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AbdelMassih A, Hassan AA, Abou-Zeid AS, Hassan A, Hussein E, Gadalla M, Hussein M, Eid MA, Elahmady M, El Nahhas N, Emad N, Zahra N, Aboushadi N, Ibrahim N, Mokhtar S, Ismail HA, El-Husseiny N, Moharam RK, Menshawey E, Menshawey R. Salivary markers and coronavirus disease 2019: insights from cross-talk between the oral microbiome and pulmonary and systemic low-grade inflammation and implications for vascular complications. Cardiovasc Endocrinol Metab 2021; 10:162-167. [PMID: 34386717 PMCID: PMC8352626 DOI: 10.1097/xce.0000000000000242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/22/2020] [Indexed: 12/25/2022]
Abstract
To date, coronavirus disease 2019 (COVID-19) has affected over 6.2 million individuals worldwide, including 1.46 million deaths. COVID-19 complications are mainly induced by low-grade inflammation-causing vascular degeneration. There is an increasing body of evidence that suggests that oral dysbiotic taxa are associated with worse prognosis in COVID-19 patients, especially the Prevotella genus, which was retrieved from nasopharyngeal and bronchoalveolar lavage samples in affected patients. Oral dysbiosis may act by increasing the likelihood of vascular complications through low-grade inflammation, as well as impairing respiratory mucosal barrier mechanisms against SARS-CoV-2. Salivary markers can be used to reflect this oral dysbiosis and its subsequent damaging effects on and the lungs and vasculature. Salivary sampling can be self-collected, and is less costly and less invasive, and thus may be a superior option to serum markers in risk stratification of COVID-19 patients. Prospective studies are needed to confirm such hypothesis. Video Abstract: http://links.lww.com/CAEN/A28.
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Affiliation(s)
- Antoine AbdelMassih
- Pediatric Cardiology Unit, Pediatrics' Department, Faculty of Medicine, Cairo University, Giza
- Pediatric Cardio-Oncology Department, Children Cancer Hospital of Egypt
| | - Alaa A Hassan
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Aya S Abou-Zeid
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Aya Hassan
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Engy Hussein
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Mahenar Gadalla
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Mahinour Hussein
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Maryam A Eid
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Maryam Elahmady
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Nadine El Nahhas
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Nadine Emad
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Nihal Zahra
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Nour Aboushadi
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Nourhan Ibrahim
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Sherouk Mokhtar
- Research Department, School of Oral and Dental Medicine, New Giza University, New Giza
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | | | - Nadine El-Husseiny
- Research Department, Faculty of Medicine, Cairo University, Cairo
- Department of Oral and Maxillo-facial Surgery, Faculty of Dentistry, Cairo University, Giza
- Department of Scientific Design, Pixagon Graphic Design Agency, Cairo
| | - Reham Khaled Moharam
- Residency Training Program of Plastic Surgery Department, Faculty of Medicine, Cairo University, Giza, Egypt
| | - Esraa Menshawey
- Research Department, Faculty of Medicine, Cairo University, Cairo
| | - Rahma Menshawey
- Research Department, Faculty of Medicine, Cairo University, Cairo
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Nadar SK, Daar S, Abdelmottaleb WA, Shaikh MM, Al Mahrouqi H, Al-Raiisi M, Hassan M, Al Rawahi B, Al Rahbi S. Abnormal diastolic function and Global longitudinal strain in patients with Thalassemia Major on long term chelation therapy. Int J Cardiovasc Imaging 2020; 37:643-649. [PMID: 32965605 DOI: 10.1007/s10554-020-02036-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 09/18/2020] [Indexed: 11/30/2022]
Abstract
Cardiac complications are the major cause of mortality in patients with Thalassemia major (TM). Cardiac T2* MRI is currently the gold standard for assessing myocardial iron concentration. The aim of our study was to assess whether any echocardiographic parameter would correlate with these findings in patients well established on chelation therapy. This was a prospective study on patients with TM who are regularly followed in our clinic. Patients had a cardiac MRI and echocardiogram within 2 months of each other. Echo parameters included global longitudinal strain and diastolic function. We also compared these findings with those from a cohort of thalassemia intermedia (TI) and normal controls. A total of 84 patients (mean age 26.3 ± 6.1 years, 42.8% male) with TM were enrolled. All had normal left ventricular ejection fraction and only 8 patients had MRI T2* < 10. As compared to 17 patients with TI and 53 controls, these patients had significantly higher E/E' and lower pulmonary vein s/dd ratio suggesting early diastolic dysfunction. 28 patients fulfilled criteria for diastolic dysfunction even in the presence of normal MRI T2*. Global longitudinal strain (GLS) was significantly lower in the TM group as compared to the TI and controls. We found no correlation between any of the echo findings and the MRI T2*in TM patients. In patients with thalassemia and MRI T2* > 20 ms features of diastolic dysfunction persist even in the presence of normal LV function and normal GLS. This suggests that diastolic function remains abnormal even when myocardial iron concentrations are normal and follow up therefore is essential.
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Affiliation(s)
- Sunil K Nadar
- Department of Medicine, Sultan Qaboos University Hospital, POBox 38, Muscat, 123, Oman.
