Delayed Hyper-Enhancement Magnetic Resonance Imaging Provides Incremental Diagnostic and Prognostic Utility in Suspected Cardiac Amyloidosis.
Bethany A. Austin, MD*, W.H. Wilson Tang, MD*, E. Rene Rodriguez, MD, Carmela Tan, MD, Scott D. Flamm, MD*,, David O. Taylor, MD*, Randall C. Starling, MD, MPH*, Milind Y. Desai, MD*.
Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio Department of Pathology, Cleveland Clinic, Cleveland, Ohio Imaging Institute, Cleveland Clinic, Cleveland, Ohio.
Objectives: We sought to assess the diagnostic accuracy and incremental prognostic value of delayed hyper-enhancement cardiac magnetic resonance (DHE-CMR) compared with electrocardiographic and transthoracic echocardiographic (TTE) parameters in such patients.
Background: Utility of DHE-CMR in the diagnosis of patients with suspected cardiac amyloidosis (CA) has recently been demonstrated, but its incremental prognostic utility is unclear.
Methods: Forty-seven consecutive patients (mean age 63 years, 70% men, 55% New York Heart Association functional class >II) with suspected CA who underwent electrocardiography (ECG), TTE, DHE-CMR, and biopsy (38 endomyocardial, 9 extracardiac) were studied. Low voltage on ECG was defined as S-wave in lead V1 + R-wave in lead V5 or V6 <15 mm. TTE parameters, including deceleration time, E/E' ratio, and diastolic grade were recorded. CMR was considered positive with diffuse DHE of the subendocardium extending to adjacent myocardium. All-cause mortality was ascertained.
Results: In the study population, 59% had low voltage on ECG, 30% had abnormal deceleration time 150 ms, 38% had E/E' ratio >15, and 47% had advanced (pseudonormal or restrictive) diastology. The diagnostic accuracy of DHE-CMR in patients undergoing endomyocardial biopsy was as follows: sensitivity 88%, specificity 90%, positive predictive value 88%, and negative predictive value 90%. On multivariable logistic regression testing of the diagnostic ability of various noninvasive imaging parameters, only DHE-CMR was significant (Wald chi-square statistic 9.6, p < 0.01). At 1-year post-biopsy, there were 9 (19%) deaths. On Cox proportional hazards analysis, only positive DHE-CMR was a predictor of 1-year mortality (Wald chi-square statistic 4.91, p = 0.03).
Conclusions: A characteristic DHE-CMR pattern is more accurate for diagnosis and is a stronger predictor of 1-year mortality in patients with suspected CA as compared with other noninvasive parameters.
J Am Coll Cardiol Img, 2009; 2:1369-1377
Dec 30, 2009
Acute Myocardial Infarction: Serial Cardiac MR Imaging Shows a Decrease in Delayed Enhancement of the Myocardium during the 1st Week after Reperfusion1
Tareq Ibrahim, MD, Thomas Hackl, MD, Stephan G. Nekolla, PhD, Martin Breuer, MD, Michael Feldmair, MD, Albert Schömig, MD and Markus Schwaiger, MD
Purpose: To evaluate the time course of delayed gadolinium enhancement of infarcted myocardium by using serial contrast agent–enhanced (CE cardiac magnetic resonance (MR) images obtained during the acute, subacute, and chronic stages of infarction.
Materials and Methods: The study protocol was reviewed and approved by the local ethics committee, and written informed consent was obtained. Seventeen patients with reperfused acute myocardial infarction (AMI) underwent cine and CE cardiac MR a median of 1, 7, 35, and 180 days after reperfusion. Infarct size determined on the basis of delayed enhancement MR imaging at different times was compared by using nonparametric tests and Bland-Altman analysis. Extent of myocardial enhancement was compared with single photon emission computed tomographic (SPECT) measures of infarct size with Spearman correlation. Regional myocardial enhancement extent and contractility were analyzed with nonparametric tests.
