Clinical recommendations for cardiovascular magnetic resonance mapping of T1, T2, T2* and extracellular volume: A consensus statement by the Society for Cardiovascular Magnetic Resonance (SCMR) endorsed by the European Association for Cardiovascular Imaging (EACVI)

Application of Myocardial Salvage Index as a Clinical Endpoint: Assessment Methods and Future Prospects

In patients with acute myocardial infarction (AMI), traditional clinical endpoints used to assess drug efficacy and prognosis include infarct size (IS), incidence of heart failure, and mortality rates. Although these metrics are commonly employed to evaluate outcomes in AMI patients, their utility is limited in small-scale studies. The introduction of the myocardial salvage index (MSI) reduces variability in assessments across multiple dimensions, thereby enhancing the sensitivity of outcome measures and reducing the required sample size. Moreover, MSI is increasingly utilized to evaluate drug efficacy, prognosis, and risk stratification in AMI patients. Although a variety of methodologies for measuring the MSI are currently available, the incorporation of these methods as clinical endpoints remains limited. In the clinical application of cardioprotective strategies, it is recommended that MSI be evaluated using late gadolinium enhancement measured along the endocardial surface length combined with IS in cardiac magnetic resonance. In dynamic single-photon emission computed tomography, an assessment of MSI using methods based on abnormalities in myocardial wall thickening combined with perfusion anomalies is advocated. This review comprehensively outlines the principles, advantages, and limitations of different MSI assessment methods and discusses the prospects and challenges of MSI in cardiac protective therapies. Additionally, we summarize recommended strategies for employing MSI as a clinical surrogate endpoint in various clinical scenarios, providing direction for future clinical practice and research. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 4.

Comprehensive review of non-invasive-treatment-related cardiovascular toxicity in breast cancer

Cardiovascular toxicity is a significant side effect of breast cancer treatment and has emerged as a leading cause of non-tumor-related deaths among breast cancer survivors, emphasizing the critical need for effective monitoring and management of these complications. As breast cancer remains the most prevalent cancer among women, advancements in survival rates have been achieved through treatments such as chemotherapy, targeted therapy, endocrine therapy, immunotherapy, and radiotherapy. This review provides a comprehensive understanding of the cardiovascular toxicity mechanisms associated with both established and emerging breast cancer therapies, identifies potential therapeutic targets and monitoring strategies, and highlights key deficiencies and challenges in the field. By offering insights into the early detection, prevention, and management of cardiovascular complications, this review aims to guide future research directions and clinical practices, ultimately improving outcomes for breast cancer patients.

Multimodality Imaging of Arrhythmic Risk in Mitral Valve Prolapse

Mitral valve prolapse (MVP) affects 2% to 3% of the general population and is typically benign. However, a subset of patients may develop arrhythmic complications, including sudden cardiac arrest and sudden cardiac death. This review explores the critical role of multimodality imaging in risk stratification for arrhythmic MVP, emphasizing high-risk features such as bileaflet involvement, mitral annular disjunction, the double-peak strain pattern, mechanical dispersion, and myocardial fibrosis. Echocardiography remains the first-line imaging tool for MVP diagnosis, enabling detailed assessment of leaflet morphology, mitral annular disjunction, and mitral regurgitation quantification. Speckle tracking provides insights into abnormal valvular-myocardial mechanics as a potential arrhythmogenic mechanism in MVP. Cardiac magnetic resonance (CMR) offers detailed myocardial tissue characterization through assessment of replacement and interstitial fibrosis using late gadolinium enhancement and T1 mapping/extracellular volume fraction, respectively. Hybrid Positron Emission Tomography/CMR highlights the role of inflammation, which may coexist with fibrosis, in explaining the presence of malignant arrhythmias even with relatively limited fibrosis. The assessment of diffuse fibrosis and inflammation by CMR and Positron Emission Tomography/CMR is particularly valuable in patients without classic imaging risk factors such as mitral annular disjunction, severe mitral regurgitation, or replacement fibrosis. We propose an algorithm integrating clinical, rhythmic, echocardiographic, CMR, and Positron Emission Tomography/CMR parameters for arrhythmic risk stratification and management. Although multimodality imaging is essential for comprehensive risk assessment, most available parameters have not yet been validated in prospective studies nor linked directly to mortality. Consequently, these imaging findings should be interpreted alongside the presence of complex ventricular ectopy, which remains the most robust predictor of mortality in arrhythmic MVP.

CMR Findings in the Long-Term Outcomes After Multisystem Inflammatory Syndrome in Children (MUSIC) Study

BACKGROUND

Multisystem Inflammatory Syndrome in Children is characterized by high rates of acute cardiovascular involvement with rapid recovery of organ dysfunction. However, information regarding long-term sequelae is lacking. We sought to characterize the systolic function and myocardial tissue properties using cardiac magnetic resonance (CMR) imaging in a multicenter observational cohort of Multisystem Inflammatory Syndrome in Children patients.

METHODS

In this observational cohort study, comprising 32 centers in North America, CMR studies were analyzed by a core laboratory to assess ventricular volumetric data, tissue characterization, and coronary involvement.

RESULTS

A total of 263 CMRs from 255 Multisystem Inflammatory Syndrome in Children patients were analyzed. The mean patient age was 11.4±4.4 years. Most studies were performed at 3 months (33%) or 6 months (45%) after hospitalization. Left ventricular dysfunction was present in 17 (6.7%) of the first CMRs and was never worse than mild. Dysfunction was observed in 4/7 (57%) patients at admission, 5/87 (6.9%) patients at 3 months, and 6/129 (4.6%) patients imaged either at 6 months or 1 year post-hospitalization. Late gadolinium enhancement was present in 2 (0.8%) patients, 1 at 3 months and another at 6 months following hospitalization. Coronary artery dilation was present in 13 of the 174 (7.5%) patients. Nine patients met the Lake Louise criteria for myocarditis (3.5%) at the time of CMR.

CONCLUSIONS

In this largest published multiinstitutional longitudinal CMR evaluation of confirmed Multisystem Inflammatory Syndrome in Children patients, the prevalence of ventricular dysfunction and myocardial tissue characterization abnormalities on medium-term follow-up was low. However, a small number of patients had mild residual abnormalities at 6 months and 1 year following hospitalization.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05287412.

Development and Validation of Imaging-Free Myocardial Fibrosis Prediction Models, Association with Outcomes, and Sample Size Estimation for Phase 3 Trials

BACKGROUND

Phase 3 trials testing whether pharmacologic interventions targeting myocardial fibrosis improve outcomes require myocardial fibrosis measurement that does not rely on tomographic imaging with intravenous contrast.

METHODS

We developed and externally validated extracellular volume (ECV) prediction models incorporating readily available data (comorbidity and natriuretic peptide variables), excluding tomographic imaging variables. Associations between predicted ECV and incident outcomes (death or hospitalization for heart failure) were tested in survival analysis. We created various sample size estimates for a hypothetical therapeutic clinical trial testing an antifibrotic therapy using (1) predicted ECV, (2) measured ECV, or (3) no ECV.

RESULTS

Multivariable models predicting ECV had reasonable discrimination (optimism corrected C-statistic for predicted ECV ≥27%, 0.78 [95% CI, 0.75-0.80] in the derivation cohort [n=1663] and 0.74 [95% CI, 0.71-0.76] in the validation cohort [n=1578]) and reasonable calibration. Predicted ECV associated with adverse outcomes in Cox regression models: ECV ≥27% (binary variable) hazard ratio 2.21 (95% CI, 1.84-2.66). For a hypothetical clinical trial with an inclusion criterion of ECV ≥27%, use of predicted ECV (with probability threshold of 0.69 and 80% specificity) compared with measured ECV would obviate the need to perform 3940 cardiac magnetic resonance scans, at the cost of an additional 3052 participants screened and 705 participants enrolled.

CONCLUSIONS

Predicted ECV (derived without tomographic imaging) associates with outcomes and efficiently identifies vulnerable patients who might benefit from treatment. Predicted ECV may foster the design of phase 3 trials targeting myocardial fibrosis with higher numbers of screened and enrolled participants, but with simplified eligibility criteria, avoiding the complexity of tomographic imaging.

Outcomes and Left Ventricular Ejection Fraction in Cardiac Magnetic Resonance: Challenging the "Higher Is Better"

BACKGROUND

Contradictory evidence exists regarding the correlation between supranormal left ventricular ejection fraction (LVEF) and adverse outcomes. This study aimed to elucidate the prognostic value of supranormal LVEF.

METHODS

This retrospective cohort study analyzed patients referred for cardiac magnetic resonance imaging to assess myocardial ischemia or viability. Subjects were stratified into eig8ht LVEF groups: <20%, 20% to 30%, 30% to 40%, 40% to 50%, 50% to 60%, 60% to 70%, 70% to 80%, and ≥80%. Primary outcomes included cardiovascular death, heart failure, myocardial infarction, and stroke. The extracellular volume fraction was measured.

RESULTS

The study cohort comprised 3279 patients (mean age 68.0±12.7 years; 64.0% female). The group with 60% to 70% LVEF had the lowest risk and was used as the reference group. The median follow-up was 41.4 months (interquartile range, 33.9-49.7 months). The group with LVEF <20% exhibited the highest composite outcome risk (unadjusted hazard ratio [HR], 6.77 [95% CI, 3.81-12.03]; P<0.001; adjusted HR, 2.68 [95% CI, 1.28-5.62]; P<0.001). The groups with LVEF 70% to 80% and ≥80% showed increased risk (adjusted HR, 1.96 [95% CI, 1.23-3.08]; P=0.004; 2.16 [95% CI, 1.33-3.52]; P=0.002, respectively). A greater extracellular volume fraction was associated with an LVEF of 70% to 80% and ≥80% (adjusted odds ratios, 1.34 [95% CI, 1.03-1.74]; P=0.027; and 1.74 [95% CI, 1.30-2.34]; P<0.001, respectively).

