How fast perfusion sequences help MO detection

A very interesting use of a rapid MR perfusion technique with high resolution (1.5x1.5) and full LV coverage.

Read the full text here in JCMR

Inflammation in Tako-Tsubo

An inflammatory disease after all?

Inflammation in takotsubo cardiomyopathy: insights from cardiovascular magnetic resonance imaging.
Eitel I, Lücke C, Grothoff M, Sareban M, Schuler G, Thiele H, Gutberlet M.

Read the abstract here

Increasing Radiation in Medical Imaging - a window of opportunity for CMR

The recent NEJM manuscript on the increase in use of medical imaging modalities and radiation should be taken very seriously by payers, patients and practitioners. At the same time, the CMR community may be asking: should we care??? The definite answer is yes, because this issue is a big plus for CMR. We should emphasize this huge advantage of CMR and, again, educate cardiologists of the great risk/benefit ratio of the technique.

ESTAMOS ESTRATIFICANDO BIEN LOS PACIENTES CON CARDIOMIOPATIA HIPERTROFICA ?

Usefulness of cardiac magnetic resonance in assessing the risk of ventricular arrhythmias and sudden death in patients with hypertrophic cardiomyopathy

Sergio Leonardi1, Claudia Raineri1,*, Gaetano M. De Ferrari1, Stefano Ghio1, Laura Scelsi1, Michele Pasotti2, Marilena Tagliani2, Adele Valentini3, Roberto Dore3, Arturo Raisaro1 and Eloisa Arbustini2

Aims: To assess the relationship between cardiovascular magnetic resonance (CMR) parameters and both spontaneous ventricular tachycardia (VT) and risk of sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) patients.

Methods and results: One hundred and eight consecutive HCM patients (mean age 42 ± 15 years, 76% males) underwent CMR evaluation and risk assessment. Delayed contrast enhancement (DCE) was quantified with a specifically designed score. Endpoints were either the presence of clinical VT/ventricular fibrillation (VF) or of acknowledged risk factors for SCD. Compared to patients without arrhythmia, those with VT/VF (n = 33) had a higher DCE score [median 8 (2–13) vs. 11 (6–20); P = 0.01]; DCE score was also the only independent predictor of VT/VF in the multivariable model. DCE score [median 6 (1–10.5) vs. 12 (6–18); P = 0.001], mean and maximal left ventricular (LV) wall thickness (MaxLVWT), as well as LV mass index were significantly greater among patients at risk for SCD (n = 51) compared with the remaining 57 patients at low risk. DCE score and MaxLVWT were independent predictors of SCD risk.
Conclusion: In HCM patients several CMR parameters are associated with risk for SCD. A semi-quantitative index of DCE is a significant multivariable predictor of both clinical VT/VF and of risk for SCD and may contribute to risk assessment in borderline or controversial cases.

Key Words: Cardiovascular magnetic resonance • Sudden cardiac death • Hypertrophic cardiomyopathy • Ventricular tachycardia/fibrillation.

European Heart Journal 2009 30(16):2003-2010

It's education stupid!

Look at the results below: 80% of the responders think CMR will gain more use if cardiologists are more educated regarding how to use the tool. This is in great accordance to the results of the JACC paper providing the experience in Germany. We cannot stop reaching out to clinical cardiologists if we want CMR to overcome this underuse of the technique we see (at least in Brazil).

I personally do not know exactly how to do this but this is certainly the way to go.

Juliano

SCMR Abstract Deadline Approaching

Only 3 weeks left!

Look what CMR did in Germany!

CMR has had a great impact on German cardiology according to this article in JACC:

Read the abstract here

Electrocardiographic and cardiac magnetic
resonance imaging parameters as predictors
of a worse outcome in patients with
idiopathic dilated cardiomyopathy

Vinzenz Hombach1*, Nico Merkle1, Jan Torzewski1, Johann M. Kraus2,
Markus Kunze1, Oliver Zimmermann1, Hans A. Kestler2†, and Jochen Wo¨ hrle1†

Aims Clinical parameters are weak predictors of outcome in patients with idiopathic dilated cardiomyopathy (IDC). We assessed the prognostic value of cardiac magnetic resonance (CMR) parameters in addition to conventional clinical and electrocardiographic characteristics.

