1
|
Jeyaprakash P, Pathan F, Ozawa K, Robledo KP, Shah KK, Morton RL, Yu C, Madronio C, Hallani H, Loh H, Boyle A, Ford TJ, Porter TR, Negishi K. Restoring microvascular circulation with diagnostic ultrasound and contrast agent: rationale and design of the REDUCE trial. Am Heart J 2024; 275:163-172. [PMID: 38944262 DOI: 10.1016/j.ahj.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 06/22/2024] [Accepted: 06/22/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES This study aims to evaluate the efficacy and cost-effectiveness of sonothrombolysis delivered pre and post primary percutaneous coronary intervention (pPCI) on infarct size assessed by cardiac MRI, in patients presenting with STEMI, when compared against sham procedure. BACKGROUND More than a half of patients with successful pPCI have significant microvascular obstruction and residual infarction. Sonothrombolysis is a therapeutic use of ultrasound with contrast enhancement that may improve microcirculation and infarct size. The benefits and real time physiological effects of sonothrombolysis in a multicentre setting are unclear. METHODS The REDUCE (Restoring microvascular circulation with diagnostic ultrasound and contrast agent) trial is a prospective, multicentre, patient and outcome blinded, sham-controlled trial. Patients presenting with STEMI will be randomized to one of 2 treatment arms, to receive either sonothrombolysis treatment or sham echocardiography before and after pPCI. This tailored design is based on preliminary pilot data from our centre, showing that sonothrombolysis can be safely delivered, without prolonging door to balloon time. Our primary endpoint will be infarct size assessed on day 4±2 on Cardiac Magnetic Resonance (CMR). Patients will be followed up for 6 months post pPCI to assess secondary endpoints. Sample size calculations indicate we will need 150 patients recruited in total. CONCLUSIONS This multicentre trial will test whether sonothrombolysis delivered pre and post primary PCI can improve patient outcomes and is cost-effective, when compared with sham ultrasound delivered with primary PCI. The results from this trial may provide evidence for the utilization of sonothrombolysis as an adjunct therapy to pPCI to improve cardiovascular outcomes in STEMI. ANZ Clinical Trial Registration number: ACTRN 12620000807954.
Collapse
Affiliation(s)
- Prajith Jeyaprakash
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Faraz Pathan
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia; Department of Radiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Koya Ozawa
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Kristy P Robledo
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Karan K Shah
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Christopher Yu
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Christine Madronio
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia
| | - Hisham Hallani
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Han Loh
- Department of Radiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Andrew Boyle
- Department of Cardiology, John Hunter Hospital, Newcastle, New South Wales, Australia; University of Newcastle, New South Wales, Australia
| | - Thomas J Ford
- University of Newcastle, New South Wales, Australia; Department of Cardiology, Gosford Public Hospital, Gosford, New South Wales, Australia
| | - Thomas R Porter
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Kazuaki Negishi
- Faculty of Medicine and Health, Charles Perkins Centre Nepean, Sydney Medical School Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia.
| |
Collapse
|
2
|
Jeyaprakash P, Pathan F, Sivapathan S, Robledo KP, Madan K, Khor L, Yu C, Madronio C, Hallani H, Low G, Nundlall N, Burgess S, Fernandes C, Parikh D, Loh H, Mansberg R, Nguyen D, Ozawa K, Porter TR, Negishi K. Sonothrombolysis Before and After Percutaneous Coronary Intervention Provides the Largest Myocardial Salvage in ST Segment Elevation Myocardial Infarction. J Am Soc Echocardiogr 2024:S0894-7317(24)00349-3. [PMID: 38986920 DOI: 10.1016/j.echo.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Sonothrombolysis is a therapeutic application of ultrasound with ultrasound contrast for patients with ST elevation myocardial infarction (STEMI). Recent trials demonstrated that sonothrombolysis, delivered before and after primary percutaneous coronary intervention (pPCI), increases infarct vessel patency, improves microvascular flow, reduces infarct size, and improves ejection fraction. However, it is unclear whether pre-pPCI sonothrombolysis is essential for therapeutic benefit. We designed a parallel 3-arm sham-controlled randomized controlled trial to address this. METHODS Patients presenting with first STEMI undergoing pPCI within 6 hours of symptom onset were randomized 1:1:1 into 3 arms: sonothrombolysis pre-/post-pPCI (group 1), sham pre- sonothrombolysis post-pPCI (group 2), and sham pre-/post-pPCI (group 3). Our primary end point was infarct size (percentage of left ventricular mass) assessed by cardiac magnetic resonance imaging at day 4 ± 2. Secondary end points included myocardial salvage index (MSI) and echocardiographic parameters at day 4 ± 2 and 6 months. RESULTS Our trial was ceased early due to the COVID pandemic. From 122 patients screened between September 2020 and June 2021, 51 patients (age 60, male 82%) were included postrandomization. Median sonothrombolysis took 5 minutes pre-pPCI and 15 minutes post-, without significant door-to-balloon delay. There was a trend toward reduction in median infarct size between group 1 (8% [interquartile range, 4,11]), group 2 (11% [7, 19]), or group 3 (15% [9, 22]). Similarly there was a trend toward improved MSI in group 1 (79% [64, 85]) compared to groups 2 (51% [45, 70]) and 3 (48% [37, 73]) No major adverse cardiac events occurred during hospitalization. CONCLUSIONS Pre-pPCI sonothrombolysis may be key to improving MSI in STEMI. Multicenter trials and health economic analyses are required before clinical translation.
Collapse
Affiliation(s)
- Prajith Jeyaprakash
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Faraz Pathan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Shanthosh Sivapathan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Kristy P Robledo
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, New South Wales, Australia
| | - Kedar Madan
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Lynn Khor
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Christopher Yu
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Christine Madronio
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Hisham Hallani
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Gary Low
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia
| | - Nishant Nundlall
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Sonya Burgess
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Clyne Fernandes
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Devang Parikh
- Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia
| | - Han Loh
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Robert Mansberg
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Diep Nguyen
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Medical Imaging, Nepean Hospital, Sydney, New South Wales, Australia
| | - Koya Ozawa
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia
| | - Thomas R Porter
- Department of Cardiology, University of Nebraska, Lincoln, Nebraska
| | - Kazuaki Negishi
- Sydney Medical School Nepean, Faculty of Medicine and Health, Charles Perkins Centre Nepean, The University of Sydney, New South Wales, Australia; Department of Cardiology, Nepean Hospital, Sydney, New South Wales, Australia.
| |
Collapse
|
3
|
Chuah SH, Tan LK, Md Sari NA, Chan BT, Hasikin K, Lim E, Ung NM, Abdul Aziz YF, Jayabalan J, Liew YM. Remodeling in Aortic Stenosis With Reduced and Preserved Ejection Fraction: Insight on Motion Abnormality Via 3D + Time Personalized LV Modeling in Cardiac MRI. J Magn Reson Imaging 2024; 59:1242-1255. [PMID: 37452574 DOI: 10.1002/jmri.28915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 07/04/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND Increased afterload in aortic stenosis (AS) induces left ventricle (LV) remodeling to preserve a normal ejection fraction. This compensatory response can become maladaptive and manifest with motion abnormality. It is a clinical challenge to identify contractile and relaxation dysfunction during early subclinical stage to prevent irreversible deterioration. PURPOSE To evaluate the changes of regional wall dynamics in 3D + time domain as remodeling progresses in AS. STUDY TYPE Retrospective. POPULATION A total of 31 AS patients with reduced and preserved ejection fraction (14 AS_rEF: 7 male, 66.5 [7.8] years old; 17 AS_pEF: 12 male, 67.0 [6.0] years old) and 15 healthy (6 male, 61.0 [7.0] years old). FIELD STRENGTH/SEQUENCE 1.5 T Magnetic resonance imaging/steady state free precession and late-gadolinium enhancement sequences. ASSESSMENT Individual LV models were reconstructed in 3D + time domain and motion metrics including wall thickening (TI), dyssynchrony index (DI), contraction rate (CR), and relaxation rate (RR) were automatically extracted and associated with the presence of scarring and remodeling. STATISTICAL TESTS Shapiro-Wilk: data normality; Kruskal-Wallis: significant difference (P < 0.05); ICC and CV: variability; Mann-Whitney: effect size. RESULTS AS_rEF group shows distinct deterioration of cardiac motions compared to AS_pEF and healthy groups (TIAS_rEF : 0.92 [0.85] mm, TIAS_pEF : 5.13 [1.99] mm, TIhealthy : 3.61 [1.09] mm, ES: 0.48-0.83; DIAS_rEF : 17.11 [7.89]%, DIAS_pEF : 6.39 [4.04]%, DIhealthy : 5.71 [1.87]%, ES: 0.32-0.85; CRAS_rEF : 8.69 [6.11] mm/second, CRAS_pEF : 16.48 [6.70] mm/second, CRhealthy : 10.82 [4.57] mm/second, ES: 0.29-0.60; RRAS_rEF : 8.45 [4.84] mm/second; RRAS_pEF : 13.49 [8.56] mm/second, RRhealthy : 9.31 [2.48] mm/second, ES: 0.14-0.43). The difference in the motion metrics between healthy and AS_pEF groups were insignificant (P-value = 0.16-0.72). AS_rEF group was dominated by eccentric hypertrophy (47.1%) with concomitant scarring. Conversely, AS_pEF group was dominated by concentric remodeling and hypertrophy (71.4%), which could demonstrate hyperkinesia with slight wall dyssynchrony than healthy. Dysfunction of LV mechanics corresponded to the presence of myocardial scarring (54.9% in AS), which reverted the compensatory mechanisms initiated and performed by LV remodeling. DATA CONCLUSION The proposed 3D + time modeling technique may distinguish regional motion abnormalities between AS_pEF, AS_rEF, and healthy cohorts, aiding clinical diagnosis and monitoring of AS progression. Subclinical myocardial dysfunction is evident in early AS despite of normal EF. LEVEL OF EVIDENCE 4 TECHNICAL EFFICACY: Stage 1.
Collapse
Affiliation(s)
- Shoon Hui Chuah
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Li Kuo Tan
- Department of Biomedical Imaging, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
- University Malaya Research Imaging Centre, Department of Biomedical Imaging, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Nor Ashikin Md Sari
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Bee Ting Chan
- Department of Mechanical, Materials and Manufacturing Engineering, Faculty of Science and Engineering, University of Nottingham Malaysia, Semenyih, Malaysia
| | - Khairunnisa Hasikin
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Einly Lim
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Ngie Min Ung
- Clinical Oncology Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Yang Faridah Abdul Aziz
- University Malaya Research Imaging Centre, Department of Biomedical Imaging, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Jeyaraaj Jayabalan
- Department of Biomedical Imaging, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Yih Miin Liew
- Department of Biomedical Engineering, Faculty of Engineering, Universiti Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
4
|
Myklebust L, Maleckar MM, Arevalo H. Fibrosis modeling choice affects morphology of ventricular arrhythmia in non-ischemic cardiomyopathy. Front Physiol 2024; 15:1370795. [PMID: 38567113 PMCID: PMC10986182 DOI: 10.3389/fphys.2024.1370795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 02/15/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction: Patients with non-ischemic cardiomyopathy (NICM) are at risk for ventricular arrhythmias, but diagnosis and treatment planning remain a serious clinical challenge. Although computational modeling has provided valuable insight into arrhythmic mechanisms, the optimal method for simulating reentry in NICM patients with structural disease is unknown. Methods: Here, we compare the effects of fibrotic representation on both reentry initiation and reentry morphology in patient-specific cardiac models. We investigate models with heterogeneous networks of non-conducting structures (cleft models) and models where fibrosis is represented as a dense core with a surrounding border zone (non-cleft models). Using segmented cardiac magnetic resonance with late gadolinium enhancement (LGE) of five NICM patients, we created 185 3D ventricular electrophysiological models with different fibrotic representations (clefts, reduced conductivity and ionic remodeling). Results: Reentry was induced by electrical pacing in 647 out of 3,145 simulations. Both cleft and non-cleft models can give rise to double-loop reentries meandering through fibrotic regions (Type 1-reentry). When accounting for fibrotic volume, the initiation sites of these reentries are associated with high local fibrotic density (mean LGE in cleft models: p< 0.001, core volume in non-cleft models: p = 0.018, negative binomial regression). In non-cleft models, Type 1-reentries required slow conduction in core tissue (non-cleftsc models) as opposed to total conduction block. Incorporating ionic remodeling in fibrotic regions can give rise to single- or double-loop rotors close to healthy-fibrotic interfaces (Type 2-reentry). Increasing the cleft density or core-to-border zone ratio in cleft and non-cleftc models, respectively, leads to increased inducibility and a change in reentry morphology from Type 2 to Type 1. Conclusions: By demonstrating how fibrotic representation affects reentry morphology and location, our findings can aid model selection for simulating arrhythmogenesis in NICM.
Collapse
|
5
|
Kim K, Lee YJ, Kim MH, Byun BH, Woo SK. Automatic Quantitative Assessment for Diagnostic and Therapeutic Response in Rodent Myocardial Infarct Model. Biomedicines 2024; 12:219. [PMID: 38255324 PMCID: PMC10813557 DOI: 10.3390/biomedicines12010219] [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: 12/12/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open
Abstract
The purpose of this study was to investigate the most appropriate methodological approach for the automatic measurement of rodent myocardial infarct polar map using histogram-based thresholding and unsupervised deep learning (DL)-based segmentation. A rat myocardial infarction model was induced by ligation of the left coronary artery. Positron emission tomography (PET) was performed 60 min after the administration of 18F-fluoro-deoxy-glucose (18F-FDG), and PET was performed after injecting 64Cu-pyruvaldehyde-bis(N4-methylthiosemicarbazone). Single photon emission computed tomography was performed 60 min after injection of 99mTc-hexakis-2-methoxyisobutylisonitrile and 201Tl. Delayed contrast-enhanced magnetic resonance imaging was performed after injecting Gd-DTPA-BMA. Three types of thresholding methods (naive thresholding, Otsu's algorithm, and multi-Gaussian mixture model (MGMM)) were used. DL segmentation methods were based on a convolution neural network and trained with constraints on feature similarity and spatial continuity of the response map extracted from images by the network. The relative infarct sizes measured by histology and estimated R2 for 18F-FDG were 0.8477, 0.7084, 0.8353, and 0.9024 for naïve thresholding, Otsu's algorithm, MGMM, and DL segmentation, respectively. DL-based method improved the accuracy of MI size assessment.
Collapse
Affiliation(s)
- Kangsan Kim
- Division of Applied RI, Korea Institute of Radiological and Medical Sciences, Seoul 01812, Republic of Korea
| | - Yong Jin Lee
- Division of Applied RI, Korea Institute of Radiological and Medical Sciences, Seoul 01812, Republic of Korea
| | - Min Hwan Kim
- Research Institute of Radiopharmaceuticals, FutureChem Co., Ltd., Seoul 04794, Republic of Korea
| | - Byung Hyun Byun
- Department of Nuclear Medicine, Korea Institute of Radiological and Medical Sciences, Seoul 01812, Republic of Korea
| | - Sang-Keun Woo
- Division of Applied RI, Korea Institute of Radiological and Medical Sciences, Seoul 01812, Republic of Korea
| |
Collapse
|
6
|
Székely A, Steding-Ehrenborg K, Ryd D, Hedeer F, Valind K, Akil S, Hindorf C, Hedström E, Erlinge D, Arheden H, Engblom H. Quantitative myocardial perfusion should be interpreted in the light of sex and comorbidities in patients with suspected chronic coronary syndrome: A cardiac positron emission tomography study. Clin Physiol Funct Imaging 2024; 44:89-99. [PMID: 37642142 DOI: 10.1111/cpf.12854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/13/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
Diagnosis and treatment of patients with suspected chronic coronary syndrome (CCS) currently relies on the degree of coronary artery stenosis and its significance for myocardial perfusion. However, myocardial perfusion can be affected by factors other than coronary stenosis. The aim of this study was to investigate to what extent sex, age, diabetes, hypertension and smoking affect quantitative myocardial perfusion, beyond the degree of coronary artery stenosis, in patients with suspected or established CCS. Eighty-six patients [median age 69 (range 46-86) years, 24 females] planned for elective coronary angiography due to suspected or established CCS were included. All patients underwent cardiac 13 N-NH3 positron emission tomography to quantify myocardial perfusion at rest and stress. Lowest myocardial perfusion (perfusionmin ) at stress and rest and lowest myocardial perfusion reserve (MPRmin ) for all vessel territories was used as dependent variables in a linear mixed model. Independent variables were vessel territory, degree of coronary artery stenosis (as a continuous variable of 0%-100% stenosis), sex, age, diabetes, hypertension and smoking habits. Degree of coronary artery stenosis (p < 0.001), male sex (1.8 ± 0.6 vs. 2.3 ± 0.6 mL/min/g, p < 0.001), increasing age (p = 0.025), diabetes (1.6 ± 0.5 vs. 2.0 ± 0.6 mL/min/g, p = 0.023) and smoking (1.9 ± 0.6 vs. 2.1 ± 0.6 mL/min/g, p = 0.052) were independently associated with myocardial perfusionmin at stress. Degree of coronary artery stenosis (p < 0.001), age (p = 0.040), diabetes (1.8 ± 0.6 vs. 2.3 ± 0.7, p = 0.046) and hypertension (2.2 ± 0.7 vs. 2.5 ± 0.6, p = 0.033) were independently associated with MPRmin . Sex, increasing age, diabetes, hypertension and smoking affect myocardial perfusion independent of coronary artery stenosis in patients with suspected or established CCS. Thus, these factors need to be considered when assessing the significance of reduced quantitative myocardial perfusion of patients with suspected or established CCS.