| | - Shahina Daar
- Department of Hematology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman.,Stellenbosch Institute for Advanced Study (STIAS), Wallenberg Research Centre At Stellenbosch University, Stellenbosch, 7600, South Africa
| | - Wael A Abdelmottaleb
- Department of Medicine, Sultan Qaboos University Hospital, POBox 38, Muscat, 123, Oman
| | - Muhammad M Shaikh
- Department of Medicine, Sultan Qaboos University Hospital, POBox 38, Muscat, 123, Oman
| | - Hafsa Al Mahrouqi
- Department of Clinical Physiology, Sultan Qaboos University Hospital, POBox 38, Muscat, 123, Oman
| | - Majida Al-Raiisi
- Department of Clinical Physiology, Sultan Qaboos University Hospital, POBox 38, Muscat, 123, Oman
| | - Moez Hassan
- Department of Hematology, Sultan Qaboos University Hospital, POBox 38, Muscat, 123, Oman
| | - Badar Al Rawahi
- Department of Hematology, Sultan Qaboos University Hospital, POBox 38, Muscat, 123, Oman
| | - Sarah Al Rahbi
- Department of Hematology, Sultan Qaboos University Hospital, POBox 38, Muscat, 123, Oman
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Snel GJH, van den Boomen M, Hernandez LM, Nguyen CT, Sosnovik DE, Velthuis BK, Slart RHJA, Borra RJH, Prakken NHJ. Cardiovascular magnetic resonance native T 2 and T 2* quantitative values for cardiomyopathies and heart transplantations: a systematic review and meta-analysis. J Cardiovasc Magn Reson 2020; 22:34. [PMID: 32393281 PMCID: PMC7212597 DOI: 10.1186/s12968-020-00627-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/16/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The clinical application of cardiovascular magnetic resonance (CMR) T2 and T2* mapping is currently limited as ranges for healthy and cardiac diseases are poorly defined. In this meta-analysis we aimed to determine the weighted mean of T2 and T2* mapping values in patients with myocardial infarction (MI), heart transplantation, non-ischemic cardiomyopathies (NICM) and hypertension, and the standardized mean difference (SMD) of each population with healthy controls. Additionally, the variation of mapping outcomes between studies was investigated. METHODS The PRISMA guidelines were followed after literature searches on PubMed and Embase. Studies reporting CMR T2 or T2* values measured in patients were included. The SMD was calculated using a random effects model and a meta-regression analysis was performed for populations with sufficient published data. RESULTS One hundred fifty-four studies, including 13,804 patient and 4392 control measurements, were included. T2 values were higher in patients with MI, heart transplantation, sarcoidosis, systemic lupus erythematosus, amyloidosis, hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM) and myocarditis (SMD of 2.17, 1.05, 0.87, 1.39, 1.62, 1.95, 1.90 and 1.33, respectively, P < 0.01) compared with controls. T2 values in iron overload patients (SMD = - 0.54, P = 0.30) and Anderson-Fabry disease patients (SMD = 0.52, P = 0.17) did both not differ from controls. T2* values were lower in patients with MI and iron overload (SMD of - 1.99 and - 2.39, respectively, P < 0.01) compared with controls. T2* values in HCM patients (SMD = - 0.61, P = 0.22), DCM patients (SMD = - 0.54, P = 0.06) and hypertension patients (SMD = - 1.46, P = 0.10) did not differ from controls. Multiple CMR acquisition and patient demographic factors were assessed as significant covariates, thereby influencing the mapping outcomes and causing variation between studies. CONCLUSIONS The clinical utility of T2 and T2* mapping to distinguish affected myocardium in patients with cardiomyopathies or heart transplantation from healthy myocardium seemed to be confirmed based on this meta-analysis. Nevertheless, variation of mapping values between studies complicates comparison with external values and therefore require local healthy reference values to clinically interpret quantitative values. Furthermore, disease differentiation seems limited, since changes in T2 and T2* values of most cardiomyopathies are similar.
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Affiliation(s)
- G J H Snel
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - M van den Boomen
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
| | - L M Hernandez
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - C T Nguyen
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
| | - D E Sosnovik
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, 149 13th Street, Charlestown, MA, 02129, USA
- Division of Health Sciences and Technology, Harvard-MIT, 7 Massachusetts Avenue, Cambridge, MA, 02139, USA
| | - B K Velthuis
- Department of Radiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - R H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, University of Twente, Dienstweg 1, 7522 ND, Enschede, The Netherlands
| | - R J H Borra
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - N H J Prakken
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
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Betts M, Flight PA, Paramore LC, Tian L, Milenković D, Sheth S. Systematic Literature Review of the Burden of Disease and Treatment for Transfusion-dependent β-Thalassemia. Clin Ther 2019; 42:322-337.e2. [PMID: 31882227 DOI: 10.1016/j.clinthera.2019.12.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/25/2019] [Accepted: 12/04/2019] [Indexed: 01/27/2023]
Abstract
PURPOSE β-Thalassemia is an inherited blood disorder characterized by reduced or no production of adult hemoglobin. Systematic identification of the burden of β-thalassemia with contemporary treatments is lacking in published literature. Thus, a gap exists in understanding the baseline burden on which to assess future treatments. Therefore, a systematic literature review (SLR) was performed to assess management and outcomes in patients with transfusion-dependent β-thalassemia (TDT) who received long-term transfusion regimens. METHODS Searches of MEDLINE, EMBASE, and 5 conference websites were conducted to identify clinical-practice studies in Italy, France, Germany, Greece, the United States, and the United Kingdom, published since January 2007. The review found 135 articles meeting the SLR criteria. FINDINGS Among patients carrying 2 β-thalassemia mutations, 64%-89% underwent regular transfusions at intervals of between 2 and 4 weeks. Transfusion-associated complications that were reported included iron overload, transfusion reactions, alloimmunization, and infections. Analyses of 42, 25, and 73 studies reporting liver iron concentration (median, 8.5 mg/g of dry weight [dw]; interquartile range [IQR], 4.5-11.0 mg/g dw), cardiac T2* magnetic resonance imaging (median, 27.4 ms; IQR, 26.0-30.2 ms), and serum ferritin (median, 1465.0 ng/mL; IQR, 1238.2-1797.0 ng/mL), respectively, showed wide ranges in iron levels and a general trend toward improved iron control in recent years. Adverse transfusion reactions and alloimmunization were reported in ~50% and 10%-20% in patients, respectively. Rates of transfusion-transmitted infections were highly variable by study but were lower in more recent cohorts. Complications stemming from iron overload and underlying disease captured in this SLR included cardiac disease, liver disease, and endocrine and musculoskeletal disorders. Approximately 10% of patients were diagnosed with heart failure, with rates ranging from 2.9% to 20.9% across 6 studies. Other significant complications reported with β-thalassemia included pain (25%-69%), psychiatric disorders (25%-30%), and reduced health-related quality of life. Despite substantial improvements in survival, patients with TDT remained at an increased risk for early mortality. IMPLICATIONS Consistent with improvements in transfusion practices and iron monitoring and management, outcomes in patients with TDT have improved. However, iron overload and disease-associated complications remain a challenge in this population. This review supports the burden of disease affecting patients with β-thalassemia and provides a baseline health status against which to assess future improvements in care.
