bluuebunny/crossref_metadata_2025 huggingface dataset:
Vein of Marshall visualization in cardiac computed tomography
Authors: Mlynarski R , Mlynarska A , Golba K.S , Sosnowski M
Published: November 2020

The oblique vein of the left atrium (vein of Marshall) is a small vessel that descends obliquely on the back of the left atrium and ends in the coronary sinus near the area where great cardiac vein continues into the coronary sinus. Its cannulation can be useful, e.g. before selected electrophysiology procedures such as paroxysmal focal atrial fibrillation ablation. Because the vein of Marshall should also be avoided at the site of the implantation of the left ventricle lead, knowledge about its existence, position or diameters could be useful. There is a lack of complex data about the possibilities of visualizing the vein of Marshall in cardiac computed tomography.

Methods

354 patients were included into the research. Cardiac computed tomography (Aquilion 64, Toshiba: 64 slices, 0.5 mm; retrospective gating; contrast enhanced) was performed for all of the patients. A precise retrospective analysis of the CT data in all phases (every 10%) of the cardiac cycle during post processing was performed including searching for the target vein by using Vitrea workstations (Vital Images). Both multi planar reformatted reconstructions (MPR) and 3D volume renderings were used. The analyses were performed by two experienced researchers (more than 200 coronary venous system analyses previously performed).

Results

The vein of Marshall was found in 66 of the 354 patients (16.6%). An example of the visualization is presented in the figure below (MPR and 3D volume rendering). Its ostium to coronary sinus was found an average of 42.6±10.8 mm from the coronary sinus ostium to the right atrium. This value was statistically higher (p=0.0082) in the men (45.3±11.2) compared to the women (38.5±9.7). The vein of Marshall is a small vessel; its average diameter was 1.8±0.8 mm and length of the visible vessel that was measured was 8.7±7.5 mm. It was visualized statistically more frequently (p=0.0009) in the end-systolic phases (30–40–50% RR; 68.85% cases) compared to the end-diastolic phases (70–80% RR; 21.31% cases). Occasionally, it was optimally visualized in the other phases (9.83%).

Conclusion

It is possible to visualize the vein of Marshall using cardiac computed tomography. Because it exists in about 20% of population, during visualization, special attention needs to paid to obtaining quality images in CT especially in the end-systolic phases.

Vein of Marshall imaging (VR, MPR)

Funding Acknowledgement

Type of funding source: None
Compositional differences in atherosclerosis between the major epicardial arteries; a secondary analysis from the PARADIGM study
Authors: Bax A.M , Ma X , Van Den Hoogen I.J , Gianni U , Van Rosendael A.R , Tantawy S.W , Chun E.J , Kim Y.J , Lee B.K , Lee S.E , Min J.K , Chang H.J , Narula J , Lin F.Y , Shaw L.J
Published: November 2020

Background

Atherosclerotic plaques in the left circumflex artery (LCx) are associated with a lower risk of future events than plaques in the right coronary artery (RCA) and left anterior descending artery (LAD). High risk plaque subtypes including necrotic core and fibrofatty plaque can be evaluated on computed coronary tomography angiography (CCTA) by Hounsfield Unit (HU) density. To date, little is known regarding differences in high risk plaque composition between major epicardial vessels.

Purpose

The aim of this analysis was to compare plaque extent and composition between the three coronary arteries.

Methods

This is a secondary analysis of baseline scans from the PARADIGM study which enrolled consecutive patients with suspected coronary artery disease undergoing serial CCTA at a scan interval of ≥2 years. Plaque quantification by composition was performed in the three coronary arteries based on fixed HU thresholds: high risk subtypes consisting of necrotic core (<30 HU) and fibrofatty plaque (31–130 HU), and other subtypes including fibrous (131–350 HU) and calcified plaque (≥351 HU). Comparisons between the coronary arteries were made using Generalized Estimating Equations (GEE) models, accounting for within-patient clustering of the coronary arteries and adjusting for ASCVD risk score and diabetes mellitus.

Results

From 1,271 patients (mean age 60.3±9.3 years; 57% men; median ASCVD score 9.3%), 3,813 vessels were analyzed. The prevalence of any plaque was lowest in the LCx, as was the prevalence of high risk plaque (Figure; P<0.001 for both). The share of total plaque volume made up by high risk plaque subtypes was the lowest in the LCx (17.3% versus 22.5% [RCA] versus 24.4% [LAD]; P<0.001). In contrast, calcified plaque made up the largest proportion in the LCx (44.5% versus 35.6% [RCA] versus 34.9% [LAD]; P<0.001).

Conclusion

Prevalence of any plaque as well as high risk plaque subtypes was significantly higher in the LAD and RCA than in the LCx. Also, high risk plaque subtypes made up significantly the lowest proportion in the LCx, whereas calcified plaque made up the largest proportion in the LCx. These data support a different atherogenic milieu contributing to the variable risk patterns between the epicardial coronary arteries.

Figure 1. Prevalence of (high risk) plaque

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was supported by the Leading Foreign Research Institute Recruitment Program through the National Research Foundation (NRF) of Korea funded by the Ministry of Science and ICT (MSIT) (Grant no. 2012027176).
320-multidetector cardiac computed tomography in the evaluation of conotruncal anomalies
Authors: Elnagar R , Ghieda U , Ibrahim A , Dawoud M
Published: November 2020

Background

Multi-detector computed tomography (MDCT) has become an effective tool in the assessment of congenital heart disease in infants and children.

Purpose

To evaluate the role of 320-row MDCT in the assessment of conotruncal anomalies and compare it with echocardiography (echo) considering the operative and/or catheter findings as the gold standard.