Collapse
Affiliation(s)
- Anna Székely
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Katarina Steding-Ehrenborg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Daniel Ryd
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Fredrik Hedeer
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Kristian Valind
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Shahnaz Akil
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Cecilia Hindorf
- Department of Medical Radiation Physics, Lund University, Lund, Sweden
| | - Erik Hedström
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Cardiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Håkan Arheden
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Henrik Engblom
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
7
|
Raja DC, Samarawickrema I, Srinivasan JR, Menon S, Das SK, Jain S, Tuan LQ, Desjardins B, Marchlinski FE, Abhayaratna WP, Sanders P, Pathak RK. Correlation of myocardial strain by CMR-feature tracking with substrate abnormalities detected by electro-anatomical mapping in patients with nonischemic cardiomyopathy. J Interv Card Electrophysiol 2023; 66:2113-2123. [PMID: 37129791 PMCID: PMC10694091 DOI: 10.1007/s10840-023-01553-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/14/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Late gadolinium enhancement (LGE) detected by cardiac MRI (CMR) has low correlation with low voltage zones (LVZs) detected by electroanatomical mapping (EAM). We aim to study correlation of myocardial strain by CMR- Feature Tracking (FT) alongside LGE with LVZs detected by EAM. METHODS Nineteen consecutive CMRs of patients with EAM were analyzed offline by CMR-FT. Peak value of circumferential strain (CS), longitudinal strain (LS), and LGE was measured in each segment of the left ventricle (17-segment model). The percentage of myocardial segments with CS and LS > -17% was determined. Percentage area of LGE-scar was calculated. Global and segment-wise bipolar and unipolar voltage was collected. Percentage area of bipolar LVZ (<1.5 mV) and unipolar LVZ (<8.3 mV) was calculated. RESULTS Mean age was 62±11 years. Mean LVEF was 37±13%. Mean global CS was -11.8±5%. Mean global LS was -11.2±4%. LGE-scar was noted in 74% of the patients. Mean percentage area of LGE-scar was 5%. There was significant correlation between percentage abnormality detected by LS with percentage bipolar LVZ (r = +0.5, p = 0.03) and combined percentage CS+LS abnormality with percentage unipolar LVZ (r = +0.5, p = 0.02). Per-unit increase in CS increased the percentage area of unipolar LVZ by 2.09 (p = 0.07) and per-unit increase in LS increased the percentage area of unipolar LVZ by 2.49 (p = 0.06). The concordance rates between CS and LS to localize segments with bipolar/unipolar LVZ were 79% and 95% compared to 63% with LGE. CONCLUSIONS Myocardial strain detected by CMR-FT has a better correlation with electrical low voltage zones than the conventional LGE.
Collapse
Affiliation(s)
- Deep Chandh Raja
- ANU School of Medicine and Psychology, Australian National University, 54 Mills Road, Acton, 2601, ACT, Australia
- Canberra Health Services, 2 Garran place, Garran, Canberra, 2605, Australia
- Canberra Heart Rhythm, 2 Garran Place, Garran, 2605, Australia
| | | | | | - SaratKrishna Menon
- University of Newcastle, Newcastle, NSW, Australia
- Canberra Heart Rhythm, 2 Garran Place, Garran, 2605, Australia
| | - Souvik Kumar Das
- Canberra Health Services, 2 Garran place, Garran, Canberra, 2605, Australia
| | - Sanjiv Jain
- Canberra Health Services, 2 Garran place, Garran, Canberra, 2605, Australia
| | - Lukah Q Tuan
- ANU School of Medicine and Psychology, Australian National University, 54 Mills Road, Acton, 2601, ACT, Australia
- Canberra Heart Rhythm, 2 Garran Place, Garran, 2605, Australia
| | - Benoit Desjardins
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Francis E Marchlinski
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Walter P Abhayaratna
- ANU School of Medicine and Psychology, Australian National University, 54 Mills Road, Acton, 2601, ACT, Australia
- Canberra Health Services, 2 Garran place, Garran, Canberra, 2605, Australia
| | - Prashanthan Sanders
- Center for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Rajeev K Pathak
- ANU School of Medicine and Psychology, Australian National University, 54 Mills Road, Acton, 2601, ACT, Australia.
- Canberra Health Services, 2 Garran place, Garran, Canberra, 2605, Australia.
- Canberra Heart Rhythm, 2 Garran Place, Garran, 2605, Australia.
| |
Collapse
|
8
|
Halvorsrød MI, Thorstensen A, Kiss G, Støylen A. Segmental myocardial viability by echocardiography at rest. SCAND CARDIOVASC J 2023; 57:2181390. [PMID: 38095169 DOI: 10.1080/14017431.2023.2181390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 02/12/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Myocardial viability assessment adds value to the therapeutic decision-making of patients with ischemic heart disease. In this feasibility study, we investigated whether established echocardiographic measurements of post-systolic shortening (PSS), strain, strain rate and wall motion score (WMS) can discover viable myocardial segments. Our hypothesis is that non-viable myocardial segments are both akinetic and without PSS. METHODS The study population consisted of 26 examinations strictly selected by visible dysfunction. We assessed WMS, strain by speckle tracking and strain rate by tissue Doppler. The segments (16*26 = 416) were categorized into either normokinetic/hypokinetic or akinetic/dyskinetic and whether there was PSS. The reference method was the presence of scar with segmental percentage volume scar fraction >50%, detected by late gadolinium-enhanced cardiovascular magnetic resonance. Agreement with echocardiography was evaluated by Kappa coefficient. RESULTS WMS had Kappa coefficient 0.43 (sensitivity 99%, specificity 35%). Kappa coefficient of strain was 0.28 (sensitivity 98%, specificity 23%). By combining PSS in akinetic segments with WMS and strain, the Kappa coefficient was 0.06 and 0.08 respectively. CONCLUSION Segmental viability was best shown by the presence of systolic function. Post-systolic shortening adds no value to the assessment of segmental myocardial viability.
Collapse
Affiliation(s)
- Marlene Iversen Halvorsrød
- Department of Circulation and Medical Imaging (ISB), Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Cardiology, St. Olavs University Hospital, Trondheim, Norway
| | - Anders Thorstensen
- Department of Circulation and Medical Imaging (ISB), Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Cardiology, St. Olavs University Hospital, Trondheim, Norway
| | - Gabriel Kiss
- St. Olavs University Hospital, Trondheim, Norway
- Department of Computer Science (IDI), Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Asbjørn Støylen
- Department of Circulation and Medical Imaging (ISB), Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Cardiology, St. Olavs University Hospital, Trondheim, Norway
| |
Collapse
|
9
|
Larsen CK, Smiseth OA, Duchenne J, Galli E, Aalen JM, Lederlin M, Bogaert J, Kongsgaard E, Linde C, Penicka M, Donal E, Voigt JU, Hopp E. Cardiac Magnetic Resonance Identifies Responders to Cardiac Resynchronization Therapy with an Assessment of Septal Scar and Left Ventricular Dyssynchrony. J Clin Med 2023; 12:7182. [PMID: 38002795 PMCID: PMC10672328 DOI: 10.3390/jcm12227182] [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: 10/11/2023] [Revised: 11/15/2023] [Accepted: 11/18/2023] [Indexed: 11/26/2023] Open
Abstract
Background: The response to cardiac resynchronization therapy (CRT) depends on septal viability and correction of abnormal septal motion. This study investigates if cardiac magnetic resonance (CMR) as a single modality can identify CRT responders with combined imaging of pathological septal motion (septal flash) and septal scar. Methods: In a prospective, multicenter, observational study of 136 CRT recipients, septal scar was assessed using late gadolinium enhancement (LGE) (n = 127) and septal flash visually from cine CMR sequences. The primary endpoint was CRT response, defined as ≥15% reduction in LV end-systolic volume with echocardiography after 6 months. The secondary endpoint was heart transplantation or death of any cause assessed after 39 ± 13 months. Results: Septal scar and septal flash were independent predictors of CRT response in multivariable analysis (both p < 0.001), while QRS duration and morphology were not. The combined approach of septal scar and septal flash predicted CRT response with an area under the curve of 0.86 (95% confidence interval (CI): 0.78-0.94) and was a strong predictor of long-term survival without heart transplantation (hazard ratio 0.27, 95% CI: 0.10-0.79). The accuracy of the approach was similar in the subgroup with intermediate (130-150 ms) QRS duration. The combined approach was superior to septal scar and septal flash alone (p < 0.01). Conclusions: The combined assessment of septal scar and septal flash using CMR as a single-image modality identifies CRT responders with high accuracy and predicts long-term survival.
Collapse
Affiliation(s)
- Camilla Kjellstad Larsen
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Otto A. Smiseth
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Jürgen Duchenne
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium (J.-U.V.)
- Department of Cardiovascular Sciences, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Elena Galli
- Department of Cardiology, University Hospital of Rennes, 35000 Rennes, France; (E.G.); (E.D.)
| | - John Moene Aalen
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Mathieu Lederlin
- Department of Radiology, University Hospital of Rennes, 35000 Rennes, France;
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Erik Kongsgaard
- Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway;
| | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, 171 64 Solna, Sweden;
| | | | - Erwan Donal
- Department of Cardiology, University Hospital of Rennes, 35000 Rennes, France; (E.G.); (E.D.)
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium (J.-U.V.)
- Department of Cardiovascular Sciences, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Einar Hopp
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, 0027 Oslo, Norway
| |
Collapse
|
10
|
Berg J, Jablonowski R, Nordlund D, Ryd D, Heiberg E, Carlsson M, Arheden H. Mild hypothermia attenuates ischaemia/reperfusion injury: insights from serial non-invasive pressure-volume loops. Cardiovasc Res 2023; 119:2230-2243. [PMID: 36734080 PMCID: PMC10578916 DOI: 10.1093/cvr/cvad028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 10/31/2022] [Accepted: 12/20/2022] [Indexed: 02/04/2023] Open
Abstract
AIMS Mild hypothermia, 32-35°C, reduces infarct size in experimental studies, potentially mediating reperfusion injuries, but human trials have been ambiguous. To elucidate the cardioprotective mechanisms of mild hypothermia, we analysed cardiac performance in a porcine model of ischaemia/reperfusion, with serial cardiovascular magnetic resonance (CMR) imaging throughout 1 week using non-invasive pressure-volume (PV) loops. METHODS AND RESULTS Normothermia and Hypothermia group sessions (n = 7 + 7 pigs, non-random allocation) were imaged with Cardiovascular magnetic resonance (CMR) at baseline and subjected to 40 min of normothermic ischaemia by catheter intervention. Thereafter, the Hypothermia group was rapidly cooled (mean 34.5°C) for 5 min before reperfusion. Additional CMR sessions at 2 h, 24 h, and 7 days acquired ventricular volumes and ischaemic injuries (unblinded analysis). Stroke volume (SV: -24%; P = 0.029; Friedmans test) and ejection fraction (EF: -20%; P = 0.068) were notably reduced at 24 h in the Normothermia group compared with baseline. In contrast, the decreases were ameliorated in the Hypothermia group (SV: -6%; P = 0.77; EF: -6%; P = 0.13). Mean arterial pressure remained stable in Normothermic animals (-3%, P = 0.77) but dropped 2 h post-reperfusion in hypothermic animals (-18%, P = 0.007). Both groups experienced a decrease and partial recovery pattern for PV loop-derived variables over 1 week, but the adverse effects tended to attenuate in the Hypothermia group. Infarct sizes were 10 ± 8% in Hypothermic and 15 ± 8% in Normothermic animals (P = 0.32). Analysis of covariance at 24 h indicated that hypothermia has cardioprotective properties incremental to reducing infarct size, such as higher external power (P = 0.061) and lower arterial elastance (P = 0.015). CONCLUSION Using non-invasive PV loops by CMR, we observed that mild hypothermia at reperfusion alleviates the heart's work after ischaemia/reperfusion injuries during the first week and preserves short-term cardiac performance. This hypothesis-generating study suggests hypothermia to have cardioprotective properties, incremental to reducing infarct size. The primary cardioprotective mechanism was likely an afterload reduction acutely unloading the left ventricle.
Collapse
Affiliation(s)
- Jonathan Berg
- Clinical Physiology, Department of Clinical Sciences LundFaculty of Medicine, Lund University, Box 117 221 00 Lund, Sweden
- Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28 Malmö, Sweden
- Syntach AB, Lund, Sweden
| | - Robert Jablonowski
- Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28 Malmö, Sweden
| | - David Nordlund
- Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28 Malmö, Sweden
| | - Daniel Ryd
- Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28 Malmö, Sweden
| | - Einar Heiberg
- Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28 Malmö, Sweden
| | - Marcus Carlsson
- Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28 Malmö, Sweden
| | - Håkan Arheden
- Skåne University Hospital, Carl-Bertil Laurells gata 9, 214 28 Malmö, Sweden
| |
Collapse
|
11
|
Hedeer F, Akil S, Oddstig J, Hindorf C, Arheden H, Carlsson M, Engblom H. Diagnostic accuracy for CZT gamma camera compared to conventional gamma camera technique with myocardial perfusion single-photon emission computed tomography: Assessment of myocardial infarction and function. J Nucl Cardiol 2023; 30:1935-1946. [PMID: 36913172 PMCID: PMC10558368 DOI: 10.1007/s12350-022-03185-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 11/23/2022] [Indexed: 03/14/2023]
Abstract
BACKGROUND The solid-state cadmium-zinc-telluride (CZT) gamma camera for myocardial perfusion single-photon emission computed tomography (MPS) has theoretical advantages compared to the conventional gamma camera technique. This includes more sensitive detectors and better energy resolution. We aimed to explore the diagnostic performance of gated MPS with a CZT gamma camera compared to a conventional gamma camera for detection of myocardial infarct (MI) and assessment of left ventricular (LV) volumes and ejection fraction (LVEF), using cardiac magnetic resonance (CMR) as the reference method. METHODS Seventy-three patients (26% female) with known or suspected chronic coronary syndrome were examined with gated MPS using both a CZT gamma camera and a conventional gamma camera as well as with CMR. Presence and extent of MI on MPS and late gadolinium enhancement (LGE) CMR was evaluated. For LV volumes, LVEF and LV mass, gated MPS images and cine CMR images were evaluated. RESULTS MI was found in 42 patients on CMR. The overall sensitivity, specificity, positive and negative predictive values for the CZT and the conventional gamma camera were the same (67%, 100%, 100% and 69%). For infarct size > 3% on CMR, the sensitivity was 82% for the CZT and 73% for the conventional gamma camera, respectively. LV volumes were significantly underestimated by MPS compared to CMR (P ≤ .002 for all measures). The underestimation was slightly less pronounced for the CZT compared to the conventional gamma camera (2-10 mL, P ≤ .03 for all measures). For LVEF, however, accuracy was high for both gamma cameras. CONCLUSION Differences between a CZT and a conventional gamma camera for detection of MI and assessment of LV volumes and LVEF are small and do not appear to be clinically significant.
Collapse
Affiliation(s)
- Fredrik Hedeer
- Department of Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Shahnaz Akil
- Department of Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jenny Oddstig
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Cecilia Hindorf
- Radiation Physics, Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Håkan Arheden
- Department of Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Marcus Carlsson
- Department of Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Henrik Engblom
- Department of Clinical Physiology, Skåne University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
12
|
Duchenne J, Larsen CK, Cvijic M, Galli E, Aalen JM, Klop B, Mirea O, Puvrez A, Bézy S, Wouters L, Minten L, Sirnes PA, Khan FH, Voros G, Willems R, Penicka M, Kongsgård E, Hopp E, Bogaert J, Smiseth OA, Donal E, Voigt JU. Mechanical Dyssynchrony Combined with Septal Scarring Reliably Identifies Responders to Cardiac Resynchronization Therapy. J Clin Med 2023; 12:6108. [PMID: 37763048 PMCID: PMC10531814 DOI: 10.3390/jcm12186108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
Background and aim: The presence of mechanical dyssynchrony on echocardiography is associated with reverse remodelling and decreased mortality after cardiac resynchronization therapy (CRT). Contrarily, myocardial scar reduces the effect of CRT. This study investigated how well a combined assessment of different markers of mechanical dyssynchrony and scarring identifies CRT responders. Methods: In a prospective multicentre study of 170 CRT recipients, septal flash (SF), apical rocking (ApRock), systolic stretch index (SSI), and lateral-to-septal (LW-S) work differences were assessed using echocardiography. Myocardial scarring was quantified using cardiac magnetic resonance imaging (CMR) or excluded based on a coronary angiogram and clinical history. The primary endpoint was a CRT response, defined as a ≥15% reduction in LV end-systolic volume 12 months after implantation. The secondary endpoint was time-to-death. Results: The combined assessment of mechanical dyssynchrony and septal scarring showed AUCs ranging between 0.81 (95%CI: 0.74-0.88) and 0.86 (95%CI: 0.79-0.91) for predicting a CRT response, without significant differences between the markers, but significantly higher than mechanical dyssynchrony alone. QRS morphology, QRS duration, and LV ejection fraction were not superior in their prediction. Predictive power was similar in the subgroups of patients with ischemic cardiomyopathy. The combined assessments significantly predicted all-cause mortality at 44 ± 13 months after CRT with a hazard ratio ranging from 0.28 (95%CI: 0.12-0.67) to 0.20 (95%CI: 0.08-0.49). Conclusions: The combined assessment of mechanical dyssynchrony and septal scarring identified CRT responders with high predictive power. Both visual and quantitative markers were highly feasible and demonstrated similar results. This work demonstrates the value of imaging LV mechanics and scarring in CRT candidates, which can already be achieved in a clinical routine.