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Affiliation(s)
| | | | | | | | | | - Sujit Sheth
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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5
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Agha HM, AbdelMassih AF, AbdelRahman MY, Milanesi O, Castaldi B, Geranio G, Putti MC, Kharabish A, Esmail R, El-Kamah G, Hamdy M, El-Baz H, Behairy N, Hanna C, El-Tagy H, Mishriky MA, Mamdouh M, Antonazzo L, Ramadan T. Can myocardial remodeling be a useful surrogate predictor of myocardial iron load? A 3D echocardiographic multicentric study. Pediatr Blood Cancer 2018; 65:e27272. [PMID: 29873876 DOI: 10.1002/pbc.27272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/06/2022]
Abstract
The relationship between myocardial iron load and eccentric myocardial remodeling remains an under-investigated area; it was thought that remodeling is rather linked to fibrosis. This study aims to determine whether or not measures of remodeling can be used as predictors of myocardial iron. For this purpose, 60 patients with thalassemia were studied with 3D echocardiography and myocardial relaxometry (T2*) by Cardiac MRI. 3D derived sphericity index was significantly higher in patients with myocardial iron load. It was correlated with T2* with a 100% sensitivity and specificity (cut-off value of 0.34) to discriminate between patients with and without myocardial iron overload.
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Affiliation(s)
- Hala Mounir Agha
- Pediatric, Cardiology Unit, Pediatrics Department, Specialized Children Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Antoine Fakhry AbdelMassih
- Pediatric, Cardiology Unit, Pediatrics Department, Specialized Children Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt.,Children's Cancer Hospital, Egypt 57357, Cairo, Egypt
| | - Mohamed Youssef AbdelRahman
- Pediatric, Cardiology Unit, Pediatrics Department, Specialized Children Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ornella Milanesi
- Pediatric Cardiology Unit, Department of Woman and Child Health, Faculty of Medicine, Padova University, Padova, Italy
| | - Biagio Castaldi
- Pediatric Cardiology Unit, Department of Woman and Child Health, Faculty of Medicine, Padova University, Padova, Italy
| | - Giulia Geranio
- Pediatric Hematology Unit, Department of Woman and Child Health, Faculty of Medicine, Padova University, Padova, Italy
| | - Maria Caterina Putti
- Pediatric Hematology Unit, Department of Woman and Child Health, Faculty of Medicine, Padova University, Padova, Italy
| | - Ahmed Kharabish
- Cardiac MRI Unit, Radiology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Reem Esmail
- Pediatric, Cardiology Unit, Pediatrics Department, Specialized Children Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ghada El-Kamah
- Clinical Genetics Department, National Research Centre, Cairo, Egypt
| | - Mona Hamdy
- Pediatric Hematology Unit, Pediatrics Department, Specialized Children Hospital, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Heba El-Baz
- Clinical Pathology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Noha Behairy
- Cardiac MRI Unit, Radiology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Carol Hanna
- Computer Science and Software Development Department, American University of Cairo, Cairo, Egypt
| | - Hassan El-Tagy
- Orthopedics Residency Program, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mary Atef Mishriky
- Cardiology Residency Program, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mirna Mamdouh
- Cardiology Residency Program, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Livio Antonazzo
- Pediatric Hematology Unit, Department of Woman and Child Health, Faculty of Medicine, Padova University, Padova, Italy
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Kirk P, Sheppard M, Carpenter JP, Anderson L, He T, St Pierre T, Galanello R, Catani G, Wood J, Fucharoen S, Porter JB, Walker JM, Forni GL, Pennell DJ. Post-mortem study of the association between cardiac iron and fibrosis in transfusion dependent anaemia. J Cardiovasc Magn Reson 2017; 19:36. [PMID: 28343449 PMCID: PMC5367003 DOI: 10.1186/s12968-017-0349-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/01/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Heart failure related to cardiac siderosis remains a major cause of death in transfusion dependent anaemias. Replacement fibrosis has been reported as causative of heart failure in siderotic cardiomyopathy in historical reports, but these findings do not accord with the reversible nature of siderotic heart failure achievable with intensive iron chelation. METHODS Ten whole human hearts (9 beta-thalassemia major, 1 sideroblastic anaemia) were examined for iron loading and fibrosis (replacement and interstitial). Five had died from heart failure, 4 had cardiac transplantation for heart failure, and 1 had no heart failure (death from a stroke). Heart samples iron content was measured using atomic emission spectroscopy. Interstitial fibrosis was quantified by computer using picrosirius red (PSR) staining and expressed as collagen volume fraction (CVF) with normal value for left ventricle <3%. RESULTS The 9 hearts affected by heart failure had severe iron loading with very low T2* of 5.0 ± 2.0 ms (iron concentration 8.5 ± 7.0 mg/g dw) and diffuse granular myocardial iron deposition. In none of the 10 hearts was significant macroscopic replacement fibrosis present. In only 2 hearts was interstitial fibrosis present, but with low CVF: in one patient with no cardiac siderosis (death by stroke, CVF 5.9%) and in a heart failure patient (CVF 2%). In the remaining 8 patients, no interstitial fibrosis was seen despite all having severe cardiac siderosis and heart failure (CVF 1.86% ±0.87%). CONCLUSION Replacement cardiac fibrosis was not seen in the 9 post-mortem hearts from patients with severe cardiac siderosis and heart failure leading to death or transplantation, which contrasts markedly to historical reports. Minor interstitial fibrosis was also unusual and very limited in extent. These findings accord with the potential for reversibility of heart failure seen in iron overload cardiomyopathy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00520559.