CONCLUSIONS

LVEF >70% demonstrated increased event rates compared with an LVEF of 60% to 70%. The supranormal LVEF warrants further investigation into its pathogenesis and management.

Immunosuppressive therapy to treat newly diagnosed primary heart involvement in patients with systemic sclerosis: An Italian cardiac magnetic resonance based study

BACKGROUND

Primary heart involvement (pHI) is frequent in systemic sclerosis (SSc), and is associated with a poor prognosis. Therapeutic strategies to treat SSc-pHI are not yet defined.

OBJECTIVES

To evaluate the efficacy of immunosuppressive therapy on cardiac magnetic resonance (CMR) features in patients with CMR-proven SSc-pHI.

METHODS

The data from SSc patients with CMR-proven pHI who start or modify immunosuppressive therapy as indication for the newly diagnosed pHI and who had a follow-up CMR with parametric mapping after 6 to 18 months were analyzed. All patients underwent a comprehensive baseline evaluation of disease characteristics and organ involvement. In all patients, cardiac involvement was investigated at baseline and at follow up with CMR, evaluating: myocardial edema at STIR images, native-T1 and T2-mapping, extracellular volume fraction (ECV), and late gadoliunum enhancement (LGE). A p value <0.05 was considered as statistically significant.

RESULTS

Out of a cohort of 684 SSc patients, 35 (5.1 %) with SSc-pHI (females 77.1 %; median age 59 [46-64] years; anti-topoisomerase-I positivity 48.6 %; diffuse disease 34.3 %) were selected. In the majority of patients (74.3 %) at baseline CMR, signs of active myocardial inflammation (edema at STIR and/or increased T2-mapping) were found. Mycophenolate mofetil (MMF) was started in 15 (42.9 %) or increased in 7 (20.0 %) cases; 7 patients (20.0 %) received rituximab, 3 (8.6 %) azathioprine, while 3 patients were treated each one with cyclophosphamide (with pulse steroids), tocilizumab and hydroxychloroquine (with steroids). The median duration of immunosuppression was 12.0 [6.0-15.5] months. At follow-up CMR (performed after a median time 12.0 [6.5-16.0] months), increased T2-mapping suggestive for active myocardial inflammation was present in only 14 patients (40 %) (p = 0.003), and edema at STIR was present in 5 cases only (14.3 %) (p = 0.002). A significant reduction of T2-mapping (from 53.0 [49.0-55.0] to 51.0 [50.0-54.0] ms, p < 0.001), native-T1-mapping (from 1050.0 [1007.0-1084.0] to 1039.0 [1020.5-1080.5] ms, p = 0.022) and ECV (from 34.0 [31.0-36.75] to 33.0 [29.0-34.25] %, p = 0.041) was observed, especially in those with baseline increased mapping (T2-mapping from 53.0 [53.0-56.0] to 52.0 [50.0-57.0] ms; T1-mapping from 1066.0 [1050.0-1089.0] to 1057.0 [1027.5-1090.0] ms, p < 0.0001 for both]. The amelioration of the CMR features was paralleled by significant reduction of NT-proBNP (p = 0.008), high-sensitive troponin T (p = 0.003) and C-reactive protein (p = 0.010). No treatment-related adverse events were recorded.

CONCLUSIONS

Our data show that immunosuppression is a therapeutic strategy which has the potentiality to treat newly diagnosed SSc-pHI, by curbing signs of myocardial inflammation at CMR, and by significantly reducing cardiac enzymes, inflammatory markers and overall clinical burden. Larger prospective randomized studies are needed to confirm these data.

Evaluating the Effect of Heart Rate on T2 Balanced Steady-State Free Precession Cardiac MRI Mapping

Purpose To evaluate heart rate as a patient-related confounder in a commonly applied T2 balanced steady-state free precession (bSSFP) mapping sequence used for myocardial tissue characterization. Materials and Methods This retrospective analysis included prospectively (from December 2013 to November 2021) acquired cardiac MRI (1.5 T) datasets with T2 bSSFP mapping from 69 healthy volunteers. Phantom studies and Bloch simulations were performed with heart rates of 60-130 beats per minute and different resting periods (three, six, or nine R-R intervals). Sequence parameters (repetition time, echo time, flip angle, echo train length) were matched across volunteer, phantom, and simulation measurements. Reference values covered clinically relevant T1 and T2 properties found in native myocardium (short, 1041 and 44 msec; medium, 1293 and 43 msec; long, 1534 and 40 msec). A mixed linear model assessed the effect of heart rate on T2 values in volunteer measurements. Results The study included 69 healthy volunteers (median age, 34 years; 44 female and 25 male). Heart rate influenced T2 values acquired with three R-R resting periods (r = -0.38, P = .002; linear regression slope, -0.7 msec/10 beats per minute [95% CI: -1.2, -0.1]). In simulation and phantom measurements, T2 values acquired with three R-R resting periods strongly correlated with heart rate, irrespective of myocardial T1 and T2 properties (r ≤ -0.88; P < .01 for all measurements). Heart rate dependency was reduced with increased resting periods in simulations and phantom measurements. Short myocardial T1 and T2 values derived from T2 bSSFP with nine R-R resting periods were not dependent on heart rate (r = -0.41; P = .33). Conclusion T2 bSSFP with three R-R resting periods underestimates T2 values with increasing heart rates. Use of longer resting periods with T2 bSSFP mapping sequences reduced heart rate dependency. Keywords: Cardiac, Phantom Studies, Myocardium, MRI, Confounding Variables Supplemental material is available for this article. Published under a CC BY 4.0 license.

Non-invasive Imaging Findings of Wild-type Transthyretin Amyloid Cardiomyopathy in Women: A Retrospective Study

RATIONALE AND OBJECTIVES

Wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) predominantly affects males; however, female patients can also develop this condition. This study assessed the non-invasive imaging features of ATTRwt-CM in female patients.

MATERIALS AND METHODS

In this study, 106 consecutive patients diagnosed with ATTRwt-CM were retrospectively analyzed, evaluating sex-related differences in imaging features, including echocardiography, cardiac magnetic resonance (CMR), and 99mTc-labeled pyrophosphate (99mTc-PYP) scintigraphy.

RESULTS

12 of 106 patients (11.3%) were female. They were significantly older at diagnosis (75 years [interquartile range, 71-79 years] vs. 79 years [77-83 years]; p<0.01). The proportion of female patients increased with age, from 7.5% (6/80) in those aged <80 years to 23.1% (6/26) in those aged ≥80 years. CMR-measured left ventricular ejection fraction (LVEF) was significantly higher in female patients (50.0% [42.0-61.0%] vs. 59.5% [44.3-72.3%]; p=0.04). No significant sex-related differences in LV mass and global longitudinal strain were observed. In T1 mapping, no significant difference in native T1 was observed; however, the extracellular volume fraction (ECV) was significantly lower in female patients (54.2% [46.5-66.0%] vs. 50.4% [42.0-55.0%]; p=0.04). Furthermore, no significant difference in myocardial T2 value was observed. Late gadolinium enhancement was more extensively observed in males than in females. The heart-to-contralateral ratio in 99mTc-PYP scintigraphy was significantly lower among female patients (1.88 [1.70-2.04] vs. 1.64 [1.58-1.74]; p=0.02).

CONCLUSION

CMR findings revealed that females exhibited higher LVEF, lower ECV, and weaker cardiac uptake on 99mTc-PYP scintigraphy, indicating a milder myocardial amyloid burden. No significant sex-related differences in echocardiographic parameters or other CMR indices were observed.

Sex-Specific Associations of Cardiovascular Risk Factors with Subclinical Cardiac Remodeling: A Magnetic Resonance Imaging Study

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women, yet sex-specific risk factor influences remain understudied. Cardiac magnetic resonance imaging (CMR) detects early remodeling via left ventricular mass-to-volume ratio (LVMV), a validated concentricity marker. This study examines sex differences in the association of CV risk factors, diet, and cardiac remodeling.

METHODS

We analyzed 622 age-matched adults (51% female, mean age 50.8 ± 9.5) from the Courtois Cardiovascular Signature Program. LVMV was defined as LV systolic mass divided by end-diastolic volume. Alcohol and sugar intake was self-rated on a Likert scale. Mann-Whitney U and regression analyses assessed sex-specific associations between CV risk factors and LVMV.

RESULTS

Hypertension was present in 20.6% of males and 17.4% of females; diabetes in 9.8% and 6.0%. Males had higher triglycerides, alcohol/sugar intake, and LVMV (0.92 ± 0.20 vs. 0.77 ± 0.18 g/ml). Hypertension correlated with higher LVMV in both sexes (males: ß=0.099, p<0.001; females: ß=0.078, p<0.05), while triglycerides (ß=0.032, p<0.05) and alcohol intake (H=19.41, p<0.0001) were male-specific predictors. In females, diabetes and sugar intake were significantly associated with LVMV (ß=0.102, ß=0.062, p<0.05).

