Role of Cardiac Magnetic Resonance Imaging in the Detection of Cardiac Amyloidosis

Imran S. Syed, MD*,*, James F. Glockner, MD, PhD, DaLi Feng, MD*, Philip A. Araoz, MD, Matthew W. Martinez, MD*,, William D. Edwards, MD, Morie A. Gertz, MD, Angela Dispenzieri, MD, Jae K. Oh, MD*, Diego Bellavia, MD, PhD*, A. Jamil Tajik, MD||, Martha Grogan, MD*

Objectives: Our aim was to evaluate the role and mechanism of late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) in identifying cardiac amyloidosis (CA) and to investigate associations between LGE and clinical, morphologic, functional, and biochemical features.

Background: CA can be challenging to diagnose by echocardiography. Recent studies have demonstrated an emerging role for LGE-CMR.

Methods: LGE-CMR was performed in 120 patients with amyloidosis. Cardiac histology was available in 35 patients. The remaining 85 patients were divided into those with and without echocardiographic evidence of CA.

Results: Of the 35 patients with histologically verified CA, abnormal LGE was present in 34 (97%) patients and increased echocardiographic left ventricular wall thickness in 32 (91%) patients. Global transmural or subendocardial LGE (83%) was most common and was associated with greater interstitial amyloid deposition (p = 0.03). Suboptimal myocardial nulling (8%) and patchy focal LGE (6%) were also observed. LGE distribution matched the deposition pattern of interstitial amyloid. Among patients without cardiac histology, LGE was present in 86% of those with evidence of CA by echocardiography and in 47% of those without evidence of CA by echocardiography. In patients without echocardiographic evidence of CA, the presence of LGE was associated with worse clinical, electrocardiographic (ECG), and cardiac biomarker profiles. In all patients, LGE presence and pattern was associated with New York Heart Association functional class, ECG voltage, left ventricular mass index, right ventricular wall thickness, troponin-T, and B-type natriuretic peptide levels.

Conclusions: LGE is common in CA and detects interstitial expansion from amyloid deposition. Global transmural or subendocardial LGE is most common, but suboptimal myocardial nulling and focal patchy LGE are also observed. LGE-CMR may detect early cardiac abnormalities in patients with amyloidosis with normal left ventricular thickness. The presence and pattern of LGE is strongly associated with clinical, morphologic, functional, and biochemical markers of prognosis.


Key Words: amyloidosis • cardiac magnetic resonance • cardiomyopathy

J Am Coll Cardiol Img, 2010; 3:155-164

Cardiac MRI studies of transient left ventricular apical ballooning syndrome (takotsubo cardiomyopathy): A systematic review

International Journal of Cardiology 135 (2009) 146 – 149

Cardiac MRI studies of transient left ventricular apical ballooning syndrome (takotsubo cardiomyopathy): A systematic review

Guillaume Leurent a , b , c , d ,⁎, Antoine Larralde e , Dominique Boulmier a , b , c , d , Claire Fougerou f , Bernard Langella e , Romain Ollivier a , b , c , d , Marc Bedossa a , b , c , d , Hervé Le Breton a , b , c , d

a INSERM, U642, Rennes, F-35000, France b Université de Rennes 1, LTSI, Rennes, F-35000, France c CHU Rennes, Service de cardiologie et maladies vasculaires, Rennes, F-35000, France d INSERM, CIC-IT 804, CHU de Rennes, F-35000, France e Département d'imagerie médicale, CHU de Rennes, F-35000, France f Centre d'Investigation Clinique, INSERM 0203, F-35000, France

Abstract

Background: Since its first description in 1991, many cases of transient left ventricular apical ballooning syndrome (TLVABS) have been

described, but the use of cardiac MRI in this condition is much more recent.

Methods and results: We performed a systematic review of the present literature in the MEDLINE and EMBASE databases for relevant case

series of TLVABS (≥ 5 reported original cases, MRI analysis in the acute phase) and summarized the main results in a narrative synthesis.

Only 8 studies met the eligible criteria, counting 176 patients (women: 95%; age: 68, stress trigger: 80%). MRI assessed an improvement of

mean left ventricular ejection fraction from 39 (in the acute phase) to 64% (in the recovery phase). A right ventricular dysfunction was

reported in 38%, a myocardial oedema in 81% and an apical thrombus in 5%.

Conclusions: Although cardiac MRI is a very useful and inescapable tool in the management of TLVABS, there is no large published study

concerning this topic. A systematic and multicentric register of TLVABS studied by cardiac MRI is necessary.