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Affiliation(s)
- Paul Kirk
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Mary Sheppard
- National Heart and Lung Institute, Imperial College, London, UK
- CRY Centre for Cardiac Pathology, Royal Brompton Hospital, London, UK
| | - John-Paul Carpenter
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Lisa Anderson
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Taigang He
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | | | | | | | - John Wood
- Children’s Hospital, Los Angeles, USA
| | | | - John B Porter
- The Hatter Cardiovascular Institute, University College Hospital, London, UK
| | - J Malcolm Walker
- The Hatter Cardiovascular Institute, University College Hospital, London, UK
| | | | - Dudley J Pennell
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
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Farmakis D, Triposkiadis F, Lekakis J, Parissis J. Heart failure in haemoglobinopathies: pathophysiology, clinical phenotypes, and management. Eur J Heart Fail 2016; 19:479-489. [PMID: 28000341 DOI: 10.1002/ejhf.708] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/18/2016] [Accepted: 11/07/2016] [Indexed: 12/28/2022] Open
Abstract
Hereditary haemoglobinopathies, mainly beta-thalassemia and sickle cell disease, constitute the most common monogenic disorders in humans, and although once geographically confined, they are currently globally distributed. They are demanding clinical entities that require multidisciplinary medical management. Despite their genotypic and phenotypic heterogeneity, the haemoglobinopathies share several similarities in pathophysiology, clinical manifestations, therapeutic requirements, and complications, among which heart failure (HF) represents a leading cause of mortality and morbidity. However, haemoglobinopathies have generally been addressed in a rather fragmentary manner. A unifying approach focusing on the underlying similarities of HF attributes in the two main entities might contribute to their better understanding, characterization, and management. In the present review, we attempt such an approach to the pathophysiology, clinical phenotypes, and management of HF in haemoglobinopathies.
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Affiliation(s)
- Dimitrios Farmakis
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - John Lekakis
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Parissis
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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8
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Pepe A, Meloni A, Borsellino Z, Cuccia L, Borgna-Pignatti C, Maggio A, Restaino G, Gagliardotto F, Caruso V, Spasiano A, Filosa A, Centra M, D'Ascola D, Quarta A, Peluso A, Midiri M, Rossi G, Positano V, Capra M. Myocardial fibrosis by late gadolinium enhancement cardiac magnetic resonance and hepatitis C virus infection in thalassemia major patients. J Cardiovasc Med (Hagerstown) 2016; 16:689-95. [PMID: 26090920 DOI: 10.2459/jcm.0000000000000278] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Our aim was to evaluate the correlation between myocardial fibrosis detected using the late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) technique and chronic hepatitis C (CHC) in a large, retrospective, multicentre cohort of thalassemia major patients. METHODS LGE images were acquired in 434 thalassemia major patients (233 men, 31 ± 9 years) enrolled in the MIOT (Myocardial Iron Overload in Thalassemia) study. Hepatitis C virus (HCV)-RNA tests were sensitive to detect more than 50 copies/ml. RESULTS No patient manifested moderate/severe adverse events associated with the use of Gadobutrol. Myocardial fibrosis was detected in 90 (21%) patients. Among the 312 patients tested for HCV-RNA, there was a significant correlation between the presence of myocardial fibrosis and CHC (P = 0.011). Among the 62 patients with myocardial fibrosis tested for HCV-RNA, we found a significantly higher prevalence of diabetes mellitus in CHC patients versus the no-CHC patients (P = 0.049). CONCLUSION Our findings support the use of the LGE CMR approach well tolerated in the thalassemia major patients with CHC. HCV infection can be involved in the pathogenesis of myocardial fibrosis through both myocarditis directly and the pancreas and liver damage with the development of diabetes indirectly. These patients could therefore benefit from cardioactive drugs and therapeutic interventions directed towards the eradication of virus.
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Affiliation(s)
- Alessia Pepe
- aCMR Unit, Fondazione 'G. Monasterio' CNR-Regione Toscana, Pisa bEmatologia-Emoglobinopatie, Civico ARNAS Hospital, Palermo cDepartment of Clinical and Experimental Medicine (Pediatrics), University of Ferrara, Ferrara dHaematology II with Thalassemia, 'V. Cervello' Hospital, Palermo eRadiology Department, 'John Paul II' Catholic University, Campobasso fCentro Talassemie, ARNAS Garibaldi, Catania gUOSD Centro per le Microcitemie, AORN Cardarelli, Napoli hDepartment of Microcitemia, 'Casa Sollievo della Sofferenza' Hospital, San Giovanni Rotondo (FG) iU.O. Microcitemie, A.O. 'Bianchi-Melacrino-Morelli', Reggio Calabria jEmatologia, 'A. Perrino' Hospital, Brindisi kMicrocitemia - Azienda Unità Sanitaria Locale TA/1, Presidio Ospedaliero Centrale, Taranto lDepartment of Radiology, University of Palermo, Palermo mEpidemiology and Biostatistics Unit, Institute of Clinical Physiology, CNR, Pisa, Italy
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9
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Abstract
The myocardium is particularly susceptible to complications from iron loading in thalassemia major. In the first years of life, severe anemia leads to high-output cardiac failure and death if not treated. The necessary supportive blood transfusions create loading of iron that cannot be naturally excreted, and this iron accumulates within tissues, including the heart. Free unbound iron catalyzes the formation of toxic hydroxyl radicals, which damage cells and cause cardiac dysfunction. Significant cardiac siderosis may present by the age of 10 and may lead to acute clinical heart failure, which must be treated urgently. Atrial fibrillation is the most frequently encountered iron-related arrhythmia. Iron chelation is effective at removing iron from the myocardium, at the expense of side effects that hamper compliance to therapy. Monitoring of myocardial iron content is mandatory for clinical management of cardiac risk. T2* cardiac magnetic resonance measures myocardial iron and is the strongest biomarker for prediction of heart failure and arrhythmic events. It has been calibrated to human myocardial tissue iron concentration and is highly reproducible across all magnetic resonance scanner vendors. As survival and patient age increases, endothelial dysfunction and diabetes may become new factors in the cardiovascular health of thalassemia patients. Promising new imaging technology and therapies could ameliorate the long-term prognosis.
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Affiliation(s)
- Dominique Auger
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom.,Imperial College London, London, United Kingdom
| | - Dudley J Pennell
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom.,Imperial College London, London, United Kingdom
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10
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Comparison of myocardial T1 and T2 values in 3 T with T2* in 1.5 T in patients with iron overload and controls. Int J Hematol 2016; 103:530-6. [PMID: 26872908 DOI: 10.1007/s12185-016-1950-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/26/2016] [Accepted: 01/26/2016] [Indexed: 12/31/2022]
Abstract
Myocardial iron quantification remains limited to 1.5 T systems with T2* measurement. The present study aimed at comparing myocardial T2* values at 1.5 T to T1 and T2 mapping at 3.0 T in patients with iron overload and healthy controls. A total of 17 normal volunteers and seven patients with a history of myocardial iron overload were prospectively enrolled. Mid-interventricular septum T2*, native T1 and T2 times were quantified on the same day, using a multi-echo gradient-echo sequence at 1.5 T and T1 and T2 mapping sequences at 3.0 T, respectively. Subjects with myocardial iron overload (T2* < 20 ms) in comparison with those without had significantly lower mean myocardial T1 times (868.9 ± 120.2 vs. 1170.3 ± 25.0 ms P = 0.005 respectively) and T2 times (34.9 ± 4.7 vs. 45.1 ± 2.0 ms P = 0.007 respectively). 3 T T1 and T2 times strongly correlated with 1.5 T, T2* times (Pearson's r = 0.95 and 0.91 respectively). T1 and T2 measures presented less variability than T2* in inter- and intra-observer analysis. Native myocardial T1 and T2 times at 3 T correlate closely with T2* times at 1.5 T and may be useful for myocardial iron overload quantification.