CONCLUSIONS

CV risk factors impact cardiac remodeling differently by sex. In males, LVMV was linked to triglycerides and alcohol intake, while in females, diabetes and sugar intake showed stronger associations. These results underscore the need for tailored cardiovascular prevention strategies that account for sex differences in metabolic and lifestyle risk factors.

Comprehensive reference ranges for cardiovascular magnetic resonance: time to move on from single centre data?

Cardiovascular magnetic resonance (CMR) provides gold standard, and often unique, measurements of cardiovascular structure, function and tissue character. Fundamental to such capabilities are clearly defined normal ranges. This study aimed to (1) Determine normal ranges for an extensive set of CMR measurements, and the inter-scan reproducibility of these measurements; (2) Determine the impact of common variations in practice, and; (3) Systematically evaluate the findings in the context of published reference ranges. One hundred and 22 healthy adults, including a minimum of 10 males and 10 females per age decile, underwent assessment including CMR (3 T, Siemens). Twenty participants returned for a second CMR. Image analysis was performed using cvi42 by experienced observers. Age- and sex-specific reference ranges, in tabular and normogram formats, and their interscan reproducibility, are provided for left ventricular mass, wall thickness, volumes and ejection fraction; right ventricular volumes and ejection fraction; longitudinal, radial and circumferential LV strains; atrial area, volume and strains; native T1, T2, T2*, aortic distensibility and pulse wave velocity. Measurement reproducibility improved when baseline scans were used for reference, e.g., for basal slice selection. Myocardial T1 was the most reproducible of all CMR measurements. Common variations in practice resulted in significant measurement differences e.g., indexed left atrial volume was larger (47.3 vs 40.3 ml/m2, P < 0.0001), and its measurement less variable, when measured from atrial short-axis cine stacks compared to biplanar measurement from 4- to 2-chamber cines. Studies using similar methods to define normal ranges demonstrate clinically-relevant differences in the normal ranges produced. A comprehensive set of age and sex specific CMR reference ranges are provided, along with inter-scan reproducibility and the impact of common variations in practice. Single centre studies, whilst meticulous in design and delivery, result in clinically-relevant variations in normal ranges. We advocate that larger cohorts, including diverse ethnicities, such as the Healthy Hearts Consortium, may be a better approach to defining normal ranges for common CMR measurements.

Protocol of the follow-up of patients with transthyretin amyloid cardiomyopathy by multimodality imaging (FAITH) study: a prospective observational study in patients with ATTR-CM undergoing treatment with tafamidis

INTRODUCTION

This prospective observational study of patients with transthyretin amyloid cardiomyopathy (ATTR-CM) undergoing treatment with tafamidis aims at identifying quantitative image markers and comparing imaging modalities regarding the follow-up and prognostication of these patients, with the goal of providing a multiparametric score to predict treatment response.

METHODS AND ANALYSIS

Patients with a board-approved decision to receive tafamidis will undergo, in addition to standard of care, baseline and follow-up cardiovascular magnetic resonance (CMR) scans at 9 and 18 months. In total, the study plans to recruit and scan 60 patients. A blinded read will take place in a CMR research core laboratory. The final statistical analysis will be based on developing a multiparametric score for the prediction of treatment response. The study will be managed through the Amyloidosis Center Charité Berlin, a clinical unit formed from the three clinical campus sites of the Charité in Berlin, using the Berlin Research Network for CMR.

ETHICS AND DISSEMINATION

The study was approved by the Charité-Universitätsmedizin Berlin ethics committee EA1/262/23. The results of the study will be disseminated through international peer-reviewed publications and congress presentations.

TRIAL REGISTRATION NUMBER

Approved WHO primary register: German Clinical Trials Register: https://www.drks.de/DRKS00033884. WHO International Clinical Registry Platform: https://trialsearch.who.int/?TrialID=DRKS00033884. Recruitment started on 1 July 2024.

MRI-Extracellular Volume Fraction Versus Histological Amyloid Load in Cardiac Amyloidosis: The Importance of T2 Mapping

BACKGROUND

MRI-derived myocardial extracellular volume fraction (ECV) is elevated in the presence of fibrosis, amyloid deposition, inflammation and edema. In patients with cardiac amyloidosis and prolonged T2 due to concomitant inflammation or edema, MRI-ECV may not correctly reflect histological amyloid load. The authors sought to determine whether MRI-ECV can accurately reflect histological amyloid load in 2 groups of patients with wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM), with and without T2 prolongation.

METHODS

This retrospective study included consecutive patients with ATTRwt-CM who underwent endomyocardial biopsy and cardiac MRI from March 2017 to October 2021 for initial evaluation of ATTRwt-CM. We measured MRI-ECV and T2, and evaluated correlation between MRI-ECV and amyloid load from endomyocardial biopsy by means of Pearson correlation analysis.

RESULTS

Of 44 patients (mean age, 75±6 years [SD]; 40 men), 24 showed T2 prolongation (T2≥50 milliseconds). All specimens obtained by endomyocardial biopsy were suitable for analysis. The interval between endomyocardial biopsy and cardiac MRI examination was a median of 3 days (interquartile range, 2-4). In the absence of T2 prolongation due to increased water content, MRI-ECV and amyloid load showed a moderately significant correlation (Spearman ρ=0.50, P=0.03). However, in the presence of T2 prolongation, there was no significant correlation between MRI-ECV and amyloid load (Spearman ρ=-0.05, P=0.83).

CONCLUSIONS

In patients with ATTRwt-CM and prolonged T2, MRI-ECV did not accurately reflect histological amyloid load. Our findings underscore the need for a multiparametric imaging approach, combining both ECV and T2 mapping, to better characterize myocardial tissue in patients with ATTRwt-CM, and further prospective research in larger and more diverse cohorts is needed to validate our results.

Characterizing Extravascular Lung Water - A Dual Contrast Agent Extracellular Volume Approach by Cardiovascular Magnetic Resonance

INTRODUCTION

Pathological extravascular lung water is a facet of decompensated congestive heart failure that current cardiovascular magnetic resonance (CMR) methods fail to quantify. CMR can measure total lung water density, but cannot distinguish between intravascular and extravascular fluid, and thus is not diagnostic. Therefore, we develop and evaluate a novel method to measure extravascular lung water by distinguishing intravascular from extracellular fluid compartments using two different contrast agents, extracellular gadolinium-chelates and iron-based intravascular ferumoxytol.

MATERIALS AND METHODS

We created two porcine models of pulmonary edema: reversible catheter-induced mitral regurgitation to induce extravascular lung water (n=5); intravascular volume overload using rapid colloid infusion (n=5); and compared to normal controls (n=8). We sequentially acquired lung T1-maps and lung water density maps at 0.55T with native, gadolinium-based, and ferumoxytol contrast, from which we calculated the extracellular volume (ECV) and blood plasma volume fraction in the pulmonary tissue, respectively. We computed extravascular ECV as the difference in ECV and plasma volume fractions. Extravascular lung water volumes were estimated.

RESULTS

In the mitral regurgitation model, baseline vs mitral regurgitation ECVextravascular increased from 27±4.1% to 32±1.9% (p=0.006), and extravascular lung water volume increased from 105±19ml to 143±15ml (p=0.048). Plasma volume fraction was similar at baseline vs mitral regurgitation (43±4.2% vs 46±5.4%, p=0.26). Compared to naïve pigs, we measured higher plasma volume fractions in the intravascular volume loaded model (42±4.7% vs 51±2.7%, p=0.0054), but no differences in ECVextravascular (21±4.6% vs 21±3.6%, p=0.99) or extravascular lung water volume (67±13ml vs 89±24ml, p=0.11). Assessing the regional distribution, the plasma volume was higher posteriorly, indicating gravitational dependency, whereas, the extravascular lung water was higher anteriorly.

CONCLUSION

Extravascular lung ECV measurements and derived lung water volumes corresponded well with predicted increases in extravascular and intravascular pulmonary fluid in animal models. This method may enable mechanistic studies of lung water in patients with dyspnea.

Utility of Cardiac CT for Cardiomyopathy Phenotyping

Cardiac computed tomography (CT) has rapidly advanced, becoming an invaluable tool for diagnosing and prognosticating various cardiovascular diseases. While echocardiography and cardiac magnetic resonance imaging (CMR) remain the gold standards for myocardial assessment, modern CT technologies offer enhanced spatial resolution, making it an essential tool in clinical practice. Cardiac CT has expanded beyond coronary artery disease evaluation, now playing a key role in assessing cardiomyopathies and structural heart diseases. Innovations like photon-counting CT enable precise estimation of myocardial extracellular volume, facilitating the detection of infiltrative disorders and myocardial fibrosis. Additionally, CT-based myocardial strain analysis allows for the classification of impaired myocardial contractility, while quantifying cardiac volumes and function remains crucial in cardiomyopathy evaluation. This review explores the emerging role of cardiac CT in cardiomyopathy phenotyping, emphasizing recent technological advancements.

Metrology for MRI: the field you've never heard of

Quantitative MRI has been an active area of research for decades and has produced a huge range of approaches with enormous potential for patient benefit. In many cases, however, there are challenges with reproducibility which have hampered clinical translation. Quantitative MRI is a form of measurement and like any other form of measurement it requires a supporting metrological framework to be fully consistent and compatible with the international system of units. This means not just expressing results in terms of seconds, meters, etc., but demonstrating consistency to their internationally recognized definitions. Such a framework for MRI is not yet complete, but a considerable amount of work has been done internationally towards building one. This article describes the current state of the art for MRI metrology, including a detailed description of metrological principles and how they are relevant to fully quantitative MRI. It also undertakes a gap analysis of where we are versus where we need to be to support reproducibility in MRI. It focusses particularly on the role and activities of national measurement institutes across the globe, illustrating the genuinely international and collaborative nature of the field.

