Reduced Right Ventricular Native Myocardial T1 in Anderson-Fabry Disease: Comparison to Pulmonary Hypertension and Healthy Controls

Cardiac MRI in Fabry disease

Fabry disease is a rare, progressive X-linked inherited disorder of glycosphingolipid metabolism due to a deficiency of α-galactosidase A enzyme. It leads to the accumulation of globotriaosylceramide within lysosomes of multiple organs, predominantly the vascular, renal, cardiac, and nervous systems. Fabry cardiomyopathy is characterized by increased left ventricular wall thickness/mass, functional abnormalities, valvular heart disease, arrhythmias, and heart failure. Early diagnosis and treatment are critical to avoid cardiac or renal complications that can significantly reduce life expectancy in untreated FD. This review will focus on the role of cardiovascular magnetic resonance imaging in the diagnosis, clinical decision-making, and monitoring of treatment efficacy.

Biventricular strain assessment indicates progressive impairment of myocardial contractility in phenotypically negative patients with Fabry's disease

PURPOSE

The accumulation of sphingolipids in Fabry's disease (FD) leads to left ventricular (LV) hypertrophy and shortened T1 in cardiac magnetic resonance (CMR). Early detection of myocardial involvement is essential for the timely initiation and efficacy of enzyme replacement therapy. However, there is a diagnostic gap between the onset of accumulation and detectable myocardial changes. This study aimed to evaluate the diagnostic value of biventricular strain assessment in early FD.

METHODS

Genetically proven FD patients (n = 58) and healthy volunteers (HV, n = 62) who had undergone 3 T CMR were retrospectively identified and stratified into 3 groups according to disease severity. Biventricular volumetry, global longitudinal strains (GLS), indexed biventricular masses (RVMi/LVMi), and T1 were evaluated. Group comparisons were performed by ANOVA and diagnostic accuracy was evaluated by ROC-analysis.

RESULTS

The study population included 19 group I, 20 group II and 19 group III patients. LV volumetry and T1 showed no significant difference between early FD patients and HV (all p > 0.760). However, RVMi was increased, while RV-GLS and LV-GLS were significantly impaired (p = 0.024 and < 0.001, respectively). Biventricular strains accurately discriminated early FD patients and HV with RV-GLS being non-inferior to LV-GLS (AUC for both 0.83, p > 0.05). Adding strains to the established approach using T1 and LVMi further increased diagnostic accuracy (AUC 0.99, p < 0.05).

CONCLUSIONS

Biventricular strains may help detect altered myocardial deformation patterns in phenotypically negative FD patients. These findings may lead to an earlier initiation of therapy, which in turn may slow hypertrophy and the associated long-term risks.

Cardiovascular magnetic resonance native T1 mapping in Anderson-Fabry disease: a systematic review and meta-analysis

BACKGROUND

T1 mapping is an established cardiovascular magnetic resonance (CMR) technique that can characterize myocardial tissue. We aimed to determine the weighted mean native T1 values of Anderson-Fabry disease (AFD) patients and the standardized mean differences (SMD) as compared to healthy control subjects.

METHODS

A comprehensive literature search of the PubMed, Scopus and Web of Science databases was conducted according to the PRISMA statement to retrieve original studies reporting myocardial native T1 values in AFD patients and healthy controls. A random effects model was used to calculate SMD, and meta-regression analysis was conducted to explore heterogeneity sources. Subgroup analysis was also performed according to scanner field strength and sequence type.

RESULTS

From a total of 151 items, 14 articles were included in the final analysis accounting for a total population of 982 subjects. Overall, the weighted mean native T1 values was 984 ± 47 ms in AFD patients and 1016 ± 26 ms in controls (P < 0.0001) with a pooled SMD of - 2.38. In AFD patients there was an inverse correlation between native T1 values and male gender (P = 0.002) and left ventricular hypertrophy (LVH) (P < 0.001). Subgroup analyses confirmed lower T1 values in AFD patients compared to controls with a pooled SMD of -  2.54,  -  2.28, -   2.46 for studies performed on 1.5T with modified Look-Locker inversion recovery (MOLLI), shortened MOLLI and saturation-recovery single-shot acquisition, respectively and of -  2.41 for studies conducted on 3T.

CONCLUSIONS

Our findings confirm a reduction of native T1 values in AFD patients compared to healthy controls and point out that the degree of T1 shortening in AFD is influenced by gender and LVH. Although T1 mapping is useful in proving cardiac involvement in AFD patients, there is need to standardize shreshold values according to imaging equipment and protocols.