Results: Infarct size was 18.3% of total myocardial LV volume on day 1 after AMI and decreased to 12.9% on day 7, 11.3% on day 35, and 11.6% on day 180 (all P < .001). Estimated infarct size on day 7, as compared with day 1 enhancement size, declined by 57.1% within the epicardium and by 6.3% within the endocardium (both P < .001). Infarct size on day 7 showed only minor changes at subsequent imaging and yielded a high correlation with SPECT measurements of infarct size (r = 0.84). Infarct size on day 7 inversely correlated with long-term wall thickening (P < .0001) and allowed prediction of contractile function.
Conclusion: In patients with AMI and successful coronary reperfusion, the size of delayed gadolinium enhancement at CE cardiac MR imaging significantly diminished during the 1st week after infarction. Thus, timing of CE cardiac MR imaging is crucial for accurate measurement of myocardial infarct size early after AMI.
Radiology January 2010 254:88-97.
Tareq Ibrahim, MD, Thomas Hackl, MD, Stephan G. Nekolla, PhD, Martin Breuer, MD, Michael Feldmair, MD, Albert Schömig, MD and Markus Schwaiger, MD
Purpose: To evaluate the time course of delayed gadolinium enhancement of infarcted myocardium by using serial contrast agent–enhanced (CE cardiac magnetic resonance (MR) images obtained during the acute, subacute, and chronic stages of infarction.
Materials and Methods: The study protocol was reviewed and approved by the local ethics committee, and written informed consent was obtained. Seventeen patients with reperfused acute myocardial infarction (AMI) underwent cine and CE cardiac MR a median of 1, 7, 35, and 180 days after reperfusion. Infarct size determined on the basis of delayed enhancement MR imaging at different times was compared by using nonparametric tests and Bland-Altman analysis. Extent of myocardial enhancement was compared with single photon emission computed tomographic (SPECT) measures of infarct size with Spearman correlation. Regional myocardial enhancement extent and contractility were analyzed with nonparametric tests.
Results: Infarct size was 18.3% of total myocardial LV volume on day 1 after AMI and decreased to 12.9% on day 7, 11.3% on day 35, and 11.6% on day 180 (all P < .001). Estimated infarct size on day 7, as compared with day 1 enhancement size, declined by 57.1% within the epicardium and by 6.3% within the endocardium (both P < .001). Infarct size on day 7 showed only minor changes at subsequent imaging and yielded a high correlation with SPECT measurements of infarct size (r = 0.84). Infarct size on day 7 inversely correlated with long-term wall thickening (P < .0001) and allowed prediction of contractile function.
Conclusion: In patients with AMI and successful coronary reperfusion, the size of delayed gadolinium enhancement at CE cardiac MR imaging significantly diminished during the 1st week after infarction. Thus, timing of CE cardiac MR imaging is crucial for accurate measurement of myocardial infarct size early after AMI.
Radiology January 2010 254:88-97.
Dec 28, 2009
Early Bird Registration for SCMR ends Dec 31!
Last days for early registration for the SCMR Thirteenth Annual Scientific Sessions
January 21-24, 2010:
http://www.scmr.org/meetings.html
Read the preliminary agenda: http://www.scmr.org/assets/files/meetings/SCMR_2010/Scientific%20Sessions%20Agenda.pdf
Tagging: review your knowledge
Both a powerful and under-utilized technique, myocardial tagging by CMR is reviewed in this open access JCMR paper by Shehata et al
http://jcmr-online.com/content/pdf/1532-429x-11-55.pdf
Juliano
Dec 22, 2009
Merry Christmas
This year has been fantastic and the blog is happy to have received over 3300 visits in only 9 months. We expect an even greater number of visitors next year and new and improved contributions.
Merry Christmas and Happy Holidays!
Not everyday
Most of the responders do not perform CMR studies on a daily basis. Certainly this is a little disapointing but pushes us forward to augment the presence of the method in the daily cardiologic clinic. In my personal view, the exame is underutilized and still unknown to many cardiologists. Education, again, is the key here.
