Characterization of subclinical diastolic dysfunction by cardiac magnetic resonance feature-tracking in adult survivors of non-Hodgkin lymphoma treated with anthracyclines

Cardiovascular magnetic resonance parametric techniques to characterize myocardial effects of anthracycline therapy in adults with normal left ventricular ejection fraction: a systematic review and meta-analysis

BACKGROUND

The cardiotoxic effects of anthracyclines therapy are well recognized, both in the short and long term. Echocardiography allows monitoring of cancer patients treated with this class of drugs by serial assessment of left ventricle ejection fraction (LVEF) as a surrogate of systolic function. However, changes in myocardial function may occur late in the process when cardiac damage is already established. Novel cardiac magnetic resonance (CMR) parametric techniques, like native T1 mapping and extra-cellular volume (ECV), may detect subclinical myocardial damage in these patients, recognizing early signs of cardiotoxicity before development of overt cancer therapy-related cardiac dysfunction (CTRCD) and prompting tailored therapeutic and follow-up strategies to improve outcome.

METHODS AND RESULTS

We conducted a systematic review and a meta-analysis to investigate the difference in CMR derived native T1 relaxation time and ECV values, respectively, in anthracyclines-treated cancer patients with preserved EF versus healthy controls. PubMed, Embase, Web of Science and Cochrane Central were searched for relevant studies. A total of 6 studies were retrieved from 1057 publications, of which, four studies with 547 patients were included in the systematic review on T1 mapping and five studies with 481 patients were included in the meta-analysis on ECV. Three out of the four included studies in the systematic review showed higher T1 mapping values in anthracyclines treated patients compared to healthy controls. The meta-analysis demonstrated no statistically significant difference in ECV values between the two groups in the main analysis (Hedges´s g =3.20, 95% CI -0.72-7.12, p =0.11, I2 =99%), while ECV was significantly higher in the anthracyclines-treated group when sensitivity analysis was performed.

CONCLUSIONS

Higher T1 mapping and ECV values in patients exposed to anthracyclines could represent early biomarkers of CTRCD, able to detect subclinical myocardial changes present before the development of overt myocardial dysfunction. Our results highlight the need for further studies to investigate the correlation between anthracyclines-based chemotherapy and changes in CMR mapping parameters that may guide future tailored follow-up strategies in this group of patients.

Assessment of Native Myocardial T1 Mapping for Early Detection of Anthracycline-Induced Cardiotoxicity in Patients with Cancer: a Systematic Review and Meta-analysis

Anthracycline antibiotic is one of the most effective anti-tumor drugs used to manage certain types of breast cancers, lymphomas, and leukemias. However, anthracyclines induce a dose-dependent cardiotoxicity that may progress to heart failure. Thus, using a sensitive predictor of early cardiac dysfunction in patients treated with anthracyclines can help detect subclinical cardiac dysfunction early and help initiate interventions to protect these patients. Among parameters of myocardial measure, cardiac magnetic resonance (CMR)-measured native myocardial T1 mapping is considered a sensitive and accurate quantitative measure of early subclinical cardiac changes, particularly cardiac inflammation and fibrosis. However, to understand the quality and the validity of the current evidence supporting the use of these measures in patients treated with anthracyclines, we aimed to conduct a systematic review of clinical studies of this measure to detect early myocardial changes in cancer patients treated with anthracyclines. The primary outcome was the level of native T1 mapping. We performed fixed-effects meta-analyses and assessed certainty in effect estimates. Of the 1780 publications reviewed (till 2022), 23 were retrieved, and 9 articles met the inclusion criteria. Our study showed that exposure to anthracycline was associated with a significant elevation of native myocardial T1 mapping from baseline (95% CI 0.1121 to 0.5802; p = 0.0037) as well as compared to healthy control patients (95% CI 0.2925 to 0.7448; p < 0.0001). No significant publication bias was noted on the assessment of the funnel plot and Egger's test. According to the Q test, there was no significant heterogeneity in the included studies (I2 = 0.0000% versus healthy controls and I2 = 14.0666% versus baseline). Overall, our study suggests that native myocardial T1 mapping is useful for detecting anthracycline-induced cardiotoxicity in patients with cancer.