Collapse
Affiliation(s)
- Jürgen Duchenne
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Camilla K. Larsen
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, 0450 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway
- Department of Cardiology, Oslo University Hospital, 0379 Oslo, Norway
| | - Marta Cvijic
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Elena Galli
- Inserm, LTSI-UMR, 1099, 35042 Rennes, France; (E.G.)
- Department of Cardiology, CHU Rennes, 35033 Rennes, France
| | - John M. Aalen
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, 0450 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway
- Department of Cardiology, Oslo University Hospital, 0379 Oslo, Norway
| | - Boudewijn Klop
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Oana Mirea
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Cardiology, University of Medicine and Pharmacy, 200349 Craiova, Romania
| | - Alexis Puvrez
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Stéphanie Bézy
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Laurine Wouters
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Lennert Minten
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Per A. Sirnes
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, 0450 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway
- Department of Cardiology, Oslo University Hospital, 0379 Oslo, Norway
| | - Faraz H. Khan
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, 0450 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway
- Department of Cardiology, Oslo University Hospital, 0379 Oslo, Norway
| | - Gabor Voros
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Martin Penicka
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
| | - Erik Kongsgård
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, 0450 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway
- Department of Cardiology, Oslo University Hospital, 0379 Oslo, Norway
| | - Einar Hopp
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, 0379 Oslo, Norway
| | - Jan Bogaert
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Otto A. Smiseth
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, 0450 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway
- Department of Cardiology, Oslo University Hospital, 0379 Oslo, Norway
| | - Erwan Donal
- Inserm, LTSI-UMR, 1099, 35042 Rennes, France; (E.G.)
- Department of Cardiology, CHU Rennes, 35033 Rennes, France
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium (L.M.)
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium
| |
Collapse
|
13
|
Bonner BP, Yurista SR, Coll‐Font J, Chen S, Eder RA, Foster AN, Nguyen KD, Caravan P, Gale EM, Nguyen C. Contrast-Enhanced Cardiac Magnetic Resonance Imaging With a Manganese-Based Alternative to Gadolinium for Tissue Characterization of Acute Myocardial Infarction. J Am Heart Assoc 2023; 12:e026923. [PMID: 37042259 PMCID: PMC10227253 DOI: 10.1161/jaha.122.026923] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 01/05/2023] [Indexed: 04/13/2023]
Abstract
Background Late gadolinium enhancement cardiac magnetic resonance imaging is an effective and reproducible method for characterizing myocardial infarction. However, gadolinium-based contrast agents are contraindicated in patients with acute and chronic renal insufficiency. In addition, several recent studies have noted tissue deposition of free gadolinium in patients who have undergone serial contrast-enhanced magnetic resonance imaging. There is a clinical need for alternative forms of magnetic resonance imaging contrast agents that are acceptable in the setting of renal insufficiency. Methods and Results Three days after 80 minutes of ischemia/reperfusion of the left anterior descending coronary artery, cardiac magnetic resonance imaging was performed to assess myocardial lesion burden using both contrast agents. Late gadolinium enhancement cardiac magnetic resonance imaging was examined 10 and 15 minutes after contrast injection. Contrast agents were administered in alternating manner with a 2- to 3-hour washout period between contrast agent injections. Lesion evaluation and image processing were performed using Segment Medviso software. Mean infarct size and transmurality, measured using RVP-001, were not different compared with those measured using late gadolinium enhancement images. Bland-Altman analysis demonstrated a nominal bias of 0.13 mL (<1% of average total lesion volume) for RVP-001 in terms of gross infarct size measurement. Conclusions The experimental manganese-based contrast agent RVP-001 appears to be an effective agent for assessment of myocardial infarction location, size, and transmurality, and it may be useful as an alternative to gadolinium-based agents.
Collapse
Affiliation(s)
- Benjamin P. Bonner
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
- Louisiana State University Health Sciences CenterNew OrleansLA
| | - Salva R. Yurista
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Jaume Coll‐Font
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Shi Chen
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
| | - Robert A. Eder
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
| | - Anna N. Foster
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
| | - Khoi D. Nguyen
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Peter Caravan
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Eric M. Gale
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
| | - Christopher Nguyen
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Athinoula A. Martinos Center for Biomedical ImagingMassachusetts General HospitalBostonMA
- Harvard Medical SchoolBostonMA
- Division of Health Science TechnologyHarvard–Massachusetts Institute of TechnologyCambridgeMA
- Cardiovascular Innovation Research CenterHeart, Vascular, and Thoracic Institute, Cleveland ClinicClevelandOH
| |
Collapse
|
14
|
Larsen CK, Galli E, Duchenne J, Aalen JM, Stokke C, Fjeld JG, Degtiarova G, Claus P, Gheysens O, Saberniak J, Sirnes PA, Lyseggen E, Bogaert J, Kongsgaard E, Penicka M, Voigt JU, Donal E, Hopp E, Smiseth OA. Scar imaging in the dyssynchronous left ventricle: Accuracy of myocardial metabolism by positron emission tomography and function by echocardiographic strain. Int J Cardiol 2023; 372:122-129. [PMID: 36460211 DOI: 10.1016/j.ijcard.2022.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/20/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Response to cardiac resynchronization therapy (CRT) is reduced in patients with high left ventricular (LV) scar burden, in particular when scar is located in the LV lateral wall or septum. Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) can identity scar, but is not feasible in all patients. This study investigates if myocardial metabolism by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) and contractile function by echocardiographic strain are alternatives to LGE-CMR. METHODS In a prospective multicenter study, 132 CRT candidates (91% with left bundle branch block) were studied by speckle tracking strain echocardiography, and 53 of these by FDG-PET. Regional myocardial FDG metabolism and peak systolic strain were compared to LGE-CMR as reference method. RESULTS Reduced FDG metabolism (<70% relative) precisely identified transmural scars (≥50% of myocardial volume) in the LV lateral wall, with area under the curve (AUC) 0.96 (95% confidence interval (CI) 0.90-1.00). Reduced contractile function by strain identified transmural scars in the LV lateral wall with only moderate accuracy (AUC = 0.77, CI 0.71-0.84). However, absolute peak systolic strain >10% could rule out transmural scar with high sensitivity (80%) and high negative predictive value (96%). Neither FDG-PET nor strain identified septal scars (for both, AUC < 0.80). CONCLUSIONS In CRT candidates, FDG-PET is an excellent alternative to LGE-CMR to identify scar in the LV lateral wall. Furthermore, preserved strain in the LV lateral wall has good accuracy to rule out transmural scar. None of the modalities can identify septal scar. CLINICAL TRIAL REGISTRATION The present study is part of the clinical study "Contractile Reserve in Dyssynchrony: A Novel Principle to Identify Candidates for Cardiac Resynchronization Therapy (CRID-CRT)", which was registered at clinicaltrials.gov (identifier NCT02525185).
Collapse
Affiliation(s)
- Camilla Kjellstad Larsen
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Elena Galli
- Department of Cardiology, University Hospital of Rennes and University of Rennes, Rennes, France
| | - Jürgen Duchenne
- Department of Cardiovascular Diseases, University Hospitals Leuven and Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - John M Aalen
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Caroline Stokke
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway; Department of Physics, University of Oslo, Oslo, Norway
| | - Jan Gunnar Fjeld
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway; Oslo Metropolitan University, Oslo, Norway
| | - Ganna Degtiarova
- Department of Nuclear Medicine, University Hospitals Leuven and Department of Imaging and Pathology, KU Leuven - University of Leuven, Leuven, Belgium
| | - Piet Claus
- Department of Nuclear Medicine, University Hospitals Leuven and Department of Imaging and Pathology, KU Leuven - University of Leuven, Leuven, Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc and Institute of Clinical and Experimental Research (IREC), Université Catholique de Louvain, Brussels, Belgium
| | - Jorg Saberniak
- Department of Cardiology, Akershus University Hospital, Lorenskog, Norway
| | | | - Erik Lyseggen
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Erik Kongsgaard
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | | | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven and Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Erwan Donal
- Department of Cardiology, University Hospital of Rennes and University of Rennes, Rennes, France
| | - Einar Hopp
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Oslo, Norway.
| |
Collapse
|
15
|
Navidi Z, Sun J, Chan RH, Hanneman K, Al-Arnawoot A, Munim A, Rakowski H, Maron MS, Woo A, Wang B, Tsang W. Interpretable machine learning for automated left ventricular scar quantification in hypertrophic cardiomyopathy patients. PLOS DIGITAL HEALTH 2023; 2:e0000159. [PMID: 36812626 PMCID: PMC9931226 DOI: 10.1371/journal.pdig.0000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 11/09/2022] [Indexed: 01/06/2023]
Abstract
Scar quantification on cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) images is important in risk stratifying patients with hypertrophic cardiomyopathy (HCM) due to the importance of scar burden in predicting clinical outcomes. We aimed to develop a machine learning (ML) model that contours left ventricular (LV) endo- and epicardial borders and quantifies CMR LGE images from HCM patients.We retrospectively studied 2557 unprocessed images from 307 HCM patients followed at the University Health Network (Canada) and Tufts Medical Center (USA). LGE images were manually segmented by two experts using two different software packages. Using 6SD LGE intensity cutoff as the gold standard, a 2-dimensional convolutional neural network (CNN) was trained on 80% and tested on the remaining 20% of the data. Model performance was evaluated using the Dice Similarity Coefficient (DSC), Bland-Altman, and Pearson's correlation. The 6SD model DSC scores were good to excellent at 0.91 ± 0.04, 0.83 ± 0.03, and 0.64 ± 0.09 for the LV endocardium, epicardium, and scar segmentation, respectively. The bias and limits of agreement for the percentage of LGE to LV mass were low (-0.53 ± 2.71%), and correlation high (r = 0.92). This fully automated interpretable ML algorithm allows rapid and accurate scar quantification from CMR LGE images. This program does not require manual image pre-processing, and was trained with multiple experts and software, increasing its generalizability.
Collapse
Affiliation(s)
- Zeinab Navidi
- Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
- Department of Computer Science, University of Toronto, Toronto, Canada
- Vector Institute, Toronto, Canada
| | - Jesse Sun
- Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Raymond H. Chan
- Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Kate Hanneman
- Department of Radiology, University Health Network, University of Toronto, Toronto, Canada
| | - Amna Al-Arnawoot
- Department of Radiology, University Health Network, University of Toronto, Toronto, Canada
| | | | - Harry Rakowski
- Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Martin S. Maron
- Division of Cardiology, Tufts Medical Center, Boston, United States of America
| | - Anna Woo
- Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
| | - Bo Wang
- Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
- Department of Computer Science, University of Toronto, Toronto, Canada
- Vector Institute, Toronto, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Wendy Tsang
- Division of Cardiology, Peter Munk Cardiac Center, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Canada
- * E-mail:
| |
Collapse
|
16
|
Zhang M, Quan W, Zhu T, Feng S, Huang X, Meng H, Du R, Zhu Z, Qu X, Li P, Cui Y, Shi K, Yan X, Zhang R, Li B. [ 68Ga]Ga-DOTA-FAPI-04 PET/MR in patients with acute myocardial infarction: potential role of predicting left ventricular remodeling. Eur J Nucl Med Mol Imaging 2023; 50:839-848. [PMID: 36326870 PMCID: PMC9852131 DOI: 10.1007/s00259-022-06015-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE To assess predictive value of 68Ga-labeled fibroblast activation protein inhibitor-04 ([68Ga]Ga-DOTA-FAPI-04) PET/MR for late left ventricular (LV) remodeling in patients with ST-segment elevated myocardial infarction (STEMI). METHODS Twenty-six patients with STEMI were included in the study. [68Ga]Ga-DOTA-FAPI-04 PET/MR was performed at baseline and at average 12 months after STEMI. LV remodeling was defined as >10% increase in LV end-systolic volume (LVESV) from baseline to 12 months. RESULTS The LV remodeling group demonstrated higher [68Ga]Ga-DOTA-FAPI-04 uptake volume (UV) at baseline than the non-LV remodeling group (p < 0.001). [68Ga]Ga-DOTA-FAPI-04 UV at baseline was a significant predictor (OR = 1.048, p = 0.011) for LV remodeling at 12 months after STEMI. Compared to clinical information, MR imaging and cardiac function parameters at baseline, [68Ga]Ga-DOTA-FAPI-04 UV demonstrated better predictive ability (AUC = 0.938, p < 0.001) for late LV remodeling, with sensitivity of 100.0% and specificity of 81.3%. CONCLUSIONS [68Ga]Ga-DOTA-FAPI-04 PET/MR is an effective tool to non-invasively quantify myocardial fibroblasts activation, and baseline [68Ga]Ga-DOTA-FAPI-04 UV may have potential predictive value for late LV remodeling.
Collapse
Affiliation(s)
- Min Zhang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China ,Collaboration Innovation Center for Molecular Imaging of Precision Medicine, Ruijin Center, Shanghai, China
| | - Weiwei Quan
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Tianqi Zhu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Shuo Feng
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Xinyun Huang
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China ,Collaboration Innovation Center for Molecular Imaging of Precision Medicine, Ruijin Center, Shanghai, China
| | - Hongping Meng
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China ,Collaboration Innovation Center for Molecular Imaging of Precision Medicine, Ruijin Center, Shanghai, China
| | - Run Du
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Zhengbin Zhu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Xuezheng Qu
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Ping Li
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Yuke Cui
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Kuangyu Shi
- Department of Informatics, Technical University of Munich, Munich, Germany ,Department of Nuclear Medicine, University of Bern, Bern, Switzerland
| | - Xiaoxiang Yan
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Ruiyan Zhang
- Department of Cardiovascular Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China
| | - Biao Li
- Department of Nuclear Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, 200025 China ,Collaboration Innovation Center for Molecular Imaging of Precision Medicine, Ruijin Center, Shanghai, China
| |
Collapse
|
17
|
Heiberg E, Engblom H, Carlsson M, Erlinge D, Atar D, Aletras AH, Arheden H. Infarct quantification with cardiovascular magnetic resonance using "standard deviation from remote" is unreliable: validation in multi-centre multi-vendor data. J Cardiovasc Magn Reson 2022; 24:53. [PMID: 36336693 PMCID: PMC9639305 DOI: 10.1186/s12968-022-00888-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 09/08/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The objective of the study was to investigate variability and agreement of the commonly used image processing method "n-SD from remote" and in particular for quantifying myocardial infarction by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR). LGE-CMR in tandem with the analysis method "n-SD from remote" represents the current reference standard for infarct quantification. This analytic method utilizes regions of interest (ROIs) and defines infarct as the tissue with a set number of standard deviations (SD) above the signal intensity of remote nulled myocardium. There is no consensus on what the set number of SD is supposed to be. Little is known about how size and location of ROIs and underlying signal properties in the LGE images affect results. Furthermore, the method is frequently used elsewhere in medical imaging often without careful validation. Therefore, the usage of the "n-SD" method warrants a thorough validation. METHODS Data from 214 patients from two multi-center cardioprotection trials were included. Infarct size from different remote ROI positions, ROI size, and number of standard deviations ("n-SD") were compared with reference core lab delineations. RESULTS Variability in infarct size caused by varying ROI position, ROI size, and "n-SD" was 47%, 48%, and 40%, respectively. The agreement between the "n-SD from remote" method and the reference infarct size by core lab delineations was low. Optimal "n-SD" threshold computed on a slice-by-slice basis showed high variability, n = 5.3 ± 2.2. CONCLUSION The "n-SD from remote" method is unreliable for infarct quantification due to high variability which depends on different placement and size of remote ROI, number "n-SD", and image signal properties related to the CMR-scanner and sequence used. Therefore, the "n-SD from remote" method should not be used, instead methods validated against an independent standard are recommended.
Collapse
Affiliation(s)
- Einar Heiberg
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, 222 42, Lund, SE, Sweden.
