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Pulmonary Hypertension Prognosis using CMR RV volumes
Circ Cardiovasc Imaging. 2013 Nov 25. [Epub ahead of print]
Prognostic Value of Cardiovascular Magnetic Resonance Imaging Measurements Corrected for Age and Gender in Idiopathic Pulmonary Arterial Hypertension.
Swift AJ, Rajaram S, Campbell MJ, Hurdman J, Thomas S, Capener D, Elliot C, Condliffe R, Wild JM, Kiely DG.
-There is limited data on the prognostic value of cardiovascular magnetic resonance (CMR) measurements in idiopathic pulmonary arterial hypertension, with no studies investigating the impact of correction of CMR indices for age and gender on prognostic value.
METHODS AND RESULTS:
-Consecutive patients with idiopathic pulmonary arterial hypertension (IPAH) underwent CMR imaging at 1.5T. Steady state free precession (SSFP) cardiac volumes and mass measurements were corrected for age, gender and BSA according to reference data and prognostic significance assessed. 80 patients with IPAH were identified, 23 patients died during the mean follow-up of 32 +/- 14 months. Corrected for age, gender and BSA, RV end-systolic volume (p=0.004) strongly predicted mortality, independent of WHO functional class, mean right atrial pressure (mRAP), cardiac index (CI) and mixed venous oxygen saturations (mVO2).
-Consideration should be given to correcting CMR measures, for age, gender and BSA, particularly given the changing demographics of patients with IPAH. Corrected right ventricular end-systolic volume is a strong prognostic marker in IPAH, independent of invasively derived measurements, mRAP, CI and mVO2. ...
On: 12/02/2013 By: jfernandes4125 Read more?
RBBB: an indication for further CMR investigation?
J Am Coll Cardiol. 2013 Sep 10;62(11):959-67. doi: 10.1016/j.jacc.2013.04.060. Epub 2013 May 22
Right, but not left, bundle branch block is associated with large anteroseptal scar.
Strauss DG, Loring Z, Selvester RH, Gerstenblith G, Tomaselli G, Weiss RG, Wagner GS, Wu KC.
This study sought to test the hypothesis that right bundle branch block (RBBB) patients have larger scar size than left bundle branch block (LBBB) patients do.
A proximal septal perforating branch of the left anterior descending (LAD) coronary artery most commonly perfuses the right bundle branch and left anterior fascicle, but not the left posterior fascicle. Thus, proximal LAD occlusions should cause RBBB, not LBBB.
We performed electrocardiograms and magnetic resonance imaging for scar quantification in 233 patients with left ventricular (LV) ejection fraction ≤35% who were receiving primary prevention implantable cardioverter-defibrillators (ICD cohort). Scar size and location were compared among patients with RBBB, LBBB, nonspecific LV conduction delay, and QRS <120 ms. A second cohort of 20 hypertrophic cardiomyopathy patients undergoing alcohol septal ablation was studied to determine whether controlled infarction in a proximal LAD septal perforator caused RBBB or LBBB.
In the ICD cohort, LV ejection fraction was similar between RBBB and LBBB patients (24.9% vs. 25.0%; p = 0.98); however, RBBB patients had significantly larger scar size (24.0% vs. 6.5%; p < 0.0001). Patients with nonspecific LV conduction delay or QRS <120 ms had intermediate scar size (12.9% and 14.4%, respectively). Those with RBBB (compared with LBBB) were more likely to have ischemic heart disease (79% vs. 29%; p < 0.0001). In the alcohol septal ablation cohort, 15 of 20 patients (75%) developed RBBB, but no patients developed LBBB.
In patients with...
On: 11/25/2013 By: jfernandes4125 Read more?
Cripts and HCM: new evidences
Radiology. 2013 Oct;269(1):68-76. doi: 10.1148/radiol.13122344. Epub 2013 Jun 14.
Deep basal inferoseptal crypts occur more commonly in patients with hypertrophic cardiomyopathy due to disease-causing myofilament mutations.
Deva DP, Williams LK, Care M, Siminovitch KA, Moshonov H, Wintersperger BJ, Rakowski H, Crean AM.
To determine the relationship between deep basal inferoseptal crypts and disease-causing gene mutations in hypertrophic cardiomyopathy (HCM).
MATERIALS AND METHODS:
Institutional research and ethics board approval was obtained for this retrospective study, and the requirement to obtain informed consent was waived. Two readers, who were blinded to genetic status, independently assessed cardiac magnetic resonance (MR) images obtained in 300 consecutive unrelated genetically tested patients with HCM. Readers documented the morphologic phenotype, the presence of deep basal inferoseptal crypts, and the imaging plane in which crypts were first convincingly visualized. The Student t test, the Fisher exact test, and multivariate logistic regression were used for comparisons and to evaluate the relationship between these crypts and the detection of disease-causing mutations.