Adiposity influences on myocardial deformation: a cardiovascular magnetic resonance feature tracking study in people with overweight to obesity without established cardiovascular disease

The objective of this study was to assess whether dietary-induced weight loss improves myocardial deformation in people with overweight to obesity without established cardiovascular disease applying cardiovascular magnetic resonance (CMR) with feature tracking (FT) based strain analysis. Ninety people with overweight to obesity without established cardiovascular disease (age 44.6 ± 9.3 years, body mass index (BMI) 32.6 ± 4 kg/m2) underwent CMR. We retrospectively quantified FT based strain and LA size and function at baseline and after a 6-month hypocaloric diet, with either low-carbohydrate or low-fat intake. The study cohort was compared to thirty-four healthy normal-weight controls (age 40.8 ± 16.0 years, BMI 22.5 ± 1.4 kg/m2). At baseline, the study cohort with overweight to obesity without established cardiovascular disease displayed significantly increased global circumferential strain (GCS), global radial strain (GRS) and LA size (all p < 0.0001 versus controls) but normal global longitudinal strain (GLS) and normal LA ejection fraction (all p > 0.05 versus controls). Dietary-induced weight loss led to a significant reduction in GCS, GRS and LA size irrespective of macronutrient composition (all p < 0.01). In a population with overweight to obesity without established cardiovascular disease subclinical myocardial changes can be detected applying CMR. After dietary-induced weight loss improvement of myocardial deformation could be shown. A potential clinical impact needs further studies.

Comparison of manual and artificial intelligence based quantification of myocardial strain by feature tracking-a cardiovascular MR study in health and disease

OBJECTIVES

The analysis of myocardial deformation using feature tracking in cardiovascular MR allows for the assessment of global and segmental strain values. The aim of this study was to compare strain values derived from artificial intelligence (AI)-based contours with manually derived strain values in healthy volunteers and patients with cardiac pathologies.

MATERIALS AND METHODS

A cohort of 136 subjects (60 healthy volunteers and 76 patients; of those including 46 cases with left ventricular hypertrophy (LVH) of varying etiology and 30 cases with chronic myocardial infarction) was analyzed. Comparisons were based on quantitative strain analysis and on a geometric level by the Dice similarity coefficient (DSC) of the segmentations. Strain quantification was performed in 3 long-axis slices and short-axis (SAX) stack with epi- and endocardial contours in end-diastole. AI contours were checked for plausibility and potential errors in the tracking algorithm.

RESULTS

AI-derived strain values overestimated radial strain (+ 1.8 ± 1.7% (mean difference ± standard deviation); p = 0.03) and underestimated circumferential (- 0.8 ± 0.8%; p = 0.02) and longitudinal strain (- 0.1 ± 0.8%; p = 0.54). Pairwise group comparisons revealed no significant differences for global strain. The DSC showed good agreement for healthy volunteers (85.3 ± 10.3% for SAX) and patients (80.8 ± 9.6% for SAX). In 27 cases (27/76; 35.5%), a tracking error was found, predominantly (24/27; 88.9%) in the LVH group and 22 of those (22/27; 81.5%) at the insertion of the papillary muscle in lateral segments.

CONCLUSIONS

Strain analysis based on AI-segmented images shows good results in healthy volunteers and in most of the patient groups. Hypertrophied ventricles remain a challenge for contouring and feature tracking.

CLINICAL RELEVANCE STATEMENT

AI-based segmentations can help to streamline and standardize strain analysis by feature tracking.

KEY POINTS

• Assessment of strain in cardiovascular magnetic resonance by feature tracking can generate global and segmental strain values. • Commercially available artificial intelligence algorithms provide segmentation for strain analysis comparable to manual segmentation. • Hypertrophied ventricles are challenging in regards of strain analysis by feature tracking.

Feature tracking cardiac magnetic resonance imaging to assess cardiac manifestations of systemic diseases

Feature-tracking cardiac magnetic resonance (FT-CMR), with the ability to quantify myocardial deformation, has a unique role in the evaluation of subclinical myocardial abnormalities. This review aimed to evaluate the clinical use of cardiac FT-CMR-based myocardial strain in patients with various systemic diseases with cardiac involvement, such as hypertension, diabetes, cancer-therapy-related toxicities, amyloidosis, systemic scleroderma, myopathies, rheumatoid arthritis, thalassemia major, and coronavirus disease 2019 (COVID-19). We concluded that FT-CMR-derived strain can improve the accuracy of risk stratification and predict cardiac outcomes in patients with systemic diseases prior to symptomatic cardiac dysfunction. Furthermore, FT-CMR is particularly useful for patients with diseases or conditions which are associated with subtle myocardial dysfunction that may not be accurately detected with traditional methods. Compared to patients with cardiovascular diseases, patients with systemic diseases are less likely to undergo regular cardiovascular imaging to detect cardiac defects, whereas cardiac involvement in these patients can lead to major adverse outcomes; hence, the importance of cardiac imaging modalities might be underestimated in this group of patients. In this review, we gathered currently available data on the newly introduced role of FT-CMR in the diagnosis and prognosis of various systemic conditions. Further research is needed to define reference values and establish the role of this sensitive imaging modality, as a robust marker in predicting outcomes across a wide spectrum of patients.