Cardiac MRI study of adverse events in patients treated with immune checkpoint inhibitors: a prospective cohort study of cardiac adverse events

Immune checkpoint inhibitors (ICIs) revolutionized cancer therapy, yet require management of immune-related adverse events (irAEs). Fulminant myocarditis is a rare irAE, but lower-severity cardiac events are being reported more frequently, leading to an unmet need for irAE prevention, early diagnosis, and treatment, especially for long-life-expectancy patients. We recruited 57 patients, stratified according to therapy regime (monotherapy (30%) or combination (33%) cohort) or history of cardiac disease or presence of at least two cardiovascular risk factors other than prior or active smoking (cardiovascular cohort (37%)). We performed a complete cardiological assessment with clinical visit, 12-lead ECG, multiparametric cardiac MRI as well as peripheral blood mononuclear cell immunophenotyping, prior to ICI initiation and around 2 months later. ICI treatment was associated with a significant left ventricular ejection function (LVEF) reduction pre-ICI versus post-ICI treatment (60.1±8% to 58.1±8%, p=0.002, paired t-test) and more than 3% LVEF loss in a substantial proportion of patients (18; 32%). These patients also showed significantly higher T2 values (p=0.037, unpaired t-test), putative sign of cardiac edema. The loss of cardiac function did not differ among patients with different tumor types, therapy regimes or history of cardiac disease. Immunophenotyping analyses showed a reduction of programmed cell death protein 1 staining on both CD4+ and CD8+ T cells, and an upregulation of HLA-DR on CD8+ T cells. Using a very sensitive and comprehensive approach in patients unselected for cardiac history, we found a subclinical but significant LVEF decrease. These findings may inform ongoing discussions on optimal management of cardiac irAEs in patients undergoing ICI treatment and warrant further evaluation.

Associations between Growth Differentiation Factor 15, Cardiac Troponin T, and N-terminal pro-B-type Natriuretic Peptide, and Future Myocardial Fibrosis Assessed by Cardiac Magnetic Resonance Imaging: Data from the Akershus Cardiac Examination 1950 Study

BACKGROUND

Myocardial fibrosis is associated with a poor outcome for patients with cardiovascular disease (CVD). Growth differentiation factor 15 (GDF-15) concentrations predict the risk of death in patients with CVD, but the underlying pathophysiological mechanisms are poorly understood. We aimed to assess the associations between biomarkers of cellular stress and inflammation (GDF-15), cardiac injury (cardiac troponin T [cTnT]), and stretch (N-terminal pro-B-type natriuretic peptide [NT-proBNP]), and subsequent focal and diffuse myocardial fibrosis assessed by cardiac magnetic resonance (CMR) imaging.

METHODS

We measured GDF-15, cTnT, and NT-proBNP in 200 study participants without known coronary artery disease or renal dysfunction from the population-based Akershus Cardiac Examination 1950 Study at baseline in 2012 to 2015. Focal myocardial scars and diffuse fibrosis were assessed by late gadolinium enhancement imaging and septal extracellular volume fraction (ECV) by CMR 4 to 7 years later. The relationships between cardiac biomarkers and CMR parameters were assessed by logistic regression analysis adjusted for common cardiovascular risk factors.

RESULTS

The median age was 63.9 (interquartile range 63.4-64.5) years and 49% were women. GDF-15 (adjusted odds ratio [aOR] 4.40, 95% CI 1.09-17.72) and cTnT (aOR 1.59, 95% CI 1.01-2.50) were associated with nonischemic scars in the fully adjusted model. cTnT (aOR 2.45, 95% CI 1.41-4.25) and NT-proBNP (aOR 3.12, 95% CI 1.55-6.28) were associated with ischemic scars. None of the biomarkers were significantly associated with elevated ECV.

CONCLUSIONS

In a general population cohort, GDF-15, an emerging biomarker of cellular stress and inflammation, associates with nonischemic scars. Biomarkers of myocardial injury and stretch associate with ischemic scars, while no biomarker was associated with diffuse fibrosis as assessed by CMR.

CT-derived extracellular volume fraction in aortic stenosis, cardiac amyloidosis, and dual pathology

AIMS

To investigate CT-derived extracellular volume fraction (CT-ECV) in patients with lone aortic stenosis (AS), dual pathology of AS and transthyretin cardiac amyloidosis (AS-ATTR), and lone ATTR, and to examine the diagnostic performance and optimal cut-off values of CT-ECV for differentiating between patients with lone AS and AS-ATTR and between patients with lone AS and lone ATTR.

METHODS AND RESULTS

This retrospective study included consecutive patients with severe AS (including lone AS and AS-ATTR) and lone ATTR who underwent CT-ECV analysis and technetium 99 m pyrophosphate (99mTc-PYP) scintigraphy. The diagnostic performance of CT-ECV for detecting cardiac amyloidosis was evaluated using the area under the receiver operating characteristic curve (AUC). Of 138 patients (mean age, 80 ± 8; 96 men), 55 had lone AS, 19 had AS-ATTR, and 64 had lone ATTR. CT-derived extracellular volume fraction of patients with lone AS was 31 ± 5%. CT-derived extracellular volume fraction was significantly lower in patients with AS-ATTR than lone ATTR (45 ± 12% vs. 53 ± 13%, P = 0.04). The AUC for differentiating patients with AS-ATTR from lone AS was lower than for lone ATTR from lone AS [0.90 (95% CI: 0.81, 0.96) vs. 0.95 (95% CI: 0.90, 0.98)]. The cut-off values of CT-ECV for differentiation between patients with lone AS and AS-ATTR were lower than those between patients with lone AS and lone ATTR [36.6% vs. 38.5% (Youden index)]. There was no significant difference in the proportion of 99mTc-PYP scintigraphy grade between patients with AS-ATTR and lone ATTR (P = 0.20).

CONCLUSION

Despite no significant difference in degree of ATTR between patients with AS-ATTR and lone ATTR, CT-ECV of patients with dual AS-ATTR pathology was significantly lower than that of patients with lone ATTR. The diagnostic performance and optimal cut-off values of CT-ECV for differentiating between patients with lone AS and AS-ATTR were lower than those between patients with lone AS and lone ATTR.

Prognostic value of myocardial computed tomography-derived extracellular volume in severe aortic stenosis requiring aortic valve replacement: a systematic review and meta-analysis

Computed tomography (CT)-derived extracellular volume (ECV) fraction is a non-invasive method to quantify myocardial fibrosis. Evaluating CT-ECV during aortic valve replacement (AVR) planning CT in severe aortic stenosis (AS) may aid prognostic stratification. This meta-analysis evaluated the prognostic significance of CT-ECV in severe AS necessitating AVR. Electronic database searches of PubMed, Ovid MEDLINE, and Cochrane Library were performed. The primary outcome was to compare the occurrence of a composite of cardiovascular outcomes in patients with severe AS undergoing AVR with elevated myocardial CT-ECV values vs. patients with normal values. Secondary outcomes included all-cause mortality and heart failure (HF)-related hospitalization. A total of 1223 patients undergoing AVR for severe AS were included in 10 studies: 524 patients with high values of CT-ECV and 699 with normal values of CT-ECV. The pooled CT-ECV cut-off to define elevated values and predict prognosis was 30.7% [95% confidence interval (CI): 28.5-33.7%]. At a mean follow-up of 17.9 ± 2.3 months after AVR, patients with elevated CT-ECV experienced a significantly higher number of cardiovascular events [43.4 vs. 14.0%; odds ratio (OR): 4.3, 95% CI: 3.192-5.764, P < 0.001]. Regarding secondary outcomes, all-cause mortality occurred in 29.3% of patients with elevated CT-ECV vs. 11.6% with CT-ECV below the cut-off (OR: 3.5, 95% CI: 2.276-5.311, P < 0.001), whereas HF hospitalization was observed in 25.5% vs. 5.9% (OR: 4.9, 95% CI: 2.283-10.376, P < 0.001). Patients undergoing AVR for severe AS with elevated CT-ECV values experience a worse post-intervention prognosis. The implementation of CT-ECV evaluation in routine AVR planning protocols should be considered.

Repeatability of radiomic features in myocardial T1 and T2 mapping

PURPOSE

To investigate the test-retest repeatability of radiomic features in myocardial native T1 and T2 mapping.

METHODS

In this prospective study, 50 healthy volunteers (29 women and 21 men, mean age 39.4 ± 13.7 years) underwent two identical cardiac magnetic resonance imaging (MRI) examinations at 1.5 T. The protocol included native T1 and T2 mapping in both short-axis and long-axis orientation. For T1 mapping, we investigated standard (1.9 × 1.9 mm) and high (1.4 × 1.4 mm) spatial resolution. After manual segmentation of the left ventricular myocardium, 100 radiomic features from seven feature classes were extracted and analyzed. Test-retest repeatability of radiomic features was assessed using the intraclass correlation coefficient (ICC) and classified as poor (ICC < 0.50), moderate (0.50-0.75), good (0.75-0.90), and excellent (> 0.90).