The frequency of deep basal inferoseptal crypts was significantly higher in patients with disease-causing mutations than in those without disease-causing mutations (36% and 4%, respectively; P < .001). The presence of crypts was a stronger predictor of disease-causing mutations than was reverse septal curvature (P = .025). Patients with these crypts had a higher likelihood of having disease-causing mutations than non-disease-causing mutations (P < .001). Thirty-one of the 34 patients with both deep basal inferoseptal crypts and reverse septal curvature (91%) had disease-causing mutations (sensitivity, 26%; specificity, 98%). The presence of deep basal inferoseptal crypts (odds ratio: 6.64; 95% confidence interval: 2.631, 16.755; P < .001) and reverse septal curvature (odds ratio: 4.8; 95% confidence interval: 2.552, 9.083; P < .001)...
On: 11/18/2013 By: jfernandes4125 Read more?
Saving Money in PAH studies using CMR
Circ Cardiovasc Imaging. 2013 Nov 5. [Epub ahead of print]
Sample Size and Cost Analysis for Pulmonary Arterial Hypertension Drug Trials Using Various Imaging Modalities to Assess Right Ventricular Size and Function Endpoints.
Addetia K, Bhave NM, Tabit CE, Gomberg-Maitland M, Freed BH, Dill KE, Lang RM, Mor-Avi V, Patel AR.
-Placebo-controlled trials for pulmonary arterial hypertension (PAH) are no longer acceptable because new therapies must show clinically significant effects on top of standard treatment. The purpose of this study was to estimate sample sizes and imaging costs for the planning of a hypothetical PAH drug trial using imaging to detect changes in right ventricular (RV) size and function in response to combined therapy.
METHODS AND RESULTS:
-Same-day cardiovascular magnetic resonance (CMR), 2D and 3D transthoracic echocardiography (2DTTE and 3DTTE) were performed in 22 PAH patients (54±13 years) twice, 6 months apart. Short-axis CMR cines and full-volume 3DTTE datasets of the RV were used to measure end-diastolic volume (RVEDV) and ejection fraction (RVEF). Fractional area change (FAC) was obtained from 2DTTE. Sample size calculations used a two-sample t-test model incorporating differences between baseline and 6-month measurements. Cost estimates were made using the Medicare fee schedule. No significant differences were noted between baseline and follow-up measurements. Large SDs reflected variable progression of disease in individual patients on standard therapy and measurement variability. These sources of variability resulted in inter-technique differences in sample sizes: to detect a change of 5-15% in 3DTTE-derived RVEF and FAC, or change of 15-30mL in 3DTTE RVEDV, sample sizes were 2-2.5x those required by CMR. As a result, the total cost of a trial using complete TTE was greater than CMR, which was greater than limited TTE.
-Because of lower...
On: 11/11/2013 By: jfernandes4125 Read more?
LGE in AF and its relation to atrial electograms
J Am Coll Cardiol. 2013 Aug 27;62(9):802-12. doi: 10.1016/j.jacc.2013.03.081.
Epub 2013 May 30.
Inverse relationship between fractionated electrograms and atrial fibrosis in persistent atrial fibrillation: combined magnetic resonance imaging and high-density mapping.
Jadidi AS, Cochet H, Shah AJ, Kim SJ, Duncan E, Miyazaki S, Sermesant M, Lehrmann H, Lederlin M, Linton N, Forclaz A, Nault I, Rivard L, Wright M, Liu X, Scherr D, Wilton SB, Roten L, Pascale P, Derval N, Sacher F, Knecht S, Keyl C, Hocini M, Montaudon M, Laurent F, Haïssaguerre M, Jaïs P.
This study sought to evaluate the relationship between fibrosis imaged by delayed-enhancement (DE) magnetic resonance imaging (MRI) and atrial electrograms (Egms) in persistent atrial fibrillation (AF).
Atrial fractionated Egms are strongly related to slow anisotropic conduction. Their relationship to atrial fibrosis has not yet been investigated.
Atrial high-resolution MRI of 18 patients with persistent AF (11 long-lasting persistent AF) was registered with mapping geometry (NavX electro-anatomical system (version 8.0, St. Jude Medical, St. Paul, Minnesota)). DE areas were categorized as dense or patchy, depending on their DE content. Left atrial Egms during AF were acquired using a high-density, 20-pole catheter (514 ± 77 sites/map). Fractionation, organization/regularity, local mean cycle length (CL), and voltage were analyzed with regard to DE.
Patients with long-lasting persistent versus persistent AF had larger left atrial (LA) surface area (134 ± 38 cm(2) vs. 98 ± 9 cm(2), p = 0.02), a higher amount of atrial DE (70 ± 16 cm(2) vs. 49 ± 10 cm(2), p = 0.01), more complex fractionated atrial Egm (CFAE) extent (54 ± 16 cm(2) vs. 28 ± 15 cm(2), p = 0.02), and a shorter baseline AF CL (147 ± 10 ms...