Cardiovascular Risk Stratification by Automatic Coronary Artery Calcium Scoring on Pretreatment Chest Computed Tomography in Diffuse Large B-Cell Lymphoma Receiving Anthracycline-Based Chemotherapy: A Multicenter Study

BACKGROUND

Balancing the cardiovascular risk and benefit of anthracycline-based chemotherapy in patients with diffuse large B-cell lymphoma is an important clinical issue. We aimed to evaluate whether the pretreatment coronary artery calcium score (CACS) can stratify the risk of cancer therapy-related cardiac dysfunction (CTRCD) and major adverse cardiovascular events (MACEs) in patients with diffuse large B-cell lymphoma receiving anthracycline-based chemotherapy.

METHODS

The patients with diffuse large B-cell lymphoma from 4 hospitals were retrospectively enrolled. The CACS was automatically calculated on nongated chest computed tomography before treatment using artificial intelligence-CACS software and divided into 3 categories (0, 1-100, and >100). The associations between the CACS and CTRCD and between the CACS and MACEs were assessed by logistic regression and Fine-Gray competing-risk regression model. Nelson-Aalen cumulative risk curve was performed to assess the cumulative incidence of MACEs.

RESULTS

A total of 1468 patients (785 men and 683 women; 100% Asian) were enrolled, and 362 and 185 patients developed CTRCD and MACEs, respectively. Compared with a CACS of 0 (n=826), there was stepwise higher odds of CTRCD with a CACS between 1 and 100 (n=356; odds ratio, 2.587) and a CACS >100 (n=286; odds ratio, 5.239). The CACS was associated with MACEs (1-100 versus 0: subdistribution hazard ratio 3.726; >100 versus 0: subdistribution hazard ratio 7.858; all P<0.001). Competing risk-adjusted MACEs rates for patients with a CACS of 0, 1 to 100, and >100 were 1.21%, 8.43%, and 11.19%, respectively, at 3 years, and 3.27%, 16.01%, 31.12%, respectively, at 5 years.

CONCLUSIONS

The automatic CACS derived from chest computed tomography before treatment was helpful to identify high-risk patients of CTRCD and MACE and guide clinicians to implement cardiovascular protection strategies in patients with diffuse large B-cell lymphoma who received anthracycline-based chemotherapy.

Assessment of left ventricular diastolic dysfunction following anthracyclinebased chemotherapy in breast cancer patients

Cardiotoxicity is a side effect of anthracycline-based chemotherapy. Clinical and prognostic significance of left ventricular diastolic dysfunction in heart failure patients is undeniable.The aim. To assess dynamic changes in the left ventricular diastolic function after anthracycline-based chemotherapy (ANT) in breast cancer patients.Material and methods. The study included 40 women aged 35 to 72 years with breast cancer (BC) undergoing ANT chemotherapy. The main group (n = 40) consisted of women with breast cancer examined at admission, after 6 months the same women (n = 37) were examined again. Women without breast cancer (n = 25) were used as the control group.Results. Dynamic changes in mitral annular velocities were revealed by Doppler tissue imaging. Lateral early diastolic mitral annular velocity (e’ lateral) was significantly lower in breast cancer patients as compared to the control group (p = 0.031). Six months after ANT chemotherapy, there was a definite increase in the lateral late diastolic mitral annular velocity (a’ lateral) (p = 0.033). Average early diastolic transmitral flow velocity to early diastolic velocity (E/e’ lateral) ratio was within the normative values in all groups, but E/e’ lateral in the main group was higher compared to the control group (p = 0.003). In the main group, septal early diastolic mitral annular velocity (e’ septal) was lower compared to the control group (p = 0.0005). Moreover, an increase in the septal mitral annular velocity (a’ septal) (p = 0.01) and higher E/e’ septal ratio (p = 0.011) were revealed during dynamic observation. Multiple logistic regression disclosed that E/A, e’ lateral, e’/a’ lateral, and E/e’ lateral were affected by heart rate, psychological status, age, hypertension, and body mass index, but not anthracycline chemotherapy. The total dose of anthracycline was independently associated with e’ septal and E/e’ septal: F(4.18) = 16.466 (p < 0.001; R2 = 0.775) and F(3.16) = 7.271 (p = 0.004; R2 = 0.627).Conclusion. Left ventricular diastolic function worsens in women undergoing anthracycline-based chemotherapy for breast cancer (lower e’, e’/a’ lateral, and e’ septal, higher E/e’ septal ratio). However, anthracycline does not significantly affect LVEF and LV deformation indicators. E/e’ septalande’ septal are independently associated with the total dose of anthracycline.

Cardiovascular Imaging in Cardio-Oncology: The Role of Echocardiography and Cardiac MRI in Modern Cardio-Oncology

Cardiovascular (CV) events are an increasingly common limitation of effective anticancer therapy. Over the last decade imaging has become essential to patients receiving contemporary cancer therapy. Herein we discuss the current state of CV imaging in cardio-oncology. We also provide a practical apparatus for the use of imaging in everyday cardiovascular care of oncology patients to improve outcomes for those at risk for cardiotoxicity, or with established cardiovascular disease. Finally, we consider future directions in the field given the wave of new anticancer therapies.