Methods and results One hundred and forty-one IDC patients were studied. QRS and QTc intervals were measured in 12-lead surface electrocardiogram. Patients were followed for median 1339 days, including 483 patient-years. The primaryendpoint—cardiac death or sudden death—occurred in 25 (18%) patients, including 16 patients with cardiac death, 3 patients with sudden cardiac death (SCD), and 6 patients with ICD shock. Late gadolinium enhancement (LGE) was detected in 36 patients (26%). Kaplan–Meier survival analysis displayed QRS .110 ms (P ¼ 0.010), the presence of LGE (P ¼ 0.037), and diabetes mellitus (P , 0.001) as significant parameters for a worse outcome. Multivariable analysis revealed cardiac index (P , 0.001), right ventricular end-diastolic volume index (RVEDVI) (P ¼ 0.006) derived from CMR imaging, the presence of diabetes mellitus (P ¼ 0.006), and QRS .110 ms (P ¼ 0.045) as significant predictors for the primary endpoint.

Conclusion Cardiac index and RVEDVI derived from CMR imaging in addition to QRS duration .110 ms from conventional surface ECG and diabetes mellitus provide prognostic impact for cardiac death and SCD in patients with IDC.

Keywords Idiopathic dilated cardiomyopathy † Magnetic resonance imaging † Late gadolinium enhancement † Prognosis

European Heart Journal (2009) 30, 2011–2018

Curso para atualizacao tecnica

O curso do ano passado foi muito bom. É um curso técnico, que reune basicamente especialistas onde se discutem assuntos raramente discutidos em outros eventos. Para quem faz os dois metodos, é uma oportunidade impar de discutirmos entre especialistas algumas duvidas comuns do dia-a-dia. Atualmente, é disparado o melhor evento para este fim.

Acesse o site aqui.

Cardiovascular Magnetic Resonance in Myocarditis: A JACC White Paper

"La miocarditis, proceso inflamatorio que históricamente presentó un problema clínico, empieza a ser resuelto por las imágenes de resonancia magnética. Con este método, el edema miocárdico, como la necrosis y la función ventricular puede ser evaluada con una alta sensibilidad. En este exelente artículo, se analiza que secuencias seben ser realizadas y que criterios se deben tomar para el diagnóstico de miocarditis.
Las imágenes de T2, T1 con y sin contraste deben comparase con el músculo esqueletico. Criterio 1: Se considerará aumento de la señal con la secuencia de T2 cuando la señal del miocardio aumente mas de 2 veces a la observada en el musculo esquelético. Criterio 2: Secuencia de T1 con Gadolinio precóz, si existe un área localizada de aumento mayor o igual a 4 veces con respecto a la señal del musculo esquelético. Criterio 3: Secuencia de T1 con Gado cuando el aumento de la señal "global" del miocardio sea mayor al 45% del aumento del musculo esquelético. La presencia de 2 de estos criterios son compatibles con miocarditis aguda."


Cardiovascular magnetic resonance (CMR) has become the primary tool for noninvasive
assessment of myocardial inflammation in patients with suspected myocarditis. The International Consensus Group on CMR Diagnosis of Myocarditis was founded in 2006 to achieve consensus among CMR experts and develop recommendations on the current state-of-the-art use of CMR for myocarditis. The recommendations include indications for CMR in patients with suspected myocarditis, CMR protocol standards, terminology for reporting CMR findings, and diagnostic CMR criteria for myocarditis (i.e., “Lake Louise Criteria”).JACC;2009,53:2009

Thrombus and CMR - Need more evidence???

Very robust evidence of the benefits of CMR.