Methods

The studied group included 50 patients having conotruncal anomalies. All patients were evaluated with 320-row MDCT angiography. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of MDCT and echo were calculated. The patient effective dose was reported.

Results

The overall sensitivity, specificity, accuracy, PPV and NPV for MDCT angiography in assessment of various abnormalities in patients with conotruncal anomalies were 98.97%, 100%, 99.75%, 100% and 99.67% for MDCT angiography. Sensitivity, specificity, PPV and NPV of MDCT angiography were 97.87%, 100%, 100% and 99.04% and 99.49%, 100%, 100% &99.86% for the detection of intracardiac defects and extracardiac vascular anomalies respectively. The mean absorbed radiation dose was 63.63 mGy-Cm per scan and the mean effective dose was 1.56±0.47 mSv.

Conclusion

320-MDCT angiography offers an excellent diagnostic procedure in the preoperative evaluation of the complex anatomy of the conotruncal anomalies.

Funding Acknowledgement

Type of funding source: None
Reduced orbitofrontal grey matter volume in myocardial infarction with non-obstructive coronary arteries (MINOCA)
Authors: Williams M , Liang K , De Garate E , Mitrousi K , Harries I , De Francesco V , Langley S , Lawton C , Thai N.J , Bucciarelli-Ducci C
Published: November 2020

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is seen in 6–10% of patients presenting acutely with suspected myocardial infarction. Cardiac magnetic resonance imaging (CMR) can identify an underlying cause in ∼80% of patients. These patients are more likely to have a history of mental health illness or an emotional or stressful precipitant.

Grey matter volume can be quantified in various anatomical regions of the brain and has been shown to be altered in common mental health conditions such as anxiety, stress and depression.

This is the first prospective study investigating the acute structural brain, cardiac and psychological changes using MRI in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) within 14 days of presentation compared to STEMI control patients.

Methods

Patients meeting the 2017 ESC definition of MINOCA were prospectively recruited with STEMI control patients from February to December 2019. All participants underwent brain and comprehensive cardiac MRI, bloods and baseline psychological evaluation. We used voxel-based morphometry (VBM) to quantify grey matter volume and changes were compared between groups.

Results

54 patients were included in this interim analysis (39 MINOCA, 15 STEMI controls). Demographics were largely similar but MINOCA patients were more likely to have a history of self-reported mental health disease (36% v 7%, p 0.03) and had significantly higher baseline anxiety (8.4 v 5.3, p 0.01) scores on the HADS questionnaire. We found that control patients have significantly greater grey matter volume in the orbitofrontal cortex (OFC) compared to MINOCA patients (pFWE-corr 0.002). The orbitofrontal cortex is involved in emotional processing and implicated in anxiety and depression. However, there was no association between grey matter volume in any brain region and anxiety, depression or perceived stress scale scores.

Conclusion

Patients with MINOCA are more likely to have a history of mental health disease and have higher anxiety scores at presentation than STEMI controls. They have less grey matter volume in the orbitofrontal cortex compared to STEMI controls.

Reduced Grey Matter Volume in the OFC

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Rosetrees Trust; James Tudor Foundation
Deep learning to diagnose cardiac amyloidosis from CMR findings
Authors: Aimo A , Martini N , Barison A , Della Latta D , Ripoli A , Chiappino S , Chiappino D , Passino C , Emdin M
Published: November 2020

Background

Cardiac magnetic resonance (CMR) is an important diagnostic technique for cardiac amyloidosis (CA). A deep learning (DL) approach to define the likelihood of CA based on automated interpretation of CMR images has never been attempted so far.

Methods

187 subjects underwent standard 1.5 T CMR examination (GE-Healthcare, Milwaukee, USA) as part of a diagnostic workup for either unexplained left ventricular hypertrophy or blood dyscrasia with suspected light-chain (AL) amyloidosis. Patients were randomly assigned to 3 subgroups, which were used for training (n=121, 65%), internal validation (n=28, 15%), and model testing (n=38, 20%). LGE images in different orientations (short-axis, 2- and 4-chambers) were selected as the most informative CMR features. A deep convolutional neural network was trained to classify CMR examinations as “amyloidosis” (probability ≥50%) or “no amyloidosis” (probability <50%) based on these features. Different learning strategies (data augmentation, batch normalization in convolutional layers, dropout before dense layers) were adopted to prevent model overfitting. Binary cross entropy was used as loss function. For comparison, a machine learning (ML) model based on gradient boosting trees was built for the binary classification of patients (amyloidosis vs no amyloidosis) based on clinical and imaging features extracted from the CMR exam.

Results

CA was diagnosed in 101 subjects (54%; 45 AL, 56 transthyretin amyloidosis). A model including 2C, 4C and SA LGE images was created. In the test cohort, it allowed to diagnose CA with good diagnostic accuracy (84.2%), and an area under the curve (AUC) of 0.96 (Figure). The precision (positive predictive value), recall score (sensitivity), and F1 score (a measure of test accuracy) were 0.78, 0.94, and 0.86, respectively. An ML algorithm considering all available parameters (LV volumes and function, LGE presence and pattern, early darkening, pericardial and pleural effusion, etc.) displayed a similar diagnostic performance than the DL method (AUC 0.93 vs. 0.96; p=0.45).

Conclusions

The deep learning technique allowed to create an accurate diagnostic tool for CA based on LGE patterns, which could be easily converted into an online platform for automated image analysis.

