Role of CMR in cardiac resynchronization therapy

A very thorough review in Nature Reviews Cardiology by Dr. Niti R. Aggarwal, Panithaya Chareonthaitawee et al. This is a niche where CMR has a definite advantage that has not been fully utilized.

View the abstract.

How will CT perfusion afect CMR?

The poll shows rather divided opinions. Looks like we will have some competition if radiation really goes down. This is a hard call and we will follow this issue very closely in the near future.

Multimodality Meeting in Mexico

A very special opportunity to meet renowned specialist in CMR and CCT locally.

Febrero 11-13 in Mexico City.

Instituto Nacional de Cardiologia Ignacio Chavez

Inscripciones: 55732911, ext 1478-1479

www.cardiologia.org.mx

10 Most Hot Topics in SCMR 2010

My 2 cents on what was hot in SCMR 2010:

1. F19/C13 imaging: still in basic science development yet. However, going into fast-track to clinical use. Very likely to change the way CMR is done today if its holds its promise.

2. Fast perfusion: new methods to increase the speed/resolution of first pass perfusion were shown by using high parallel factors and/or partial reconstruction methods. Some sequences allowing for the coverage of > 8 slices with high resolution.

3. CMR and prognosis: new data on systemic disease (SSc for example), more on ischemic heart disease. LGE has definite reached its maturity but it is not all.

4. Quantitative tissue mapping: new data on diffuse myocardial disease and quantitative mapping of these changes might add to the existing LGE data.

5. EURO-CMR: cited in many presentations, the results showing that CMR changes the way we clinically manage our patients was a definite recognition of the importance of the method.

6. Cost-effectiveness research: CMR is currently lacking these types of papers and this lag must be confronted if we are to gain more momentum. The EuroCMR registry was a plus in this direction but more specific data showing that CMR is actually cheaper in the long run than other methods are still not there.

7. Multi-center trials: the number of multicenter trials in CMR is slowing growing and we will see many more of these important studies in the future. This is in accordance with the need for cost-effectiveness studies in topic 6.

8. CMR in heart failure: although we see applications of CMR in different settings and etiologies of heart failure, this use has not been translated into clinical reality. One presentation illustrated that in the recent Heart Failure Guidelines from the ACC/AHA, CMR is almost not mentioned and does not merge into any significant clinical decision trees.

9. Coronary artery imaging: nothing too new: whole heart sequences, a little gain in resolution/speed and comparative use with 3T systems. However, the clinical use of this technique should not be changed with what was presented.

10. New hardware/software: 3T systems are up in the comparison to 2009 but not significantly. 32 channel coils much more widespread. CMR analysis software companies seem to have caught up with the new hardware features and clinical uses of CMR – a lot of competition going in this field.

(This expresses the personal opinion of its author and not of SCMR or SCMR-LAC).

Multimodality Comparison of Quantitative Volumetric Analysis of the Right Ventricle

Lissa Sugeng, MD*,*, Victor Mor-Avi, PhD*, Lynn Weinert, BS*, Johannes Niel, MD, Christian Ebner, MD, Regina Steringer-Mascherbauer, MD, Ralf Bartolles, MS, Rolf Baumann, MS, Georg Schummers, MS, Roberto M. Lang, MD*, Hans-Joachim Nesser, MD

University of Chicago Medical Center, Chicago, Illinois
Public Hospital Elisabethinen, Linz, Austria
TomTec Imaging Systems, Unterschleissheim, Germany


Objectives: We undertook volumetric analysis of the right ventricle (RV) by real-time 3-dimensional echocardiography (RT3DE), cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT) on images obtained in RV-shaped phantoms and in patients with a wide range of RV geometry.

Background: Assessment of the RV by 2-dimensional (2D) echocardiography remains challenging due to its unique geometry and limitations of the current analysis techniques. RT3DE, CMR, and CCT, which can quantify RV volumes, promise to overcome the limitations of 2D echocardiography.