On: 11/04/2013 By: jfernandes4125 Read more?
Exercising in the CMR room - a comparison to stress echo
J Magn Reson Imaging. 2013 Oct 10. doi: 10.1002/jmri.24263. [Epub ahead of print]
Comparison of treadmill exercise stress cardiac MRI to stress echocardiography in healthy volunteers for adequacy of left ventricular endocardial wall visualization: A pilot study.
Thavendiranathan P, Dickerson JA, Scandling D, Balasubramanian V, Pennell ML, Hinton A, Raman SV, Simonetti OP.
To compare exercise stress cardiac magnetic resonance (cardiac MR) to echocardiography in healthy volunteers with respect to adequacy of endocardial visualization and confidence of stress study interpretation.
MATERIALS AND METHODS:
Twenty-eight healthy volunteers (age 28 ± 11 years, 15 males) underwent exercise stress echo and cardiac MR one week apart assigned randomly to one test first. Stress cardiac MR was performed using an MRI-compatible treadmill; stress echo was performed as per routine protocol. Cardiac MR and echo images were independently reviewed and scored for adequacy of endocardial visualization and confidence in interpretation of the stress study.
Heart rate at the time of imaging was similar between the studies. Average time from cessation of exercise to start of imaging (21 vs. 31 s, P < 0.001) and time to acquire stress images (20 vs. 51 s, P < 0.001) was shorter for cardiac MR. The number of myocardial segments adequately visualized was significantly higher by cardiac MR at rest (99.8% vs. 96.4%, P = 0.002) and stress (99.8% vs. 94.1%, P = 0.001). The proportion of subjects in whom there was high confidence in the interpretation was higher for cardiac MR than echo (96% vs. 60%, P = 0.005).
Exercise stress cardiac MR to assess peak exercise wall motion is feasible and can be performed at least as rapidly as stress echo. ...
On: 10/19/2013 By: jfernandes4125 Read more?
Hyperpolarized C13 CMR - are we there yet?
Clinical implications of hyperpolarized C13 cardiovascular magnetic resonance
Oliver J Rider and Damian J Tyler
Journal of Cardiovascular Magnetic Resonance 2013, 15:93 doi:10.1186/1532-429X-15-93
Published: 8 October 2013
Alterations in cardiac metabolism are now considered a cause, rather than a result, of cardiac disease. Although magnetic resonance spectroscopy has allowed investigation of myocardial energetics, the inherently low sensitivity of the technique has limited its clinical application in the study of cardiac metabolism. The development of a novel hyperpolarization technique, based on the process of dynamic nuclear polarization, when combined with the metabolic tracers [1-13C] and [2-13C] pyruvate, has resulted in significant advances in the understanding of real time myocardial metabolism in the normal and diseased heart in vivo. This review focuses on the changes in myocardial substrate selection and downstream metabolism of hyperpolarized 13C labelled pyruvate that have been shown in diabetes, ischaemic heart disease, cardiac hypertrophy and heart failure in animal models of disease and how these could translate into clinical practice with the advent of clinical grade hyperpolarizer systems. ...
On: 10/12/2013 By: jfernandes4125 Read more?
CMR impact in management of HF
J Cardiovasc Magn Reson. 2013 Oct 1;15(1):89. [Epub ahead of print]
Impact of cardiovascular magnetic resonance on management and clinical decision-making in heart failure patients.
Abbasi SA, Ertel A, Shah RV, Dandekar V, Chung J, Bhat G, Desai AA, Kwong RY, Farzaneh-Far A.
Cardiovascular magnetic resonance (CMR) can provide important diagnostic and prognostic information in patients with heart failure. However, in the current health care environment, use of a new imaging modality like CMR requires evidence for direct additive impact on clinical management. We sought to evaluate the impact of CMR on clinical management and diagnosis in patients with heart failure.
We prospectively studied 150 consecutive patients with heart failure and an ejection fraction <=50% referred for CMR. Definitions for "significant clinical impact" of CMR were pre-defined and collected directly from medical records and/or from patients. Categories of significant clinical impact included: new diagnosis, medication change, hospital admission/discharge, as well as performance or avoidance of invasive procedures (angiography, revascularization, device therapy or biopsy).
Overall, CMR had a significant clinical impact in 65% of patients. This included an entirely new diagnosis in 30% of cases and a change in management in 52%. CMR results directly led to angiography in 9% and to the performance of percutaneous coronary intervention in 7%. In a multivariable model that included clinical and imaging parameters, presence of late gadolinium enhancement (LGE) was the only independent predictor of "significant clinical impact" (OR 6.72, 95% CI 2.56-17.60, p=0.0001).