Funding Acknowledgement

Type of funding source: None
The extent of pericardial involvement evaluated by cardiac MRI in patients with ST-Segment elevation myocardial infarction: predictors and outcomes
Authors: Massalha E , Di Segni E.L.I.O , Fardman A , Younis A , Brodov Y , Hersckovici R , Mazin I , Beigel R , Matetzky S , Goitein O
Published: November 2020

Background

The clinical diagnosis of peri-myocardial infarction pericarditis declined dramatically in the era of primary PCI and novel antiplatelet agents. However, recent data documents the presence of pericardial effusion in substantial proportion of acute MI patients, while recent randomized trial showed that anti-inflammatory drugs seem to improve cardiovascular outcomes, although the mechanism of the benefit remains uncertain.

Methods

We prospectively evaluated 187 consecutive patients, without known prior coronary disease, who underwent primary PCI for STEMI. All patients underwent cardiac MRI (CMR) on day 5±1 post admission. CMR was performed using a 1.5 T (n=101) and 3 T (n=86) scanners. Delayed enhancement (DE) and microvascular obstruction (MVO) were quantified as % of the left ventricular mass (LV). The presence of DE and MVO was recorded according to the AHA segments model. DE was also qualitatively assessed for the degree of transmurality in each segment. CMR pericarditis was defined as evidence of pericardial enhancement on DE images. The presence of pericardial effusion was also documented. Pericarditis extent was expressed as the number of pericardial segments with increased DE. Major adverse cardiac events were defined as the composite of death, recurrent myocardial infarction, stroke, urgent revascularization and hospitalization due to either heart failure or bleeding during the first year following STEMI.

Results

Pericardial effusion was found in 94 patients (50%) and enhancement of the pericardium on DE images in 120 patients (65%). In contrary, a clinical diagnosis of peri-myocardial infarction pericarditis was documented and anti-inflammatory therapy was initiated only in three patients (1%). A significant positive correlation was demonstrated between pericardial involvement and either quantitative or qualitative assessment of DE (p<0.001, r=0.34) and MVO (p<0.001, r=0.282). DE transmurality (per segment) was associated with both location of pericardial involvement and its extent (p<0.001). A multivariate logistic regression analysis revealed that DE extent and MVO were independent predictors of pericardial involvement (OR 1.07; CI 95% 1.06–1.13, p=0.02 and OR 1.29; CI 95% 1.01–1.64, p=0.04 for DE and MVO respectively). Additional parameters that were associated with CMR diagnosis of pericarditis included higher maximal CRP levels and proximal coronary lesions. The 1-year incidence of major adverse events was similar in patients with or without CMR-defined pericarditis.

Conclusions

In contrast to the low rate of clinically diagnosed pericarditis, CMR documented pericardial involvement in more than 65% of STEMI patients. This finding is independently associated with the extent and degree and location of myocardial damage.

Funding Acknowledgement

Type of funding source: None
The use of Cardiac MRI in diagnosis of infective endocarditis: a comparative study with echocardiography
Authors: Elagha A , Meshaal M , Elaroussy W , Beniamin Y
Published: November 2020

Introduction

Echocardiography is a reliable imaging tool in diagnosing infective endocarditis (IE) according to “modified Dukes criteria”; however, it lacks tissue characterization of cardiac masses, transthoracic echocardiography (TTE) has low sensitivity in detection of vegetations, and moreover, transesophageal echo (TEE) is considered semi-invasive and intolerable in some situations. On the other hand, cardiac magnetic resonance (CMR) is a powerful true 3D imaging tool with wide field of view, and superior capability of tissue characterization of cardiac masses; however, modest information is available about utility of CMR in diagnosing IE.

Purpose

To assess the feasibility of CMR to identify vegetations and complications of IE, and compare obtained findings obtained with those obtained from echocardiography regarding: number and size of vegetations, detection of cardiac complications (e.g. aortic root abscess, periannular abscess, and shunts).

Materials and methods

Eighty consecutive patients with suspected IE were enrolled in the study. All patients underwent TTE; only those with left-sided lesions underwent TEE. When clinical situation allowed, CMR examination using 1.5 Tesla magnet were performed: SSFP sequence for mobile masses (SSFP), T1W (± fat suppression) and T2W, first-pass perfusion, and delayed hyperenhancement were used. Moreover, chest and abdominal survey was done.

Results

Sixty-one patients (45 males and 16 females) were able to undergo and complete CMR study. Affection of tricuspid valve was seen in 39.3%, mitral 31.1%, aortic 24.6%, and pulmonary 4.9% of cases. All vegetations visualized by echocardiography were also clearly detected by CMR. The sensitivity, specificity, accuracy and Kappa agreement of CMR with echocardiography in depicting >0.5cm vegetations were all 100%. By tissue characterization, vegetations resemble features of thrombi (with variation in signal intensity according to age of vegetation). However, in some cases, masses have a unique pattern that is different from vegetations of IE, and subsequently other diagnoses were suggested (e.g. fibroelastoma, Libman-Saks endocarditis). In 22 patients, CMR provided more information than echocardiography, and in 6 patients, CMR changed completely the diagnosis.

Conclusion

Cardiac MRI is a powerful imaging tool in diagnosis of IE and its complications. In comparison with echocardiography, CMR can identify the presence, numbers, and size of vegetations accurately. Moreover, with its unique ability of tissue characterization, CMR helps distinguish vegetations from other masses; therefore changes the diagnosis of IE and subsequent management in some patients.