RESULTS

For T1 maps acquired in short-axis orientation at standard resolution, repeatability was excellent for 6 features, good for 29 features, moderate for 19 features, and poor for 46 features. We identified 15 features from 6 classes which showed good to excellent reproducibility for T1 mapping in all resolutions and all orientations. For short-axis T2 maps, repeatability was excellent for 6 features, good for 25 features, moderate for 23 features, and poor for 46 features. 12 features from 5 classes were found to have good to excellent repeatability in T2 mapping independent of slice orientation.

CONCLUSION

We have identified a subset of features with good to excellent repeatability independent of slice orientation and spatial resolution. We recommend using these features for further radiomics research in myocardial T1 and T2 mapping.

KEY POINTS

Question The study addresses the need for reliable radiomic features for quantitative analysis of the myocardium to ensure diagnostic consistency in cardiac MRI. Findings We have identified a subset of radiomic features demonstrating good to excellent repeatability in native T1 and T2 mapping independent of slice orientation and resolution. Clinical relevanceRadiomic features have been proposed as diagnostic and prognostic biomarkers in various heart diseases. By identifying a subset of particularly reproducible radiomic features our study serves to inform the selection of radiomic features in future research and clinical applications.

Fast cardiac magnetic resonance protocol. Feasibility of accelerated compressed sensing cine sequences in clinical practice

OBJECTIVE

To demonstrate the feasibility of cardiac magnetic resonance (CMR) cine sequences with compressed-sensing (CS) acceleration in the assessment of ventricular anatomy, volume, and function; and to present a fast CRM protocol that improves scan efficiency.

METHODS

Prospective study of consecutive patients with indication for CMR who underwent CS short-axis (SA) cine imaging compared with conventional SA cine imaging. We analysed ejection fraction (EF), end-diastolic volume (EDV), stroke volume (SV), and myocardial thickness. Two blinded independent observers performed the reading. Inter- and intraobserver agreement was calculated for all the measurements. Image quality of conventional and CS cine sequences was also assessed.

RESULTS

A total of 50 patients were included, 22 women (44%) with a mean age of 57.3 ± 13.2 years. Mean left ventricular EF was 59.1% ± 10.4% with the reference steady-state free precession sequences, versus 58.7% ± 10.6% with CS; and right ventricular EF with conventional imaging was 59.3% ± 5.7%, versus 59.5% ± 6.1% with CS. Mean left ventricular EDV for conventional sequences and CS were 166.8 and 165.1 ml respectively; left ventricular SV was 94.5 versus 92.6 ml; right ventricular EDV was 159.3 versus 156.4 ml; and right ventricular SV was 93.6 versus 91.2 ml, respectively. Excellent intra and interobserver correlations were obtained for all parameters (Intraclass correlation coefficient between 0.932 and 0.99; CI: 95%). There were also no significant differences in ventricular thickness (12.9 ± 2.9 mm vs 12.7 ± 3.1 mm) (p < .001). The mean time of CS SA was <40 sec versus 6-8 min for the conventional SA. The mean duration of the complete study was 15 ± 3 min.

CONCLUSIONS

Cine CS sequences are feasible for assessing biventricular function, volume, and anatomy, enabling fast CMR protocols.

Free-breathing multi-parametric SASHA (mSASHA) mapping provides reliable non-contrast myocardial characterization in a pediatric and adult congenital population

Parametric mapping has become a standard of care technique for the non-invasive assessment of myocardial edema and fibrosis. Conventional MOLLI-based T1 mapping is susceptible to many confounding effects particularly in the pediatric population. The requirement for compliant breath holds is a major limitation for younger or more ill patients. The advent of free-breathing SASHA-based multi-parametric mapping with motion correction therefore offers a significant advantage in pediatric cohorts. With IRB approval and consent/assent, children and adults with congenital heart disease underwent both conventional breath-held MOLLI-based T1 and T2 TrueFISP mapping as well as free-breathing multi-parametric SASHA assessment in the context of a clinically indicated study on a 1.5T magnet. A total of 71 subjects with mean age of 19.3 ± 8.6 years were scanned. Free-breathing multiparametric SASHA T1 and T2 values were moderately correlated with breath-held MOLLI/T2p-bSSFP (r = 0.52). Importantly free-breathing SASHA-based T1 maps were able to discriminate between patients with late gadolinium enhancement with a statistically significant difference in mean T1 values (p = 0.03). Free-breathing multiparametric SASHA allows for reliable myocardial characterization with moderate correlation to conventional breath-held T1 and T2 mapping techniques in a small and heterogenous sample of pediatric and congenital cardiac subjects.

MRI-serum-based score accurately identifies patients undergoing liver transplant without rejection avoiding the need for liver biopsy: A multisite European study

Serum liver tests (serum tests) and histological assessment for T-cell-mediated rejection are essential for post-liver transplant monitoring. Liver biopsy carries a risk of complications that are preferably avoided in low-risk patients. Multiparametric magnetic resonance imaging (mpMRI) is a reliable noninvasive diagnostic method that quantifies liver disease activity and has prognostic utility. Our aim was to determine whether using mpMRI in combination with serum tests could noninvasively identify low-risk patients who underwent liver transplants who are eligible to avoid invasive liver biopsies. In a multicenter prospective study (RADIcAL2), including 131 adult and pediatric (children and adolescent) patients with previous liver transplants from the Netherlands, Portugal, and the United Kingdom, concomitant mpMRI and liver biopsies were performed. Biopsies were centrally read by 2 expert pathologists. T-cell-mediated rejection was assessed using the BANFF global assessment. Diagnostic accuracy to discriminate no rejection versus indeterminate or T-cell-mediated liver transplant rejection was performed using the area under the receiver operating characteristic curve. In this study, 52% of patients received a routine (protocol) biopsy, while 48% had a biopsy for suspicion of pathology. Thirty-eight percent of patients had no rejection, while 62% had either indeterminate (21%) or T-cell-mediated rejection (41%). However, there was a high interobserver variability (0 < Cohen's Kappa < 0.85) across all histology scores. The combined score of mpMRI and serum tests had area under the receiver operating characteristic curve 0.7 (negative predictive value 0.8) to identify those without either indeterminate or T-cell-mediated rejection. Combining both imaging and serum biomarkers into a composite biomarker (imaging and serum biomarkers) has the potential to monitor the liver graft to effectively risk stratify patients and identify those most likely to benefit from a noninvasive diagnostic approach, reducing the need for liver biopsy.

Feasibility of the absolute quantification and left ventricular segmentation of cardiac sympathetic innervation in wild-type transthyretin amyloidosis cardiomyopathy with [123I]-MIBG SPECT/CT: The I-NERVE study

BACKGROUND

Cardiac sympathetic neuronal dysfunction is an early marker in wild-type transthyretin amyloidosis cardiomyopathy (ATTRwt-CM). Iodine-123-labeled norepinephrine analog meta-iodobenzylguanidine ([123I]-MIBG) imaging evaluates cardiac sympathetic innervation but lacks volumetric activity quantification in current methods. This study aims to quantify cardiac sympathetic neuronal dysfunction in ATTRwt-CM using [123I]-MIBG single-photon emission computed tomography/ computed tomography (SPECT/CT) and correlate findings with functional and structural cardiac parameters from echocardiogram and cardiac magnetic resonance imaging (CMR).

METHODS

We conducted a single-center, descriptive, cross-sectional study to quantify absolute myocardial sympathetic function in ATTRwt-CM using [123I]-MIBG SPECT/CT. Retrospective reconstruction allowed for absolute tracer-uptake quantification of the left ventricle, overall and segmented, in kBq/mL, standard uptake value (SUV), and percentage of the injected dose (%ID). Echocardiography, CMR, and bone scintigraphy were performed according to clinical standards. Segmented [123I]-MIBG SPECT/CT values were correlated with global longitudinal systolic strain (GLSS) on echocardiography, native-T1, and extracellular volume (ECV) on CMR using SPECT/CT fused with CMR.

RESULTS

Twenty-nine ATTRwt-CM patients (75.8 ± 6.6 years, 90% male) were prospectively included. All exhibited cardiac sympathetic neuronal dysfunction, with a median late heart-to-mediastinum ratio of 1.69 (1.45-1.89) and a washout rate of 22.7% (16.4%-27.3%). SUVmean, SUVpeak, SUVmax, and %ID were 1.80 ± .78, 3.84 ± 1.41, 4.46 ± 1.68, and .46 ± .18, respectively, correlating with semiquantitative [123I]-MIBG measures. No correlations were found with GLSS on echocardiography or native T1 and ECV on CMR.

CONCLUSIONS

The current study demonstrates the feasibility of volumetric quantification of [123I]-MIBG SPECT/CT in ATTRwt-CM. SUVmean, SUVpeak, SUVmax, and %ID correlate with semi-quantitative measures but not with key cardiac parameters on echocardiography or CMR. This confirms the sensitivity of [123I]-MIBG SPECT/CT to different aspects of cardiac function or pathology.

TRIAL REGISTRATION

EudraCT ref. 2020-003350-72, retrospectively registered March 20, 2023. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT05776212.