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.
| | - Henrik Engblom
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, 222 42, Lund, SE, Sweden
| | - Marcus Carlsson
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, 222 42, Lund, SE, Sweden
- Laboratory of Clinical Physiology, National Heart, Lung, and Blood Institute, NIH, Bethesda, USA
| | - David Erlinge
- Department of Cardiology, Skåne University Hospital, Lund University Hospital, Lund University, Lund, Sweden
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, University of Oslo, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anthony H Aletras
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, 222 42, Lund, SE, Sweden
- Laboratory of Computing, Medical Informatics and Biomedical-Imaging Technologies, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Håkan Arheden
- Department of Clinical Sciences Lund, Clinical Physiology, Skåne University Hospital, Lund University, 222 42, Lund, SE, Sweden
| |
Collapse
|
18
|
Lustermans DRPRM, Amirrajab S, Veta M, Breeuwer M, Scannell CM. Optimized automated cardiac MR scar quantification with GAN-based data augmentation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 226:107116. [PMID: 36148718 DOI: 10.1016/j.cmpb.2022.107116] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 08/26/2022] [Accepted: 09/05/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The clinical utility of late gadolinium enhancement (LGE) cardiac MRI is limited by the lack of standardization, and time-consuming postprocessing. In this work, we tested the hypothesis that a cascaded deep learning pipeline trained with augmentation by synthetically generated data would improve model accuracy and robustness for automated scar quantification. METHODS A cascaded pipeline consisting of three consecutive neural networks is proposed, starting with a bounding box regression network to identify a region of interest around the left ventricular (LV) myocardium. Two further nnU-Net models are then used to segment the myocardium and, if present, scar. The models were trained on the data from the EMIDEC challenge, supplemented with an extensive synthetic dataset generated with a conditional GAN. RESULTS The cascaded pipeline significantly outperformed a single nnU-Net directly segmenting both the myocardium (mean Dice similarity coefficient (DSC) (standard deviation (SD)): 0.84 (0.09) vs 0.63 (0.20), p < 0.01) and scar (DSC: 0.72 (0.34) vs 0.46 (0.39), p < 0.01) on a per-slice level. The inclusion of the synthetic data as data augmentation during training improved the scar segmentation DSC by 0.06 (p < 0.01). The mean DSC per-subject on the challenge test set, for the cascaded pipeline augmented by synthetic generated data, was 0.86 (0.03) and 0.67 (0.29) for myocardium and scar, respectively. CONCLUSION A cascaded deep learning-based pipeline trained with augmentation by synthetically generated data leads to myocardium and scar segmentations that are similar to the manual operator, and outperforms direct segmentation without the synthetic images.
Collapse
Affiliation(s)
- Didier R P R M Lustermans
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.
| | - Sina Amirrajab
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Mitko Veta
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Marcel Breeuwer
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands; Department of MR R&D - Clinical Science, Philips Healthcare, Best, the Netherlands
| | - Cian M Scannell
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands; School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom.
| |
Collapse
|
19
|
Jablonowski R, Bennet L, Engblom H, Aletras AH, Xue H, Kellman P, Carlsson M, Arheden H. Quantitative myocardial perfusion during stress using CMR is impaired in healthy Middle Eastern immigrants without CV risk factors. Sci Rep 2022; 12:18237. [PMID: 36309585 PMCID: PMC9617937 DOI: 10.1038/s41598-022-23131-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 10/25/2022] [Indexed: 12/31/2022] Open
Abstract
Middle Eastern immigrants constitute a growing proportion of the European population and compared to native Swedes are more insulin resistant, which can contribute to atherosclerosis. Quantitative first pass perfusion (qFPP) using cardiovascular magnetic resonance (CMR) can detect early signs of cardiovascular disease (CVD). The aim was to study if myocardial perfusion differs between healthy male Middle Eastern immigrants and native male Swedes. Eighteen Iraqi- and twelve Swedish born controls, all males, never smokers with no CVD risk factors were included. Global myocardial perfusion at rest and stress was assessed using qFPP and by phase-contrast CMR imaging of coronary sinus flow. Quantitative first pass perfusion analysis (mean ± SD) demonstrated no difference at rest between Iraqi and Swedish males (0.8 ± 0.2 vs 1.0 ± 0.4 ml/min/g, P = 0.38) but lower perfusion during adenosine in Iraqi males (2.9 ± 0.7 vs 3.5 ± 0.7 ml/min/g, P = 0.02). Myocardial perfusion assessed by coronary sinus flow demonstrated similar results with no difference in resting perfusion between groups (0.7 ± 0.2 vs 0.8 ± 0.2 ml/min/g, P = 0.21) but a lower perfusion during adenosine in the Iraqi group (3.0 ± 0.2 vs 3.7 ± 0.6 ml/min/g, P = 0.01. Myocardial perfusion during adenosine stress was lower in healthy Iraqi immigrants compared to Swedish controls suggesting impaired microvascular function and risk of underestimating CVD risk in healthy individuals of Middle Eastern origin.
Collapse
Affiliation(s)
- Robert Jablonowski
- grid.411843.b0000 0004 0623 9987Clinical Physiology, Department of Clinical Sciences Lund, Lund University Hospital, Lund University, Skane University Hospital, 221 85 Lund, Sweden
| | - Louise Bennet
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Henrik Engblom
- grid.411843.b0000 0004 0623 9987Clinical Physiology, Department of Clinical Sciences Lund, Lund University Hospital, Lund University, Skane University Hospital, 221 85 Lund, Sweden
| | - Anthony H. Aletras
- grid.411843.b0000 0004 0623 9987Clinical Physiology, Department of Clinical Sciences Lund, Lund University Hospital, Lund University, Skane University Hospital, 221 85 Lund, Sweden ,grid.4793.90000000109457005Laboratory of Computing, Medical Informatics and Biomedical-Imaging Technologies, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Hui Xue
- grid.279885.90000 0001 2293 4638National Heart-Lung and Blood Institute, Bethesda, MD USA
| | - Peter Kellman
- grid.279885.90000 0001 2293 4638National Heart-Lung and Blood Institute, Bethesda, MD USA
| | - Marcus Carlsson
- grid.411843.b0000 0004 0623 9987Clinical Physiology, Department of Clinical Sciences Lund, Lund University Hospital, Lund University, Skane University Hospital, 221 85 Lund, Sweden ,grid.279885.90000 0001 2293 4638National Heart-Lung and Blood Institute, Bethesda, MD USA
| | - Håkan Arheden
- grid.411843.b0000 0004 0623 9987Clinical Physiology, Department of Clinical Sciences Lund, Lund University Hospital, Lund University, Skane University Hospital, 221 85 Lund, Sweden
| |
Collapse
|
20
|
Xie E, Sung E, Saad E, Trayanova N, Wu KC, Chrispin J. Advanced imaging for risk stratification for ventricular arrhythmias and sudden cardiac death. Front Cardiovasc Med 2022; 9:884767. [PMID: 36072882 PMCID: PMC9441865 DOI: 10.3389/fcvm.2022.884767] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 08/02/2022] [Indexed: 11/13/2022] Open
Abstract
Sudden cardiac death (SCD) is a leading cause of mortality, comprising approximately half of all deaths from cardiovascular disease. In the US, the majority of SCD (85%) occurs in patients with ischemic cardiomyopathy (ICM) and a subset in patients with non-ischemic cardiomyopathy (NICM), who tend to be younger and whose risk of mortality is less clearly delineated than in ischemic cardiomyopathies. The conventional means of SCD risk stratification has been the determination of the ejection fraction (EF), typically via echocardiography, which is currently a means of determining candidacy for primary prevention in the form of implantable cardiac defibrillators (ICDs). Advanced cardiac imaging methods such as cardiac magnetic resonance imaging (CMR), single-photon emission computerized tomography (SPECT) and positron emission tomography (PET), and computed tomography (CT) have emerged as promising and non-invasive means of risk stratification for sudden death through their characterization of the underlying myocardial substrate that predisposes to SCD. Late gadolinium enhancement (LGE) on CMR detects myocardial scar, which can inform ICD decision-making. Overall scar burden, region-specific scar burden, and scar heterogeneity have all been studied in risk stratification. PET and SPECT are nuclear methods that determine myocardial viability and innervation, as well as inflammation. CT can be used for assessment of myocardial fat and its association with reentrant circuits. Emerging methodologies include the development of "virtual hearts" using complex electrophysiologic modeling derived from CMR to attempt to predict arrhythmic susceptibility. Recent developments have paired novel machine learning (ML) algorithms with established imaging techniques to improve predictive performance. The use of advanced imaging to augment risk stratification for sudden death is increasingly well-established and may soon have an expanded role in clinical decision-making. ML could help shift this paradigm further by advancing variable discovery and data analysis.
Collapse
Affiliation(s)
- Eric Xie
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Eric Sung
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Elie Saad
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Natalia Trayanova
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Katherine C. Wu
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Section of Cardiac Electrophysiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
21
|
Gyllenhammar T, Carlsson M, Jögi J, Arheden H, Engblom H. Myocardial perfusion by CMR coronary sinus flow shows sex differences and lowered perfusion at stress in patients with suspected microvascular angina. Clin Physiol Funct Imaging 2022; 42:208-219. [PMID: 35279944 PMCID: PMC9310583 DOI: 10.1111/cpf.12750] [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: 04/02/2021] [Accepted: 03/07/2022] [Indexed: 11/28/2022]
Abstract
Background Methods Results Conclusions
Collapse
Affiliation(s)
- Tom Gyllenhammar
- Department of Clinical Physiology Lund University, and Skåne University Hospital Sweden
| | - Marcus Carlsson
- Department of Clinical Physiology Lund University, and Skåne University Hospital Sweden
| | - Jonas Jögi
- Department of Clinical Physiology Lund University, and Skåne University Hospital Sweden
| | - Håkan Arheden
- Department of Clinical Physiology Lund University, and Skåne University Hospital Sweden
| | - Henrik Engblom
- Department of Clinical Physiology Lund University, and Skåne University Hospital Sweden
| |
Collapse
|
22
|
Monda E, Palmiero G, Lioncino M, Rubino M, Cirillo A, Fusco A, Caiazza M, Verrillo F, Diana G, Mauriello A, Iavarone M, Losi MA, De Rimini ML, Dellegrottaglie S, D’Andrea A, Bossone E, Pacileo G, Limongelli G. Multimodality Imaging in Cardiomyopathies with Hypertrophic Phenotypes. J Clin Med 2022; 11:jcm11030868. [PMID: 35160323 PMCID: PMC8836956 DOI: 10.3390/jcm11030868] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/29/2022] [Accepted: 02/04/2022] [Indexed: 12/16/2022] Open
Abstract
Multimodality imaging is a comprehensive strategy to investigate left ventricular hypertrophy (LVH), providing morphologic, functional, and often clinical information to clinicians. Hypertrophic cardiomyopathy (HCM) is defined by an increased LV wall thickness not only explainable by abnormal loading conditions. In the context of HCM, multimodality imaging, by different imaging techniques, such as echocardiography, cardiac magnetic resonance, cardiac computer tomography, and cardiac nuclear imaging, provides essential information for diagnosis, sudden cardiac death stratification, and management. Furthermore, it is essential to uncover the specific cause of HCM, such as Fabry disease and cardiac amyloidosis, which can benefit of specific treatments. This review aims to elucidate the current role of multimodality imaging in adult patients with HCM.
Collapse
Affiliation(s)
- Emanuele Monda
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Giuseppe Palmiero
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Michele Lioncino
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Marta Rubino
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Annapaola Cirillo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Adelaide Fusco
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Gaetano Diana
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Alfredo Mauriello
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Michele Iavarone
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Maria Angela Losi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, 80138 Naples, Italy;
| | - Maria Luisa De Rimini
- Department of Nuclear Medicine, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy;
| | - Santo Dellegrottaglie
- Cardiovascular MRI Laboratory, Division of Cardiology, Ospedale Medico-Chirurgico Accreditato Villa dei Fiori, 80011 Acerra, Italy;
| | - Antonello D’Andrea
- Unit of Cardiology and Intensive Coronary Care, “Umberto I” Hospital, 84014 Nocera Inferiore, Italy;
| | - Eduardo Bossone
- Department of Cardiology, Cardarelli Hospital, 80131 Naples, Italy;
| | - Giuseppe Pacileo
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, AORN Ospedali dei Colli-Monaldi Hospital, 80131 Naples, Italy; (E.M.); (G.P.); (M.L.); (M.R.); (A.C.); (A.F.); (M.C.); (F.V.); (G.D.); (A.M.); (M.I.); (G.P.)
- Correspondence:
| |
Collapse
|
23
|
Diagnostic utility of artificial intelligence for left ventricular scar identification using cardiac magnetic resonance imaging-A systematic review. CARDIOVASCULAR DIGITAL HEALTH JOURNAL 2021; 2:S21-S29. [PMID: 35265922 PMCID: PMC8890335 DOI: 10.1016/j.cvdhj.2021.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Accurate, rapid quantification of ventricular scar using cardiac magnetic resonance imaging (CMR) carries importance in arrhythmia management and patient prognosis. Artificial intelligence (AI) has been applied to other radiological challenges with success. Objective We aimed to assess AI methodologies used for left ventricular scar identification in CMR, imaging sequences used for training, and its diagnostic evaluation. Methods Following PRISMA recommendations, a systematic search of PubMed, Embase, Web of Science, CINAHL, OpenDissertations, arXiv, and IEEE Xplore was undertaken to June 2021 for full-text publications assessing left ventricular scar identification algorithms. No pre-registration was undertaken. Random-effect meta-analysis was performed to assess Dice Coefficient (DSC) overlap of learning vs predefined thresholding methods. Results Thirty-five articles were included for final review. Supervised and unsupervised learning models had similar DSC compared to predefined threshold models (0.616 vs 0.633, P = .14) but had higher sensitivity, specificity, and accuracy. Meta-analysis of 4 studies revealed standardized mean difference of 1.11; 95% confidence interval -0.16 to 2.38, P = .09, I2 = 98% favoring learning methods. Conclusion Feasibility of applying AI to the task of scar detection in CMR has been demonstrated, but model evaluation remains heterogenous. Progression toward clinical application requires detailed, transparent, standardized model comparison and increased model generalizability.
Collapse
|
24
|
Maleckar MM, Myklebust L, Uv J, Florvaag PM, Strøm V, Glinge C, Jabbari R, Vejlstrup N, Engstrøm T, Ahtarovski K, Jespersen T, Tfelt-Hansen J, Naumova V, Arevalo H. Combined In-silico and Machine Learning Approaches Toward Predicting Arrhythmic Risk in Post-infarction Patients. Front Physiol 2021; 12:745349. [PMID: 34819872 PMCID: PMC8606551 DOI: 10.3389/fphys.2021.745349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Remodeling due to myocardial infarction (MI) significantly increases patient arrhythmic risk. Simulations using patient-specific models have shown promise in predicting personalized risk for arrhythmia. However, these are computationally- and time- intensive, hindering translation to clinical practice. Classical machine learning (ML) algorithms (such as K-nearest neighbors, Gaussian support vector machines, and decision trees) as well as neural network techniques, shown to increase prediction accuracy, can be used to predict occurrence of arrhythmia as predicted by simulations based solely on infarct and ventricular geometry. We present an initial combined image-based patient-specific in silico and machine learning methodology to assess risk for dangerous arrhythmia in post-infarct patients. Furthermore, we aim to demonstrate that simulation-supported data augmentation improves prediction models, combining patient data, computational simulation, and advanced statistical modeling, improving overall accuracy for arrhythmia risk assessment. Methods: MRI-based computational models were constructed from 30 patients 5 days post-MI (the “baseline” population). In order to assess the utility biophysical model-supported data augmentation for improving arrhythmia prediction, we augmented the virtual baseline patient population. Each patient ventricular and ischemic geometry in the baseline population was used to create a subfamily of geometric models, resulting in an expanded set of patient models (the “augmented” population). Arrhythmia induction was attempted via programmed stimulation at 17 sites for each virtual patient corresponding to AHA LV segments and simulation outcome, “arrhythmia,” or “no-arrhythmia,” were used as ground truth for subsequent statistical prediction (machine learning, ML) models. For each patient geometric model, we measured and used choice data features: the myocardial volume and ischemic volume, as well as the segment-specific myocardial volume and ischemia percentage, as input to ML algorithms. For classical ML techniques (ML), we trained k-nearest neighbors, support vector machine, logistic regression, xgboost, and decision tree models to predict the simulation outcome from these geometric features alone. To explore neural network ML techniques, we trained both a three - and a four-hidden layer multilayer perceptron feed forward neural networks (NN), again predicting simulation outcomes from these geometric features alone. ML and NN models were trained on 70% of randomly selected segments and the remaining 30% was used for validation for both baseline and augmented populations. Results: Stimulation in the baseline population (30 patient models) resulted in reentry in 21.8% of sites tested; in the augmented population (129 total patient models) reentry occurred in 13.0% of sites tested. ML and NN models ranged in mean accuracy from 0.83 to 0.86 for the baseline population, improving to 0.88 to 0.89 in all cases. Conclusion: Machine learning techniques, combined with patient-specific, image-based computational simulations, can provide key clinical insights with high accuracy rapidly and efficiently. In the case of sparse or missing patient data, simulation-supported data augmentation can be employed to further improve predictive results for patient benefit. This work paves the way for using data-driven simulations for prediction of dangerous arrhythmia in MI patients.