Methods: Images were analyzed using RV Analysis software. Volumes measured in vitro were compared with the true volumes. The human protocol included 28 patients who underwent RT3DE, CMR, and CT on the same day. Volumetric analysis of CMR images was used as a reference, against which RT3DE and CCT measurements were compared using linear regression and Bland-Altman analyses. To determine the reproducibility of the volumetric analysis, repeated measurements were performed for all 3 imaging modalities in 11 patients.

Results: The in vitro measurements showed that: 1) volumetric analysis of CMR images yielded the most accurate measurements; 2) CCT measurements showed slight (4%) but consistent overestimation; and 3) RT3DE measurements showed small underestimation, but considerably wider margins of error. In humans, both RT3DE and CCT measurements correlated highly with the CMR reference (r = 0.79 to 0.89) and showed the same trends of underestimation and overestimation noted in vitro. All interobserver and intraobserver variability values were <14%, with those of CMR being the highest.

Conclusions: Volumetric quantification of RV volume was performed on CMR, CCT, and RT3DE images. Eliminating analysis-related intermodality differences allowed fair comparisons and highlighted the unique limitations of each modality. Understanding these differences promises to aid in the functional assessment of the RV.


Key Words: right ventricle • 3-dimensional echocardiography • cardiac magnetic resonance • multidetector computed tomography
J Am Coll Cardiol Img, 2010; 3:10-18

Comparison of Two Fast MRI Methods for Perfusion Imaging of the Heart

Comparison of Two Fast MRI Methods for Perfusion Imaging of the Heart

P. E. Sijens, D. D. Lubbers

Department of Radiology, University Medical Center Groningen and University of Groningen, Groningen, the Netherlands

Correspondence to:

P. E. Sijens

Department of Radiology, University Medical Center Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen,

The Netherlands

Tel: +31 50 361 3534; Fax: +31 50 361 1798; E-mail: p.e.sijens@rad.umcg.nl

Key words: Cardiovascular MR, myocardial perfusion, parallel imaging.

Summary

Time-adaptive sensitivity encoding (TSENSE) and gen-

eralized autocalibrating partially parallel acquisition

(GRAPPA) were applied to a gradient-echo sequence

used for first-pass myocardial perfusion imaging of 12

patients with coronary artery disease. The two parallel

imaging methods were compared in terms of signal-to-

noise ratio (SNR), contrast-to-noise ratio (CNR) and

image artefacts. Image acquisition was started during the

administration of a Gd-contrast bolus (0.1 mmoL/kg)

followed by a 20-mL saline flush (3 mL/s), and the next

perfusion was started at least 15 min thereafter using an

identical bolus. The order of perfusion sequences was

inverted in every other patient. Both acquisitions had an

acceleration rate of 2, and were performed during breath-

holding. The SNR, CNR and image quality of the

GRAPPA images were significantly better than were

those of the TSENSE images. An exception was the lower

CNR of GRAPPA when applied after the second bolus.

Differences between subjects were larger with GRAPPA

perfusion imaging than with TSENSE. The SNR and

CNR also varied relatively much between the GRAPPA

images, indicating that the diagnostic value of TSENSE

may be superior after all.

Imaging Decisions MRI, Volume 13, Issue 2 (p 43-48)

Nov 4 2009

Protocols and Indications for Magnetic Resonance (Stress) First-Pass Perfusion Imaging of the Myocardium

Protocols and Indications for Magnetic

Resonance (Stress) First-Pass Perfusion

Imaging of the Myocardium

D. D. Lubbers, D. Kuijpers, M.Oudkerk

Department of Radiology, University Medical Centre Groningen, Groningen, The Netherlands

Correspondence to:

D. D. Lubbers, M.D

Department of Radiology, University Medical Centre Groningen, Groningen, The Netherlands

Tel: +31 503611451; Fax: +31 503617008; E-mail: d.d.lubbers@rad.umcg.nl

Key words: MRI, heart, ischemie, perfusion, protocols.