Cardiac Magnetic Resonance Features of Fabry Disease: From Early Diagnosis to Prognostic Stratification

In the past few years, the wide application of cardiac magnetic resonance (CMR) significantly changed the approach to the study of cardiac involvement in Fabry Disease (FD). The possibility to perform non-invasive tissue characterization, including new sequences such as T1/T2 mapping, offered a powerful tool for differential diagnosis with other forms of left ventricular hypertrophy. In patients with confirmed diagnosis of FD, CMR is the most sensitive non-invasive technique for early detection of cardiac involvement and it provides new insight into the evolution of cardiac damage, including gender-specific features. Finally, CMR multiparametric detection of subtle changes in cardiac morphology, function and tissue composition is potentially useful for monitoring the efficacy of specific treatment over time. This paper aims to provide a comprehensive review of current knowledge regarding the application of CMR in FD cardiac involvement and its clinical implication.

Prognostic value of right ventricular native T1 mapping in pulmonary arterial hypertension

BACKGROUND

Right ventricular function is an important prognostic marker for pulmonary arterial hypertension. Native T1 mapping using cardiovascular magnetic resonance imaging can characterize the myocardium, but accumulating evidence indicates that T1 values of the septum or ventricular insertion points do not have predictive potential in pulmonary arterial hypertension. We aimed to elucidate whether native T1 values of the right ventricular free wall (RVT1) can predict poor outcomes in patients with pulmonary arterial hypertension.

METHODS

This retrospective study included 30 patients with pulmonary arterial hypertension (median age, 45 years; mean pulmonary artery pressure, 41±13 mmHg) and 16 healthy controls (median age, 43 years) who underwent native T1 mapping. RVT1 was obtained from the inferior right ventricular free wall during end systole.

RESULTS

Patients with pulmonary arterial hypertension had significantly higher native RVT1 than did controls (1384±74 vs. 1217±57 ms, p<0.001). Compared with T1 values of the septum or ventricular insertion points, RVT1 correlated better with the effective right ventricular elastance index (R = -0.53, p = 0.003), ventricular-arterial uncoupling (R = 0.46, p = 0.013), and serum brain natriuretic peptide levels (R = 0.65, p<0.001). Moreover, the baseline RVT1 was an accurate predictor of the reduced right ventricular ejection fraction at the 12-month follow-up (delta -3%). RVT1 was independently associated with composite events of death or hospitalization from any cause (hazard ratio = 1.02, p = 0.002).

CONCLUSIONS

RVT1 was predictive of right ventricular performance and outcomes in patients with pulmonary arterial hypertension. Thus, native T1 mapping in the right ventricular free wall may be an effective prognostic method for pulmonary arterial hypertension.

Assessment of the tricuspid valve using cardiovascular magnetic resonance

PURPOSE OF REVIEW

The rapid search for suitable tricuspid transcatheter devices has ignited renewed enthusiasm in accurate characterization of tricuspid valve disease. Cardiovascular magnetic resonance (CMR), traditionally used as the gold standard in assessment for right ventricular size and function, has recently seen its use expanded to assess both the structure and function of the tricuspid apparatus. This review will highlight the role of CMR in tricuspid valve disease and compare it with other commonly used imaging modalities.

RECENT FINDINGS

Dynamic anatomical assessment of the tricuspid apparatus, in combination with accurate leaflet identification, is possible with CMR. Tricuspid regurgitation volume and fraction are derived through an indirect volumetric method, and therefore, able to overcome many traditional hurdles involved with valve regurgitation quantitation. Adverse right heart prognostic factors in tricuspid valve disease, such as right heart volumes, function, and tissue characterization, are optimally assessed using CMR.

SUMMARY

Cardiovascular magnetic resonance is a powerful modality that should be harnessed in order to obtain a multifaceted assessment of tricuspid valve structure, function, and the effects of valve disease on right heart remodeling.

Serial T1 mapping of right ventricle in pulmonary hypertension: comparison with histology in an animal study

BACKGROUND

Right ventricular (RV) free wall fibrosis is an important component of adverse remodeling with RV dysfunction in pulmonary hypertension (PH). However, no previous reports have compared cardiovascular magnetic resonance (CMR) findings and histological analysis for RV free wall fibrosis in PH. We aimed to assess the feasibility of CMR T1 mapping with extracellular volume fraction (ECV) for evaluating the progression of RV free wall fibrosis in PH, and compared imaging findings to histological collagen density through an animal study.