Funding Acknowledgement

Type of funding source: None
Increased remote extracellular volume measured by CMR T1 mapping allows early identification of left atrial dysfunction in hypertrophic cardiomyopathy
Authors: Tondi L , Pica S , Camporeale A , Figliozzi S , Bernardini A , Pluchinotta F , Secchi F , Lombardi M
Published: November 2020

Background

Myocardial fibrosis is a hallmark of hypertrophic cardiomyopathy (HCM). Cardiac magnetic resonance (CMR) detects replacement fibrosis (RF) through late gadolinium enhancement (LGE) and interstitial fibrosis (IF) in apparently unscarred myocardium by T1 mapping-derived increased extracellular volume (ECV). Differently from LGE, to date only few small studies have explored the clinical significance of IF in HCM and a correlation between IF and diastolic dysfunction (DD) has been proposed. However, DD detection is challenging in this population since the accuracy of standard echocardiographic parameters is controversial, especially in presence of left ventricular outflow tract obstruction (LVOTO). Left atrial (LA) dysfunction is associated with high left ventricular (LV) filling pressures and may represent an early marker of DD in HCM.

Purpose

To explore the correlation between IF and LA dysfunction in HCM patients with preserved systolic function.

Methods

93 consecutive HCM patients with preserved EF underwent a standard CMR scan. Semi-automatic threshold-based quantification of ventricular volumes, function and mass was performed. LA volumes (LAV) and function were evaluated by CMR feature-tracking (FT) analysis. The three atrial phasic functions were analyzed: (i) passive strain (εe), (ii) active strain (εa) and (iii) total strain (εs). LGE was quantified using the standard deviations (SDs) method (≥4 SDs). IF was assessed by T1 mapping-derived ECV quantification in remote myocardium (r-ECV). A matched group of 15 healthy subjects (HS) served as controls.

Results

Compared to HS, HCM patients showed increased LAV (LAV max: HS 39±9ml, HCM 59±20 ml; LAV min: HS 16±4 ml, HCM 34±17 ml; p<0.001), reduced LA EF (HS 61±3%, HCM 45±12%, p<0.001), impaired εs (HS 40±7%, HCM 29±11%, p<0.001) and εe (HS 26±7%, HCM 15±7%, p<0.001). No differences in εa were observed (HS 13±4%, HCM 14±7%, p 0.56). HCM patients were divided into 2 groups according to the presence of IF, defined as r-ECV values ≥29%. The two ECV groups did not differ in terms of LV EF, LA EF, LAV, LA area, E/E', LGE, LV mass, maximal wall thickness and LVOTO (all p>0.05). HCM patients with increased r-ECV showed significantly impaired LA function in terms of all three strain parameters vs. normal r-ECV group (HCM r-ECV <29%: εs 31±12%, εe15±7%, εa 15±5%; HCM r-ECV≥29%: εs 24±7%, εe 12±4%, εa 12±5%; all p<0.05).

Conclusions

In HCM patients increased r-ECV correlates with LA dysfunction, hinting towards a possible role for IF in determining altered LV relaxation and DD.

LA strain in controls and HCM ECV groups

Funding Acknowledgement

Type of funding source: None
Real-time cardiac magnetic resonance tissue characterisation for fibrosis assessment in aortic stenosis
Authors: Backhaus S.J , Lange T , Beuthner B.E , Topci R , Wang X , Kowallick J.T , Lotz J , Seidler T , Toischer K , Zeisberg E.M , Puls M , Jacobshagen C , Uecker M , Hasenfus G , Schuster A
Published: November 2020

Background

Myocardial fibrosis is a major determinant of outcome in aortic stenosis (AS). Novel fast real-time (RT) cardiac magnetic resonance (CMR) mapping techniques allow comprehensive quantification of fibrosis but have not yet been adequately validated against standard techniques and histology.

Methods

Patients with severe AS underwent CMR before (n=110) and left ventricular (LV) endomyocardial biopsy (n=46) at transcatheter aortic valve replacement (TAVR). Midventricular short axis native, post-contrast T1 and extracellular volume fraction (ECV) maps were generated using commercially available 5(3)3 MOLLI and RT single-shot inversion recovery fast low-angle shot (FLASH) with radial undersampling. ECV and LV mass were used to calculate LV matrix volumes. Variability and agreements were assessed between RT, MOLLI and histology using intraclass correlation coefficients, coefficients of variation and Bland Altman analyses.

Results

RT and MOLLI derived ECV were similar for myocardium (26.2 vs. 26.5, p=0.073) and inter-ventricular septum (26.2 vs. 26.5, p=0.216). MOLLI native T1 time was in median 20 ms longer compared to RT (p<0.001). Agreement between RT and MOLLI was best for ECV (ICC >0.91), excellent for post-contrast T1 times (ICC >0.81) and good for native T1 times (ICC >0.62). Diffuse collagen volume fraction by biopsies was in median 7.8%. ECV (RT r=0.345, p=0.039; MOLLI r=0.40, p=0.010) and LV matrix volumes (RT r=0.45, p=0.005; MOLLI r=0.43, p=0.007) were the only parameters associated with histology.

Conclusions

RT mapping offers precise T1 and ECV assessments with similar agreement with histology as compared to conventional MOLLI techniques. Single-shot real time techniques may be advantageous in sicker patients prone to dyspnoea or arrhythmia.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): German Research Foundation
Quantitative 4D Flow CMR analysis of intracardiac blood flow energetics in ischemic cardiomyopathy patients
Authors: Riva A , Camporeale A , Sturla F , Pica S , Tondi L , Giese D , Castelvecchio S , Menicanti L , Redaelli A , Votta E , Lombardi M
Published: November 2020

Background

Ischemic cardiomyopathy (ICM) is often associated with negative LV remodelling after myocardial infarction, sometimes resulting in impaired LV function and dilation (iDCM). 4D Flow CMR has been recently exploited to assess intracardiac hemodynamic changes in presence of LV remodelling.