Summary

First-pass perfusion imaging with MRI under pharmaco-

logically induced stress for the detection of myocardial

ischemia has gained a lot of interest over the past years.

With adenosine as the main pharmacological ‘stressor’.

Issues regarding the best contrast dose and injection speed

have become clear. Several perfusion sequences have been

studied over the past. Even some large multi-centre

trail results have been published. Some issues are still

extensively research, like interpretation strategies and

patient population in regard to protocols. This review

highlights the technique of adenosine perfusion MRI and

other perfusion techniques. The short history and current

important literature are reviewed. Furthermore building

blocks for different stress perfusion examinations are

discussed.

Imaging Decisions MRI, Volume 13, Issue 2 (p 52-58)

Nov 4 2009

Final Program - SCMR 2010

Access the final program in PDF here.

SCMR-LAC MEETING IN PHOENIX

IMPORTANT: SCMR-LAC MEETING IN PHOENIX

Friday 22/jan

6:45 AM 7:45 AM

Room Maryvale B

Please join us for the latest announcements on the chapter.

Evolution or revolution?

Despite the increase in CMR utilization in the last years, the field would certainly use a change of gears to rise to a new standard. Unique features and "killer applications" are the most important aspects for the usage of a new imaging modalities. In this regard, the last paper published online in Circulation Imaging by Ebner B et al, expanding the work published by the same group in 2008 by Flögel et al in Circulation, is a sensational piece of glimpse into the future. If applied in the clinical setting - and the authors are pretty clear of the feasibility of that idea - CMR can jump to another level of usage due to this unique capability. These scientific jumps are very welcome and the authors should be congratulated on the robust work so far.

CMR expected to increase in 2010

According to the site's visitors, most users expect an increase in the demand for CMR in 2010. This is also my view since the exam is very much under utilized specially in Latin America.

New edition of the SCMR-LAC Newsletter

Just posted. Please download the PDF file at:

http://www.sendspace.com/file/w1ttlx (94KB PDF file - virus free)

Juliano

Influence of Myocardial Fibrosis on Left Ventricular

Diastolic Function

Noninvasive Assessment by Cardiac Magnetic Resonance and Echo

Antonella Moreo, MD; Giuseppe Ambrosio, MD, PhD, FAHA; Benedetta De Chiara, MD;

Min Pu, MD; Tam Tran, BS; Francesco Mauri, MD; Subha V. Raman, MD, MSEE

Background—Fibrosis is a common end point of many pathological processes affecting the myocardium and may alter myocardial relaxation properties. By measuring myocardial fibrosis with cardiac magnetic resonance and diastolic function with Doppler echocardiography, we sought to define the influence of fibrosis on left ventricular diastolic function.

Methods and Results—Two hundred four eligible subjects from 252 consecutive subjects undergoing late postgadolinium myocardial enhancement (LGE) cardiac magnetic resonance and Doppler echocardiography were investigated. Subjects with normal diastolic function exhibited no or minimal fibrosis (median LGE score, 0; interquartile range, 0 to 0). In contrast, the majority of patients with cardiomyopathy (regardless of underlying cause) had abnormal diastolic function indices and substantial fibrosis (median LGE score, 3; interquartile range, 0 to 6.25). Prevalence of LGE positivity by

diastolic filling pattern was 13% in normal, 48% in impaired relaxation, 78% in pseudonormal, and 87% in restrictive filling (P<0.0001). Similarly, LGE score was significantly higher in patients with deceleration time <150 ms (P<0.012), and it progressively increased with increasing left ventricular filling pressure estimated by tissue Doppler imaging– derived E/E' (P<0.0001). After multivariate analysis, LGE remained significantly correlated with degree of diastolic dysfunction (P=0.0001).

Conclusions—Severity of myocardial fibrosis by LGE significantly correlates with the degree of diastolic dysfunction in a broad range of cardiac conditions. Noninvasive assessment of myocardial fibrosis may provide valuable insights into the pathophysiology of left ventricular diastolic function and therapeutic response.