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11
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Hanneman K, Nguyen ET, Thavendiranathan P, Ward R, Greiser A, Jolly MP, Butany J, Yang IY, Sussman MS, Wintersperger BJ. Quantification of Myocardial Extracellular Volume Fraction with Cardiac MR Imaging in Thalassemia Major. Radiology 2015; 279:720-30. [PMID: 26653680 DOI: 10.1148/radiol.2015150341] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To quantify myocardial extracellular volume (ECV) by using cardiac magnetic resonance (MR) imaging in thalassemia major and to investigate the relationship between ECV and myocardial iron overload. Materials and Methods With institutional review board approval and informed consent, 30 patients with thalassemia major (mean age ± standard deviation, 34.6 years ± 9.5) and 10 healthy control subjects (mean age, 31.5 years ± 4.4) were prospectively recruited (clinicaltrials.gov identification number NCT02090699). Nineteen patients (63.3%) had prior myocardial iron overload (defined as midseptal T2* < 20 msec on any prior cardiac MR images). Cardiac MR imaging at 1.5 T included cine steady-state free precession for ventricular function, T2* for myocardial iron quantification, and unenhanced and contrast material-enhanced T1 mapping. ECV was calculated with input of the patient's hematocrit level. Peak systolic global longitudinal strain by means of speckle tracking was assessed with same-day transthoracic echocardiography. Statistical analysis included use of the two-sample t test, Fisher exact test, and Spearman correlation. Results Unenhanced T1 values were significantly lower in patients with prior myocardial iron overload than in control subjects (850.3 ± 115.1 vs 1006.3 ± 35.4, P < .001) and correlated strongly with T2* values (r = 0.874, P < .001). Patients with prior myocardial iron overload had higher ECV than did patients without iron overload (31.3% ± 2.8 vs 28.2% ± 3.4, P = .030) and healthy control subjects (27.0% ± 3.1, P = .003). There was no difference in ECV between patients without iron overload and control subjects (P = .647). ECV correlated with lowest historical T2* (r = -0.469, P = .010) but did not correlate significantly with left ventricular ejection fraction (r = -0.216, P = .252) or global longitudinal strain (r = -0.164, P = .423). Conclusion ECV is significantly increased in thalassemia major and is associated with myocardial iron overload. These abnormalities may potentially reflect diffuse interstitial myocardial fibrosis. (©) RSNA, 2015 Online supplemental material is available for this article.
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Affiliation(s)
- Kate Hanneman
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Elsie T Nguyen
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Paaladinesh Thavendiranathan
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Richard Ward
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Andreas Greiser
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Marie-Pierre Jolly
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Jagdish Butany
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Issac Y Yang
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Marshall S Sussman
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
| | - Bernd J Wintersperger
- Department of Medical Imaging (K.H., E.T.N., P.T., I.Y.Y., M.S.S., B.J.W.) and Division of Cardiology (P.T.), Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Ave, NCSB-1C557, Toronto, ON, Canada M5G 2N2; Division of Hematology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada (R.W.); Siemens AG Healthcare, Erlangen, Germany (A.G.); Department of Corporate Research, Siemens Corporation, Princeton, NJ (M.P.J.); and Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network, University of Toronto, Toronto, Ontario, Canada (J.B.)
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12
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Alam MH, Auger D, Smith GC, He T, Vassiliou V, Baksi AJ, Wage R, Drivas P, Feng Y, Firmin DN, Pennell DJ. T1 at 1.5T and 3T compared with conventional T2* at 1.5T for cardiac siderosis. J Cardiovasc Magn Reson 2015; 17:102. [PMID: 26602203 PMCID: PMC4659152 DOI: 10.1186/s12968-015-0207-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/16/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Myocardial black blood (BB) T2* relaxometry at 1.5T provides robust, reproducible and calibrated non-invasive assessment of cardiac iron burden. In vitro data has shown that like T2*, novel native Modified Look-Locker Inversion recovery (MOLLI) T1 shortens with increasing tissue iron. The relative merits of T1 and T2* are largely unexplored. We compared the established 1.5T BB T2* technique against native T1 values at 1.5T and 3T in iron overload patients and in normal volunteers. METHODS A total of 73 subjects (42 male) were recruited, comprising 20 healthy volunteers (controls) and 53 patients (thalassemia major 22, sickle cell disease 9, hereditary hemochromatosis 9, other iron overload conditions 13). Single mid-ventricular short axis slices were acquired for BB T2* at 1.5T and MOLLI T1 quantification at 1.5T and 3T. RESULTS In healthy volunteers, median T1 was 1014 ms (full range 939-1059 ms) at 1.5T and modestly increased to 1165ms (full range 1056-1224 ms) at 3T. All patients with significant cardiac iron overload (1.5T T2* values <20 ms) had T1 values <939 ms at 1.5T, and <1056 ms at 3T. Associations between T2* and T1 were found to be moderate with y =377 · x(0.282) at 1.5T (R(2) = 0.717), and y =406 · x(0.294) at 3T (R(2) = 0.715). Measures of reproducibility of T1 appeared superior to T2*. CONCLUSIONS T1 mapping at 1.5T and at 3T can identify individuals with significant iron loading as defined by the current gold standard T2* at 1.5T. However, there is significant scatter between results which may reflect measurement error, but it is also possible that T1 interacts with T2*, or is differentially sensitive to aspects of iron chemistry or other biology. Hurdles to clinical implementation of T1 include the lack of calibration against human myocardial iron concentration, no demonstrated relation to cardiac outcomes, and variation in absolute T1 values between scanners, which makes inter-centre comparisons difficult. The relative merits of T1 at 3T versus T2* at 3T require further consideration.
