What is the diagnosis???

27 year old man with palpitations, 2 vasovagal syncopes, 24h holter with multiple monomorphic isolated ventricular premature beats (with LVOT morphology). Symptoms have improved with beta-blockers.

Is it a normal variant or a diseased LV?

Case sent by Dr. Guilherme Azevedo from Blumenau, Brazil.

Please give your opinion by clicking on comments below.

The RV is not forgotten in CMR!

Most people quantify RV parameters routinely. That is a great plus compared to other methods where the RV is frequently forgotten.

Quantification of late gadolinium enhanced CMR in viability assessment in chronic ischemic heart disease: a comparison to functional outcome

Abstract
Background: Quantification of late gadolinium enhanced cardiovascular magnetic resonance (LGECMR) by objective window setting increases reproducibility and facilitates multicenter comparison and cooperation. So far, quantification methods or models have only been validated to postmortem animal studies. This study was undertaken to evaluate quantification of LGE in relation to the clinical standard of viability, i.e. functional outcome after revascularization.

Thirty-eight patients with chronic ischemic myocardial dysfunction underwent cine and LGE 1month before and cine CMR 6 months after coronary revascularization. Enhancement was quantified by thresholding window setting at: 2-8SD above mean signal intensity of a remote normal region, and according to the full width at half maximum method (FWHM). Dysfunctional segmentswere divided in 5 groups according to segmental extent of enhancement (SEE): SEE 1 – no enhancement to SEE 5 – 76–100% with each quantification method.

Results: Quantification methods had a strong influence on SEE and total infarct size. Multilevel
analysis showed that thresholding contrast images at 6SD best predicted segmental functional outcome after revascularization, but the difference with other methods was small and nonsignificant.

Conclusion: Simple thresholding techniques strongly influence global and segmental extent of
LGE, but have relatively little influence on the accuracy to predict segmental functional improvement after revascularization.

Journal of Cardiovascular Magnetic Resonance 2009, 11:6

Realmente queda claro el papel que juega la RMC a través de la técnica de Realce Tardío en la detección de zonas infartadas, para predecir mejora o no de la función ventricular después de la Revascularización Miocardica quirúrgica o percutánea.

Florangel Martínez. Centro Clinico Valentina Canabal. Barquisimeto. Venezuela.

El tema de la "disincronía ventricular" está en la mira científica en los últimos tiempos. El estudio PROSPECT, diseñado para evaluar en forma prospectiva los resultados de la resincronización ventricular, nos brinda resultados "no tan buenos" como los publicados en estudios pequeños en forma individual. El resultado mas impactante es que el 30 % de los pacientes no responden a la resincronización. En el estudio de Jeroen J. Bax y John Gorcsan III publicado este mes en el JACC (Vol. 53, No. 21, 2009) se analizas "los porque" de estos resultados, y la utilidad que cobran los métodos alternativos de imágenes como la tomografía computada multislice (para definir mejor las venas coronarias) y la Resonancia magnética cardiovascular para definir las áreas de necrosis, el tamaño y la transmuralidad de las mismas previa a la implantación del marcapaso resincronizador.
Me parece un trabajo interesante que abre una ventrana práctica para la utilización de la Resonancia cardiovasular en estos pacientes. Además, como verán en el trabajo, uno de los puntos déviles del PROSPECT es la importante discrepancia que la mediciones que se realizan con la ecocardiografía en modo M, acá la resonancia magnética podría ayudar a definir la "verdadera" función ventricular antes de indicar esta terapia.

How to keep up with new CMR articles? Easy...

Having trouble finding what are the latest news in CMR??? Let us help...

This week we updated the site with a direct link to new CMR articles published weekly. We will update this link every week so that with a single click you can access what is most current in CMR, directly from PubMed.

We also added a PubMed search option directly from our home page.

We hope that this will keep everyone as updated as one can regarding new advances in the field.

Juliano

Gray in research but black and white in clinical daily life?

More information regarding the importance of the Grey Zone. However, how can we apply this important concept clinically? Is there a viable and practical way to determine the gray zone in our routine load of exams or will it still be regarded as a research tool? How can we translate this information into useful clinical findings for the clinical cardiologist? We hope the software designers can work with new tools for us to explore these findings on a regular basis.

Read more and access the full text of the article below:

Infarct Tissue Heterogeneity Assessed with Contrast-Enhanced Magnetic Resonance Imaging Predicts Spontaneous Ventricular Arrhythmia in Patients with Ischemic Cardiomyopathy and Implantable Cardioverter-Defibrillator.


Juliano - University of Campinas (Unicamp) - Brazil

Controversias Sobre los Cálculos de Función Ventricular a Través de los Métodos no Invasivos.

Comparison of MRI, 64-slice MDCT and DSCT
in assessing functional cardiac parameters
of a moving heart phantom.