METHODS

Among 42 6-week-old Wistar male rats, 30 were classified according to disease duration (baseline before monocrotaline injection, and 2, 4, 6 and 8 weeks after injection) and 12 were used to control for aging (4 and 8 weeks after the baseline). We obtained pre and post-contrast T1 maps for native T1 and ECV of RV and left ventricular (LV) free wall for six animals in each disease-duration group. Collagen density of RV free wall was calculated with Masson's trichrome staining. The Kruskall-Wallis test was performed to compare the groups. Native T1 and ECV to collagen density were analyzed with Spearman's correlation.

RESULTS

The mean values of native T1, ECV and collagen density of the RV free wall at baseline were 1541 ± 33 ms, 17.2 ± 1.3%, and 4.7 ± 0.5%, respectively. The values of RV free wall did not differ according to aging (P = 0.244, 0.504 and 0.331, respectively). However, the values significantly increased according to disease duration (P < 0.001 for all). Significant correlations were observed between native T1 and collagen density (r = 0.770, P < 0.001), and between ECV and collagen density for the RV free wall (r = 0.815, P < 0.001) in PH. However, there was no significant difference in native T1 and ECV values for the LV free wall according to the disease duration from the baseline (P = 0.349 and 0.240, respectively).

CONCLUSIONS

We observed significantly increased values for native T1 and ECV of the RV free wall without significant increase of the LV free wall according to the disease duration of PH, and findings were well correlated with histological collagen density.

Right Ventricular Function and T1-Mapping in Boys With Duchenne Muscular Dystrophy

BACKGROUND

Clinical management of boys with Duchenne muscular dystrophy (DMD) relies on in-depth understanding of cardiac involvement, but right ventricular (RV) structural and functional remodeling remains understudied.

PURPOSE

To evaluate several analysis methods and identify the most reliable one to measure RV pre- and postcontrast T1 (RV-T1) and to characterize myocardial remodeling in the RV of boys with DMD.

STUDY TYPE

Prospective.

POPULATION

Boys with DMD (N = 27) and age-/sex-matched healthy controls (N = 17) from two sites.

FIELD STRENGTH/SEQUENCE

3.0 T using balanced steady state free precession, motion-corrected phase sensitive inversion recovery and modified Look-Locker inversion recovery sequences.

ASSESSMENT

Biventricular mass (Mi), end-diastolic volume (EDVi) and ejection fraction (EF) assessment, tricuspid annular excursion (TAE), late gadolinium enhancement (LGE), pre- and postcontrast myocardial T1 maps. The RV-T1 reliability was assessed by three observers in four different RV regions of interest (ROI) using intraclass correlation (ICC).

STATISTICAL TESTS

The Wilcoxon rank sum test was used to compare RV-T1 differences between DMD boys with negative LGE(-) or positive LGE(+) and healthy controls. Additionally, correlation of precontrast RV-T1 with functional measures was performed. A P-value <0.05 was considered statistically significant.

RESULTS

A 1-pixel thick RV circumferential ROI proved most reliable (ICC > 0.91) for assessing RV-T1. Precontrast RV-T1 was significantly higher in boys with DMD compared to controls. Both LGE(-) and LGE(+) boys had significantly elevated precontrast RV-T1 compared to controls (1543 [1489-1597] msec and 1550 [1402-1699] msec vs. 1436 [1399-1473] msec, respectively). Compared to healthy controls, boys with DMD had preserved RVEF (51.8 [9.9]% vs. 54.2 [7.2]%, P = 0.31) and significantly reduced RVMi (29.8 [9.7] g vs. 48.0 [15.7] g), RVEDVi (69.8 [29.7] mL/m² vs. 89.1 [21.9] mL/m² ), and TAE (22.0 [3.2] cm vs. 26.0 [4.7] cm). Significant correlations were found between precontrast RV-T1 and RVEF (β = -0.48%/msec) and between LV-T1 and LVEF (β = -0.51%/msec).

DATA CONCLUSION

Precontrast RV-T1 is elevated in boys with DMD compared to healthy controls and is negatively correlated with RVEF.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 2.

Cardiac Magnetic Resonance Imaging in Pulmonary Arterial Hypertension: Ready for Clinical Practice and Guidelines?

Purpose of Review

Pulmonary arterial hypertension (PAH) is a progressive disease with high mortality. A greater understanding of the physiology and function of the cardiovascular system in PAH will help improve survival. This review covers the latest advances within cardiovascular magnetic resonance imaging (CMR) regarding diagnosis, evaluation of treatment, and prognostication of patients with PAH.