Purpose

To quantify 4D Flow intracardiac kinetic energy (KE) and viscous energy loss (EL) and investigate their relation with LV dysfunction and remodelling.

Methods

Patients with prior anterior myocardial infarction underwent a CMR study with 4D Flow sequences acquisition; they were divided into ICM (n=10) and iDCM (n=10, EDV>208 ml and EF<40%). 10 controls were used for comparison. LV was semi-automatically segmented using short axis CMR stacks and co-registered with 4D Flow. Global KE and EL were computed over the cardiac cycle. NT-proBNP measurements were correlated with average and peak values, during systole and diastole.

Results

Both LV volume and EF significantly differ (P<0.0001) between iDCM (EDV=294±56 ml, EF=24±8%), ICM (EDV=181±32 ml, EF=34±6%) and controls (EDV=124±29 ml, EF=72±5%). If compared to controls, both ICM and iDCM showed significantly lower KE (P≤0.0008); though lower than controls, EL was higher in iDCM than ICM. Within the iDCM subgroup, diastolic mean KE and peak EL reported good inverse correlation with NT-proBNP (r=−0.75 and r=−0.69, respectively). EL indexed (ELI) to average KE during systole was higher in the entire ischemic group as compared to controls (ELI(ischemic) = 0.17 vs. ELI(controls) = 0.10, P=0.0054).

Conclusions

4D Flow analyses effectively mapped post-ischemic LV energetic changes, highlighting the disproportionate intraventricular EL relative to produced KE; preliminary good correlation between LV energetic changes and NT-proBNP will deserve further investigation in order to contribute to early detection of heart failure.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Italian Ministry of Health
Prognostic value of vasodilator stress perfusion CMR in patients with previous coronary artery bypass graft (CABG)
Authors: Pezel T , Kinnel M , Sanguineti F , Garot P , Hovasse T , Landon V , Unterseeh T , Champagne S , Louvard Y , Morice M.C , Garot J
Published: November 2020

Background

The accuracy and prognostic value of stress perfusion cardiac magnetic resonance (CMR) are well established in patients with suspected or proven coronary artery disease (CAD). Because myocardial contrast kinetics may be altered in patients with previous coronary artery bypass graft (CABG), most studies have excluded those patients in whom prognostic data are missing.

Purpose

To assess the safety and prognostic value of vasodilator stress perfusion CMR in patients with previous CABG.

Material

Between 2008 and 2018, we prospectively included consecutive patients with CABG referred for vasodilator stress perfusion CMR with dipyridamole. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined by cardiovascular death, nonfatal myocardial infarction or late coronary revascularization (>90 days after CMR). The safety of the stress perfusion CMR was assessed by clinical monitoring for 1 hour after the end of the CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic association of inducible ischemia and late gadolinium enhancement (LGE) on CMR.

Results

Of 866 CABG patients (70±9 years, 89% men), 852 (98%) completed the CMR protocol and 771 (89%) completed the follow-up (median 4.2±2.7 years). Reasons for failure to complete CMR included renal failure (n=4), intolerance to stress agent (n=4), claustrophobia (n=2), poor gating (n=2) and declining participation (n=2).

Stress CMR was well tolerated without occurrence of death or severe adverse event. In this cohort, 531 (61%) patients had a myocardial infarction defined by the presence of LGE with ischemic patterns in CMR. Patients without inducible ischemia or LGE experienced a substantially lower annual event rate of MACE (12.8%) than those with ischemia and without LGE (27.6%), or those with both ischemia and LGE (28.2%; p<0.001 for all). Using Kaplan-Meier analyses, the presence of myocardial ischemia was correlated with the occurrence of MACE and cardiac mortality (both p<0.0001) (Figure). In multivariable stepwise Cox regression, the absence of inducible ischemia was an independent predictor of a lower incidence of MACE (HR 2.17, 95% CI 1.56–3.13; p<0.001) and cardiovascular mortality (HR 2.38; 95% CI 1.39 0.25–4.03; p=0.001).

Conclusions

Stress CMR is feasible, safe and has a good discriminative prognostic value to predict the occurrence of MACE and cardiovascular mortality in patients with CABG.

Kaplan-Meier: MACE (A) – CV Mortality (B)

Funding Acknowledgement

Type of funding source: None
The relationship between arrhythmogenicity and novel parametric cardiac magnetic resonance indices in systemic sclerosis patients
Authors: Mavrogeni S , Gargani L , Pepe A , Monti L , Markousis-Mavrogenis G , Koutsogeorgopoulou L , Karabela G , Katsifis G , Bruni C , Dimitroulas T , Mukherjee M , Lima J , Kitas G.D , Sfikakis P.P , Matucci-Cerinic M
Published: November 2020

Introduction

Cardiac involvement in systemic sclerosis (SSc) accounts for 26–36% of deaths. This most frequently manifests as ventricular rhythm disturbances (VRDs), eventually culminating in sudden cardiac death. However, no specific guidelines exist for implantation of cardioverter defibrillators (ICD) in SSc patients. Parametric cardiovascular magnetic resonance (CMR) indices of myocardial oedema and fibrosis like native T1/T2 mapping have been shown to be associated with prognosis in SSc patients with acute cardiac events and normal echocardiograms. However, their relationship with arrhythmogenicity per se has not been previously investigated in SSc.

Objectives

To investigate the relationship between parametric CMR indices and arrhythmogenicity in SSc patients.

