health, Berlin, Germany.,German Centre for Cardiovascular Research, Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin, Germany
| | - Christoph Gräni
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - David J Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christian Seiler
- Department of Cardiology, Inselspital Bern, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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