(Circ Cardiovasc Imaging. 2009;2:437-443.)

Key Words: diastole, myocardium, collagen, MRI, echocardiography

Research article

Prognostic implication of late gadolinium enhancement on cardiac

MRI in light chain (AL) amyloidosis on long term follow up

RaymondQMigrino*1,2, RichardChristenson2, AnikoSzabo3,

MeganBright1, SethTruran1 and ParameswaranHari4

Abstract

Background: Light chain amyloidosis (AL) is a rare plasma cell dyscrasia associated with poor

survival especially in the setting of heart failure. Late gadolinium enhancement (LGE) on cardiac MRI

was recently found to correlate with myocardial amyloid deposition but the prognostic role is not

established. The aim is to determine the prognostic significance of LGE in AL by comparing long

term survival of AL patients with and without LGE.

Methods: Twenty nine consecutive patients (14 females; 62 ± 11 years) with biopsy-proven AL

undergoing cardiac MRI with gadolinium as part of AL workup were included. Survival was

prospectively followed 29 months (median) following MRI and compared between those with and

without LGE by Kaplan-Meier and log-rank analyses.

Results: LGE was positive in 23 subjects (79%) and negative in 6 (21%). Left ventricular ejection

fraction was 66 ± 17% in LGE-positive and 69 ± 12% in LGE-negative patients (p = 0.8). Overall 1-

year mortality was 36%. On follow-up, 14/23 LGE-positive and none of LGE-negative patients died

(log rank p = 0.0061). Presenting New York Heart Association heart failure class was also

associated with poor survival (p = 0.0059). Survival between two LGE groups stratified by heart

failure class still showed a significant difference by a stratified log-rank test (p = 0.04).

Conclusion: Late gadolinium enhancement is common and is associated with poor long-term

survival in light chain amyloidosis, even after adjustment for heart failure class presentation. The

prognostic significance of late gadolinium enhancement in this disease may be useful in patient risk-

stratification.

BMC Medical Physics 2009, 9:5

CMR WISH LIST 2010

My top ten wishes for CMR in 2010:

1. Development of better, easier and more readable reporting tools/graphs for qualitative assessment of stress perfusion.

2. Outside of the magnet stress test and injection.

3. Detection of chronic perfusion defects (eg CAD > 70% obstructions) with no stress at all (!!!) by CMR.

4. Using the method to annually follow up patients with chronic heart conditions (eg hypertension and the development of chronic fibrosis).

5. Monitoring the response of the myocardium to statins, antihypertensives and other drugs by CMR.

6. Standardization of names/protocols by all CMR vendors.

7. Making CMR education obligatory in all cardiology residency programs.

8. Calcium/atherosclerosis score by CMR as the imaging modality for screening for subclinical CAD.

9. Coding and payment in a simpler and more direct way.

10. Affordable upgrades from 1.5T to 3T.

Latest issue of JACC packed with CMR papers

The last 2009 edition of JACC is full of great CMR papers - a nice way to close 2009 and start 2010. Some are only letters to the editor but nevertheless quite interesting.

http://www.sciencedirect.com/science/issue/4884-2009-999449998-1578355

Cardiovascular Magnetic Resonance in Patients With Myocardial Infarction: Current and Emerging Applications
Han W. Kim, Afshin Farzaneh-Far, Raymond J. Kim

Diagnosis of Acute Myocarditis by Cardiovascular Magnetic Resonance in a Patient With Chest Pain, Positive Troponin, and Normal Coronary Arteries
Christopher A. Miller, Rory O'Hanlon, Sanjay K. Prasad

Delayed Hyperenhancement Magnetic Resonance Imaging for Sudden Cardiac Death Risk Stratification in Hypertrophic Cardiomyopathy
Georgios K. Efthimiadis, Efstathios D. Pagourelias

Perfusion Cardiovascular Magnetic Resonance in the Clinical Scenario of Patients With Coronary Artery Disease
Chiara Bucciarelli-Ducci, Carlo Di Mario, Dudley J. Pennell