Cardiovascular magnetic resonance in Tetralogy of Fallot-state of the art

Tetralogy of Fallot (TOF) is the most common type of cyanotic congenital heart disease expressing different severity. There is an increasing survival into adulthood and most patients now experience a good quality of life. Still, complications will develop over time related to the primary surgery and the resulting remodeling of the heart and vessels, which will require reintervention or operation several times during their lives. Imaging plays an increasingly important role in the diagnosis and follow-up of these patients, such as echocardiography as the basic modality, as well as computed tomography angiography (CTA) and cardiac catheterization, providing important anatomical data and the possibility for interventional treatment. Cardiovascular magnetic resonance (CMR) imaging is increasingly used and has a central role in finding the optimal time point for reintervention and provides excellent morphological as well as functional and hemodynamic data that have been proven indicative for reintervention and patient outcome. New MR techniques have been developed providing quantitative information of myocardial tissue characterization, deformation and 4-dimensional phase contrast (PC) imaging technique for advanced blood flow measurements with promising results to provide more refined indications for reoperations and interventions. This review will treat the current role of CMR in the diagnosis and follow up in TOF after repair involving the traditional MR sequences as well as new emerging techniques and their potential role in repaired TOF.

Cardiac magnetic resonance imaging in the follow-up of patients with Fabry cardiomyopathy

PURPOSE

The purpose of this study was to evaluate the role of cardiac magnetic resonance imaging (MRI) in the follow-up of patients with Fabry disease. Our hypothesis was that LV functional parameters and native myocardial T1 and T2 values could be used to monitor treatment efficacy.

MATERIALS AND METHODS

This prospective, observational, multicenter study included patients with Fabry disease who underwent two cardiac MRI examinations performed at 1.5 T 24 months apart at five University Hospitals between March 2017 and December 2022. Changes in cardiac MRI parameters were compared between two groups of patients according to whether or not they were receiving specific treatment.

RESULTS

Twenty-six patients with Fabry disease were enrolled. There were 17 women and 9 men, with a mean age of 45.3 ± 17.4 (standard deviation [SD]) years. Both treated and untreated patients showed an increase in native T1 values over time, but the T1 increase was higher in treated patients (global T1, +39.4 ± 28.9 [SD] ms) than in untreated ones (global T1, +14.5 ± 30.3 [SD] ms) (P = 0.04). T2 values decreased in treated patients (global T2, -2.11 [SD] ms ± 3.36 but increased in untreated ones (global T2, +0.57 ± 1.63 [SD] ms) (P = 0.02). No significant changes in extracellular cardiac volume, left ventricular functional parameters, late gadolinium enhancement or left atrial volume were observed. However, LV mass index increased in untreated patients and decreased in treated patients. Intra- and interobserver reproducibility of T1 measurements showed mean biases of -0.18 ms (limit of agreement:11.61, 11.24) and -0.64 ms (limit of agreement:23.82; 22.54), respectively.

CONCLUSION

Variations in native myocardial T1 values at cardiac MRI are significantly greater in patients with Fabry disease receiving treatment than in untreated patients, suggesting an effect of treatment on lipid storage. In addition, changes in T2 values suggest an anti-inflammatory effect of the treatment.

Stress T1 Mapping and Quantitative Perfusion Cardiovascular Magnetic Resonance in Patients with Suspected Obstructive Coronary Artery Disease

AIMS

T1 mapping reactivity (ΔT1) has been proposed as a novel contrast-free technique to detect obstructive coronary artery disease (CAD). The aims of the study are: 1) to compare the cardiovascular magnetic resonance (CMR)-derived ΔT1 with quantitative perfusion (QP CMR) measures; 2) to assess the influence of sex and comorbidities on ΔT1; and 3) to assess the diagnostic accuracy of ΔT1 to detect obstructive CAD diagnosed with the invasive coronary angiography (ICA) and/or fractional flow reserve.

METHODS AND RESULTS

This study retrospectively analyzed 51 patients with suspected obstructive CAD who underwent CMR including rest and adenosine stress first-pass perfusion and native T1 mapping (MOLLI). A moderate correlation was found between pooled rest and stress native T1 mapping and MBF (Pearson's r=0.476; p<0.001). When stratified by MPR, ischemic myocardium had significantly lower stress T1 mapping values (p<0.001) and ΔT1 (p=0.005) vs. nonischemic myocardium. Male sex and history of diabetes were independently associated with lower ΔT1. The optimal cut-off value of Δ T1 to detect impaired MPR on a per-vessel basis was ≤5.4%, with an AUC of 0.662 (95% CI: 0.563-0.752, p=0.003), sensitivity of 84% (95% CI: 67-95) and specificity of 46% (95% CI: 34-58). When validated against ICA, stress T1 and Δ T1 did not reach statistical significance in detecting obstructive CAD.

CONCLUSION

ΔT1 is significantly influenced by sex and comorbidities and has poor diagnostic accuracy for detecting myocardial ischemia. Therefore, the clinical utility of ΔT1 in a real-world cohort of patients to detect obstructive CAD is limited.

Basic verification of myocardial extracellular volume quantification by prototype photon-counting detector computed tomography: A phantom study

Objectives

This study aimed to investigate the accuracy of myocardial extracellular volume (ECV) quantification using a prototype photon-counting detector (PCD) computed tomography (CT) and examine the association between radiation dose and spectral image settings.

Material and Methods

A multi-energy CT phantom that simulated the blood pool and myocardium was used. The tube voltage was set at 120 kVp and three types of tube current-time products (105, 150, and 300 mAs) were applied for pre- and post-contrast scans. Virtual monoenergetic images (VMIs) at 50-100 keV were reconstructed. The ECV value was calculated from the CT numbers between pre-contrast and post-contrast. We compared the accuracy of ECV values at each VMI level.

Results

Each radiation dose setting demonstrated a small but significant difference in ECV values at each keV level. ECV was overestimated at higher keV in all radiation dose settings. A significant difference in ECV value variabilities was found among keV levels in all three radiation dose settings, with higher keV exhibiting greater variability. The variation was particularly large in the low-dose setting. The residual values were significantly larger at higher keV levels in all radiation dose settings. The residual values were smaller at 50 and 60 keV with no significant difference in 150- and 300-mAs settings.

Conclusion

Setting appropriate VMI keV and radiation dose settings was necessary when quantifying myocardial ECV with PCD-CT because the keV levels caused differences in the quantification value and measurement variation.

Shaping cardiac diagnostics: The role of myocardial tissue mapping in unraveling ring-like fibrosis

BACKGROUND

Patients with non-ischemic cardiomyopathy exhibit a range of myocardial fibrosis (MF) patterns on cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) imaging. Data suggests that ring-like MF is associated with worse prognosis. In the present study it was sought to analyze the prevalence of parametric mapping abnormalities in ring-like MF and their prognostic value for arrhythmic events.

METHODS

Patients undergoing clinical CMR at 1.5T/3T were evaluated for ring-like MF defined as midwall/subepicardial fibrosis involving ≥ 3 contiguous left ventricular segments. CMR protocol included cine imaging, T1 and T2 mapping, and LGE. Mean native T1, ECV, and T2 values and a number of mid short axis segments with elevated values were calculated. LGE extent was assessed segmentally. Arrhythmic outcomes were defined as appropriate device shock, premature ventricular contractions ≥ 10%, non-sustained/sustained ventricular tachycardia, or ventricular fibrillation.

RESULTS

In total 49 patients (53 ± 17 years, 26.5% female) were analyzed. Many patients had elevated global/segmental mapping values: 45%/76% in native T1, 57%/57% in T2, and 57%/78% in ECV. During median follow-up of 12 months, arrhythmic events occurred in 65% of patients. There was no association between native T1/T2 elevation or number of LGE segments and arrhythmic outcomes. There was a significant association between ECV and arrhythmic outcomes, both septal ECV (p = 0.036) and any segmental ECV elevation (p = 0.03).

CONCLUSION

T1 and T2 myocardial tissue abnormalities are common in patients with ring-like MF. ECV elevation was associated with arrhythmic events in this cohort. Further studies are needed to establish the diagnostic and prognostic value of parametric mapping in patients with ring-like MF.

Anaemia predicts iron homoeostasis dysregulation and modulates the response to empagliflozin in heart failure with reduced ejection fraction: the EMPATROPISM-FE trial

BACKGROUND AND AIMS

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) impact iron metabolism in patients with heart failure but mechanisms are incompletely understood. This post hoc analysis explored interrelations between iron homeostasis, cardiac structure/function, exercise capacity, haematopoiesis, and sympathetic activity at baseline, and the effects of 6-month treatment with empagliflozin vs. placebo by anaemia status in EMPATROPISM-FE study participants.

METHODS

Myocardial iron content (MIC, estimated by cardiac magnetic resonance T2* imaging), left ventricular (LV) volumes and LV ejection fraction (LVEF), exercise capacity, laboratory iron markers (LIM), haemoglobin/haematocrit, erythropoietin, and plasma norepinephrine were determined at baseline and 6 months.

RESULTS

At baseline, 24/80 participants (30%) had anaemia (haemoglobin < 13/<12 mg/dL in men/women). Patients with vs. without anaemia had higher T2* (indicating lower MIC, P < .001), lower peak oxygen consumption (VO2max, P = .024) and hepcidin (P = .017), and higher erythropoietin (P = .040) and norepinephrine (P = .016). Across subgroups, lower MIC correlated with higher LV volumes (P < .01) and norepinephrine (P < .001), and lower LVEF (P < .01), VO2max (P < .001) and haemoglobin/haematocrit (P < .001). Associations with LIM were poor (all P > .10). Empagliflozin increased MIC (P < .012), improved exercise capacity, and activated haematopoiesis. Changes in LIM and norepinephrine suggested progressive systemic iron depletion and sympatholysis. LV reverse remodelling was greater in individuals with anaemia.