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Affiliation(s)
- Mohammed H Alam
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Imperial College London, London, UK.
| | - Dominique Auger
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Imperial College London, London, UK.
| | - Gillian C Smith
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Imperial College London, London, UK.
| | - Taigang He
- St George's, University of London, London, UK.
| | - Vassilis Vassiliou
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Imperial College London, London, UK.
| | - A John Baksi
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Imperial College London, London, UK.
| | - Rick Wage
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
| | - Peter Drivas
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
| | - Yanqiu Feng
- School of Biomedical Engineering, Southern Medical University, Guangzhou, China.
| | - David N Firmin
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Imperial College London, London, UK.
| | - Dudley J Pennell
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Imperial College London, London, UK.
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13
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Sado DM, Maestrini V, Piechnik SK, Banypersad SM, White SK, Flett AS, Robson MD, Neubauer S, Ariti C, Arai A, Kellman P, Yamamura J, Schoennagel BP, Shah F, Davis B, Trompeter S, Walker M, Porter J, Moon JC. Noncontrast myocardial T1 mapping using cardiovascular magnetic resonance for iron overload. J Magn Reson Imaging 2014; 41:1505-11. [PMID: 25104503 DOI: 10.1002/jmri.24727] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 07/31/2014] [Indexed: 12/18/2022] Open
Abstract
PURPOSE To explore the use and reproducibility of magnetic resonance-derived myocardial T1 mapping in patients with iron overload. MATERIALS AND METHODS The research received ethics committee approval and all patients provided written informed consent. This was a prospective study of 88 patients and 67 healthy volunteers. Thirty-five patients underwent repeat scanning for reproducibility. T1 mapping used the shortened modified Look-Locker inversion recovery sequence (ShMOLLI) with a second, confirmatory MOLLI sequence in the reproducibility group. T2 * was performed using a commercially available sequence. The analysis of the T2 * interstudy reproducibility data was performed by two different research groups using two different methods. RESULTS Myocardial T1 was lower in patients than healthy volunteers (836 ± 138 msec vs. 968 ± 32 msec, P < 0.0001). Myocardial T1 correlated with T2 * (R = 0.79, P < 0.0001). No patient with low T2 * had normal T1 , but 32% (n = 28) of cases characterized by a normal T2 * had low myocardial T1 . Interstudy reproducibility of either T1 sequence was significantly better than T2 *, with the results suggesting that the use of T1 in clinical trials could decrease potential sample sizes by 7-fold. CONCLUSION Myocardial T1 mapping is an alternative method for cardiac iron quantification. T1 mapping shows the potential for improved detection of mild iron loading. The superior reproducibility of T1 has potential implications for clinical trial design and therapeutic monitoring.
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Affiliation(s)
- Daniel M Sado
- The Heart Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Viviana Maestrini
- Department of Cardiovascular, Respiratory, Nephrology and Geriatrics Sciences, La Sapienza, University of Rome, Rome, Italy
| | - Stefan K Piechnik
- Oxford Centre for Clinical Magnetic Resonance Research, Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Sanjay M Banypersad
- The Heart Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - Steven K White
- The Heart Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | | | - Matthew D Robson
- Oxford Centre for Clinical Magnetic Resonance Research, Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Stefan Neubauer
- Oxford Centre for Clinical Magnetic Resonance Research, Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Cono Ariti
- Department of Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Arai
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jin Yamamura
- University Medical Centre Hamburg-Eppendorf, Department of Diagnostic and Interventional Radiology, Hamburg, Germany
| | - Bjoern P Schoennagel
- University Medical Centre Hamburg-Eppendorf, Department of Diagnostic and Interventional Radiology, Hamburg, Germany
| | | | | | | | - Malcolm Walker
- The Heart Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | | | - James C Moon
- The Heart Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
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14
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Kassi M, Nabi F. Role of cardiac MRI in the assessment of nonischemic cardiomyopathies. Methodist Debakey Cardiovasc J 2014; 9:149-55. [PMID: 24066198 DOI: 10.14797/mdcj-9-3-149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In this review, we will highlight the role of late gadolinium enhancement, along with other strengths available by cardiac MRI, in determining the underlying etiology of various nonischemic cardiomyopathies. Furthermore, we will also emphasize how late gadolinium enhancement may serve as a novel risk stratification tool to further impact patient care.
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Affiliation(s)
- Mahwash Kassi
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas
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15
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Bayar N, Kurtoğlu E, Arslan Ş, Erkal Z, Çay S, Çağırcı G, Deveci B, Küçükseymen S. Assessment of the relationship between fragmented QRS and cardiac iron overload in patients with beta-thalassemia major. Anatol J Cardiol 2014; 15:132-6. [PMID: 25252297 PMCID: PMC5336998 DOI: 10.5152/akd.2014.5188] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: Beta-thalassemia major (TM) is a genetic hemoglobin disorder causing chronic hemolytic anemia. Since cardiac insufficiency and arrhythmias are the primary causes of mortality in such patients, monitoring of cardiac iron load is important in management of the disorder. The purpose of this study was to investigate the importance of fragmented QRS (fQRS) and its relation to the cardiac T2* value for the evaluation of cardiac iron load in TM patients. Methods: This retrospective study included 103 TM patients. The patients’ T2* values, measured by cardiac MRI and 12-lead surface ECGs, were interpreted. The cardiac T2* values under 20 were considered as cardiac iron overload. The relationship between the cardiac T2* value and fQRS in ECG was investigated. Results: The median age of the patients was 22.6±6.6 years. All patients were on regular blood transfusions and iron chelators. The patients had no risk factors for coronary artery disease. In 50 (48%) patients fQRS was detected, and in 37 (74%) of these the T2* values were low. 86% of patients with cardiac involvement (37) had fQRS, but 22% of patients with non-involvement (13) had fQRS (p<0.001). Conclusion: Since cardiac involvement is the primary cause of mortality in TM patients, the early diagnosis of cardiac dysfunction is of vital importance. The search for fQRS in the ECGs of these patients, particularly when cardiac T2* values cannot be determined and followed, is a non-expensive and easy-to-attain method for therapy management.