Adverse effect of increased left ventricular wall thickness on five year outcomes
of patients with negative dobutamine stress

Abstract
Background
To determine if patients without dobutamine induced left ventricular wall motion abnormalities
(WMA) but an increased LV end-diastolic wall thickness (EDWT) exhibit a favorable cardiac prognosis.

Results
Between 1999 and 2001, 175 patients underwent a dobutamine stress cardiovascular magnetic
resonance (DCMR) procedure utilizing gradient-echo cines. Participants had a LV ejection fraction >55% without evidence of an inducible WMA during peak dobutamine/atropine stress.
After an average of 5.5 years, all participants were contacted and medical records were reviewed to determine the post-DCMR occurrence of cardiac death, myocardial infarction (MI), and unstable angina (USA) or congestive heart failure (CHF) warranting hospitalization. In a multivariate analysis, that took into account Framingham and other risk factors associated with cardiac events, a cine gradient-echo derived LV EDWT
12mm was associated independently with an increase in cardiac death and MI (HR 6.0, p=0.0016), and the combined end point of MI, cardiac death, and USA or CHF warranting hospitalization (HR 3.0, p=0.0005).

Conclusions
Similar to echocardiography, CMR measures of increased LV wall thickness should be considered a risk factor for cardiac events in individuals receiving negative reports of inducible ischemia after dobutamine stress. Additional prognostic studies of the importance of LV wall thickness and mass measured with steady-state free precession techniques are warranted.

Journal of Cardiovascular Magnetic Resonance 2009, 11:25.

Fibrosis in Aortic Stenosis

Impact of Myocardial Fibrosis in Patients With Symptomatic Severe Aortic Stenosis.
Weidemann F, Herrmann S, Störk S, Niemann M, Frantz S, Lange V, Beer M, Gattenlöhner S, Voelker W, Ertl G, Strotmann JM.

Circulation. 2009 Aug 3. [Epub ahead of print]Click here to read

University Clinic of Internal Medicine I/Center for Cardiovascular Disease, Clinic for Heart Surgery, Clinic for Radiology, and Institute of Pathology, University of Würzburg, Würzburg, Germany.

BACKGROUND: -In this prospective follow-up study, the effect of myocardial fibrosis on myocardial performance in symptomatic severe aortic stenosis was investigated, and the impact of fibrosis on clinical outcome after aortic valve replacement (AVR) was estimated. Methods and Results-Fifty-eight consecutive patients with isolated symptomatic severe aortic stenosis underwent extensive baseline characterization before AVR. Standard and tissue Doppler echocardiography and cardiac magnetic resonance imaging (late-enhancement imaging for replacement fibrosis) were performed at baseline and 9 months after AVR. Endomyocardial biopsies were obtained intraoperatively to determine the degree of myocardial fibrosis. Patients were analyzed according to the severity of interstitial fibrosis in cardiac biopsies (severe, n=21; mild, n=15; none, n=22). The extent of histologically determined cardiac fibrosis at baseline correlated closely with New York Heart Association functional class and markers of longitudinal systolic function (all P<0.001) but not global ejection fraction or aortic valve area. Nine months after AVR, the degree of late enhancement remained unchanged, implying that AVR failed to reduce the degree of replacement fibrosis. Patients with no fibrosis experienced a marked improvement in New York Heart Association class from 2.8+/-0.4 to 1.4+/-0.5 (P<0.001). Only parameters of longitudinal systolic function predicted this functional improvement. Four patients with severe fibrosis died during follow-up, but no patient from the other groups died. Conclusions-Myocardial fibrosis is an important morphological substrate of postoperative clinical outcome in patients with severe aortic stenosis and was not reversible after AVR over the 9 months of follow-up examined in this study. Because markers of longitudinal systolic function appear to indicate sensitively both the severity of myocardial fibrosis and the clinical outcome, they may prove valuable for preoperative risk assessment in patients with aortic stenosis.

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