Recent Findings

New CMR measures that have been proven relevant in PAH include measures of ventricular and atrial volumes and function, tissue characterization, pulmonary artery velocities, and arterio-ventricular coupling.

Summary

CMR markers carry prognostic information relevant for clinical care such as treatment response and thereby can affect survival. Future research should investigate if CMR, as a non-invasive method, can improve existing measures or even provide new and better measures in the diagnosis, evaluation of treatment, and determination of prognosis of PAH.

Fabry Disease and the Heart: A Comprehensive Review

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by mutations of the GLA gene that result in a deficiency of the enzymatic activity of α-galactosidase A and consequent accumulation of glycosphingolipids in body fluids and lysosomes of the cells throughout the body. GB3 accumulation occurs in virtually all cardiac cells (cardiomyocytes, conduction system cells, fibroblasts, and endothelial and smooth muscle vascular cells), ultimately leading to ventricular hypertrophy and fibrosis, heart failure, valve disease, angina, dysrhythmias, cardiac conduction abnormalities, and sudden death. Despite available therapies and supportive treatment, cardiac involvement carries a major prognostic impact, representing the main cause of death in FD. In the last years, knowledge has substantially evolved on the pathophysiological mechanisms leading to cardiac damage, the natural history of cardiac manifestations, the late-onset phenotypes with predominant cardiac involvement, the early markers of cardiac damage, the role of multimodality cardiac imaging on the diagnosis, management and follow-up of Fabry patients, and the cardiac efficacy of available therapies. Herein, we provide a comprehensive and integrated review on the cardiac involvement of FD, at the pathophysiological, anatomopathological, laboratory, imaging, and clinical levels, as well as on the diagnosis and management of cardiac manifestations, their supportive treatment, and the cardiac efficacy of specific therapies, such as enzyme replacement therapy and migalastat.

Myocardial T1-mapping and extracellular volume in pulmonary arterial hypertension: A systematic review and meta-analysis

INTRODUCTION

Elevated myocardial T₁-mapping and extracellular volume (ECV) measured on cardiac MR (CMR) imaging is associated with myocardial abnormalities such as oedema or fibrosis. This meta-analysis aims to provide a summary of T₁-mapping and ECV values in pulmonary arterial hypertension (PAH) and compare their values with controls.

METHODS

We searched CENTRAL, MEDLINE, Embase, and Web of Science in August 2020. We included CMR studies reporting T₁-mapping or ECV values in adults with any type of PAH. We calculated the mean difference of T₁-values and ECV between PAH and controls.

RESULTS

We included 12 studies with 674 participants. T₁-values were significantly higher in PAH with the highest mean difference (MD) recorded at the RV insertion points (RVIP) (108 milliseconds (ms), 95% confidence intervals (CI) 89 to 128), followed by the RV free wall (MD 91 ms, 95% CI 56 to 126). The pooled mean T₁-value in PAH at the RVIP was 1084, 95% CI (1071 to 1097) measured using 1.5 Tesla Siemens systems. ECV was also higher in PAH with an MD of 7.5%, 95% CI (5.9 to 9.1) at the RV free wall.

CONCLUSION

T₁ mapping values in PAH patients are on average 9% higher than healthy controls when assessed under the same conditions including the same MRI system, magnetic field strength or sequence used for acquisition. The highest T₁ and ECV values are at the RVIP. T₁ mapping and ECV values in PH are higher than the values reported in cardiomyopathies and were associated with poor RV function and RV dilatation.

Prevalence and Clinical Characteristics of Fabry Disease in Chinese Patients With Hypertrophic Cardiomyopathy

BACKGROUND

The prevalence of Fabry disease (FD) in Chinese patients with hypertrophic cardiomyopathy (HCM) is unclear. We aimed to evaluate the prevalence, clinical characteristics, and outcomes of FD in Chinese patients with HCM.

METHODS

Of 217 patients with HCM, FD probands were screened by next-generation sequencing at Fuwai Hospital. Medical data from α-galactosidase A activity, electrocardiography, echocardiography, coronary angiography, cardiac magnetic resonance, pathological examination, and follow up was analyzed.