Dec 16, 2009
Brazilian paper on Circulation
A very interesting and comprehensive case report on Circulation by Loureiro et al.
Circulation. 2009;120:e285-e287
Juliano
Circulation. 2009;120:e285-e287
Juliano
Dec 13, 2009
FDA Paper on NSF
A very complete review on NSF by the FDA.
The PDF full text can be downloaded here (again, no virus or other unwanted stuff).
Juliano
The PDF full text can be downloaded here (again, no virus or other unwanted stuff).
Juliano
Early Bird Registration for SCMR ends Dec 31!
Registration for SCMR 2010 Meeting with lower prices ends on 2 weeks.
Hurry up to get the discounted rates!
http://www.scmr.org/meetings
Juliano
Dec 9, 2009
MR Angiography of Infrapopliteal Arteries in Patients with Peripheral Arterial Occlusive Disease by Using Gadofosveset at 3.0 T: Diagnostic Accuracy Compared with Selective DSA.
Harald Marcel Bonel, MD, Bettina Saar, MD, Hanno Hoppe, MD, Hak Hong Keo, MD, Marc Husmann, MD2, Konstantin Nikolaou, MD, Karin Ludwig, MD, Zsolt Szucs-Farkas, MD, PhD, Sudesh Srivastav, PhD and Ralph Kickuth, MD
Purpose: To prospectively compare the diagnostic accuracy of steady-state, high-spatial-resolution magnetic resonance (MR) angiography of the lower leg, performed with a blood pool contrast agent, with selective digital subtraction angiography (DSA) as the reference standard in patients with symptomatic peripheral arterial disease.
Materials and Methods: Local ethics committee approval and written informed consent were obtained. In a nonrandomized trial, selective DSA and MR angiography were performed at 3.0 T with a blood pool contrast agent on 22 calves in 20 patients (mean age, 69.4 years ± 11.3 [standard deviation]), 16 men (mean age, 67.8 years ± 12.4) and four women (mean age, 75.6 years ± 3.6 years), to evaluate 352 arterial segments. DSA and MR angiography were performed within 24 hours of each other and directly compared by three experienced, blinded radiologists by using high-spatial-resolution steady-state MR angiograms. Consensus reading for both DSA and MR angiography served as the reference standard.
Results: MR angiography was successful and occurred without serious adverse events in all patients. Seven significantly stenosed and 40 occluded segments were rated equally in both modalities. In three cases, the tibial arteries were shown to be occluded or significantly stenosed at DSA but appeared normal or significantly stenosed at MR angiography. The respective average segment sensitivity, specificity, and accuracy were 98.3% (59 of 60), 98% (113.7 of 116), and 98.1% (172.7 of 176) for DSA and 100% (60 of 60), 100% (116 of 116), and 100% (176 of 176) for MR angiography. Steady-state MR angiography was especially useful for the distal peroneal artery and the proximal anterior tibial artery.
Conclusion: MR angiography performed with blood pool agents has an accuracy comparable with that of selective DSA in the lower leg but with less risk involved. Steady-state imaging performed with blood pool agents facilitates evaluation of MR angiography of infrapopliteal arteries.
Radiology.December 2009; 253 (3)
Harald Marcel Bonel, MD, Bettina Saar, MD, Hanno Hoppe, MD, Hak Hong Keo, MD, Marc Husmann, MD2, Konstantin Nikolaou, MD, Karin Ludwig, MD, Zsolt Szucs-Farkas, MD, PhD, Sudesh Srivastav, PhD and Ralph Kickuth, MD
Purpose: To prospectively compare the diagnostic accuracy of steady-state, high-spatial-resolution magnetic resonance (MR) angiography of the lower leg, performed with a blood pool contrast agent, with selective digital subtraction angiography (DSA) as the reference standard in patients with symptomatic peripheral arterial disease.