Collapse
Affiliation(s)
- Mary M Maleckar
- Computational Physiology, Simula Research Laboratory, Oslo, Norway
| | - Lena Myklebust
- Computational Physiology, Simula Research Laboratory, Oslo, Norway
| | - Julie Uv
- Computational Physiology, Simula Research Laboratory, Oslo, Norway
| | | | - Vilde Strøm
- Computational Physiology, Simula Research Laboratory, Oslo, Norway
| | - Charlotte Glinge
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Reza Jabbari
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kiril Ahtarovski
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Jespersen
- Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Tfelt-Hansen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Forensic Medicine, Faculty of Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Valeriya Naumova
- Computational Physiology, Simula Research Laboratory, Oslo, Norway
| | | |
Collapse
|
25
|
Noc M, Laanmets P, Neskovic A, Petrović M, Stanetic B, Aradi D, Kiss R, Ungi I, Merkely B, Hudec M, Blasko P, Horvath I, Davies J, Vukcevic V, Holzer M, Metzler B, Witkowski AR, Erglis A, Fister M, Nagy G, Bulum J, Édes I, Peruga J, Średniawa B, Erlinge D, Keeble TR. A multicentre, prospective, randomised controlled trial to assess the safety and effectiveness of cooling as an adjunctive therapy to percutaneous intervention in patients with acute myocardial infarction: the COOL AMI EU Pivotal Trial. EUROINTERVENTION 2021; 17:466-473. [PMID: 34031023 PMCID: PMC9725068 DOI: 10.4244/eij-d-21-00348] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite primary PCI (PPCI), ST-elevation myocardial infarction (STEMI) can still result in large infarct size (IS). New technology with rapid intravascular cooling showed positive signals for reduction in IS in anterior STEMI. AIMS We investigated the effectiveness and safety of rapid systemic intravascular hypothermia as an adjunct to PPCI in conscious patients, with anterior STEMI, without cardiac arrest. METHODS Hypothermia was induced using the ZOLL® Proteus™ intravascular cooling system. After randomisation of 111 patients, 58 to hypothermia and 53 to control groups, the study was prematurely discontinued by the sponsor due to inconsistent patient logistics between the groups resulting in significantly longer total ischaemic delay in the hypothermia group (232 vs 188 minutes; p<0.001). RESULTS There were no differences in angiographic features and PPCI result between the groups. Intravascular temperature at wire crossing was 33.3+0.9°C. Infarct size/left ventricular (IS/LV) mass by cardiac magnetic resonance (CMR) at day 4-6 was 21.3% in the hypothermia group and 20.0% in the control group (p=0.540). Major adverse cardiac events at 30 days increased non-significantly in the hypothermia group (8.6% vs 1.9%; p=0.117) while cardiogenic shock (10.3% vs 0%; p=0.028) and paroxysmal atrial fibrillation (43.1% vs 3.8%; p<0.001) were significantly more frequent in the hypothermia group. CONCLUSIONS The ZOLL Proteus intravascular cooling system reduced temperature to 33.3°C before PPCI in patients with anterior STEMI. Due to inconsistent patient logistics between the groups, this hypothermia protocol resulted in a longer ischaemic delay, did not reduce IS/LV mass and was associated with increased adverse events.
Collapse
Affiliation(s)
- Marko Noc
- Center for Intensive Internal Medicine, University Medical Center, Zaloska 7, 1000 Ljubljana, Slovenia
| | - Peep Laanmets
- North-Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Aleksandar Neskovic
- Clinical Hospital Center Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milovan Petrović
- Institute of Cardiovascular Diseases of Vojvodina, Sremska Kamenica, Faculty of Medicine, Novi Sad, Serbia
| | - Bojan Stanetic
- University Clinical Center of the Republic of Srpska, Medical Faculty of University of Banja Luka, Banja Luka, Bosnia
| | | | | | - Imre Ungi
- University of Szeged, Szeged, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Martin Hudec
- Stredoslovenski Ustav Srdcovych a Cievnych Chorob, Banska Bystrica, Slovakia
| | | | - Ivan Horvath
- Department of Cardiology, Health Faculty of Medicine, University of Pecs, Hungary
| | - John Davies
- Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital NHS Foundation Trust, Basildon, UK
| | | | - Michael Holzer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Bernhard Metzler
- University Hospital of Internal Medicine lll/Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | | | - Andrejs Erglis
- Pauls Stradiņš Clinical University Hospital, University of Latvia, Riga, Latvia
| | - Misa Fister
- University Medical Centre Ljubljana, Slovenia
| | - Gergely Nagy
- Borsod-Abauj-Zemplen County Central Hospital and University Teaching Hospital, 1st Department of Internal Medicine and Cardiology, Miskolc, Miskolc, Hungary
| | - Josko Bulum
- University Hospital Center Zagreb, Zagreb, Croatia
| | - István Édes
- Department of Cardiology, Faculty of Medicine, Medical and Health Science Center, University of Debrecen, Debrbrecen, Hungary
| | - Jan Peruga
- Medical University in Łódź, Bieganski Hospital, Łódź, Poland
| | - Beata Średniawa
- Silesian Center for Heart Diseases, Department of Cardiology, Medical University of Silesia, DMS in Zabrze, Zabrze, Poland
| | - David Erlinge
- Department of Cardiology, Lund University, Clinical Sciences, Skane University Hospital, Lund, Sweden
| | - Thomas R. Keeble
- Essex Cardiothoracic Centre, Basildon and Thurrock University Hospital NHS Foundation Trust, Basildon, UK,Anglia Ruskin School of Medicine, Chelmsford, Essex, UK
| |
Collapse
|
26
|
Wu Y, Tang Z, Li B, Firmin D, Yang G. Recent Advances in Fibrosis and Scar Segmentation From Cardiac MRI: A State-of-the-Art Review and Future Perspectives. Front Physiol 2021; 12:709230. [PMID: 34413789 PMCID: PMC8369509 DOI: 10.3389/fphys.2021.709230] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 06/28/2021] [Indexed: 12/03/2022] Open
Abstract
Segmentation of cardiac fibrosis and scars is essential for clinical diagnosis and can provide invaluable guidance for the treatment of cardiac diseases. Late Gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) has been successful in guiding the clinical diagnosis and treatment reliably. For LGE CMR, many methods have demonstrated success in accurately segmenting scarring regions. Co-registration with other non-contrast-agent (non-CA) modalities [e.g., balanced steady-state free precession (bSSFP) cine magnetic resonance imaging (MRI)] can further enhance the efficacy of automated segmentation of cardiac anatomies. Many conventional methods have been proposed to provide automated or semi-automated segmentation of scars. With the development of deep learning in recent years, we can also see more advanced methods that are more efficient in providing more accurate segmentations. This paper conducts a state-of-the-art review of conventional and current state-of-the-art approaches utilizing different modalities for accurate cardiac fibrosis and scar segmentation.
Collapse
Affiliation(s)
- Yinzhe Wu
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.,Department of Bioengineering, Faculty of Engineering, Imperial College London, London, United Kingdom
| | - Zeyu Tang
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.,Department of Bioengineering, Faculty of Engineering, Imperial College London, London, United Kingdom
| | - Binghuan Li
- Department of Bioengineering, Faculty of Engineering, Imperial College London, London, United Kingdom
| | - David Firmin
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.,Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom
| | - Guang Yang
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.,Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom
| |
Collapse
|
27
|
Myocardial Infarction Quantification from Late Gadolinium Enhancement MRI Using Top-Hat Transforms and Neural Networks. ALGORITHMS 2021. [DOI: 10.3390/a14080249] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Late gadolinium enhancement (LGE) MRI is the gold standard technique for myocardial viability assessment. Although the technique accurately reflects the damaged tissue, there is no clinical standard to quantify myocardial infarction (MI). Moreover, commercial software used in clinical practice are mostly semi-automatic, and hence require direct intervention of experts. In this work, a new automatic method for MI quantification from LGE-MRI is proposed. Our novel segmentation approach is devised for accurately detecting not only hyper-enhanced lesions, but also microvascular obstruction areas. Moreover, it includes a myocardial disease detection step which extends the algorithm for working under healthy scans. The method is based on a cascade approach where firstly, diseased slices are identified by a convolutional neural network (CNN). Secondly, by means of morphological operations a fast coarse scar segmentation is obtained. Thirdly, the segmentation is refined by a boundary-voxel reclassification strategy using an ensemble of very light CNNs. We tested the method on a LGE-MRI database with healthy (n = 20) and diseased (n = 80) cases following a 5-fold cross-validation scheme. Our approach segmented myocardial scars with an average Dice coefficient of 77.22 ± 14.3% and with a volumetric error of 1.0 ± 6.9 cm3. In a comparison against nine reference algorithms, the proposed method achieved the highest agreement in volumetric scar quantification with the expert delineations (p< 0.001 when compared to the other approaches). Moreover, it was able to reproduce the scar segmentation intra- and inter-rater variability. Our approach was shown to be a good first attempt towards automatic and accurate myocardial scar segmentation, although validation over larger LGE-MRI databases is needed.
Collapse
|
28
|
Akil S, Hedeer F, Oddstig J, Olsson T, Jögi J, Erlinge D, Carlsson M, Arheden H, Hindorf C, Engblom H. Appropriate coronary revascularization can be accomplished if myocardial perfusion is quantified by positron emission tomography prior to treatment decision. J Nucl Cardiol 2021; 28:1664-1672. [PMID: 31705424 PMCID: PMC8421314 DOI: 10.1007/s12350-019-01938-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/14/2019] [Accepted: 10/15/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Many patients undergo percutaneous coronary intervention (PCI) without the use of non-invasive stress testing prior to treatment. The aim of this study was to determine the potential added value of guiding revascularization by quantitative assessment of myocardial perfusion prior to intervention. METHODS AND RESULTS Thirty-three patients (10 females) with suspected or established CAD who had been referred for a clinical coronary angiography (CA) with possibility for PCI were included. Adenosine stress and rest 13N-NH3 PET, cardiac magnetic resonance (CMR), and cardiopulmonary exercise test were performed 4 ± 3 weeks before and 5 ± 1 months after CA. The angiographer was blinded to the PET and CMR results. Myocardial flow reserve (MFR) < 2.0 by PET was considered abnormal. A PCI was performed in 19/33 patients. In 41% (11/27) of the revascularized vessel territories, a normal regional MFR was found prior to the PCI and no improvement in MFR was found at follow-up (P = 0.9). However, vessel territories with regional MFR < 2.0 at baseline improved significantly after PCI (P = 0.003). Of the 14 patients not undergoing PCI, four had MFR < 2.0 in one or more coronary territories. CONCLUSION Assessment of quantitative myocardial perfusion prior to revascularization could lead to more appropriate use of CA when managing patients with stable CAD.
Collapse
Affiliation(s)
- Shahnaz Akil
- Department of Radiological Sciences, College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden.
| | - Fredrik Hedeer
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Jenny Oddstig
- Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Thomas Olsson
- Radiation Physics, Skane University Hospital, Lund, Sweden
| | - Jonas Jögi
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Cardiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Marcus Carlsson
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Håkan Arheden
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| | | | - Henrik Engblom
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
29
|
Paddock S, Tsampasian V, Assadi H, Mota BC, Swift AJ, Chowdhary A, Swoboda P, Levelt E, Sammut E, Dastidar A, Broncano Cabrero J, Del Val JR, Malcolm P, Sun J, Ryding A, Sawh C, Greenwood R, Hewson D, Vassiliou V, Garg P. Clinical Translation of Three-Dimensional Scar, Diffusion Tensor Imaging, Four-Dimensional Flow, and Quantitative Perfusion in Cardiac MRI: A Comprehensive Review. Front Cardiovasc Med 2021; 8:682027. [PMID: 34307496 PMCID: PMC8292630 DOI: 10.3389/fcvm.2021.682027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/04/2021] [Indexed: 01/05/2023] Open
Abstract
Cardiovascular magnetic resonance (CMR) imaging is a versatile tool that has established itself as the reference method for functional assessment and tissue characterisation. CMR helps to diagnose, monitor disease course and sub-phenotype disease states. Several emerging CMR methods have the potential to offer a personalised medicine approach to treatment. CMR tissue characterisation is used to assess myocardial oedema, inflammation or thrombus in various disease conditions. CMR derived scar maps have the potential to inform ablation therapy—both in atrial and ventricular arrhythmias. Quantitative CMR is pushing boundaries with motion corrections in tissue characterisation and first-pass perfusion. Advanced tissue characterisation by imaging the myocardial fibre orientation using diffusion tensor imaging (DTI), has also demonstrated novel insights in patients with cardiomyopathies. Enhanced flow assessment using four-dimensional flow (4D flow) CMR, where time is the fourth dimension, allows quantification of transvalvular flow to a high degree of accuracy for all four-valves within the same cardiac cycle. This review discusses these emerging methods and others in detail and gives the reader a foresight of how CMR will evolve into a powerful clinical tool in offering a precision medicine approach to treatment, diagnosis, and detection of disease.
Collapse
Affiliation(s)
- Sophie Paddock
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Vasiliki Tsampasian
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Hosamadin Assadi
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Bruno Calife Mota
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Amrit Chowdhary
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Peter Swoboda
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Eylem Levelt
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Eva Sammut
- Bristol Heart Institute and Translational Biomedical Research Centre, Faculty of Health Science, University of Bristol, Bristol, United Kingdom
| | - Amardeep Dastidar
- Bristol Heart Institute and Translational Biomedical Research Centre, Faculty of Health Science, University of Bristol, Bristol, United Kingdom
| | - Jordi Broncano Cabrero
- Cardiothoracic Imaging Unit, Hospital San Juan De Dios, Ressalta, HT Medica, Córdoba, Spain
| | - Javier Royuela Del Val
- Cardiothoracic Imaging Unit, Hospital San Juan De Dios, Ressalta, HT Medica, Córdoba, Spain
| | - Paul Malcolm
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Julia Sun
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Alisdair Ryding
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Chris Sawh
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Richard Greenwood
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - David Hewson
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Vassilios Vassiliou
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Pankaj Garg
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
30
|
Gonzales RA, Seemann F, Lamy J, Arvidsson PM, Heiberg E, Murray V, Peters DC. Automated left atrial time-resolved segmentation in MRI long-axis cine images using active contours. BMC Med Imaging 2021; 21:101. [PMID: 34147081 PMCID: PMC8214286 DOI: 10.1186/s12880-021-00630-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/10/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Segmentation of the left atrium (LA) is required to evaluate atrial size and function, which are important imaging biomarkers for a wide range of cardiovascular conditions, such as atrial fibrillation, stroke, and diastolic dysfunction. LA segmentations are currently being performed manually, which is time-consuming and observer-dependent. METHODS This study presents an automated image processing algorithm for time-resolved LA segmentation in cardiac magnetic resonance imaging (MRI) long-axis cine images of the 2-chamber (2ch) and 4-chamber (4ch) views using active contours. The proposed algorithm combines mitral valve tracking, automated threshold calculation, edge detection on a radially resampled image, edge tracking based on Dijkstra's algorithm, and post-processing involving smoothing and interpolation. The algorithm was evaluated in 37 patients diagnosed mainly with paroxysmal atrial fibrillation. Segmentation accuracy was assessed using the Dice similarity coefficient (DSC) and Hausdorff distance (HD), with manual segmentations in all time frames as the reference standard. For inter-observer variability analysis, a second observer performed manual segmentations at end-diastole and end-systole on all subjects. RESULTS The proposed automated method achieved high performance in segmenting the LA in long-axis cine sequences, with a DSC of 0.96 for 2ch and 0.95 for 4ch, and an HD of 5.5 mm for 2ch and 6.4 mm for 4ch. The manual inter-observer variability analysis had an average DSC of 0.95 and an average HD of 4.9 mm. CONCLUSION The proposed automated method achieved performance on par with human experts analyzing MRI images for evaluation of atrial size and function. Video Abstract.