RESULTS

Two FD probands were observed (0.93% of patients with HCM), both of which were diagnosed with symptomatic obstructive HCM at 49 years of age. One proband had a GLA mutation (c.887T>C [p.M296T]) with a late-onset cardiac variant, which was characterized by dual ventricular hypertrophy and conduction disease with a permanent pacemaker. The other patient had a GLA mutation (c.758T>C [p.I253T]) with a classic phenotype and dual ventricular hypertrophy, atrioventricular block, renal failure, and recurrent cerebral infarction. Both probands had late gadolinium enhancement mainly in the basal segment of the inferolateral wall. Follow up revealed no exertional symptoms or outflow obstruction after surgical septal myectomy in the two probands, and stable renal function was observed after 6 months of migalastat therapy in the later one. A family study revealed six female carriers and three sudden cardiac deaths.

CONCLUSIONS

FD is not uncommon in Chinese patients with HCM. Multiple organic involvement, dual ventricular hypertrophy, and conduction disease provide clinical clues for suspected FD, and early genetic screening is necessary. Surgical septal myectomy and migalastat improve the long-term prognosis of patients with FD.

Systolic modified Look-Locker inversion recovery myocardial T1 mapping improves the accuracy of T1 and extracellular volume fraction measurements of patients with high heart rate or atrial fibrillation

Image data for T1 mapping are generally acquired during mid-diastole period. However, T1 mapping tends to fail for patients with high heart rate or atrial fibrillation because of short or irregular R-R interval. Focusing on the evidence that the timing of systole is more stable than that of diastole from the R wave, we compared systolic T1 mapping with conventional diastolic T1 mapping for all participants (n = 58) by visual scoring of T1 calculation error. The systolic scores were significantly better than the diastolic scores (p < 0.05). This advantage of the systolic scores was confirmed selectively for patients with atrial fibrillation (p < 0.05, n = 19). The successful number of nonrigid image registration alignment for extracellular volume fraction (ECV) analysis also increased significantly for systolic images compared with diastolic images (p < 0.05). Thus, systolic T1 mapping improves the accuracy of T1 values and ECV analysis.

An expert consensus document on the management of cardiovascular manifestations of Fabry disease

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by pathogenic variants in the α-galactosidase A (GLA) gene that leads to reduced or undetectable α-galactosidase A enzyme activity and progressive accumulation of globotriaosylceramide and its deacylated form globotriaosylsphingosine in cells throughout the body. FD can be multisystemic with neurological, renal, cutaneous and cardiac involvement or be limited to the heart. Cardiac involvement is characterized by progressive cardiac hypertrophy, fibrosis, arrhythmias, heart failure and sudden cardiac death. The cardiac management of FD requires specific measures including enzyme replacement therapy or small pharmacological chaperones in patients carrying amenable pathogenic GLA gene variants and more general management of cardiac symptoms and complications. In this paper, we summarize current knowledge of FD-related heart disease and expert consensus recommendations for its management.

Multimodality Imaging of the Tricuspid Valve and Right Heart Anatomy

The characterization of tricuspid valve and right-heart anatomy has been gaining significant interest in the setting of new percutaneous transcatheter interventions for tricuspid regurgitation. Multimodality cardiac imaging provides a wealth of information about the anatomy and function of the tricuspid valve apparatus, right ventricle, and right atrium, which is pivotal for diagnosis and prognosis and for planning of percutaneous interventions. The present review describes the role of echocardiography, cardiac magnetic resonance, and multidetector row cardiac computed tomography for right heart and tricuspid valve assessment.

Right Ventricular Fibrosis

The role of right ventricular (RV) fibrosis in pulmonary hypertension (PH) remains a subject of ongoing discussion. Alterations of the collagen network of the extracellular matrix may help prevent ventricular dilatation in the pressure-overloaded RV. At the same time, fibrosis impairs cardiac function, and a growing body of experimental data suggests that fibrosis plays a crucial role in the development of RV failure. In idiopathic pulmonary arterial hypertension and chronic thromboembolic PH, the RV is exposed to a ≈5 times increased afterload, which makes these conditions excellent models for studying the impact of pressure overload on RV structure. With this review, we present clinical evidence of RV fibrosis in idiopathic pulmonary arterial hypertension and chronic thromboembolic PH, explore the correlation between fibrosis and RV function, and discuss the clinical relevance of RV fibrosis in patients with PH. We postulate that RV fibrosis has a dual role in patients with pressure-overloaded RVs of idiopathic pulmonary arterial hypertension and chronic thromboembolic PH: as part of an adaptive response to prevent cardiomyocyte overstretch and to maintain RV shape for optimal function, and as part of a maladaptive response that increases diastolic stiffness, perturbs cardiomyocyte excitation-contraction coupling, and disrupts the coordination of myocardial contraction. Finally, we discuss potential novel therapeutic strategies and describe more sensitive techniques to quantify RV fibrosis, which may be used to clarify the causal relation between RV fibrosis and RV function in future research.