Methods

84 consecutive SSc patients (80% diffuse-cutaneous SSc) from eight European centers presenting with cardiac symptoms were examined using a 1.5 T CMR system. 24h Holter recordings were obtained within a month of the CMR scan. The presence of VRDs was defined as any type of premature ventricular contraction (PVC) in couples, triplets, bigeminism, trigeminism, quadrigeminism and non-sustained ventricular tachycardia, as well as having >30 PVCs per hour. Logistic regression analysis was used to evaluate the relationship between VRD occurrence and native T1/T2 mapping as well as myocardial extracellular volume fraction (ECV).

Results

Mean age in the cohort was 55 (13) years and 78 (93%) patients were female. Of these, 67 (80%) experienced at least one type of VRDs. Each 10 ms increase of native T1-mapping was associated with a higher occurrence of VRDs [odds ratio (95% confidence interval): 1.21 (1.08–1.36), p=0.001]. Similarly, a 1% increase in ECV conferred an increased probability of experiencing VRDs [1.25 (1.01–1.53), p=0.037]. Lastly, a 1ms unit increase in T2-mapping also led to increased probability of having experienced VRDs [1.09 (1.01–1.19), p=0.035].

Conclusion

Parametric CMR indices are associated with arrhythmogenicity in SSc patients with cardiac symptoms and should be investigated further in larger studies for their clinical utility in selecting high-risk SSc patients for ICD implantation.

Funding Acknowledgement

Type of funding source: None
Isolated apical perfusion defect in SPECT-CT scans, is there any prognostic value?
Authors: Lopes J , Monteiro M , Campos D , Saleiro C , Costa S , Sousa J , Puga L , Gomes A , Silva J , Ferreira M , Goncalves L
Published: November 2020

Background

Myocardial perfusion imaging (MPI) plays a significant role in diagnostic and therapeutic decision making in coronary artery disease (CAD). An isolated apical defect in the 17th segment in SPECT/CT scans is a common finding, sometimes attributed to the apical thinning phenomenon. However, the clinical significance of apical thinning or other isolated apical defects is unknown.

Purpose

The purpose of this study is to assess the prognostic impact of an isolated apical perfusion defect (17th segment) in patients (P) with suspicion of significant CAD.

Methods

A cohort of 612 consecutive P that underwent a MPI test with a SPECT/CT scanner, between January 2017 and December 2017, in a single nuclear medicine centre, was included in this retrospective study.

The inclusion criteria for this study were either a normal perfusion exam (group 1 – G1) or only an isolated apical defect in the 17th segment, either reversible suggesting ischemia (group 2 – G2) or fixed suggesting necrosis (group 3 – G3). Images with and without attenuation correction were analysed. Mean follow-up was 29±4 months.

The chi square test was used for categorical variables, and analysis of variance for continuous variables. Binary logistic regression was used to control for confounding.

Results

A total of 612 P were included (57% male sex, mean age of 69±10) and divided in G1 (n=494, 80.7%), G2 (n=62, 10%) and G3 (n=56, 9.2%). P in G3 had higher body mass index (31±7, p=0.028) and higher prevalence of dyslipidemia (84%, p=0.001), while P in G1 had lower ejection fraction at rest (54±15, p=0.001). There was no association between the presence of isolated apical defect and all- cause mortality (G1 = 7.3% vs G2 = 6.5% vs G3 = 5.4%, p=0.851). There was a statistically significant difference between groups in the referral for coronary angiography in the bivariate analysis (G1 = 7.9% vs G2 = 35.5% vs G3 = 10.7%, p=0.001), but this association did not remain when accounted for potential confounders (angina, ejection fraction, previous CAD and diabetes) – OR=3.94, 95% CI: [0.968–16.093], p=0.056.

In those P that underwent coronary angiography, there was no statistically significant difference between the 3 groups in revascularization of significant CAD (G1 = 38.5% vs G2 = 36.4% vs G3 = 50%, p=0.830). During the follow-up time, 11 P of group 1 suffered an acute coronary syndrome (ACS), but there were no events in group 2 or 3.

Conclusion

Isolated apical myocardial defect on a SPECT/CT exam has no association with all-cause mortality in this patients. There is no significant difference in referral for coronary angiography or need for coronary revascularization between P with normal exams and P with isolated apical defects.

Funding Acknowledgement

Type of funding source: None
Prediction of myocardial viability in chronic phase in patients with acute myocardial infarction by simultaneous dual-isotope imaging with 99mTc-sestamibi/123I-BMIPP SPECT using CZT camera system
Authors: Fujita Y , Hida S , Igarashi Y , Hatano T , Morishima T , Yamashita J , Murata N , Ito R , Chikamori T
Published: November 2020

Objectives

The objective of this study was to determine the optimal cut-off value of % uptake of simultaneous dual-isotope (99mTc-sestamibi/123I-BMIPP) SPECT in patients with acute myocardial infarction (AMI) for prediction of myocardial viability in chronic phase.

Methods

We evaluated 30 consecutive patients with AMI who had undergone both dual-SPECT in acute phase and stress myocardial SPECT using 99mTc-tracers in chronic phase by Discovery NM530c. Regional % uptake with a 17-segment model was obtained using QPS software. The presence of myocardial viability was defined when regional % uptake ≥50% in 99mTc SPECT at rest in chronic phase was observed. Receiver operating characteristic (ROC) curves were analyzed to determine the optimal cutoff values of regional % uptake in both left anterior descending artery (LAD) territory and non-LAD coronary territory in acute phase to predict the myocardial viability in chronic phase.