Keywords: Cardiac MRI; Transient left ventricular apical ballooning syndrome; Takotsubo cardiomyopathy; Left ventricular dysfunction

© 2009 Elsevier Ireland Ltd. All rights reserved.

Received 11 February 2009; accepted 2 March 2009

Available online 28 April 2009

N Engl J Med 2009;360:1526-38.

review article

The new england journal of medicine

Medical Progress

Myocarditis

Leslie T. Cooper, Jr., M.D.

From the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.

cooper.leslie@mayo.edu.

Myocarditis may present with a wide range of symptoms, ranging from mild dyspnea or chest pain that resolves without specific therapy to cardiogenic shock and death. Dilated cardiomyopathy with chronic heart failure is the major long-term sequela of myocarditis. Most often, myocarditis results from common viral infections; less commonly, specific forms of myocarditis may result from other pathogens, toxic or hypersensitivity drug reactions, giant-cell myocarditis, or sarcoidosis. The prognosis and treatment of myocarditis vary according to the cause, and clinical and hemodynamic data usually provide guidance to decide when to refer a patient to a specialist for endomyocardial biopsy. The aim of this review is to provide a practical and current approach to the evaluation and treatment of suspected myocarditis.

N Engl J Med 2009;360:1526-38.

Copyright © 2009 Massachusetts Medical Society.

C13/F19 - see you in 2015!!!

Looks like we'll have to come back on the subject in a few years from now. But my hopes are still very high!

Quantitative versus Qualitative Analysis in CMR

The very practical and fast qualitative analysis used by most physicians in CMR does the job in the clinical scenario:

Head to head comparison of quantitative versus visual analysis of contrast CMR in the setting of myocardial stunning after STEMI: implications on late systolic function and patient outcome.

Husser O, Bodi V, Sanchis J, Nunez J, Mainar L, Merlos P, Lopez-Lereu MP, Monmeneu JV, Chaustre F, Rumiz E, Riegger GA, Chorro FJ, Llacer A.

Department of Cardiology, Hospital Clinico Universitario, INCLIVA, Universidad de Valencia, Blasco Ibanez 17, 46010, Valencia, Spain.

To compare a quantitative assessment of contrast cardiovascular magnetic resonance (CMR) after ST-segment elevation myocardial infarction (STEMI) with visual analysis for predicting depressed ejection fraction (dEF) and major adverse cardiac events (MACE). 192 patients underwent CMR at 1 week and 6 months after STEMI. Three quantitative (initial slope, maximal signal intensity and contrast delay in first-pass imaging) and 2 visual perfusion indexes (hypoenhancement in first-pass and microvascular obstruction in late enhancement imaging (LE)) were determined. Quantification of infarct mass and visual assessment of the extent of transmural necrosis (ETN) were also performed. At 6 months, 69 patients displayed dEF. During follow-up (mean 655 days) 20 MACE (death, re-infarction, re-admission for heart failure) occurred. Perfusion quantification took longer (P < 0.001) and, in ROC curve analyses and the C-statistic, was not superior to visual perfusion analysis for predicting late EF or MACE (P = ns). Similarly, infarct size quantification was not superior to visual assessment of ETN (P = ns). In multivariate analyses, only visual assessment of ETN (per segment) predicted dEF (OR 1.30 95%CI [1.04-1.61], P = 0.02) and MACE (HR 1.38 95%CI [1.19-1.60], P < 0.001). Visual analysis of CMR after STEMI is not time consuming and predicts dEF and MACE comparable to quantification. ETN was the strongest parameter.

Anatomy by CCT - Ischemia by CMR: a perfect combination?

The manuscript previously posted by Dr. Florangel is a definite must read for anyone studying CAD by advanced imaging. Before the article, we could only compare data on anatomy versus perfusion with SPECT/PET. This new data is really important and illustrates how can a non-radiating method be complementary to CCT. One could argue that every patient with low/intermediate risk CAD by anatomy should undergo a stress perfusion by CMR. More to be seen.

PS: for the ones who don't understand the picture: cheese and goiabada are a traditional desert in Brazil, where the acid and sweet taste of each food complements each other into a delicious flavour...

Low to Intermediate Probability of Coronary Artery Disease: Comparison of Coronary CT Angiography with First-Pass MR Myocardial Perfusion Imaging1

Jan G. J. Groothuis, MD, Aernout M. Beek, MD, Stijn L. Brinckman, MD, Martijn R. Meijerink, MD, Simon C. Koestner, MD, Robin Nijveldt, MD, PhD, Marco J. W. Götte, MD, PhD, Mark B. M. Hofman, PhD, Cornelis van Kuijk, MD, PhD and Albert C. van Rossum, MD, PhD

Abstract
Purpose: To compare coronary computed tomographic (CT) angiography with first-pass magnetic resonance (MR) myocardial perfusion imaging in patients with chest pain and low to intermediate probability of coronary artery disease (CAD).