Myocardial Tissue Characterization and Fibrosis by Imaging

Myocardial fibrosis, either focal or diffuse, is a common feature of many cardiac diseases and is associated with a poor prognosis for major adverse cardiovascular events. Although histological analysis remains the gold standard for confirming the presence of myocardial fibrosis, endomyocardial biopsy is invasive, has sampling errors, and is not practical in the routine clinical setting. Cardiac imaging modalities offer noninvasive surrogate biomarkers not only for fibrosis but also for myocardial edema and infiltration to varying degrees, and have important roles in the diagnosis and management of cardiac diseases. This review summarizes important pathophysiological features in the development of commonly encountered cardiac diseases, and the principles, advantages, and disadvantages of various cardiac imaging modalities (echocardiography, single-photon emission computer tomography, positron emission tomography, multidetector computer tomography, and cardiac magnetic resonance) for myocardial tissue characterization, with an emphasis on imaging focal and diffuse myocardial fibrosis.

Diagnostic and prognostic significance of cardiovascular magnetic resonance native myocardial T1 mapping in patients with pulmonary hypertension

BACKGROUND

Native T1 may be a sensitive, contrast-free, non-invasive cardiovascular magnetic resonance (CMR) marker of myocardial tissue changes in patients with pulmonary artery hypertension. However, the diagnostic and prognostic value of native T1 mapping in this patient group has not been fully explored. The aim of this work was to determine whether elevation of native T1 in myocardial tissue in pulmonary hypertension: (a) varies according to pulmonary hypertension subtype; (b) has prognostic value and (c) is associated with ventricular function and interaction.

METHODS

Data were retrospectively collected from a total of 490 consecutive patients during their clinical 1.5 T CMR assessment at a pulmonary hypertension referral centre in 2015. Three hundred sixty-nine patients had pulmonary hypertension [58 ± 15 years; 66% female], an additional 39 had pulmonary hypertension due to left heart disease [68 ± 13 years; 60% female], 82 patients did not have pulmonary hypertension [55 ± 18; 68% female]. Twenty five healthy subjects were also recruited [58 ±4 years); 51% female]. T1 mapping was performed with a MOdified Look-Locker Inversion Recovery (MOLLI) sequence. T1 prognostic value in patients with pulmonary arterial hypertension was assessed using multivariate Cox proportional hazards regression analysis.

RESULTS

Patients with pulmonary artery hypertension had elevated T1 in the right ventricular (RV) insertion point (pulmonary hypertension patients: T1 = 1060 ± 90 ms; No pulmonary hypertension patients: T1 = 1020 ± 80 ms p < 0.001; healthy subjects T1 = 940 ± 50 ms p < 0.001) with no significant difference between the major pulmonary hypertension subtypes. The RV insertion point was the most successful T1 region for discriminating patients with pulmonary hypertension from healthy subjects (area under the curve = 0.863) however it could not accurately discriminate between patients with and without pulmonary hypertension (area under the curve = 0.654). T1 metrics did not contribute to prediction of overall mortality (septal: p = 0.552; RV insertion point: p = 0.688; left ventricular free wall: p = 0.258). Systolic interventricular septal angle was a significant predictor of T1 in patients with pulmonary hypertension (p < 0.001).

CONCLUSIONS

Elevated myocardial native T1 was found to a similar extent in pulmonary hypertension patient subgroups and is independently associated with increased interventricular septal angle. Native T1 mapping may not be of additive value in the diagnostic or prognostic evaluation of patients with pulmonary artery hypertension.

Elevated Inflammatory Plasma Biomarkers in Patients With Fabry Disease: A Critical Link to Heart Failure With Preserved Ejection Fraction