CMR made a significant additive clinical impact on management, decision-making and diagnosis in 65% of heart failure patients. This additive impact was seen despite universal use of prior echocardiography in this patient group. The presence of LGE was the best independent predictor...
On: 10/06/2013 By: jfernandes4125 Read more?
Choose your CMR stressor drug
J Cardiovasc Magn Reson. 2013 Sep 24;15(1):85. [Epub ahead of print]
Regadenoson and adenosine are equivalent vasodilators and are superior than dipyridamole- a study of first pass quantitative perfusion cardiovascular magnetic resonance.
Vasu S, Bandettini WP, Hsu LY, Kellman P, Leung S, Mancini C, Shanbhag SM, Wilson J, Booker OJ, Arai AE.
Regadenoson, dipyridamole and adenosine are commonly used vasodilators in myocardial perfusion imaging for the detection of obstructive coronary artery disease. There are few comparative studies of the vasodilator properties of regadenoson, adenosine and dipyridamole in humans. The specific aim of this study was to determine the relative potency of these three vasodilators by quantifying stress and rest myocardial perfusion in humans using cardiovascular magnetic resonance (CMR).
Fifteen healthy normal volunteers, with Framingham score less than 1% underwent vasodilator stress testing with regadenoson (400 mug bolus), dipyridamole (0.56 mg/kg) and adenosine (140 mug /kg/min) on separate days. Rest perfusion imaging was performed initially. Twenty minutes later, stress imaging was performed at peak vasodilation, i.e. 70 seconds after regadenoson, 4 minutes after dipyridamole infusion and between 3--4 minutes of the adenosine infusion. Myocardial blood flow (MBF) in ml/min/g and myocardial perfusion reserve (MPR) were quantified using a fully quantitative model constrained deconvolution.
Regadenoson produced higher stress MBF than dipyridamole and adenosine (3.58 +/-0.58 vs. 2.81+/- 0.67 vs. 2.78 +/- 0.61 ml/min/g, p = 0.0009 and p = 0.0008 respectively). Regadenoson had a much higher heart rate response than adenosine and dipyridamole respectively (95 +/- 11 vs. 76 +/- 13 vs. 86 +/- 12 beats/ minute) When stress MBF was adjusted for heart rate, there were no differences between regadenoson and adenosine (37.8 +/- 6 vs. 36.6 +/- 4 mul/sec/g, p =...
On: 09/28/2013 By: jfernandes4125 Read more?
Remodeling in IDC - LGE still ruling
Myocardial Fibrosis as a Key Determinant of Left Ventricular Remodeling in Idiopathic Dilated Cardiomyopathy: A Contrast-Enhanced Cardiovascular Magnetic Study
http://circimaging.ahajournals.org/content/6/5/790.long (FREE PDF)
Circ Cardiovasc Imaging. 2013 Sep 1;6(5):790-9. doi: 10.1161/CIRCIMAGING.113.000438. Epub 2013 Aug 9.
Masci PG et al
Background- In idiopathic dilated cardiomyopathy, there are scarce data on the influence of late gadolinium enhancement (LGE) assessed by cardiovascular magnetic resonance on left ventricular (LV) remodeling. Methods and Results- Fifty-eight consecutive patients with idiopathic dilated cardiomyopathy underwent baseline clinical, biohumoral, and instrumental workup. Medical therapy was optimized after study enrollment. Cardiovascular magnetic resonance was used to assess ventricular volumes, function, and LGE extent at baseline and 24-month follow-up. LV reverse remodeling (RR) was defined as an increase in LV ejection fraction ≥10 U, combined with a decrease in LV end-diastolic volume ≥10% at follow-up. ΔLGE extent was the difference in LGE extent between follow-up and baseline. LV-RR was observed in 22 patients (38%). Multivariate regression analysis showed that the absence of LGE at baseline cardiovascular magnetic resonance was a strong predictor of LV-RR (odds ratio, 10.857 [95% confidence interval, 1.844-63.911]; P=0.008) after correction for age, heart rate, New York Heart Association class, LV volumes, and LV and right ventricular ejection fractions. All patients with baseline LGE (n=26; 45%) demonstrated LGE at follow-up, and no patient without baseline LGE developed LGE at follow-up. In LGE-positive patients, there was an increase in LGE extent over time (P=0.034), which was inversely related to LV ejection fraction variation (Spearman ρ, -0.440; P=0.041). Five patients showed an increase in LGE extent >75th percentile of ΔLGE extent, and among these none experienced LV-RR and 4 had a decrease in LV ejection fraction ≥10 U at follow-up. Conclusions- In patients with idiopathic dilated cardiomyopathy, the absence of LGE...
On: 09/23/2013 By: jfernandes4125 Read more?
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