Materials and Methods: Local ethics committee approval and written informed consent were obtained. In a nonrandomized trial, selective DSA and MR angiography were performed at 3.0 T with a blood pool contrast agent on 22 calves in 20 patients (mean age, 69.4 years ± 11.3 [standard deviation]), 16 men (mean age, 67.8 years ± 12.4) and four women (mean age, 75.6 years ± 3.6 years), to evaluate 352 arterial segments. DSA and MR angiography were performed within 24 hours of each other and directly compared by three experienced, blinded radiologists by using high-spatial-resolution steady-state MR angiograms. Consensus reading for both DSA and MR angiography served as the reference standard.
Results: MR angiography was successful and occurred without serious adverse events in all patients. Seven significantly stenosed and 40 occluded segments were rated equally in both modalities. In three cases, the tibial arteries were shown to be occluded or significantly stenosed at DSA but appeared normal or significantly stenosed at MR angiography. The respective average segment sensitivity, specificity, and accuracy were 98.3% (59 of 60), 98% (113.7 of 116), and 98.1% (172.7 of 176) for DSA and 100% (60 of 60), 100% (116 of 116), and 100% (176 of 176) for MR angiography. Steady-state MR angiography was especially useful for the distal peroneal artery and the proximal anterior tibial artery.
Conclusion: MR angiography performed with blood pool agents has an accuracy comparable with that of selective DSA in the lower leg but with less risk involved. Steady-state imaging performed with blood pool agents facilitates evaluation of MR angiography of infrapopliteal arteries.
Radiology.December 2009; 253 (3)
Noninvasive Assessment of Pulmonary Artery Flow and Resistance by Cardiac Magnetic Resonance in Congenital Heart Diseases With Unrestricted Left-to-Right.
Kings College London, BHF Centre of Excellence, Division of Imaging Sciences, London, United Kingdom Guy's and St. Thomas' NHS Foundation Trust Biomedical Research Centre, London, United Kingdom Division of Health and Social Care Research, Kings College, London, United Kingdom
Objectives: To determine whether noninvasive assessment of pulmonary artery flow (Qp) by cardiac magnetic resonance (CMR) would predict pulmonary vascular resistance (PVR) in patients with congenital heart disease characterized by an unrestricted left-to-right shunt.
Background: Patients with an unrestricted left-to-right shunt who are at risk of obstructive pulmonary vascular disease require PVR evaluation preoperatively. CMR cardiac catheter (XMR) combines noninvasive measurement of Qp by phase contrast imaging with invasive pressure measurement to accurately determine the PVR.
Methods: Patients referred for clinical assessment of the PVR were included. The XMR was used to determine the PVR. The noninvasive parameters, Qp and left-to-right shunt (Qp/Qs), were compared with the PVR using univariate regression models.
Results: The XMR was undertaken in 26 patients (median age 0.87 years)—ventricular septal defect 46.2%, atrioventricular septal defect 42.3%. Mean aortic flow was 2.24 ± 0.59 l/min/m2, and mean Qp was 6.25 ± 2.78 l/min/m2. Mean Qp/Qs was 2.77 ± 1.02. Mean pulmonary artery pressure was 34.8 ± 10.9 mm Hg. Mean/median PVR was 5.5/3.0 Woods Units (WU)/m2 (range 1.7 to 31.4 WU/m2). The PVR was related to both Qp and Qp/Qs in an inverse exponential fashion by the univariate regression equations PVR = exp(2.53 – 0.20[Qp]) and PVR = exp(2.75 – 0.52[Qp/Qs]). Receiver-operator characteristic (ROC) analysis was used to determine cutoff values for Qp and Qp/Qs above which the PVR could be regarded as clinically acceptable. A Qp of 6.05 l/min/m2 predicted a PVR of 3.5 WU/m2 with sensitivity 72%, specificity 100%, and area under the ROC curve 0.90 (p = 0.002). A Qp/Qs of 2.5/1 predicted a PVR of 3.5 WU/m2 with sensitivity 83%, specificity 100%, and area under the curve ROC 0.94 (p < 0.001).
