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
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