Abstract To compare magnetic resonance imaging (MRI), 64-slice multidetectorcomputed tomography (MDCT) and dual-source computed tomography (DSCT) in assessing global function parameters using a moving heart phantom. A moving heart phantom with known volumes (215–258 ml) moving at 50–100 beats per minute was examined by three different imaging modalities usingclinically implemented scanning protocols. End-diastolic and end-systolic volumes were calculated by two experienced observers using dedicated post-processing tools. Ejection fraction (EF) and cardiac output (CO)were calculated and mutually compared using Bland-Altman plots. MRI underestimated the ejection EF by 16.1% with a Bland-Altman interval (B-A) of [-4.35 (-2.48) -0.60]. Sixtyfour- slice MDCT overestimated theEF by 2.6% with a relatively wide BA interval of [-3.40 (0.40) 4.20].
DSCT deviated the least from the known phantom volumes, underestimating the volumes by 0.8% with a BA interval of [-1.17 (-0.13) 0.91]. CO analysis showed similar results. Furthermore, a good correlation was found between DSCT and MRI for EF and CO results. MRI systematically underestimates functional cardiac parameters, ejection fraction and cardiac output of a moving heartphantom. Sixty-four-slice MDCT underestimatesor overestimates these functional parameters depending on the heart rate because of limited spatial resolution. DSCT deviates the least from these functional parameters compared to MRI, EBT and 64-slice MDCT.
Eur Radiol (2009) 19: 577–583

Datos muy interesantes acerca de estos métodos, en lo que se refiere a parametros funcionales cardiacos.

Who has been visiting SCMR online?

Look at the cluster map below. From Latin America, Brazil has had a very active participation. We hope to see more red dots from LatAm on the map.

New SCMR Website Launched

Check the new and updated website. The Latin American WG is now linked in

http://scmr.org/working-groups/1579.html

www.scmr.org



Juliano

Delayed-Enhancement: Aportando su contribución en el área de la Electrofisiologia Invasiva.

Robert S. Oakes, et al, realmente nos muestra la utilidad tan valiosa de la técnica de realce tardío en los pacientes con Fibrilación Atrial. Barbela y colaboradores en el 2005 realizaron una revisión del tema y exponian que :La fibrilación auricular es la arritmia cardíaca sostenida más frecuente. Afecta a 0,6% de la población, y a 6% y 8% de los sujetos mayores de 60 y 80 años, respectivamente. Los pacientes con fibrilación auricular tienen una morbilidad cinco veces mayor (incluyendo cardiomiopatía dilatada e insuficiencia cardíaca congestiva) y el doble de mortalidad que los que tienen ritmo sinusal. Además de la importancia del remodelamiento auricular que tiene dos componentes uno eléctrico y el otro anatómico, los cuales son dos puntos importantes para el manejo de la terapéutica, que pudiera ser quirurgico o por ablación con radiofrecuencia. De ahí la importancia del aporte de la RMC con sus nuevas técnicas para ayudar al manejo, no solo terapéutico si no también para determinar el pronostico de los pacientes con dicha patología.

Detection and Quantification of Left Atrial Structural Remodeling With Delayed-Enhancement Magnetic Resonance Imaging in Patients With Atrial Fibrillation
Robert S. Oakes, BS; Troy J. Badger, MD; Eugene G. Kholmovski, PhD; Nazem Akoum, MD; Nathan S. Burgon, BS; Eric N. Fish; Joshua J.E. Blauer, BS;Swati N. Rao; Edward V.R. DiBella, PhD; Nathan M. Segerson, MD; Marcos Daccarett, MD;Jessiciah Windfelder, NP; Christopher J. McGann, MD; Dennis Parker, PhD;Rob S. MacLeod, PhD; Nassir F. Marrouche, MD

Background—Atrial fibrillation (AF) is associated with diffuse left atrial fibrosis and a reduction in endocardial voltage.These changes are indicators of AF severity and appear to be predictors of treatment outcome. In this study, we reportthe utility of delayed-enhancement magnetic resonance imaging (DE-MRI) in detecting abnormal atrial tissue before radiofrequency ablation and in predicting procedural outcome.
Methods and Results—Eighty-one patients presenting for pulmonary vein antrum isolation for treatment of AF underwent 3-dimensional DE-MRI of the left atrium before the ablation. Six healthy volunteers also were scanned. DE-MRI imageswere manually segmented to isolate the left atrium, and custom software was implemented to quantify the spatial extent of delayed enhancement, which was then compared with the regions of low voltage from electroanatomic maps fromthe pulmonary vein antrum isolation procedure. Patients were assessed for AF recurrence at least 6 months afterpulmonary vein antrum isolation, with an average follow-up of 9.6
3.7 months (range, 6 to 19 months). On the basis of the extent of preablation enhancement, 43 patients were classified as having minimal enhancement (averageenhancement, 8.0
4.2%), 30 as having moderate enhancement (21.3
5.8%), and 8 as having extensive enhancement (50.1
15.4%). The rate of AF recurrence was 6 patients (14.0%) with minimal enhancement, 13 (43.3%) with moderate enhancement, and 6 (75%) with extensive enhancement (P0.001).
Conclusions—DE-MRI provides a noninvasive means of assessing left atrial myocardial tissue in patients suffering from AF and might provide insight into the progress of the disease. Preablation DE-MRI holds promise for predicting responders to AF ablation and may provide a metric of overall disease progression. (Circulation. 2009;119:1758-1767.)