Conclusions: Measurement of Qp or left-to-right shunt noninvasively by CMR has potential to predict the PVR in patients with an unrestricted left-to-right shunt and could potentially determine operability without having to undertake invasive testing.
Key Words: cardiac magnetic resonance • congenital • heart defects • pediatrics • pulmonary vascular resistance • shunts
J Am Coll Cardiol Img, 2009; 2:1285-1291.
Kings College London, BHF Centre of Excellence, Division of Imaging Sciences, London, United Kingdom Guy's and St. Thomas' NHS Foundation Trust Biomedical Research Centre, London, United Kingdom Division of Health and Social Care Research, Kings College, London, United Kingdom
Objectives: To determine whether noninvasive assessment of pulmonary artery flow (Qp) by cardiac magnetic resonance (CMR) would predict pulmonary vascular resistance (PVR) in patients with congenital heart disease characterized by an unrestricted left-to-right shunt.
Background: Patients with an unrestricted left-to-right shunt who are at risk of obstructive pulmonary vascular disease require PVR evaluation preoperatively. CMR cardiac catheter (XMR) combines noninvasive measurement of Qp by phase contrast imaging with invasive pressure measurement to accurately determine the PVR.
Methods: Patients referred for clinical assessment of the PVR were included. The XMR was used to determine the PVR. The noninvasive parameters, Qp and left-to-right shunt (Qp/Qs), were compared with the PVR using univariate regression models.
Results: The XMR was undertaken in 26 patients (median age 0.87 years)—ventricular septal defect 46.2%, atrioventricular septal defect 42.3%. Mean aortic flow was 2.24 ± 0.59 l/min/m2, and mean Qp was 6.25 ± 2.78 l/min/m2. Mean Qp/Qs was 2.77 ± 1.02. Mean pulmonary artery pressure was 34.8 ± 10.9 mm Hg. Mean/median PVR was 5.5/3.0 Woods Units (WU)/m2 (range 1.7 to 31.4 WU/m2). The PVR was related to both Qp and Qp/Qs in an inverse exponential fashion by the univariate regression equations PVR = exp(2.53 – 0.20[Qp]) and PVR = exp(2.75 – 0.52[Qp/Qs]). Receiver-operator characteristic (ROC) analysis was used to determine cutoff values for Qp and Qp/Qs above which the PVR could be regarded as clinically acceptable. A Qp of 6.05 l/min/m2 predicted a PVR of 3.5 WU/m2 with sensitivity 72%, specificity 100%, and area under the ROC curve 0.90 (p = 0.002). A Qp/Qs of 2.5/1 predicted a PVR of 3.5 WU/m2 with sensitivity 83%, specificity 100%, and area under the curve ROC 0.94 (p < 0.001).
Conclusions: Measurement of Qp or left-to-right shunt noninvasively by CMR has potential to predict the PVR in patients with an unrestricted left-to-right shunt and could potentially determine operability without having to undertake invasive testing.
Key Words: cardiac magnetic resonance • congenital • heart defects • pediatrics • pulmonary vascular resistance • shunts
J Am Coll Cardiol Img, 2009; 2:1285-1291.
Dec 6, 2009
Difficult exams in children
CMR in children is not so straightforward. This paper provides some hints on how to get better images when doing perfusion studies.
A direct link to the free PDF is here.