Collapse
Affiliation(s)
- Ricardo A Gonzales
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale University, New Haven, Connecticut, United States of America
- Department of Electrical Engineering, Universidad de Ingeniería y Tecnología, Lima, Peru
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Felicia Seemann
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale University, New Haven, Connecticut, United States of America
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Jérôme Lamy
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale University, New Haven, Connecticut, United States of America
| | - Per M Arvidsson
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Einar Heiberg
- Department of Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
- Department of Biomedical Engineering, Lund University, Lund, Sweden
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Victor Murray
- Department of Electrical Engineering, Universidad de Ingeniería y Tecnología, Lima, Peru
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, United States of America
- Department of Electrical and Computer Engineering, University of New Mexico, Albuquerque, New Mexico, United States of America
| | - Dana C Peters
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Yale University, New Haven, Connecticut, United States of America.
| |
Collapse
|
31
|
Randomized Trial of Interleukin-6 Receptor Inhibition in Patients With Acute ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2021; 77:1845-1855. [PMID: 33858620 DOI: 10.1016/j.jacc.2021.02.049] [Citation(s) in RCA: 177] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Prompt myocardial revascularization with percutaneous coronary intervention (PCI) reduces infarct size and improves outcomes in patients with ST-segment elevation myocardial infarction (STEMI). However, as much as 50% of the loss of viable myocardium may be attributed to the reperfusion injury and the associated inflammatory response. OBJECTIVES This study sought to evaluate the effect of the interleukin-6 receptor inhibitor tocilizumab on myocardial salvage in acute STEMI. METHODS The ASSAIL-MI trial was a randomized, double-blind, placebo-controlled trial conducted at 3 high-volume PCI centers in Norway. Patients admitted with STEMI within 6 h of symptom onset were eligible. Consenting patients were randomized in a 1:1 fashion to promptly receive a single infusion of 280 mg tocilizumab or placebo. The primary endpoint was the myocardial salvage index as measured by magnetic resonance imaging after 3 to 7 days. RESULTS We randomized 101 patients to tocilizumab and 98 patients to placebo. The myocardial salvage index was larger in the tocilizumab group than in the placebo group (adjusted between-group difference 5.6 [95% confidence interval: 0.2 to 11.3] percentage points, p = 0.04). Microvascular obstruction was less extensive in the tocilizumab arm, but there was no significant difference in the final infarct size between the tocilizumab arm and the placebo arm (7.2% vs. 9.1% of myocardial volume, p = 0.08). Adverse events were evenly distributed across the treatment groups. CONCLUSIONS Tocilizumab increased myocardial salvage in patients with acute STEMI. (ASSessing the effect of Anti-IL-6 treatment in Myocardial Infarction [ASSAIL-MI]; NCT03004703).
Collapse
|
32
|
Myocardial motion-corrected phase-sensitive inversion recovery late gadolinium enhancement in free breathing paediatric patients: a comparison with single-shot coherent gradient echo ("TrueFISP") phase-sensitive inversion recovery. Clin Radiol 2021; 76:471.e17-471.e25. [PMID: 33663913 DOI: 10.1016/j.crad.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/26/2021] [Indexed: 11/23/2022]
Abstract
AIM To investigate the value of motion-corrected (MOCO) phase-sensitive inversion recovery (PSIR) late gadolinium enhancement (LGE) compared with single-shot balanced steady-state gradient echo ("TrueFISP", Siemens) PSIR in free breathing paediatric patients. MATERIALS AND METHODS In this retrospective study, 238 paediatric patients underwent clinical contrast-enhanced cardiovascular magnetic resonance imaging (CMRI). Both the single-shot TrueFISP PSIR and MOCO PSIR sequences were performed on each child. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated. Two radiologists rated the quality of the images on a scale of 1-5 (1 = poor, 5 = very good). Bland-Altman, linear regression, and intraclass correlation coefficient were used to compared the extent of LGE of the single-shot TrueFISP PSIR and MOCO PSIR. Imaging artefacts were described and compared. RESULTS Children ranged in age from 60 days to 17 years with an average age of 8.1 ± 3.8 years. MOCO PSIR had higher SNR and CNR than the single-shot TrueFISP PSIR (p<0.001). Mean quality ratings for short-axis imaging were 4 (interquartile range, 3-4) for single-shot TrueFISP PSIR and 4 (interquartile range, 4-5) for MOCO PSIR (p<0.001). The scan time was faster for single-shot TrueFISP PSIR than for MOCO PSIR. The myocardial LGE results were similar with high agreement between the single-shot TrueFISP PSIR and MOCO PSIR (ICC = 0.955-0.986). CONCLUSION The MOCO PSIR sequence is feasible in children. MOCO PSIR is robust at high heart rates and can be performed without breath-holding with higher image-quality ratings than the single-shot TrueFISP PSIR.
Collapse
|
33
|
Österberg AW, Östman-Smith I, Jablonowski R, Carlsson M, Green H, Gunnarsson C, Liuba P, Fernlund E. High ECG Risk-Scores Predict Late Gadolinium Enhancement on Magnetic Resonance Imaging in HCM in the Young. Pediatr Cardiol 2021; 42:492-500. [PMID: 33515326 DOI: 10.1007/s00246-020-02506-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/17/2020] [Indexed: 01/14/2023]
Abstract
An ECG risk-score has been described that predicts high risk of subsequent cardiac arrest in young patients with hypertrophic cardiomyopathy (HCM). Myocardial fibrosis measured by cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) also affects prognosis. We assessed whether an ECG risk-score could be used as an indicator of myocardial fibrosis or perfusion deficit on CMR in HCM. In total 42 individuals (7-31 years); 26 HCM patients, seven genotype-positive, phenotype-negative individuals at risk of HCM (first-degree relatives) and nine healthy volunteers, underwent CMR to identify, and grade extent of, myocardial fibrosis and perfusion defect. 12-lead ECG was used for calculating the ECG risk-score (grading 0-14p). High-risk ECG (risk-score > 5p) occurred only in the HCM group (9/26), and the proportion was significantly higher vs mutation carriers combined with healthy volunteers (0/16, p = 0.008). Extent of LGE correlated to the ECG-score (R2 = 0.47, p = 0.001) in sarcomeric mutations. In low-risk ECG-score patients (0-2p), median percent of myocardium showing LGE (LGE%LVM) were: 0% [interquartile range, IQR, 0-0%], in intermediate-risk (3-5p): 5.4% [IQR 0-13.5%] and in high-risk (6-14p): 10.9% [IQR 4.2-12.3%]. ECG-score > 2p had a sensitivity and specificity of 79% and 84% to detect positive LGE on CMR and 77% vs. 75% to detect perfusion defects in sarcomeric mutations carriers. In patients with myocardial fibrosis as identified by LGE, median ECG risk-score was 8p [range 3-10p]. In conclusions, ECG risk-score > 2 p could be used as a cut-off for screening of myocardial fibrosis. Thus ECG risk-score is an inexpensive complementary tool in risk stratification of HCM in the young.
Collapse
Affiliation(s)
- Anna Wålinder Österberg
- Crown Princess Victoria Children's Hospital, Department of Biomedical and Clinical Sciences, Department of Pediatrics, Linköping University, 581 85, Linköping, Sweden
| | - Ingegerd Östman-Smith
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Robert Jablonowski
- Clinical Physiology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Marcus Carlsson
- Clinical Physiology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Henrik Green
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Linköping, Sweden.,Division of Drug Research, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Cecilia Gunnarsson
- Department of Clinical Genetics, Department of Biomedical and Clinical Sciences, Centre for Rare Diseases in South East Region of Sweden, Linköping University, Linköping, Sweden
| | - Petru Liuba
- Pediatric Heart Centre, Skåne University Hospital and Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Eva Fernlund
- Crown Princess Victoria Children's Hospital, Department of Biomedical and Clinical Sciences, Department of Pediatrics, Linköping University, 581 85, Linköping, Sweden. .,Pediatric Heart Centre, Skåne University Hospital and Department of Clinical Sciences, Lund University, Lund, Sweden.
| |
Collapse
|
34
|
Akil S, Hedeer F, Carlsson M, Arheden H, Oddstig J, Hindorf C, Jögi J, Erlinge D, Engblom H. Qualitative assessments of myocardial ischemia by cardiac MRI and coronary stenosis by invasive coronary angiography in relation to quantitative perfusion by positron emission tomography in patients with known or suspected stable coronary artery disease. J Nucl Cardiol 2020; 27:2351-2359. [PMID: 30535919 PMCID: PMC7749089 DOI: 10.1007/s12350-018-01555-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/26/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND To relate findings of qualitative evaluation of first-pass perfusion-CMR and anatomical evaluation on coronary angiography (CA) to the reference standard of quantitative perfusion, cardiac PET, in patients with suspected or known stable coronary artery disease (CAD). METHODS AND RESULTS Forty-one patients referred for CA due to suspected stable CAD, prospectively performed adenosine stress/rest first-pass perfusion-CMR as well as 13N-NH3 PET on the same day, 4 ± 3 weeks before CA. Angiographers were blinded to PET and CMR results. Regional myocardial flow reserve (MFR) < 2.0 on PET was considered pathological. Vessel territories with stress-induced ischemia by CMR or vessels with stenosis needing revascularization had a significantly lower MFR compared to those with no regional stress-induced ischemia or vessels not needing revascularization (P < 0.001). In 4 of 123 vessel territories with stress-induced ischemia by CMR, PET showed a normal MFR. In addition, 12 of 123 vessels that underwent intervention showed normal MFR assessed by PET. CONCLUSION The limited performance of qualitative assessment of presence of stable CAD with CMR and CA, when related to quantitative 13N-NH3 cardiac PET, shows the need for fully quantitative assessment of myocardial perfusion and the use of invasive flow reserve measurements for CA, to confirm the need of elective revascularization.
Collapse
Affiliation(s)
- Shahnaz Akil
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, 22185 Lund, Sweden
- Department of Radiological Sciences, College of Health and Rehabilitation Sciences, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Fredrik Hedeer
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, 22185 Lund, Sweden
| | - Marcus Carlsson
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, 22185 Lund, Sweden
| | - Håkan Arheden
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, 22185 Lund, Sweden
| | - Jenny Oddstig
- Radiation Physics, Skåne University Hospital, Lund, Sweden
| | | | - Jonas Jögi
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, 22185 Lund, Sweden
| | - David Erlinge
- Department of Clinical Sciences Lund, Department of Cardiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Henrik Engblom
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, 22185 Lund, Sweden
| |
Collapse
|
35
|
Structural and Functional Correlates of Gradient-Area Patterns in Severe Aortic Stenosis and Normal Ejection Fraction. JACC Cardiovasc Imaging 2020; 14:525-536. [PMID: 33221240 DOI: 10.1016/j.jcmg.2020.09.031] [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: 04/29/2020] [Revised: 08/31/2020] [Accepted: 09/14/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The authors sought to characterize the functional and structural myocardial phenotypes of patients with moderate-to-severe aortic stenosis (AS) and to determine whether severe paradoxical low-gradient AS (LG-AS) is specifically associated with left ventricular (LV) remodeling and fibrosis. BACKGROUND Recently, it was suggested that severe paradoxical LG-AS is a more advanced form of AS, with greater reduction of longitudinal deformation, adverse LV remodeling, and more interstitial fibrosis. METHODS The study population includes 147 patients with moderate-to-severe AS and a normal LV ejection fraction, and 75 normal control subjects. They prospectively underwent 2-dimensional speckle-tracking echocardiography and cardiac magnetic resonance to evaluate myocardial deformation, LV remodeling, and age- and sex-adjusted extravascular volume fraction (ECV, %). Among AS patients, 18 had moderate AS, 74 had severe high-gradient AS (HG-AS), and 55 had severe paradoxical LG-AS. RESULTS Reduced longitudinal and circumferential deformation was observed in 21% and 6% of the AS patients, respectively. Multivariate analyses identified increased ECV (ß = 1.99; p = 0.001) and the absence of normal LV geometry (ß = -1.37; p = 0.007) and as independent predictors of reduced longitudinal deformation. Increased ECV was an independent predictor of reduced circumferential deformation (ß = 2.19; p = 0.001). Over a median follow-up of 29 months, reduced longitudinal deformation (hazard ratio: 0.82; p = 0.023) and higher transvalvular gradients (hazard ratio: 1.05; p < 0.001) increased the risk of death or need for aortic valve replacement. LV hypertrophy was more frequently observed among patients with severe HG-AS (65%) than among the other AS patients (14%; p < 0.001). On average, ECV was within normal limits and did not differ among gradient-area subgroups. When present, increased ECV was associated with reduced longitudinal deformation. CONCLUSIONS This study's data show that patients with severe paradoxical LG-AS less frequently display reduced longitudinal deformation, LV hypertrophy, or myocardial fibrosis than patients with HG-AS. Also, interstitial fibrosis only occurs when reduced longitudinal deformation and severe HG-AS are present together. Finally, this study suggests that reduced longitudinal deformation and higher transvalvular gradients adversely affect patients' outcomes.
Collapse
|
36
|
Polaková E, Liebregts M, Marková N, Adla T, Kara B, Ten Berg J, Bonaventura J, Veselka J. Effectiveness of alcohol septal ablation for hypertrophic obstructive cardiomyopathy in patients with late gadolinium enhancement on cardiac magnetic resonance. Int J Cardiol 2020; 319:101-105. [PMID: 32682963 DOI: 10.1016/j.ijcard.2020.06.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/21/2020] [Accepted: 06/24/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND According to European guidelines, alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) may be less effective in patients with extensive septal scarring on cardiac magnetic resonance (CMR). This study aimed to analyze the impact of late gadolinium enhancement (LGE) on CMR on the effectiveness of ASA. METHOD We conducted an observational retrospective study involving adult patients with symptomatic drug-refractory HOCM who underwent CMR before ASA at two European centres from May 2010 through June 2019. Patients were compared in binary format based on LGE presence. Moreover, a subanalysis focused on patients with septal fibrosis was performed. The effectiveness of ASA was evaluated by echocardiographic, ECG and clinical findings. RESULTS Of the 113 study patients, 54 (48%) had LGE on CMR. The LGE quantification performed in 29 patients revealed septal fibrosis in 17. The mean follow-up was 4.4 ± 2.6 years. Baseline parameters were similar between groups except for basal septal thickness that was greater in LGE+ group (21.1 ± 3.9 mm for LGE+ vs. 19.2 ± 3.2 mm for LGE-: p = .005). ASA improved symptoms in all groups and reduced left ventricular outflow tract obstruction (LVOTO) (delta gradient reduction: LGE+: 62 ± 37.3%; septal LGE+: 75.6 ± 20.8%; LGE-: 72.5 ± 21.0%). However, 13% of the LGE+ and 2% of the LGE- group had residual LVOTO above 30 mmHg (p = .027). CONCLUSION ASA was effective in all patients with HOCM, whether they had LGE on CMR or not and whether they had septal fibrosis or not.
Collapse
Affiliation(s)
- Eva Polaková
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic.
| | - Max Liebregts
- Department of Cardiology, St.Antonius Hospital, Nieuwegein, the Netherlands
| | - Natália Marková
- Department of Radiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Theodor Adla
- Department of Radiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Basak Kara
- Department of Cardiology, St.Antonius Hospital, Nieuwegein, the Netherlands
| | - Jurriën Ten Berg
- Department of Cardiology, St.Antonius Hospital, Nieuwegein, the Netherlands
| | - Jiří Bonaventura
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| |
Collapse
|
37
|
Aalen JM, Donal E, Larsen CK, Duchenne J, Lederlin M, Cvijic M, Hubert A, Voros G, Leclercq C, Bogaert J, Hopp E, Fjeld JG, Penicka M, Linde C, Aalen OO, Kongsgård E, Galli E, Voigt JU, Smiseth OA. Imaging predictors of response to cardiac resynchronization therapy: left ventricular work asymmetry by echocardiography and septal viability by cardiac magnetic resonance. Eur Heart J 2020; 41:3813-3823. [PMID: 32918449 PMCID: PMC7599033 DOI: 10.1093/eurheartj/ehaa603] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/02/2020] [Accepted: 07/03/2020] [Indexed: 12/26/2022] Open
Abstract
AIMS Left ventricular (LV) failure in left bundle branch block is caused by loss of septal function and compensatory hyperfunction of the LV lateral wall (LW) which stimulates adverse remodelling. This study investigates if septal and LW function measured as myocardial work, alone and combined with assessment of septal viability, identifies responders to cardiac resynchronization therapy (CRT). METHODS AND RESULTS In a prospective multicentre study of 200 CRT recipients, myocardial work was measured by pressure-strain analysis and viability by cardiac magnetic resonance (CMR) imaging (n = 125). CRT response was defined as ≥15% reduction in LV end-systolic volume after 6 months. Before CRT, septal work was markedly lower than LW work (P < 0.0001), and the difference was largest in CRT responders (P < 0.001). Work difference between septum and LW predicted CRT response with area under the curve (AUC) 0.77 (95% CI: 0.70-0.84) and was feasible in 98% of patients. In patients undergoing CMR, combining work difference and septal viability significantly increased AUC to 0.88 (95% CI: 0.81-0.95). This was superior to the predictive power of QRS morphology, QRS duration and the echocardiographic parameters septal flash, apical rocking, and systolic stretch index. Accuracy was similar for the subgroup of patients with QRS 120-150 ms as for the entire study group. Both work difference alone and work difference combined with septal viability predicted long-term survival without heart transplantation with hazard ratio 0.36 (95% CI: 0.18-0.74) and 0.21 (95% CI: 0.072-0.61), respectively. CONCLUSION Assessment of myocardial work and septal viability identified CRT responders with high accuracy.