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Affiliation(s)
- Nermin Bayar
- Clinic of Cardiology, Antalya Education and Research Hospital; Antalya-Turkey.
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16
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Borgna-Pignatti C, Gamberini MR. Complications of thalassemia major and their treatment. Expert Rev Hematol 2014; 4:353-66. [DOI: 10.1586/ehm.11.29] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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17
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Pepe A, Meloni A, Rossi G, Caruso V, Cuccia L, Spasiano A, Gerardi C, Zuccarelli A, D'Ascola DG, Grimaldi S, Santodirocco M, Campisi S, Lai ME, Piraino B, Chiodi E, Ascioti C, Gulino L, Positano V, Lombardi M, Gamberini MR. Cardiac complications and diabetes in thalassaemia major: a large historical multicentre study. Br J Haematol 2013; 163:520-7. [DOI: 10.1111/bjh.12557] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 07/29/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Alessia Pepe
- Cardiovascular MR Unit; Fondazione G. Monasterio CNR-Regione Toscana and Institute of Clinical Physiology; Pisa Italy
| | - Antonella Meloni
- Cardiovascular MR Unit; Fondazione G. Monasterio CNR-Regione Toscana and Institute of Clinical Physiology; Pisa Italy
| | - Giuseppe Rossi
- Epidemiology and Biostatistics Unit; Institute of Clinical Physiology; CNR; Pisa Italy
| | - Vincenzo Caruso
- Unità Operativa Dipartimentale Talassemia; P.O. “S. Luigi-Currò” - ARNAS Garibaldi; Catania Italy
| | - Liana Cuccia
- Serv. Prevenz. Diagnosi e Cura Talassemia; Ospedale “G. di Cristina”; Palermo Italy
| | - Anna Spasiano
- Unità Microcitemia; A.O.R.N. Cardarelli; Napoli Italy
| | | | - Angelo Zuccarelli
- Centro trasfusionale e di microcitemia; Ospedale civile; Olbia Italy
| | | | | | - Michele Santodirocco
- Centro Microcitemia - D.H. Thalassemia Poliambulatorio “Giovanni Paolo II”; Ospedale Casa Sollievo della Sofferenza; San Giovanni Rotondo Italy
| | | | - Maria E. Lai
- Centro Talassemici Adulti; Ospedale microcitemico; Cagliari Italy
| | - Basilia Piraino
- U.O. Genetica e Immunologia Pediatrica; Policlinico “G. Martino”; Messina Italy
| | - Elisabetta Chiodi
- Servizio Radiologia Ospedaliera-Universitaria; Arcispedale “S. Anna”; Ferrara Italy
| | - Claudio Ascioti
- Struttura Complessa di Cardioradiologia-UTIC; P.O. “Giovanni Paolo II”; Lamezia Terme Italy
| | - Letizia Gulino
- Cardiovascular MR Unit; Fondazione G. Monasterio CNR-Regione Toscana and Institute of Clinical Physiology; Pisa Italy
| | - Vincenzo Positano
- Cardiovascular MR Unit; Fondazione G. Monasterio CNR-Regione Toscana and Institute of Clinical Physiology; Pisa Italy
| | - Massimo Lombardi
- Cardiovascular MR Unit; Fondazione G. Monasterio CNR-Regione Toscana and Institute of Clinical Physiology; Pisa Italy
| | - Maria R. Gamberini
- Pediatria; Adolescentologia e Talassemia; Arcispedale “S. Anna”; Ferrara Italy
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18
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Pennell DJ, Baksi AJ, Carpenter JP, Firmin DN, Kilner PJ, Mohiaddin RH, Prasad SK. Review of Journal of Cardiovascular Magnetic Resonance 2012. J Cardiovasc Magn Reson 2013; 15:76. [PMID: 24006874 PMCID: PMC3847143 DOI: 10.1186/1532-429x-15-76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 08/22/2013] [Indexed: 02/07/2023] Open
Abstract
There were 90 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2012, which is an 8% increase in the number of articles since 2011. The quality of the submissions continues to increase. The editors are delighted to report that the 2011 JCMR Impact Factor (which is published in June 2012) has risen to 4.44, up from 3.72 for 2010 (as published in June 2011), a 20% increase. The 2011 impact factor means that the JCMR papers that were published in 2009 and 2010 were cited on average 4.44 times in 2011. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, the progress of the journal's impact over the last 5 years has been impressive. Our acceptance rate is approximately 25%, and has been falling as the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors have felt that it is useful once per calendar year to summarize the papers for the readership into broad areas of interest or theme, so that areas of interest can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.
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Affiliation(s)
- Dudley J Pennell
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - A John Baksi
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - John Paul Carpenter
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - David N Firmin
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - Philip J Kilner
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - Raad H Mohiaddin
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
| | - Sanjay K Prasad
- Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Imperial College, London, UK
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Pennell DJ, Udelson JE, Arai AE, Bozkurt B, Cohen AR, Galanello R, Hoffman TM, Kiernan MS, Lerakis S, Piga A, Porter JB, Walker JM, Wood J. Cardiovascular function and treatment in β-thalassemia major: a consensus statement from the American Heart Association. Circulation 2013; 128:281-308. [PMID: 23775258 DOI: 10.1161/cir.0b013e31829b2be6] [Citation(s) in RCA: 261] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This aim of this statement is to report an expert consensus on the diagnosis and treatment of cardiac dysfunction in β-thalassemia major (TM). This consensus statement does not cover other hemoglobinopathies, including thalassemia intermedia and sickle cell anemia, in which a different spectrum of cardiovascular complications is typical. There are considerable uncertainties in this field, with a few randomized controlled trials relating to treatment of chronic myocardial siderosis but none relating to treatment of acute heart failure. The principles of diagnosis and treatment of cardiac iron loading in TM are directly relevant to other iron-overload conditions, including in particular Diamond-Blackfan anemia, sideroblastic anemia, and hereditary hemochromatosis. Heart failure is the most common cause of death in TM and primarily results from cardiac iron accumulation. The diagnosis of ventricular dysfunction in TM patients differs from that in nonanemic patients because of the cardiovascular adaptation to chronic anemia in non-cardiac-loaded TM patients, which includes resting tachycardia, low blood pressure, enlarged end-diastolic volume, high ejection fraction, and high cardiac output. Chronic anemia also leads to background symptomatology such as dyspnea, which can mask the clinical diagnosis of cardiac dysfunction. Central to early identification of cardiac iron overload in TM is the estimation of cardiac iron by cardiac T2* magnetic resonance. Cardiac T2* <10 ms is the most important predictor of development of heart failure. Serum ferritin and liver iron concentration are not adequate surrogates for cardiac iron measurement. Assessment of cardiac function by noninvasive techniques can also be valuable clinically, but serial measurements to establish trends are usually required because interpretation of single absolute values is complicated by the abnormal cardiovascular hemodynamics in TM and measurement imprecision. Acute decompensated heart failure is a medical emergency and requires urgent consultation with a center with expertise in its management. The first principle of management of acute heart failure is control of cardiac toxicity related to free iron by urgent commencement of a continuous, uninterrupted infusion of high-dose intravenous deferoxamine, augmented by oral deferiprone. Considerable care is required to not exacerbate cardiovascular problems from overuse of diuretics or inotropes because of the unusual loading conditions in TM. The current knowledge on the efficacy of removal of cardiac iron by the 3 commercially available iron chelators is summarized for cardiac iron overload without overt cardiac dysfunction. Evidence from well-conducted randomized controlled trials shows superior efficacy of deferiprone versus deferoxamine, the superiority of combined deferiprone with deferoxamine versus deferoxamine alone, and the equivalence of deferasirox versus deferoxamine.