Background Because systemic inflammation and endothelial dysfunction lead to heart failure with preserved ejection fraction, we characterized plasma levels of inflammatory and cardiac remodeling biomarkers in patients with Fabry disease ( FD ). Methods and Results Plasma biomarkers were studied in multicenter cohorts of patients with FD (n=68) and healthy controls (n=40). Plasma levels of the following markers of inflammation and cardiac remodeling were determined: tumor necrosis factor ( TNF ), TNF receptor 1 ( TNFR 1) and 2 ( TNFR 2), interleukin-6, matrix metalloprotease-2 ( MMP -2), MMP -8, MMP -9, galectin-1, galectin-3, B-type natriuretic peptide ( BNP ), midregional pro-atrial natriuretic peptide ( MR -pro ANP ), and globotriaosylsphingosine. Clinical profile, cardiac magnetic resonance imaging, and echocardiogram were reviewed and correlated with biomarkers. Patients with FD had elevated plasma levels of BNP , MR -pro ANP , MMP -2, MMP -9, TNF , TNFR 1, TNFR 2, interleukin-6, galectin-1, globotriaosylsphingosine, and analogues. Plasma TNFR 2, TNF , interleukin-6, MMP -2, and globotriaosylsphingosine were elevated in FD patients with left ventricular hypertrophy, whereas diastolic dysfunction correlated with higher BNP , MR -pro ANP , and MMP -2 levels. Patients with late gadolinium enhancement on cardiac magnetic resonance imaging had greater levels of BNP , MR -pro ANP , TNFR 1, TNFR 2, and MMP -2. Plasma BNP , MR -pro ANP , MMP -2, MMP -8, TNF , TNFR 1, TNFR 2, galectin-1, and galectin-3 were elevated in patients with renal dysfunction. Patients undergoing enzyme replacement therapy who have more severe disease had higher MMP -2, TNF , TNFR 1, TNFR 2, and globotriaosylsphingosine analogue levels. Conclusions Inflammatory and cardiac remodeling biomarkers are elevated in FD patients and correlate with disease progression. These features are consistent with a phenotype dominated by heart failure with preserved ejection fraction and suggest a key pathogenic role of systemic inflammation in FD .

Accurate and robust systolic myocardial T1 mapping using saturation recovery with individualized delay time: comparison with diastolic T1 mapping

T₁ mapping data are generally acquired in patients' diastolic phase, wherein their myocardium is the thinnest in the cardiac cycle. However, the analysis of the thin myocardium may cause errors in image registrations and settings related to the region of interest. In this study, we validated systolic T₁ mapping using the saturation recovery with individualized delay time (SR-IDT) method and compared it with conventional diastolic T₁ mapping. Both diastolic and systolic T₁ mappings were performed in the mid-ventricular plane in 10 healthy volunteers (35 ± 9 years, 9 males) and 29 consecutive patients with cardiac diseases (68 ± 14 years, 19 males). Comparison of the myocardial T₁ value at diastole and systole was performed with both the Pearson correlation coefficient (r) and the Bland-Altman analysis. Additionally, the systolic myocardial T₁ value was compared between the volunteers and patients by using Tukey's test. Pearson correlation analysis demonstrated a strong positive correlation between diastolic and systolic T₁ values (r = 0.88, P < 0.001). The Bland-Altman plot suggested that left ventricular T₁ values in the diastole and systole showed high agreement (mean difference and 95% limits of agreement = 17 ± 104 ms). Further, systolic T₁ values with SR-IDT in patients in the late gadolinium enhancement (LGE) group were significantly higher than those in the control group (1585 ± 118 ms vs 1469 ± 69 ms; P = 0.024). Therefore, the proposed systolic T₁ mapping with the SR-IDT, which was validated with respect to the conventional diastolic method, is a useful clinical tool for the quantitative characterization of the myocardium.

Comparison of Native T1, Strain, and Traditional Measures of Cardiovascular Structure and Function by Cardiac Magnetic Resonance Imaging in Patients With Anderson-Fabry Disease

Cardiovascular magnetic resonance imaging (CMR) has emerged as a powerful tool to illuminate cardiovascular pathology in Anderson-Fabry disease (AFD); however, further study is required to develop clinically useful monitoring paradigms. The objective of this study was to retrospectively evaluate strain, native septal T1 values, and standard CMR measurements in a cohort of AFD patients to characterize useful measures of cardiovascular dysfunction that may be derived from a CMR platform. Eighteen patients were identified (n = 8 males) and divided according to presence or absence of left ventricular hypertrophy (LVH). Biometric data were gathered and native T1 and strain values were measured for all patients. Patients with LVH were older and had significantly lower native T1 measured at the apical septal (893 ± 78 vs 1044 ± 217 ms, p = 0.035), midventricular septal (864 ± 76 vs 988 ± 67 ms, p = 0.016), and basal septal (867 ± 58 vs 1027 ± 84 ms, p = 0.006) regions. Circumferential strain was more positive in patients with LVH (-13.5% ± 5.0% vs -18.7% ± 2.7%, p = 0.042), but longitudinal strain was not significantly different between groups. Patients with LVH had higher stroke volumes (114.5 ± 9.7 vs 96.7 ± 17.8 ml, p = 0.050), but other standard CMR measures were not significantly different. In conclusion, AFD patients with LVH have reduced native T1 and more positive circumferential strain compared to those without. The basal septum may be an appropriate region for standard measure of native T1 in this population.