CONCLUSIONS

Dysregulated cellular iron uptake/availability may be a shared mechanism in myocardial structural/functional impairment, reduced exercise capacity, and restricted haematopoiesis in heart failure, which are worse in patients with anaemia, and improve with empagliflozin. Empagliflozin increases MIC and decreases norepinephrine. Given this inverse association, sympatholysis may help explain the diverse cardiac and systemic benefits from SGLT2i therapy.

CLINICAL TRIAL REGISTRATION

NCT03485222 (www.clinicaltrials.gov).

Free-breathing 3D cardiac extracellular volume (ECV) mapping using a linear tangent space alignment (LTSA) model

PURPOSE

To develop a new method for free-breathing 3D extracellular volume (ECV) mapping of the whole heart at 3 T.

METHODS

A free-breathing 3D cardiac ECV mapping method was developed at 3 T. T1 mapping was performed before and after contrast agent injection using a free-breathing electrocardiogram-gated inversion recovery sequence with spoiled gradient echo readout. A linear tangent space alignment model-based method was used to reconstruct high-frame-rate dynamic images from (k,t)-space data sparsely sampled along a random stack-of-stars trajectory. Joint T1 and transmit B1 estimation were performed voxel-by-voxel for pre- and post-contrast T1 mapping. To account for the time-varying T1 after contrast agent injection, a linearly time-varying T1 model was introduced for post-contrast T1 mapping. ECV maps were generated by aligning pre- and post-contrast T1 maps through affine transformation.

RESULTS

The feasibility of the proposed method was demonstrated using in vivo studies with six healthy volunteers at 3 T. We obtained 3D ECV maps at a spatial resolution of 1.9 × 1.9 × 4.5 mm3 and a FOV of 308 × 308 × 144 mm3, with a scan time of 10.1 ± 1.4 and 10.6 ± 1.6 min before and after contrast agent injection, respectively. The ECV maps and the pre- and post-contrast T1 maps obtained by the proposed method were in good agreement with the 2D MOLLI method both qualitatively and quantitatively.

CONCLUSION

The proposed method allows for free-breathing 3D ECV mapping of the whole heart within a practically feasible imaging time. The estimated ECV values from the proposed method were comparable to those from the existing method.

Effect of magnetic field strength and segmentation variability on the reproducibility and repeatability of radiomic texture features in cardiovascular magnetic resonance parametric mapping

Our study aims to assess the robustness of myocardial radiomic texture features (RTF) to segmentation variability and variations across scanners with different field strengths, addressing concerns about reliability in clinical practices. We conducted a retrospective analysis on 45 pairs of CMR T1 maps from 15 healthy volunteers using 1.5 T and 3 T Siemens scanners. Manual left ventricular myocardium segmentation and a deep learning-based model with Monte Carlo Dropout generated masks with different levels of variability and 1023 RTFs extracted from each region of interest (ROI). Reproducibility: the extent to which RTFs extracted from 1.5 T and 3 T images are consistent, and repeatability: the extent to which RTFs extracted from multiple segmentation runs at the same field strength agree with each other, were measured by the intraclass correlation coefficient (ICC). We categorized ICC values as excellent, good, moderate, and poor. We reported the proportion of RTFs that fell in each category. The proportion of RTFs with excellent repeatability decreased as the proportion of ROI pixels in congruence across segmentation runs decreased. Up to 31% of RTFs showed excellent repeatability, while 35% showed good repeatability across segmentation runs from the manually generated masks. Across scanners (i.e., 1.5 T vs 3 T), only 7% exhibited good reproducibility. While our results demonstrate RTF sensitivity to differences in field strength and segmentation variability, we identified certain preprocessing filters and feature classes that are less sensitive to these variations and, as such, may be good candidates for imaging biomarkers or building machine-learning models.

3D B1+ corrected simultaneous myocardial T1 and T1ρ mapping with subject-specific respiratory motion correction and water-fat separation

PURPOSE

To develop a 3D free-breathing cardiac multi-parametric mapping framework that is robust to confounders of respiratory motion, fat, and B1+ inhomogeneities and validate it for joint myocardial T1 and T1ρ mapping at 3T.

METHODS

An electrocardiogram-triggered sequence with dual-echo Dixon readout was developed, where nine cardiac cycles were repeatedly acquired with inversion recovery and T1ρ preparation pulses for T1 and T1ρ sensitization. A subject-specific respiratory motion model relating the 1D diaphragmatic navigator to the respiration-induced 3D translational motion of the heart was constructed followed by respiratory motion binning and intra-bin 3D translational and inter-bin non-rigid motion correction. Spin history B1+ inhomogeneities were corrected with optimized dual flip angle strategy. After water-fat separation, the water images were matched to the simulated dictionary for T1 and T1ρ quantification. Phantoms and 10 heathy subjects were imaged to validate the proposed technique.

RESULTS

The proposed technique achieved strong correlation (T1: R2 = 0.99; T1ρ: R2 = 0.98) with the reference measurements in phantoms. 3D cardiac T1 and T1ρ maps with spatial resolution of 2 × 2 × 4 mm were obtained with scan time of 5.4 ± 0.5 min, demonstrating comparable T1 (1236 ± 59 ms) and T1ρ (50.2 ± 2.4 ms) measurements to 2D separate breath-hold mapping techniques. The estimated B1+ maps showed spatial variations across the left ventricle with the septal and inferior regions being 10%-25% lower than the anterior and septal regions.

CONCLUSION

The proposed technique achieved efficient 3D joint myocardial T1 and T1ρ mapping at 3T with respiratory motion correction, spin history B1+ correction and water-fat separation.

Prognostic Value of Myocardial Parametric Mapping in Patients with Acute Myocarditis: A Retrospective Study

Purpose To investigate the prognostic value of T1 mapping, extracellular volume fraction (ECV), and T2 mapping in a large cohort of patients with acute myocarditis. Materials and Methods This retrospective study included patients with acute myocarditis who underwent cardiac MRI (3.0 T) between March 2016 and October 2022. Diagnosis was confirmed by diagnostic cardiac MRI criteria or endomyocardial biopsy. The primary end point was major adverse cardiovascular events (MACEs), defined as the composite of cardiac death, heart failure hospitalization, heart transplantation, sustained ventricular arrhythmia, and recurrent myocarditis. Univariable and multivariable Cox regression analyses were performed to assess the association of clinical and cardiac MRI variables with the primary end point. The prognostic value of each model was assessed using the Harrell C index. Results A total of 235 patients (mean age, 32 years ± 13 [SD]; 150 [63.8%] men) were included. During a mean follow-up of 1637 days (IQR: 1441-1833 days), MACEs occurred in 45 (19%) patients. Patients with MACEs had higher global native T1, ECV, and T2 values (1342 msec ± 64 vs 1263 msec ± 48; P < .001; 39.1% ± 8.7 vs 32.7% ± 5.7; P < .001; 61.1 msec ± 10.0 vs 55.3 msec ± 9.4; P = .03, respectively). In a series of multivariable Cox regression models, native T1 (per 10-msec increase: hazard ratio, 1.61; 95% CI: 1.31, 1.98; P < .001) and ECV (per 5% increase: hazard ratio, 1.70; 95% CI: 1.38, 2.08; P < .001) independently predicted MACE occurrence, and the addition of native T1 (Harrell C index = 0.76) or ECV (Harrell C index = 0.79) to the model including only clinical variables, left ventricular ejection fraction, and septal late gadolinium enhancement (Harrell C index = 0.72) improved discrimination for the primary end point. Conclusion Cardiac MRI-derived native T1 and ECV were independent predictors of MACEs in patients with acute myocarditis and provided incremental prognostic value when combined with conventional parameters. Keywords: MRI, Cardiac, Heart, Inflammation Supplemental material is available for this article. © RSNA, 2025.

Cardiac Manifestations in Fabry Disease: A Case Report on Two Siblings

Background/objectives: Anderson-Fabry disease (FD) is a rare hereditary disorder caused by deficient alpha-galactosidase A activity, which leads to multisystemic complications, including significant cardiac involvement. In this case report, we describe two siblings with distinct cardiac manifestations of FD. Methods: The medical data of two siblings who were managed and treated at a tertiary hospital center in Croatia were obtained by detailed analysis of electronic medical records. All available data were structured in chronological order. Results: A 42-year-old male with chronic renal failure and severe left ventricular hypertrophy (LVH) was diagnosed with FD during testing for inclusion on the kidney transplant waiting list. The diagnosis was confirmed by cardiac magnetic resonance imaging (CMR), which revealed non-ischemic fibrosis typical of FD. Following enzyme replacement therapy (ERT), he underwent a successful kidney transplantation. The second case describes the 36-year-old brother, who was diagnosed through family screening and, despite normal initial cardiac ultrasound findings, exhibited early cardiac involvement through reduced T1-mapping values. Immediate initiation of ERT led to normalization of T1 values and successful renal transplantation. Conclusions: This report underscores the importance of family screening and early diagnosis in FD and highlights the role of CMR in detecting preclinical cardiac involvement.