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Pennell DJ, Carpenter JP, Firmin DN, Kilner PJ, Mohiaddin RH, Prasad SK. Review of Journal of Cardiovascular Magnetic Resonance 2011. J Cardiovasc Magn Reson 2012; 14:78. [PMID: 23158097 PMCID: PMC3519784 DOI: 10.1186/1532-429x-14-78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 11/08/2012] [Indexed: 12/15/2022] Open
Abstract
There were 83 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2011, which is an 11% increase in the number of articles since 2010. The quality of the submissions continues to increase. The editors had been delighted with the 2010 JCMR Impact Factor of 4.33, although this fell modestly to 3.72 for 2011. The impact factor undergoes natural variation according to citation rates of papers in the 2 years following publication, and is significantly influenced by highly cited papers such as official reports. However, we remain very pleased with the progress of the journal's impact over the last 5 years. Our acceptance rate is approximately 25%, and has been falling as the number of articles being submitted has been increasing. In accordance with Open-Access publishing, the JCMR articles go on-line as they are accepted with no collating of the articles into sections or special thematic issues. For this reason, the Editors feel it is useful to summarize the papers for the readership into broad areas of interest or theme, which we feel would be useful, so that areas of interest from the previous year can be reviewed in a single article in relation to each other and other recent JCMR articles. The papers are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought in the journal. We hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your quality manuscripts to JCMR for publication.
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Affiliation(s)
- Dudley J Pennell
- CMR Unit Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Exhibition Road, London, SW7 2AZ, UK
| | - John Paul Carpenter
- CMR Unit Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Exhibition Road, London, SW7 2AZ, UK
| | - David N Firmin
- CMR Unit Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Exhibition Road, London, SW7 2AZ, UK
| | - Philip J Kilner
- CMR Unit Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Exhibition Road, London, SW7 2AZ, UK
| | - Raad H Mohiaddin
- CMR Unit Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Exhibition Road, London, SW7 2AZ, UK
| | - Sanjay K Prasad
- CMR Unit Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, Exhibition Road, London, SW7 2AZ, UK
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Parsai C, O’Hanlon R, Prasad SK, Mohiaddin RH. Diagnostic and prognostic value of cardiovascular magnetic resonance in non-ischaemic cardiomyopathies. J Cardiovasc Magn Reson 2012; 14:54. [PMID: 22857649 PMCID: PMC3436728 DOI: 10.1186/1532-429x-14-54] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 07/10/2012] [Indexed: 02/06/2023] Open
Abstract
Cardiovascular Magnetic Resonance (CMR) is recognised as a valuable clinical tool which in a single scan setting can assess ventricular volumes and function, myocardial fibrosis, iron loading, flow quantification, tissue characterisation and myocardial perfusion imaging. The advent of CMR using extrinsic and intrinsic contrast-enhanced protocols for tissue characterisation have dramatically changed the non-invasive work-up of patients with suspected or known cardiomyopathy. Although the technique initially focused on the in vivo identification of myocardial necrosis through the late gadolinium enhancement (LGE) technique, recent work highlighted the ability of CMR to provide more detailed in vivo tissue characterisation to help establish a differential diagnosis of the underlying aetiology, to exclude an ischaemic substrate and to provide important prognostic markers. The potential application of CMR in the clinical approach of a patient with suspected non-ischaemic cardiomyopathy is discussed in this review.
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Affiliation(s)
- Chirine Parsai
- Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Trust, London, UK
- Cardiology and CMR Unit, Polyclinique Les Fleurs, Toulon, France
| | - Rory O’Hanlon
- Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Trust, London, UK
- Centre for Cardiovascular Magnetic Resonance, Blackrock Clinic, Dublin, Ireland
| | - Sanjay K Prasad
- Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Raad H Mohiaddin
- Cardiovascular Magnetic Resonance Unit, Royal Brompton and Harefield NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
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Abstract
T2* is a magnetic relaxation property of any tissue and is inversely related to intracellular iron stores. Measurement is simple, quick, and robust and has high reproducibility. The ability to measure ventricular function plus T2* in the heart and liver during the same scan has revolutionized the understanding of iron storage disease and the management of the iron-loaded patient. The early findings using T2* challenged conventional teachings, and both the technique and the findings were initially viewed with scepticism. However, after a decade of work in validating, calibrating, and expanding access to this method, it is now accepted as the method of choice for tissue iron assessment. In the UK, where T2* measurement was first used in the clinical care of patients with thalassemia major, a large and significant fall in mortality has been seen in this patient group.
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Affiliation(s)
- Lisa J Anderson
- Department of Cardiology, St George's University of London, Tooting, London, UK.
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Affiliation(s)
| | - Dimitrios Farmakis
- From the Second Department of Cardiology, Attikon University Hospital, Athens, Greece
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