Collapse
Affiliation(s)
- John M Aalen
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway,Department of Cardiology, Oslo University Hospital, Rikshospitalet, N-0027 Oslo, Norway,Center for Cardiological Innovation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Erwan Donal
- Department of Cardiology, CHU Rennes and Inserm, LTSI, University of Rennes, Rennes, France
| | - Camilla K Larsen
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway,Department of Cardiology, Oslo University Hospital, Rikshospitalet, N-0027 Oslo, Norway,Center for Cardiological Innovation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jürgen Duchenne
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Mathieu Lederlin
- Center for Cardiological Innovation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marta Cvijic
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Arnaud Hubert
- Center for Cardiological Innovation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Gabor Voros
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Leclercq
- Center for Cardiological Innovation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jan Bogaert
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium,Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Einar Hopp
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Jan Gunnar Fjeld
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway,Oslo Metropolitan University, Oslo, Norway
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Odd O Aalen
- Department of Biostatistics, University of Oslo, Oslo, Norway
| | - Erik Kongsgård
- Institute for Surgical Research, Oslo University Hospital and University of Oslo, Oslo, Norway,Department of Cardiology, Oslo University Hospital, Rikshospitalet, N-0027 Oslo, Norway,Center for Cardiological Innovation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Elena Galli
- Center for Cardiological Innovation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | | | - Otto A Smiseth
- Corresponding author. Tel: + 47 23 07 00 00, Fax: + 47 23 07 35 30,
| |
Collapse
|
38
|
Borgquist R, Carlsson M, Markstad H, Werther-Evaldsson A, Ostenfeld E, Roijer A, Bakos Z. Cardiac Resynchronization Therapy Guided by Echocardiography, MRI, and CT Imaging: A Randomized Controlled Study. JACC Clin Electrophysiol 2020; 6:1300-1309. [PMID: 33092758 DOI: 10.1016/j.jacep.2020.05.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/12/2020] [Accepted: 05/12/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study evaluated if selecting the left ventricular (LV) target segment by echocardiography-derived late mechanical activation, with access to multimodality imaging for scar and venous anatomy, could help to increase responder rates to cardiac resynchronization therapy (CRT). BACKGROUND LV lead placement is important for clinical outcome, but the optimal strategy for LV lead placement in CRT is still debated. METHODS This study conducted a prospective, blinded randomized controlled trial on 102 patients with indication for CRT (27% women, 46% with ischemic cardiomyopathy, 63% in New York Heart Association functional class III, 74% with left bundle branch block, and with mean ejection fraction of 23%). Optimal LV lead location was defined as the latest mechanically activated available segment (free of transmural scar), determined by radial strain echocardiography, cardiac computed tomography, and cardiac magnetic resonance (n = 70). The primary endpoint was reduction of LV end-systolic volume by ≥15% at 6 months post-implantation. RESULTS Patients were followed for 47 ± 21 months. Based on imaging, optimal or adjacent lead placement was feasible in 96% of all cases and was obtained in 83% of the intervention group versus 80% of the control group. Fifty-six percent of the patients were LV end-systolic volume responders compared with the control group (55%) (p = 0.96), and 71% improved ≥1 New York Heart Association functional class (74% vs. 67%; p = 0.43). Death or heart failure hospitalization within 2 years occurred in 6% (2% of the intervention group vs. 10% of the control group; p = 0.07). CONCLUSIONS Radial strain-guided LV lead placement, in combination with multimodality imaging, did not result in increased clinical or echocardiographic response, nor in a significant reduction of death or heart failure hospitalization. (Combining Myocardial Strain and Cardiac CT to Optimize Left Ventricular Lead Placement in CRT Treatment [CRT Clinic]; NCT01426321).
Collapse
Affiliation(s)
- Rasmus Borgquist
- Cardiology Division, Arrhythmia Section, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden.
| | - Marcus Carlsson
- Clinical Physiology Section, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Hanna Markstad
- Radiology Section, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Anna Werther-Evaldsson
- Heart Failure and Valvular Heart Disease Section, Skane University Hospital, Lund, Sweden
| | - Ellen Ostenfeld
- Clinical Physiology Section, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden; Radiology Section, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| | - Anders Roijer
- Heart Failure and Valvular Heart Disease Section, Skane University Hospital, Lund, Sweden
| | - Zoltan Bakos
- Cardiology Division, Arrhythmia Section, Department of Clinical Sciences Lund, Skane University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
39
|
Rysz S, Lundberg J, Nordberg P, Eriksson H, Wieslander B, Lundin M, Fyrdahl A, Pernow J, Ugander M, Djärv T, Jonsson Fagerlund M. The effect of levosimendan on survival and cardiac performance in an ischemic cardiac arrest model - A blinded randomized placebo-controlled study in swine. Resuscitation 2020; 150:113-120. [PMID: 32234367 DOI: 10.1016/j.resuscitation.2020.02.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/03/2020] [Accepted: 02/27/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Survival after out-of-hospital cardiac arrest remains poor. Levosimendan could be a new intervention in this setting. Therefore, we conducted a blinded, placebo controlled randomized study investigating the effects of levosimendan on survival and cardiac performance in an ischemic cardiac arrest model in swine. METHODS Twenty-four anesthetised swines underwent experimentally-induced acute myocardial infarction and ventricular fibrillation. At the start of CPR, a bolus dose of levosimendan (12 μg kg-1) or placebo was given followed by a 24-h infusion (0.2 μg kg-1 min-1) after return of spontaneously circulation. Animals were evaluated by risk of death, post-resuscitation hemodynamics and infarction size by magnetic resonance imaging (MRI) up to 32 h post arrest. RESULTS Spontaneous circulation was restored in all (12/12) animals in the levosimendan group compared to two thirds (8/12) in the placebo group (P = 0.09). Protocol survival was higher for the levosimendan group (P = 0.02) with an estimated 88% lower risk of death compared to placebo (hazard ratio [95% confidence interval] 0.12 [0.01-0.96], P = 0.046). Cardiac output (CO) recovered 40% faster during the first hour of the intensive care period for the levosimendan group (difference 0.13 [0.01-0.26] L min-1P = 0.04). The placebo group required higher inotropic support during the intensive care period which masked an even bigger recovery in CO in the levosimendan group (58%). The MRI showed no difference in myocardial scar size or in myocardial area at risk. CONCLUSIONS Levosimendan given intra-arrest and during the first 24-h of post-resuscitation care improved survival and cardiac performance in this ischemic cardiac arrest model. Institutional Protocol Number; KERIC 5.2.18-14933.
Collapse
Affiliation(s)
- Susanne Rysz
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Per Nordberg
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Helen Eriksson
- Stockholm University Demography Unit, Department of Sociology, Stockholm University, Sweden
| | - Björn Wieslander
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Magnus Lundin
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - Alexander Fyrdahl
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden
| | - John Pernow
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Sweden
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska University Hospital, and Karolinska Institutet, Stockholm, Sweden; Kolling Institute, Royal North Shore Hospital, and Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Therese Djärv
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Function Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Malin Jonsson Fagerlund
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; Department of Physiology and Pharmacology, Karolinska Institutet, Sweden
| |
Collapse
|
40
|
Li W. Biomechanics of infarcted left Ventricle-A review of experiments. J Mech Behav Biomed Mater 2020; 103:103591. [PMID: 32090920 DOI: 10.1016/j.jmbbm.2019.103591] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 01/14/2023]
Abstract
Myocardial infarction (MI) is one of leading diseases to contribute to annual death rate of 5% in the world. In the past decades, significant work has been devoted to this subject. Biomechanics of infarcted left ventricle (LV) is associated with MI diagnosis, understanding of remodelling, MI micro-structure and biomechanical property characterizations as well as MI therapy design and optimization, but the subject has not been reviewed presently. In the article, biomechanics of infarcted LV was reviewed in terms of experiments achieved in the subject so far. The concerned content includes experimental remodelling, kinematics and kinetics of infarcted LVs. A few important issues were discussed and several essential topics that need to be investigated further were summarized. Microstructure of MI tissue should be observed even carefully and compared between different methods for producing MI scar in the same animal model, and eventually correlated to passive biomechanical property by establishing innovative constitutive laws. More uniaxial or biaxial tensile tests are desirable on MI, border and remote tissues, and viscoelastic property identification should be performed in various time scales. Active contraction experiments on LV wall with MI should be conducted to clarify impaired LV pumping function and supply necessary data to the function modelling. Pressure-volume curves of LV with MI during diastole and systole for the human are also desirable to propose and validate constitutive laws for LV walls with MI.
Collapse
Affiliation(s)
- Wenguang Li
- School of Engineering, University of Glasgow, Glasgow, G12 8QQ, UK.
| |
Collapse
|
41
|
Mokhtari A, Akbarzadeh M, Sparv D, Bhiladvala P, Arheden H, Erlinge D, Khoshnood A. Oxygen therapy in patients with ST elevation myocardial infarction based on the culprit vessel: results from the randomized controlled SOCCER trial. BMC Emerg Med 2020; 20:12. [PMID: 32070283 PMCID: PMC7027294 DOI: 10.1186/s12873-020-00309-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 02/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oxygen (O2) treatment has been a cornerstone in the treatment of patients with myocardial infarction. Recent studies, however, state that supplemental O2 therapy may have no effect or harmful effects in these patients. The aim of this study was thus to evaluate the effect of O2 therapy in patients with ST Elevation Myocardial Infarction (STEMI) based on the culprit vessel; Left Anterior Descending Artery (LAD) or Non-LAD. METHODS This was a two-center, investigator-initiated, single-blind, parallel-group, randomized controlled trial at the Skåne university hospital, Sweden. A simple computer-generated randomization was used. Patients were either randomized to standard care with O2 therapy (10 l/min) or air until the end of the primary percutaneous coronary intervention. The patients underwent a Cardiac Magnetic Resonance Imaging (CMRI) days 2-6. The main outcome measures were Myocardium at Risk (MaR), Infarct Size (IS) and Myocardial Salvage Index (MSI) as measured by CMRI, and median high-sensitive troponin T (hs-cTnT). RESULTS A total of 229 patients were assessed for eligibility, and 160 of them were randomized to the oxygen or air arm. Because of primarily technical problems with the CMRI, 95 patients were included in the final analyses; 46 in the oxygen arm and 49 in the air arm. There were no significant differences between patients with LAD and Non-LAD as culprit vessel with regard to their allocation (oxygen or air) with regards to MSI, MaR, IS and hs-cTnT. CONCLUSION The results indicate that the location of the culprit vessel has probably no effect on the role of supplemental oxygen therapy in STEMI patients. TRIAL REGISTRATION Swedish Medical Products Agency (EudraCT No. 2011-001452-11) and ClinicalTrials.gov Identifier (NCT01423929).
Collapse
Affiliation(s)
- Arash Mokhtari
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Mahin Akbarzadeh
- Department of Clinical Sciences Lund, Emergency and Internal Medicine, Lund University, Skåne University Hospital, Akutmottagningen, EA10, SUS Lund, 221 85, Lund, Sweden
| | - David Sparv
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Håkan Arheden
- Department of Clinical Sciences Lund, Clinical Physiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - David Erlinge
- Department of Clinical Sciences Lund, Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Ardavan Khoshnood
- Department of Clinical Sciences Lund, Emergency and Internal Medicine, Lund University, Skåne University Hospital, Akutmottagningen, EA10, SUS Lund, 221 85, Lund, Sweden.
| |
Collapse
|
42
|
Berg J, Jablonowski R, Nordlund D, Kopic S, Bidhult S, Xanthis CG, Saeed M, Solem K, Arheden H, Carlsson M. Decreased atrioventricular plane displacement after acute myocardial infarction yields a concomitant decrease in stroke volume. J Appl Physiol (1985) 2019; 128:252-263. [PMID: 31854250 PMCID: PMC7052588 DOI: 10.1152/japplphysiol.00480.2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Acute myocardial infarction (AMI) can progress to heart failure, which has a poor prognosis. Normally, 60% of stroke volume (SV) is attributed to the longitudinal ventricular shortening and lengthening evident in the atrioventricular plane displacement (AVPD) during the cardiac cycle, but there is no information on how the relationship changes between SV and AVPD before and after AMI. Therefore, the aim of this study was to determine how SV depends on AVPD before and after AMI in two swine models. Serial cardiac magnetic resonance imaging was carried out before and 1–2 h after AMI in a microembolization model (n = 12) and an ischemia-reperfusion model (n = 14). A subset of pigs (n = 7) were additionally imaged at 24 h and at 7 days. Cine and late gadolinium enhancement images were analyzed for cardiac function, AVPD measurements and infarct size estimation, respectively. AVPD decreased (P < 0.05) in all myocardial regions after AMI, with a concomitant SV decrease (P < 0.001). The ischemia-reperfusion model affected SV to a higher degree and had a larger AVPD decrease than the microembolization model (−29 ± 14% vs. −15 ± 18%; P < 0.05). Wall thickening decreased in infarcted areas (P < 0.001), and A-wave AVPD remained unchanged (P = 0.93) whereas E-wave AVPD decreased (P < 0.001) after AMI. We conclude that AVPD is coupled to SV independent of infarct type but likely to a greater degree in ischemia-reperfusion infarcts compared with microembolization infarcts. AMI reduces diastolic early filling AVPD but not AVPD from atrial contraction. These findings shed light on the physiological significance of atrioventricular plane motion when assessing acute and subacute myocardial infarction. NEW & NOTEWORTHY The link between cardiac longitudinal motion, measured as atrioventricular plane displacement (AVPD), and stroke volume (SV) is investigated in swine after acute myocardial infarction (AMI). This cardiac magnetic resonance study demonstrates a close coupling between AVPD and SV before and after AMI in an experimental setting and demonstrates that this connection is present in ischemia-reperfusion and microembolization infarcts, acutely and during the first week. Furthermore, AVPD is equally and persistently depressed in infarcted and remote myocardium after AMI.
Collapse
Affiliation(s)
- J Berg
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - R Jablonowski
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - D Nordlund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - S Kopic
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - S Bidhult
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - C G Xanthis
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - M Saeed
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | | | - H Arheden
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden
| | - M Carlsson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Clinical Physiology, Lund, Sweden.,Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| |
Collapse
|
43
|
Aalen JM, Remme EW, Larsen CK, Andersen OS, Krogh M, Duchenne J, Hopp E, Ross S, Beela AS, Kongsgaard E, Bergsland J, Odland HH, Skulstad H, Opdahl A, Voigt JU, Smiseth OA. Mechanism of Abnormal Septal Motion in Left Bundle Branch Block. JACC Cardiovasc Imaging 2019; 12:2402-2413. [DOI: 10.1016/j.jcmg.2018.11.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/05/2018] [Accepted: 11/30/2018] [Indexed: 12/28/2022]
|
44
|
Karthikeyan B, Sonkawade SD, Pokharel S, Preda M, Schweser F, Zivadinov R, Kim M, Sharma UC. Tagged cine magnetic resonance imaging to quantify regional mechanical changes after acute myocardial infarction. Magn Reson Imaging 2019; 66:208-218. [PMID: 31668928 DOI: 10.1016/j.mri.2019.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 08/16/2019] [Accepted: 09/15/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE The conventional volumetric approaches of measuring cardiac function are load-dependent, and are not able to discriminate functional changes in the infarct, transition and remote myocardium. We examined phase-dependent regional mechanical changes in the infarct, transition and remote regions after acute myocardial infarction (MI) in a preclinical mouse model using cardiovascular magnetic resonance imaging (CMR). METHODS We induced acute MI in six mice with left anterior descending coronary artery ligation. We then examined cardiac (infarct, transition and remote-zone) morphology and function utilizing 9.4 T high field CMR before and 2 weeks after the induction of acute MI. Myocardial scar tissue was evaluated by using CMR with late gadolinium enhancement (LGE). After determining global function through volumetric analysis, regional wall motion was evaluated by measuring wall thickening and radial velocities. Strain rate imaging was performed to assess circumferential contraction and relaxation at the myocardium, endocardium, and epicardium. RESULTS There was abnormal LGE in the anterior walls after acute MI suggesting a successful MI procedure. The transition zone consisted of a mixed signal intensity, while the remote zone contained viable myocardium. As expected, the infarct zone had demonstrated severely decreased myocardial velocities and strain rates, suggesting reduced contraction and relaxation function. Compared to pre-infarct baseline, systolic and diastolic velocities (vS and vD) were significantly reduced at the transition zone (vS: -1.86 ± 0.16 cm/s vs -0.68 ± 0.13 cm/s, P < 0.001; vD: 1.86 ± 0.17 cm/s vs 0.53 ± 0.06 cm/s, P < 0.001) and remote zone (vS: -1.86 ± 0.16 cm/s vs -0.65 ± 0.12 cm/s, P < 0.001; vD: 1.86 ± 0.16 cm/s vs 0.51 ± 0.04 cm/s, P < 0.001). Myocardial peak systolic and diastolic strain rates (SRS and SRD) were significantly lower in the transition zone (SRS: -4.2 ± 0.3 s-1 vs -1.3 ± 0.2 s-1, P < 0.001; SRD: 3.9 ± 0.3 s-1 vs 1.3 ± 0.2 s-1, P < 0.001) and remote zone (SRS: -3.8 ± 0.3 s-1 vs -1.4 ± 0.3 s-1, P < 0.001; SRD: 3.5 ± 0.2 s-1 vs 1.5 ± 0.4 s-1, P = 0.006). Endocardial and epicardial SRS and SRD were similarly reduced in the transition and remote zones compared to baseline. CONCLUSIONS This study, for the first time, utilized state-of-the art high-field CMR algorithms in a preclinical mouse model for a comprehensive and controlled evaluation of the regional mechanical changes in the transition and remote zones, after acute MI. Our data demonstrate that CMR can quantitatively monitor dynamic post-MI remodeling in the transition and remote zones, thereby serving as a gold standard tool for therapeutic surveillance.