Results

The cutoff values for prediction of viable myocardium were %uptake ≥47% for 99mTc-sestamibi, %uptake ≥31% for 123I-BMIPP in acute phase in LAD territory and %uptake ≥52% for 99mTc-sestamibi, %uptake ≥48% for 123I-BMIPP in non-LAD territory. The respective sensitivities, specificities and the area under the ROC curve (AUC) values in the prediction of myocardial viability were 92%, 92% and 0.94 with 99mTc-sestamibi, 90%, 85%, 0.92 with 123I-BMIPP in LAD territory, and 81%, 93% and 0.92 with 99mTc-sestamibi, 81%, 90%, 0.92 with 123I-BMIPP in non-LAD territory. There were no significant differences in AUC values between 99mTc-sestamibi and 123I-BMIPP in both LAD territory and non-LAD coronary territory.

Conclusions

In the simultaneous 99mTc-sestamibi/123I-BMIPP dual-isotope imaging in patients with AMI, these results suggest that not only 99mTc-sestamibi SPECT, but also 123I-BMIPP SPECT may be possible to predict the presence of myocardial viability in chronic phase. But it should be noted that the optimal cutoff values of regional % uptake in acute phase to predict the myocardial viability may differ for LAD territory and non-LAD coronary territory.

Funding Acknowledgement

Type of funding source: None
Impact of early post-stress LV Dis-sinchrony assessed by TC99m GSPECT myocardial perfusion: ischemic patients vs. normal subjects
Authors: Cortes C.M , Aramayo G E.N , Barboza P , Embon M
Published: November 2020

Purpose

We aimed to determine the value of early post-stress Tc99msestamibi gated SPECT imaging for detecting changes in the two phase analysis synchrony parameters: Histogram bandwidth (HB) and Standard deviation (SD) in ischemic patients compared to normal subjects.

Methods

We prospectively included normal subjects and consecutive patients who had a positive stress test (angina or ST deviation during stress test). Both groups followed the same GSPECT protocol: an early stress image (acquired at maximum 10 minutes after the tracer injection), a delayed stress image (after 45 min of tracer injection) and the rest image. Phase analysis indices HB and SD were compared from early stress/ rest images and delayed stress/rest images in both groups. We compared the change of SD and HB indices (stress minus rest) for early and delayed images. The ischemic group was divided into mild ischemia (SDS≤3), moderate ischemia (SDS>3 and<8), and severe ischemia (SDS≥8)

Results

Twenty nine normal subjects and 57 ischemic patients were included. Thirty per cent of the ischemic group had mild ischemia, 32% moderate ischemia and 37% severe ischemia. SD and HB values decreased in early and delayed-stress images compared to those of rest images in normal subjects (all p<0,05). In the ischemic group early-stress SD increased compared to rest SD (p<0,05) while delayed- stress SD did not change. Early-stress HB did not change in comparison to rest HB while delayed-stress HB decrease compared to rest HB.The figure shows the comparison of SD and HB between early-stress, delayed-stress and rest images in normal subjects and ischemic patients. The Table shows the comparison of the change of SD and HB indices (stress minus rest) for early and delay images.

Conclusion

LVMS indices obtained by phase analysis of Tc99sestamibi GSPECT imaging, HB and SD decrease significantly when derived from early and delayed stress images compared to rest images in normal subjects. A progressive significant increase in SD and HB values in delayed and early stress images was observed in this population what could be an expression of post-ischemic LV dis-synchrony. Larger amounts of ischemia are related to progressive higher changes in SD and HB from early and delayed stress images versus rest images.

Funding Acknowledgement

Type of funding source: None
Prediction of the improvement of left ventricular wall motion after acute myocardial infarction by simultaneous dual-isotope imaging with 99mTc-sestamibi/123I-BMIPP using cadmium-zinc-telluride SPECT
Authors: Hida S , Fujita Y , Igarashi Y , Hatano T , Morishima T , Yamashita J , Murata N , Ito R , Chikamori T
Published: November 2020

Background/Introduction

Although both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and the reverse redistribution of 99mTc-sestamibi in patients with acute myocardial infarction (AMI) are known to significant markers for predicting the improvement of left ventricular (LV) wall motion in the infarcted territory in chronic phase, few studies evaluated them by simultaneous dual-isotope (99mTc-sestamibi/123I-BMIPP) imaging using cadmium-zinc-telluride (CZT) SPECT system.

Purpose

The purpose of this study was to evaluate whether the presence of 99mTc-sestamibi/123I-BMIPP mismatch or the reverse redistribution of 99mTc-sestamibi make better prediction of the improvement of LV wall motion in the infarcted territory.

Methods

We evaluated 30 consecutive patients with AMI who had undergone both dual-isotope (99mTc-sestamibi/123I-BMIPP) SPECT in acute phase and stress myocardial SPECT using 99mTc-tracers in chronic phase by Discovery NM530c. Both 99mTc-sestamibi/123I-BMIPP mismatch and reverse redistribution of 99mTc-sestamibi were determined using traditional definition. The improvement of LV wall motion in the infarcted territory from acute phase to chronic phase was assessed using QGS.

Results

Of 30 patients, the improvement of LV wall motion in the infarcted territory from acute phase to chronic phase was found in 20 patients. Both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and reverse redistribution of 99mTc-sestamibi were significantly linked to predict the improvement of LV wall motion (p=0.0001, p=0.011, respectively). The respective sensitivities, specificities and accuracies in the prediction of the improvement of LV wall motion in the infarcted territory were 90%, 90% and 90% with 99mTc-sestamibi/123I-BMIPP mismatch, and 60%, 90%, 70% with reverse redistribution of 99mTc-sestamibi.

Conclusions

In the simultaneous 99mTc-sestamibi/123I-BMIPP dual-isotope imaging using CZT SPECT system, both the presence of 99mTc-sestamibi/123I-BMIPP mismatch and the reverse redistribution of 99mTc-sestamibi in acute phase are useful for predicting the improvement of LV wall motion in chronic phase, but the presence of 99mTc-sestamibi/123I-BMIPP mismatch is superior to the reverse redistribution of 99mTc-sestamibi for it.