Association and diagnostic utility of diastolic dysfunction and myocardial fibrosis in patients with Fabry disease

Objectives

Current guidelines highlight important therapy implications of cardiac fibrosis in patients with Fabry disease (FD). However, association between morphological and functional impairments with cardiac fibrosis in hereditary cardiomyopathies remains elusive. We investigated the association between echocardiography-determined cardiac dysfunction and cardiac MRI (cMRI)-detected myocardial fibrosis (late gadolinium enhancement, LE) in patients with FD with preserved left ventricular ejection fraction (≥50%).

Methods

146 patients with FD (aged 39±14 years, 57 men) were analysed, all receiving echocardiography and cMRI within a 1 week interval. Longitudinal systolic strain (LS_sys), strain rate (LSr_sys) and diastolic strain rate (LSr_E/LSr_A) were assessed using speckle-tracking imaging. Receiver operating characteristic (ROC) analysis was performed to identify the diagnostic performance of various markers for LE.

Results

LE was detected in 57 (39%) patients with FD. LV wall thickness, left atrial volume, septal E/e', diastolic dysfunction grade, global LS_sys and E/LSr_E, mid-lateral LS_sys and LSr_E, as well as N-terminal pro-brain natriuretic peptide were all associated with LE independent of age, sex, body mass index, New York Heart Association functional class and kidney function. In ROC curve analysis, septal E/e' performed best (area under the curve=0.86, 95% CI=0.79 to 0.92). Septal E/e'>14.8 was strongly associated with LE (specificity=97.8% and sensitivity=49.1%). In 9% of patients, localised LE was present even though no other cardiac or kidney abnormalities were detected.

Conclusions

Echocardiography-derived diastolic dysfunction is closely linked to LE in FD. Septal E/e' ratio is the best echocardiographic marker suggestive of LE. Diastolic dysfunction is not a prerequisite for LE in FD, since LE can be detected in the absence of measurable cardiac functional impairments.

Trial registration number

ClinicalTrials.gov Identifier (NCT03362164).

Use of Myocardial T1 Mapping at 3.0 T to Differentiate Anderson-Fabry Disease from Hypertrophic Cardiomyopathy

Purpose To compare left ventricular (LV) and right ventricular (RV) 3.0-T cardiac magnetic resonance (MR) imaging T1 values in Anderson-Fabry disease (AFD) and hypertrophic cardiomyopathy (HCM) and evaluate the diagnostic value of native T1 values beyond age, sex, and conventional imaging features. Materials and Methods For this prospective study, 30 patients with gene-positive AFD (37% male; mean age ± standard deviation, 45.0 years ± 14.1) and 30 patients with HCM (57% male; mean age, 49.3 years ± 13.5) were prospectively recruited between June 2016 and September 2017 to undergo cardiac MR imaging T1 mapping with a modified Look-Locker inversion recovery (MOLLI) acquisition scheme at 3.0 T (repetition time msec/echo time msec, 280/1.12; section thickness, 8 mm). LV and RV T1 values were evaluated. Statistical analysis included independent samples t test, receiver operating characteristic curve analysis, multivariable logistic regression, and likelihood ratio test. Results Septal LV, global LV, and RV native T1 values were significantly lower in AFD compared with those in HCM (1161 msec ± 47 vs 1296 msec ± 55, respectively [P < .001]; 1192 msec ± 52 vs 1268 msec ± 55 [P < .001]; and 1221 msec ± 54 vs 1271 msec ± 37 [P = .001], respectively). A septal LV native T1 cutoff point of 1220 msec or lower distinguished AFD from HCM with sensitivity of 97%, specificity of 93%, and accuracy of 95%. Septal LV native T1 values differentiated AFD from HCM after adjustment for age, sex, and conventional imaging features (odds ratio, 0.94; 95% confidence interval: 0.91, 0.98; P = < .001). In a nested logistic regression model with age, sex, and conventional imaging features, model fit was significantly improved by the addition of septal LV native T1 values (χ² [df = 1] = 33.4; P < .001). Conclusion Cardiac MR imaging native T1 values at 3.0 T are significantly lower in patients with AFD compared with those with HCM and provide independent and incremental diagnostic value beyond age, sex, and conventional imaging features. ^© RSNA, 2018.