Cuál es el aporte de los métodos no invasivos para determinar enfermedad arterial coronaria en pacientes diabéticos?

Imaging diabetes mellitus with coronary
computed tomography angiography,
cardiovascular magnetic resonance, and
positron emission tomography

The prevalence and medical expense associated with diabetes mellitus continue to increase.
Using the diagnostic imaging techniques of coronary computed tomography angiography,
cardiovascular magnetic resonance, and positron emission tomography, it may be possible to
make earlier, non-invasive diagnoses of the type and extent of disease, thereby preventing or
delaying some morbidity and mortality.

Key Words: Diabetes mellitus Æ computed tomography Æ magnetic resonance imaging Æ
positron emission tomography

Maleah Grover-McKay, MD en J Nucl Cardiol 2009;16:135–8, realiza una pequeña revisión de que pueden aportar los métodos no invasivos para evaluar pacientes diabéticos con sospecha de enfermedad arterial coronaria.

US$750,00 for Best Abstract in Atherosclerosis Imaging

The XII Brazilian Congress of Atherosclerosis will award the best abstract in Atherosclerosis Imaging with a US$750,00 prize in August 6-9.

All accepted abstracts will also be published in the journal Atherosclerosis.

Please read more in http://congresso.cardiol.br/da/xii/default.asp

Juliano

3T is now!

According to the poll on our site, 3T for cardiology is now!

I totally agree, despite the initial costs, but as in CT, we have to push the hardware further. 3T coupled with multichannel coils is a winning combination that can really drive innovations in CMR.


Juliano

SERÁ QUE LA RESPUESTA ES INDIVIDUALIZAR LA DOSIS DE DIPIRIDAMOL TOLERABLE POR EL PACIENTE ?

Realmente los artículos que mas hablan del uso del dipiridamol y determinación de defectos de perfusión asociados a parámetros funcionales, como la fracción de eyección son los realizados con SPECT cardiaco, que posterior a someter el corazón a un estress, en este caso farmacológico nos da una idea global de que tanto de enfermedad coronaria posee un individuo. Sin embargo todos los estudios de SPECT cardiaco han sido enfocados para determinar cual es la probabilidad que tiene un grupo de individuos, que de acuerdo a su estratificación de riesgo podría sufrir un evento cardiaco en determinado tiempo.

Por otra parte este artículo que habla sobre: Valor diagnóstico adicional de la disfunción sistólica inducida para la detección de enfermedad coronaria mediante resonancia magnética cardiaca de estrés con dipiridamol, nos debe hacer reflexionar un poco acerca si será que debemos individualizar la dosis de Dipiridamol tolerable por el paciente. Ya es sabido por las diferentes publicaciones que los defectos de perfusión detectados con estres farmacologico con Dipiridamol tienen asociación angiográfica con con estenosis mayores del 50 %, asi ha sido mostrado con SPECT cardiaco. Sin embargo en la practica diaria hemos tenido pacientes con lesiones angiograficas significativas que no mostraron defectos de perfusión asociados a alteración de la fracción de eyección por SPECT así como también por RM cardiaca. Ahora el punto que tenemos que analizar es el siguiente, será que debemos aumentar la dosis de Dipiridamol en algunos pacientes ? o será que no estamos tomando en cuenta las variabilidades anatómicas que pudieran tener cada paciente que justifique aquellos casos con estenosis angiográficas significativas con estres con dipiridamol normal ? o simplemente no estamos tomando en cuenta si hay o no colaterales, o si los segmentos arteriales son de buen calibre o no ?...................... Como muchos autores, Paetsch et al observo déficit de contractilidad inducidos con el uso de Adenosina asociados a deficit de perfusión menores a 70 %, pero que angiograficamente se asociaban a lesiones mayores de 70%, en contra parte otros autores no observaron defectos de perfusión con dobutamina, que angiograficamente demostraron lesiones mayores a 50 %.

En fin creo que la iniciativa de este grupo español ha sido buena, pero, creo que hubiese sido bueno saber un poco mas de los parámetros hemodinamicos de los pacientes que tomaron en cuenta para utilizar la dosis descrita de dipiridamol.

Centro Clinico Valentina Canabal. Barquisimeto-Venezuela.

Dipyridamole: incremental value of regional contractile dysfunction to perfusion

A recent article from Husser et al from Valencia, Spain, shows that adding a cine sequence to evaluate stress regional function might add to the accuracy of a perfusion stress test with dipyridamole. However, to achieve that, they used the higher 0.84mg/kg dose of the drug instead of the routine 0.56mg/kg most Latin American sites are accustomed to.

Nevertheless, a very interesting finding considering the widespread use of dipyridamole worldwide due to its lower cost and fewer side effects compared to adenosine.

The full text can be accessed at:

http://www.revespcardiol.org/cardio_eng/ctl_servlet?_f=40&ident=13136491


Juliano