Funding Acknowledgement

Type of funding source: None
Pharmacological stress test for myocardial ischemia when Adenosine is contraindicated: prospective documentation of side effects in over 700 patients with COPD or bronchial asthma
Authors: Keller M , Silber S
Published: November 2020

Background

In the face of an increasingly elder population, physical exercise tests become less feasible with an increasing need for pharmacological stress tests, preferably with imaging techniques. For myocardial stress tests provoking myocardial ischemia, vasodilator stress is most frequently used. Whereas Dipyridamole should be obsolete, the predominant drug applied within this context is Adenosine for myocardial scintigraphy, magnetic resonance imaging and FFR. Adenosine, however, is contraindicated in patients with COPD or bronchial asthma, predominantly due to a possible exacerbation of bronchospasm or other pulmonary side effects. In contrast, Regadenoson, was especially developed as a highly selective A2A receptor agonist to circumvent these problems.

Methods

Regadenoson was applied with the standard injection dose of 400 μg in 780 consecutive patients with a history of COPD or bronchial asthma for SPECT myocardial perfusion scintigraphy. 12% of the patients had a preexisting first degree AV-block. Blood pressure, heart rate and possible side effects were prospectively monitored and documented for 10 minutes after the injection.

Results

The mean age was 70.8±8.9 years, 52% of the patients were female, 48% were male. 69% had a history of COPD and 31% of bronchial asthma. The maximum increase in heart rate was significant from 66.1±8.1 to 98.3±17.4 bpm. The maximum decrease in systolic blood pressure was significant from 124.3±12.9 to 117.3±24.7 mmHg. Most frequent side effects were a feeling if increased breathing (73%), headache (22%), feeling of warmth (22%), pressure in the stomach (17%) and pressure in the chest (16%). Complications: only 1 patient (without preexisting first degree AV-block) developed a systolic drop in blood pressure from 107 to 60 mmHg with transient severe dyspnoea. No induction of bronchospasm or other pulmonary side effects were observed.

Conclusion

In patients with COPD or bronchial asthma undergoing a pharmacological stress test, Adenosine is contraindicated due to its – potentially severe – pulmonary side effects, Regadenoson is the vasodilator of choice in these patients. In our series, no severe complication was observed – even not in patients with a preexisting first degree AV-block.

Funding Acknowledgement

Type of funding source: None
High-risk plaque burdens myocardial flow reserve in intermediate coronary artery disease: hybrid analysis of 13N-ammonia PET and coronary CT angiography
Authors: Yamamoto A , Nagao M , Ando K , Nakao R , Sakai A , Watanabe E , Momose M , Sato K , Sakai S , Hagiwara N
Published: November 2020

Background

13N-ammonia PET (NH3-PET) can detect myocardial perfusion abnormalities in patients with coronary artery disease (CAD) and also obtain diagnostic quantitative values of absolute myocardial blood flow and myocardial flow reserve (MFR). Low MFR (MFR<2.0) is an independent prognostic factor for major adverse cardiac event in patients with ischemic and non-ischemic heart disease. A feature of low attenuation plaque (LAP) on coronary CT angiography (CCTA) has been known as high-risk plaque (HRP) for acute coronary syndrome even if there is no significant coronary stenosis. The presence of HRP potentially adversely affects MFR, but the hypothesis has not been elucidated.

Purpose

We aimed to investigate the affect of LAP to MFR in intermediate CAD.

Methods

One hundred five patients (age 67±9 years, 65% male) with CAD underwent NH3-PET and CCTA within 6 months between April 2015 and March 2019 were enrolled. Based on the results of CCTA, mild and moderate stenosis were defined as 1% to 49% and 50% to 69% stenosis. Ischemic territories for major three vessels were identified by stress/rest NH3-PET images. Finally, 194 coronary arteries with mild to moderate stenosis corresponding to non-ischemic territory were analyzed in this study. LAP was defined as plaques containing CT value less than 90HU. Partially calcified plaques were included in LAP. Entirely calcification plaque without LAP was defined as calcified plaque. MFR for major three vessels were calculated from dynamic scan at stress/rest NH3-PET.

Results

CCTA showed 80 coronary arteries with LAP (41%), 104 coronary arteries with calcified plaque (54%), 102 vessels with mild stenosis (53%), and 92 vessels with moderate stenosis (47%). MFRs for coronary arteries with LAP were significantly lower than those without LAP (2.1±0.6 vs 2.5±0.6, p<0.0001). The significant difference in MFR between with and without LAP was observed in both mild and moderate stenosis (mild: 2.0±0.6 vs 2.5±0.6, p=0.0015, moderate: 2.1±0.6 vs 2.5±0.6, p<0.0001). In contrast, coronary arteries with calcified plaque had significantly higher MFR than those without (2.5±0.6 vs 2.1±0.6, p<0.0001).

In 58 coronary arteries with MFR<2.0, 71% (41/58) had LAP and 24% (14/58) had calcified plaque. In 136 coronary arteries with MFR≥2.0, 29% (39/136) had LAP and 66% (90/136) had calcified plaque. LAP was significantly more frequent in the former and calcified plaque was significantly more frequent in the latter.

Conclusion

The presence of LAP burdens MFR in mild to moderate CAD. On the other hand, calcified plaque alone had no adverse effect on MFR. LAP is an important sign in CAD risk assessment even without significant coronary stenosis.

MFR and stress MPI

Funding Acknowledgement

Type of funding source: None