Collapse
Affiliation(s)
- Badri Karthikeyan
- Department of Medicine, Division of Cardiology, Jacob's School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America
| | - Swati D Sonkawade
- Department of Medicine, Division of Cardiology, Jacob's School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America
| | - Saraswati Pokharel
- Department of Pathology and Laboratory Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States of America
| | - Marilena Preda
- Center for Biomedical Imaging at the Clinical and Translational Science Institute, University at Buffalo, Buffalo, NY, United States of America
| | - Ferdinand Schweser
- Center for Biomedical Imaging at the Clinical and Translational Science Institute, University at Buffalo, Buffalo, NY, United States of America
| | - Robert Zivadinov
- Center for Biomedical Imaging at the Clinical and Translational Science Institute, University at Buffalo, Buffalo, NY, United States of America
| | - Minhyung Kim
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States of America
| | - Umesh C Sharma
- Department of Medicine, Division of Cardiology, Jacob's School of Medicine and Biomedical Sciences, Buffalo, NY, United States of America.
| |
Collapse
|
45
|
Whitaker J, Neji R, Byrne N, Puyol-Antón E, Mukherjee RK, Williams SE, Chubb H, O’Neill L, Razeghi O, Connolly A, Rhode K, Niederer S, King A, Tschabrunn C, Anter E, Nezafat R, Bishop MJ, O’Neill M, Razavi R, Roujol S. Improved co-registration of ex-vivo and in-vivo cardiovascular magnetic resonance images using heart-specific flexible 3D printed acrylic scaffold combined with non-rigid registration. J Cardiovasc Magn Reson 2019; 21:62. [PMID: 31597563 PMCID: PMC6785908 DOI: 10.1186/s12968-019-0574-z] [Citation(s) in RCA: 10] [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: 11/11/2018] [Accepted: 09/02/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Ex-vivo cardiovascular magnetic resonance (CMR) imaging has played an important role in the validation of in-vivo CMR characterization of pathological processes. However, comparison between in-vivo and ex-vivo imaging remains challenging due to shape changes occurring between the two states, which may be non-uniform across the diseased heart. A novel two-step process to facilitate registration between ex-vivo and in-vivo CMR was developed and evaluated in a porcine model of chronic myocardial infarction (MI). METHODS Seven weeks after ischemia-reperfusion MI, 12 swine underwent in-vivo CMR imaging with late gadolinium enhancement followed by ex-vivo CMR 1 week later. Five animals comprised the control group, in which ex-vivo imaging was undertaken without any support in the LV cavity, 7 animals comprised the experimental group, in which a two-step registration optimization process was undertaken. The first step involved a heart specific flexible 3D printed scaffold generated from in-vivo CMR, which was used to maintain left ventricular (LV) shape during ex-vivo imaging. In the second step, a non-rigid co-registration algorithm was applied to align in-vivo and ex-vivo data. Tissue dimension changes between in-vivo and ex-vivo imaging were compared between the experimental and control group. In the experimental group, tissue compartment volumes and thickness were compared between in-vivo and ex-vivo data before and after non-rigid registration. The effectiveness of the alignment was assessed quantitatively using the DICE similarity coefficient. RESULTS LV cavity volume changed more in the control group (ratio of cavity volume between ex-vivo and in-vivo imaging in control and experimental group 0.14 vs 0.56, p < 0.0001) and there was a significantly greater change in the short axis dimensions in the control group (ratio of short axis dimensions in control and experimental group 0.38 vs 0.79, p < 0.001). In the experimental group, prior to non-rigid co-registration the LV cavity contracted isotropically in the ex-vivo condition by less than 20% in each dimension. There was a significant proportional change in tissue thickness in the healthy myocardium (change = 29 ± 21%), but not in dense scar (change = - 2 ± 2%, p = 0.034). Following the non-rigid co-registration step of the process, the DICE similarity coefficients for the myocardium, LV cavity and scar were 0.93 (±0.02), 0.89 (±0.01) and 0.77 (±0.07) respectively and the myocardial tissue and LV cavity volumes had a ratio of 1.03 and 1.00 respectively. CONCLUSIONS The pattern of the morphological changes seen between the in-vivo and the ex-vivo LV differs between scar and healthy myocardium. A 3D printed flexible scaffold based on the in-vivo shape of the LV cavity is an effective strategy to minimize morphological changes in the ex-vivo LV. The subsequent non-rigid registration step further improved the co-registration and local comparison between in-vivo and ex-vivo data.
Collapse
Affiliation(s)
- John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Radhouene Neji
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
- Siemens Healthcare Limited, Frimley, UK
| | - Nicholas Byrne
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
- Medical Physics, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Esther Puyol-Antón
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Rahul K. Mukherjee
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Steven E. Williams
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Henry Chubb
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Louisa O’Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Orod Razeghi
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Adam Connolly
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Kawal Rhode
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Andrew King
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Cory Tschabrunn
- Cardiology Department, University of Pennsylvania, Philadelphia, PA USA
| | - Elad Anter
- Cardiology Department, Beth Israel Deaconess Medical Centre / Harvard Medical School, Boston, MA USA
| | - Reza Nezafat
- Cardiology Department, Beth Israel Deaconess Medical Centre / Harvard Medical School, Boston, MA USA
| | - Martin J. Bishop
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Mark O’Neill
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, King’s College, London, Fourth Floor Lambeth Wing, St Thomas’ Hospital, London, SE1 7EH UK
| |
Collapse
|
46
|
Leiner T, Rueckert D, Suinesiaputra A, Baeßler B, Nezafat R, Išgum I, Young AA. Machine learning in cardiovascular magnetic resonance: basic concepts and applications. J Cardiovasc Magn Reson 2019; 21:61. [PMID: 31590664 PMCID: PMC6778980 DOI: 10.1186/s12968-019-0575-y] [Citation(s) in RCA: 120] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 09/02/2019] [Indexed: 12/18/2022] Open
Abstract
Machine learning (ML) is making a dramatic impact on cardiovascular magnetic resonance (CMR) in many ways. This review seeks to highlight the major areas in CMR where ML, and deep learning in particular, can assist clinicians and engineers in improving imaging efficiency, quality, image analysis and interpretation, as well as patient evaluation. We discuss recent developments in the field of ML relevant to CMR in the areas of image acquisition & reconstruction, image analysis, diagnostic evaluation and derivation of prognostic information. To date, the main impact of ML in CMR has been to significantly reduce the time required for image segmentation and analysis. Accurate and reproducible fully automated quantification of left and right ventricular mass and volume is now available in commercial products. Active research areas include reduction of image acquisition and reconstruction time, improving spatial and temporal resolution, and analysis of perfusion and myocardial mapping. Although large cohort studies are providing valuable data sets for ML training, care must be taken in extending applications to specific patient groups. Since ML algorithms can fail in unpredictable ways, it is important to mitigate this by open source publication of computational processes and datasets. Furthermore, controlled trials are needed to evaluate methods across multiple centers and patient groups.
Collapse
Affiliation(s)
- Tim Leiner
- Department of Radiology | E.01.132, Utrecht University Medical Center, Heidelberglaan 100, 3584CX Utrecht, The Netherlands
| | - Daniel Rueckert
- Biomedical Image Analysis Group, Department of Computing, Imperial College, London, UK
| | - Avan Suinesiaputra
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
| | - Bettina Baeßler
- Department of Radiology, University Hospital of Cologne, Cologne, Germany
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Reza Nezafat
- Department of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA USA
| | - Ivana Išgum
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, Netherlands
| | - Alistair A. Young
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
- Department of Biomedical Engineering, King’s College London, London, UK
| |
Collapse
|
47
|
Keeble TR, Karamasis GV, Noc M, Sredniawa B, Aradi D, Neskovic AN, Arheden H, Erlinge D, Holzer M. Effect of Intravascular Cooling on Microvascular Obstruction (MVO) in Conscious Patients with ST-Elevation Myocardial Infarction Undergoing Primary PCI: Results from the COOL AMI EU Pilot Study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:799-804. [DOI: 10.1016/j.carrev.2018.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/07/2018] [Accepted: 09/19/2018] [Indexed: 10/28/2022]
|
48
|
Loring Z, Atwater BD, Xia X, Axelsson J, Klem I, Nijveldt R, Schelbert EB, Couderc JP, Strauss DG, Ugander M, Wieslander B. Low lead one ratio predicts clinical outcomes in left bundle branch block. J Cardiovasc Electrophysiol 2019; 30:709-716. [PMID: 30740823 DOI: 10.1111/jce.13875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/02/2019] [Accepted: 02/06/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION We evaluated the association between a novel electrocardiographic (ECG) marker of late, rightward electrocardiographic forces (termed the lead one ratio [LOR]), and left ventricular ejection fraction (LVEF), myocardial scar, and clinical outcomes in patients with left bundle branch block (LBBB). METHODS AND RESULTS LOR was calculated in patients with LBBB from a derivation cohort (n = 240) and receiver operator characteristic curves identified optimal threshold values for predicting myocardial scar and LVEF less than 35%. An independent validation cohort of patients with LBBB (n = 196) was used to test the association of LOR with the myocardial scar, LVEF, and the likelihood of death, heart transplant or left ventricular assist device (LVAD) implantation. The optimal thresholds in the derivation cohort were LOR less than 13.7 for identification of scar (sensitivity 55%, specificity 80%), and LOR less than 12.1 for LVEF less than 35% (sensitivity 49%, specificity 80%). In the validation cohort, LOR less than 13.7 was not associated with scar size or presence (P > 0.05 for both). LOR less than 12.1 was associated with lower LVEF (30 [20-40] versus 40 [25-55]%; P = 0.002) and predicted LVEF less than 35% in univariable (odds ratio [OR], 2.2 [1.2-4.1]; P = 0.01) and multivariable analysis (OR, 2.2 [1.2-4.3]; P = 0.02). LOR less than 12.1 was associated with scar presence when patients with nonischemic cardiomyopathy were excluded (OR = 7.2 [1.5-33.2]; P = 0.002). LOR less than 12.1 had an adjusted hazard ratio of 1.53 ([1.05-2.21]; P = 0.03) for death, transplant or LVAD implantation. CONCLUSIONS In conclusion, ECG LOR less than 12.1 predicts reduced-LV systolic function and poorer prognosis in patients with LBBB.
Collapse
Affiliation(s)
- Zak Loring
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Department of Health Services, University of Washington, Seattle, Washington
| | - Brett D Atwater
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Department of Health Services, University of Washington, Seattle, Washington
| | - Xiaojuan Xia
- Department of Health Services, University of Washington, Seattle, Washington.,Cardiology Department, Heart Research Follow-Up Program, University of Rochester, New York
| | - Jimmy Axelsson
- Department of Health Services, University of Washington, Seattle, Washington.,Department of Clinical Physiology, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden
| | - Igor Klem
- Department of Health Services, University of Washington, Seattle, Washington
| | - Robin Nijveldt
- Department of Health Services, University of Washington, Seattle, Washington.,Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Erik B Schelbert
- Department of Health Services, University of Washington, Seattle, Washington.,Division of Cardiology, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jean-Philippe Couderc
- Department of Health Services, University of Washington, Seattle, Washington.,Cardiology Department, Heart Research Follow-Up Program, University of Rochester, New York
| | - David G Strauss
- Department of Health Services, University of Washington, Seattle, Washington.,Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Martin Ugander
- Department of Health Services, University of Washington, Seattle, Washington.,Department of Clinical Physiology, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden
| | - Björn Wieslander
- Department of Health Services, University of Washington, Seattle, Washington.,Cardiology Department, Heart Research Follow-Up Program, University of Rochester, New York.,Department of Clinical Physiology, Karolinska Institute, and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
49
|
Manning WJ. Journal of Cardiovascular Magnetic Resonance 2017. J Cardiovasc Magn Reson 2018; 20:89. [PMID: 30593280 PMCID: PMC6309095 DOI: 10.1186/s12968-018-0518-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 12/06/2018] [Indexed: 02/07/2023] Open
Abstract
There were 106 articles published in the Journal of Cardiovascular Magnetic Resonance (JCMR) in 2017, including 92 original research papers, 3 reviews, 9 technical notes, and 1 Position paper, 1 erratum and 1 correction. The volume was similar to 2016 despite an increase in manuscript submissions to 405 and thus reflects a slight decrease in the acceptance rate to 26.7%. The quality of the submissions continues to be high. The 2017 JCMR Impact Factor (which is published in June 2018) was minimally lower at 5.46 (vs. 5.71 for 2016; as published in June 2017), which is the second highest impact factor ever recorded for JCMR. The 2017 impact factor means that an average, each JCMR paper that were published in 2015 and 2016 was cited 5.46 times in 2017.In accordance with Open-Access publishing of Biomed Central, the JCMR articles are published on-line in continuus fashion and in the chronologic order of acceptance, with no collating of the articles into sections or special thematic issues. For this reason, over the years, the Editors have felt that it is useful to annually summarize the publications into broad areas of interest or theme, so that readers can view areas of interest in a single article in relation to each other and other contemporary JCMR articles. In this publication, the manuscripts are presented in broad themes and set in context with related literature and previously published JCMR papers to guide continuity of thought within the journal. In addition, I have elected to use this format to convey information regarding the editorial process to the readership.I hope that you find the open-access system increases wider reading and citation of your papers, and that you will continue to send your very best, high quality manuscripts to JCMR for consideration. I thank our very dedicated Associate Editors, Guest Editors, and Reviewers for their efforts to ensure that the review process occurs in a timely and responsible manner and that the JCMR continues to be recognized as the forefront journal of our field. And finally, I thank you for entrusting me with the editorship of the JCMR as I begin my 3rd year as your editor-in-chief. It has been a tremendous learning experience for me and the opportunity to review manuscripts that reflect the best in our field remains a great joy and highlight of my week!
Collapse
Affiliation(s)
- Warren J Manning
- Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
| |
Collapse
|
50
|
Axelsson J, Wieslander B, Jablonowski R, Klem I, Nijveldt R, Schelbert EB, Sörensson P, Sigfridsson A, Chaudhry U, Platonov PG, Borgquist R, Engblom H, Strauss DG, Arheden H, Atwater BD, Ugander M. Ejection fraction in left bundle branch block is disproportionately reduced in relation to amount of myocardial scar. J Electrocardiol 2018; 51:1071-1076. [PMID: 30497733 DOI: 10.1016/j.jelectrocard.2018.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/09/2018] [Accepted: 09/15/2018] [Indexed: 01/22/2023]
Abstract
INTRODUCTION The relationship between left ventricular (LV) ejection fraction (EF) and LV myocardial scar can identify potentially reversible causes of LV dysfunction. Left bundle branch block (LBBB) alters the electrical and mechanical activation of the LV. We hypothesized that the relationship between LVEF and scar extent is different in LBBB compared to controls. METHODS We compared the relationship between LVEF and scar burden between patients with LBBB and scar (n = 83), and patients with chronic ischemic heart disease and scar but no electrocardiographic conduction abnormality (controls, n = 90), who had undergone cardiovascular magnetic resonance (CMR) imaging at one of three centers. LVEF (%) was measured in CMR cine images. Scar burden was quantified by CMR late gadolinium enhancement (LGE) and expressed as % of LV mass (%LVM). Maximum possible LVEF (LVEFmax) was defined as the function describing the hypotenuse in the LVEF versus myocardial scar extent scatter plot. Dysfunction index was defined as LVEFmax derived from the control cohort minus the measured LVEF. RESULTS Compared to controls with scar, LBBB with scar had a lower LVEF (median [interquartile range] 27 [19-38] vs 36 [25-50] %, p < 0.001), smaller scar (4 [1-9] vs 11 [6-20] %LVM, p < 0.001), and greater dysfunction index (39 [30-52] vs 21 [12-35] % points, p < 0.001). CONCLUSIONS Among LBBB patients referred for CMR, LVEF is disproportionately reduced in relation to the amount of scar. Dyssynchrony in LBBB may thus impair compensation for loss of contractile myocardium.
Collapse
Affiliation(s)
- Jimmy Axelsson
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Björn Wieslander
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Robert Jablonowski
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Igor Klem
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Robin Nijveldt
- Department of Cardiology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Peder Sörensson
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Sigfridsson
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Uzma Chaudhry
- Arrhythmia Clinic, Skåne University Hospital, Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Pyotr G Platonov
- Arrhythmia Clinic, Skåne University Hospital, Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Rasmus Borgquist
- Arrhythmia Clinic, Skåne University Hospital, Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Henrik Engblom
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - David G Strauss
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden; US Food and Drug Administration, Silver Spring, MD, USA
| | - Håkan Arheden
- Department of Clinical Physiology and Nuclear Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Brett D Atwater
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.
| |
Collapse
|