Research
Feasibility of perfusion cardiovascular magnetic resonance in paediatric patients
Emanuela R Valsangiacomo Buechel1 email, Christian Balmer1 email, Urs Bauersfeld1 email, Christian J Kellenberger2 email and Juerg Schwitter3 email
1University Children's Hospital Zurich, Division of Paediatric Cardiology, 8032 Zurich, Switzerland
2University Children's Hospital Zurich, Division of Diagnostic Imaging, 8032 Zurich, Switzerland
3University Hospital Zurich, Clinic of Cardiology, Zurich, Switzerland
author email corresponding author email
Journal of Cardiovascular Magnetic Resonance 2009, 11:51doi:10.1186/1532-429X-11-51
Published: 30 November 2009
Abstract
Aims
As coronary artery disease may also occur during childhood in some specific conditions, we sought to assess the feasibility and accuracy of perfusion cardiovascular magnetic resonance (CMR) in paediatric patients.
Methods and results
First-pass perfusion CMR studies were performed under pharmacological stress with adenosine and by using a hybrid echo-planar pulse sequence with slice-selective saturation recovery preparation. Fifty-six perfusion CMR examinations were performed in 47 patients. The median age was 12 years (1 month-18 years), and weight 42.8 kg (2.6-82 kg). General anaesthesia was required in 18 patients. Mean examination time was 67 ± 19 min. Diagnostic image quality was obtained in 54/56 examinations. In 23 cases the acquisition parameters were adapted to patient's size. Perfusion CMR was abnormal in 16 examinations. The perfusion defects affected the territory of the left anterior descending coronary artery in 11, of the right coronary artery in 3, and of the circumflex coronary artery in 2 cases. Compared to coronary angiography, perfusion CMR showed a sensitivity of 87% (CI 52-97%) and a specificity of 95% (CI 79-99%).
Conclusion
In children, perfusion CMR is feasible and accurate. In very young children (less than 1 year old), diagnostic image quality may be limited.
A direct link to the free PDF is here.
Research
Feasibility of perfusion cardiovascular magnetic resonance in paediatric patients
Emanuela R Valsangiacomo Buechel1 email, Christian Balmer1 email, Urs Bauersfeld1 email, Christian J Kellenberger2 email and Juerg Schwitter3 email
1University Children's Hospital Zurich, Division of Paediatric Cardiology, 8032 Zurich, Switzerland
2University Children's Hospital Zurich, Division of Diagnostic Imaging, 8032 Zurich, Switzerland
3University Hospital Zurich, Clinic of Cardiology, Zurich, Switzerland
author email corresponding author email
Journal of Cardiovascular Magnetic Resonance 2009, 11:51doi:10.1186/1532-429X-11-51
Published: 30 November 2009
Abstract
Aims
As coronary artery disease may also occur during childhood in some specific conditions, we sought to assess the feasibility and accuracy of perfusion cardiovascular magnetic resonance (CMR) in paediatric patients.
Methods and results
First-pass perfusion CMR studies were performed under pharmacological stress with adenosine and by using a hybrid echo-planar pulse sequence with slice-selective saturation recovery preparation. Fifty-six perfusion CMR examinations were performed in 47 patients. The median age was 12 years (1 month-18 years), and weight 42.8 kg (2.6-82 kg). General anaesthesia was required in 18 patients. Mean examination time was 67 ± 19 min. Diagnostic image quality was obtained in 54/56 examinations. In 23 cases the acquisition parameters were adapted to patient's size. Perfusion CMR was abnormal in 16 examinations. The perfusion defects affected the territory of the left anterior descending coronary artery in 11, of the right coronary artery in 3, and of the circumflex coronary artery in 2 cases. Compared to coronary angiography, perfusion CMR showed a sensitivity of 87% (CI 52-97%) and a specificity of 95% (CI 79-99%).
Conclusion
In children, perfusion CMR is feasible and accurate. In very young children (less than 1 year old), diagnostic image quality may be limited.
Dec 2, 2009
Wide and Three
The buzz at the RSNA 2009 on CMR was the use of the new hardware systems with 3T and wide 70cm bores from many vendors. This, combined with parallel imaging, seems to bring a new level of speed and temporal/spatial resolution to CMR exams. We still have to see the results of this on clinical papers as sites upgrade their machines to the newer platforms but the perspectives look very good (not cheap though!).
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