Advancing Cardiovascular Diagnostics: The Expanding Role of CMR in Heart Failure and Cardiomyopathies

Cardiovascular magnetic resonance (CMR) imaging has become a cornerstone in the diagnosis, risk stratification, and management of cardiovascular disease (CVD), particularly heart failure (HF) and cardiomyopathies. Renowned as the gold standard for non-invasive quantification of ventricular volumes and ejection fraction, CMR delivers superior spatial and temporal resolution with excellent tissue-blood contrast. Recent advancements, including T1, T2, and T2* mapping, extracellular volume quantification, and late gadolinium enhancement, enable precise tissue characterization, allowing early detection of myocardial changes such as fibrosis, edema, and infiltration. These features provide critical insights into the pathophysiological mechanisms underlying HF phenotypes and diverse cardiomyopathies, enhancing diagnostic accuracy and guiding therapeutic decisions. This review explores the expanding role of CMR in CV disease, highlighting its diagnostic value in HF and in several cardiomyopathies, as well as its contribution to improving patient outcomes through detailed tissue characterization and prognosis.

Data- and Physics-Driven Deep Learning Based Reconstruction for Fast MRI: Fundamentals and Methodologies

Magnetic Resonance Imaging (MRI) is a pivotal clinical diagnostic tool, yet its extended scanning times often compromise patient comfort and image quality, especially in volumetric, temporal and quantitative scans. This review elucidates recent advances in MRI acceleration via data and physics-driven models, leveraging techniques from algorithm unrolling models, enhancement-based methods, and plug-and-play models to the emerging full spectrum of generative model-based methods. We also explore the synergistic integration of data models with physics-based insights, encompassing the advancements in multi-coil hardware accelerations like parallel imaging and simultaneous multi-slice imaging, and the optimization of sampling patterns. We then focus on domain-specific challenges and opportunities, including image redundancy exploitation, image integrity, evaluation metrics, data heterogeneity, and model generalization. This work also discusses potential solutions and future research directions, with an emphasis on the role of data harmonization and federated learning for further improving the general applicability and performance of these methods in MRI reconstruction.

Society for Cardiovascular Magnetic Resonance recommendations toward environmentally sustainable cardiovascular magnetic resonance

Delivery of health care, including medical imaging, generates substantial global greenhouse gas emissions. The cardiovascular magnetic resonance (CMR) community has an opportunity to decrease our carbon footprint, mitigate the effects of the climate crisis, and develop resiliency to current and future impacts of climate change. The goal of this document is to review and recommend actions and strategies to allow for CMR operation with improved sustainability, including efficient CMR protocols and CMR imaging workflow strategies for reducing greenhouse gas emissions, energy, and waste, and to decrease reliance on finite resources, including helium and waterbody contamination by gadolinium-based contrast agents. The article also highlights the potential of artificial intelligence and new hardware concepts, such as low-helium and low-field CMR, in achieving these aims. Specific actions include powering down magnetic resonance imaging scanners overnight and when not in use, reducing low-value CMR, and implementing efficient, non-contrast, and abbreviated CMR protocols when feasible. Data on estimated energy and greenhouse gas savings are provided where it is available, and areas of future research are highlighted.

Normal variations of myocardial T1, T2 and T2* values at 1.5 T cardiac MRI in sex-matched healthy volunteers

PURPOSE

The purpose of this study was to determine the normal variations of myocardial T1, T2, and T2* relaxation times on cardiac MRI obtained at 1.5 T in healthy, sex-balanced volunteers aged between 18 and 69 years.

MATERIAL AND METHODS

A total of 172 healthy volunteers were recruited prospectively. They were further divided into seven sex-balanced age groups (18-19 years, 20-24 years, 25-29 years, 30-39 years, 40-49 years, 50-59 years, and 60-69 years). T1, T2, and T2* mapping were acquired in a single short-axis slice at the mid-level of the left ventricle. Global T1, T2, and T2* values were the mean of all segments. Comparisons between females and males were performed in each age group using independent samples t-test or Wilcoxon rank sum test, as appropriate. Multivariable linear effects models were used to analyze the effect of heart rate, body mass index, left ventricular mass, age, and sex on T1, T2, and T2* values. Inter- and intra-observer correlation (ICC) was evaluated.

RESULTS

A total of 172 healthy participants were included. There were 83 males and 89 females, with a mean age of 37.3 ± 15.6 (standard deviation [SD]) years. Females had greater T1 values (980.9 ± 26.2 [SD] ms) compared to males (949.7 ± 18.3 [SD] ms) (P < 0.001). T1 values decreased with age (974.3 ± 26.97 [SD] ms when ≤ 39 years vs. 954.4 ± 24.12 [SD] ms when > 39 years; P < 0.001), with smaller sex-related differences in older participants. Male sex and age were independently associated with lower values of T1 mapping. Age in females was independently associated with lower T1, T2, and T2* values. Moderate to good inter- and intra-observer agreement was found for T1, T2, and T2* (ICC ranging from 0.72 to 0.89).

CONCLUSION

T1, T2, and T2* values are influenced by age and sex, emphasizing the need to read and calibrate MRI values with respect to patient characteristics to avoid misdiagnosis.

Longitudinal cardiac imaging for assessment of myocardial injury in non-hospitalised community-dwelling individuals after COVID-19 infection: the Rotterdam Study

BACKGROUND

The aim of this study was to assess the presence of myocardial injury after COVID-19 infection and to evaluate the relation between persistent cardiac symptoms after COVID-19 and myocardial function in participants with known cardiovascular health status before infection.

METHODS

In the prospective population-based Rotterdam Study cohort, echocardiography and cardiovascular magnetic resonance (CMR) were performed among participants who recovered from COVID-19 at home within 2 years prior to inclusion in the current study. Persistent cardiac symptoms comprised only self-reported symptoms of chest pain, dyspnoea or palpitations lasting >4 weeks after COVID-19 infection. We used linear regression and linear mixed models to estimate and test age-adjusted and sex-adjusted mean differences (95% CIs) of (1) post-COVID-19 CMR-derived and echocardiographic-derived parameters among participants with and without persistent post-COVID-19 symptoms and (2) pre-COVID-19 and post-COVID-19 echocardiographic assessments.

RESULTS

92 participants were included, with a mean age of 59±8 years of whom 52% were male. Normal post-COVID-19 CMR-derived left ventricular (LV) function and right ventricular ejection fraction were observed in 92% and 98% of participants, respectively. We observed normal native T1 relaxation times in 100%, normal extracellular volume in 98% and normal T2 relaxation times in 98% of the participants. Comparison of pre-COVID-19 and post-COVID-19 echocardiography revealed a significant but small decline in left ventricular ejection fraction (adjusted mean change -1.37% (95% CI -2.57%, -0.17%)) and global longitudinal strain (1.32% (95% CI 0.50%, 2.15%)). Comparing participants with and without persistent symptoms, there were no significant differences in adjusted CMR-derived ventricular volumes, LV function or presence of myocardial injury.

CONCLUSIONS

Almost all recovered non-hospitalised COVID-19 participants had normal CMR-derived ventricular volumes and function, without relevant myocardial injury.

Multiparametric cardiovascular magnetic resonance in patients with myocarditis with consecutive follow-up and a comparison between non-COVID-19 and COVID-19-associated myocarditis

Background

The pattern of myocardial injury and dysfunction development during follow-up is unclear in patients with myocarditis. This study aims to explore the developmental pattern of myocardial injury and cardiac dysfunction during the follow-up of myocarditis by cardiac magnetic resonance (CMR) and differences in short-term follow-up CMR performance between patients with coronavirus disease 2019 (COVID-19)-associated myocarditis (CAM) and non-COVID-19-associated myocarditis (NCAM).

Methods

Data of patients with clinically diagnosed myocarditis who underwent follow-up CMR were retrospectively collected. Patients were divided into the NCAM follow-up and CAM follow-up groups. A portion of patients with normal CMR and volunteers was categorized as control. Qualitative and quantitative assessments of CMR images were used to analyze cardiac structure, function and myocardial damage; compare the differences between the groups; and reveal the developmental pattern in the consecutive follow-up for patients with myocarditis.

Results

This study included 75 patients with NCAM, 25 patients with CAM and 75 cases as control group. Compared with the control group, there was an increase in left ventricular volume, right ventricular volume, extracellular volume in the NCAM follow-up (the last time) group, left ventricular volume, right ventricular ejection fraction, global radial strain (GRS), global circumferential strain, global longitudinal strain (GLS), post-contrast T1 value were decreased. The area under the curve of the GLS was the best (0.836) in discriminating between the two groups, with 78.7% sensitivity and 84.0% specificity. The discriminatory efficacy of the combined right ventricular ejection fraction, GRS, and GLS multiparameter showed the best area under the curve at 0.847, with 80.0% sensitivity and 85.3% specificity. Between the CMR parameter of short- (3 months), medium-, and long-term follow-up (>6 months) for patients with NCAM, a decrease in native T1 (1,256.50±18.63 vs. 1,248.30±17.87 ms, P=0.007) and T2 (49.00±1.34 vs. 47.50±0.97 ms, P=0.015) values was noted in the short-term follow-up group. The short-term follow-up group showed increased ventricular volume, decreased ejection fraction, and impaired myocardial strain in CAM and NCAM compared with the control group. The CAM short-term follow-up group showed an increased T2 value (52.56±3.64 vs. 49.08±3.84 ms, P=0.008) compared with the NCAM short-term follow-up group, and the T2 value was identified with an area under the curve of 0.772, 76% sensitivity, and 83% specificity for the discrimination.

Conclusions

This study revealed that myocarditis led to myocardial damage, cardiac remodeling, and dysfunction during follow-up. An improvement in myocardial edema in the medium- and long-term follow-up groups was observed. In the short-term follow-up, CAM showed more severe myocardial edema. These findings may contribute to the clinical assessment and management of post-myocarditis status.