Materials and Methods: Local ethics committee approval and patient written informed consent were obtained. Patients with chest pain and low to intermediate pretest probability of CAD underwent both coronary CT angiography and MR myocardial perfusion imaging. Coronary CT angiographic and MR myocardial perfusion images were analyzed qualitatively by blinded observers. Obstructive CAD was defined as more than 50% diameter stenosis at coronary CT angiography. Data were expressed with 95% confidence intervals (CIs) calculated from binomial expression.

Results: In 145 (94.2%) of 154 eligible patients, both coronary CT angiography and MR myocardial perfusion imaging were performed successfully. Mean age was 57 years ± 10 (standard deviation), and 45.5% of patients were male. Mean interval between coronary CT angiography and MR myocardial perfusion imaging was 4.6 days ± 3.0; median was 5.0 days. CT coronary angiography revealed obstructive CAD in 52 (35.9%) patients and 78 (17.9%) coronary arteries. At MR myocardial perfusion imaging, myocardial ischemia was demonstrated in 33 (22.8%) patients and 59 (13.6%) vessel territories. Of patients without CAD at coronary CT angiography, 90.5% (57 of 63; 95%CI: 82.6%, 95.0%) had normal myocardial perfusion at MR myocardial perfusion imaging. Of patients with nonobstructive CAD, 83.3% (25 of 30; 95% CI: 69.5%, 91.6%) had normal myocardial perfusion at MR myocardial perfusion imaging. Myocardial ischemia was detected at MR myocardial perfusion imaging in 42.3% (22 of 52; 95% CI: 29.5%, 56%) of patients with obstructive CAD at coronary CT angiography.

Conclusion: MR myocardial perfusion imaging and coronary CT angiography have complementary roles in evaluation of patients who are suspected of having CAD. Coronary CT angiography can be used to reliably rule out CAD, but its capability to demonstrate hemodynamically significant CAD is limited. The combination of both techniques enables the clinician to evaluate morphology and functional relevance of CAD comprehensively and noninvasively.

Radiology. February 2010; 254 (2)

Send this review to your referrals!

We always say that education of your referral base is key to increasing your CMR volume. Send this link to your clinical cardiologists - a must read for any clinician who practices modern cardiology!

Cardiovascular Magnetic Resonance
Dudley J. Pennell, MD, FRCP, FESC, FACC

Hybrid Ultrasound MRI for Improved Cardiac Imaging

and Real-Time Respiration Control

David A. Feinberg,1–3* Daniel Giese,6 D. Andre Bongers,4 Sudhir Ramanna,1

Maxim Zaitsev,6 Michael Markl,6 and Matthias Gu¨ nther1,4,5

Magnetic Resonance in Medicine 63:290–296 (2010)

A hybridized dual-imaging system combining real-time ultra-

sound imaging and MRI was utilized for cardiac imaging at

1.5 T and 3 T. The ultrasound scanner with a programmable

software interface was connected via computer to the MRI

scanner. Electronic noise was eliminated with electromagnetic

shielding and grounding to the screen room. At 3 T, real-time

prospective motion compensation in dynamic cine cardiac

imaging was implemented using B-mode ultrasound imaging.

The ultrasound technique avoided drawbacks such as signal

saturation or steady-state interruption of the MR navigator

gating. At 1.5 T, a low-latency real-time feedback to balanced

steady state free precision MR imaging was performed in

three normal volunteers. Results showed active tracking of

the heart during respiratory motion and improvement in time-

averaged cardiovascular images. Future studies can fully

exploit the potential of the high-frequency position informa-

tion provided by the ultrasound system for more advanced

applications in real-time organ tracking.

Key words: ultrasound; MRI; cardiac MRI; navigator echo

Latins versus LVH

Are Latins more prone to LVH and abnormal LV remodeling? This is the opinion according to the manuscript below:


J Am Coll Cardiol. 2010 Jan 19;55(3):234-42.

Left ventricular mass and ventricular remodeling among Hispanic subgroups compared with non-Hispanic blacks and whites: MESA (Multi-ethnic Study of Atherosclerosis).

Rodriguez CJ, Diez-Roux AV, Moran A, Jin Z, Kronmal RA, Lima J, Homma S, Bluemke DA, Barr RG.

Department of Medicine, Mailman School of Public Health, Columbia University, New York, New York, USA.