28Impact of non-invasive rapid cardiac magnetic resonance for the assessment of cardiomyopathies in developing countries
Authors: Menacho Medina K D , Ramirez S , Katekaru D , Dragonetti L , Perez D , Illatopa V , Rodriguez B , Bansal R , Rodriguez I , Jacob R , Ntusi N , Herrey A , Westwood M , Walker M , Mooon J 
Published: October 2019

Abstract

Background
Cardiovascular mortality is higher in developing countries. Part of that is suboptimal testing. Cardiac magnetic resonance (CMR) is the gold standard for measuring structure, function of the heart and adds incremental value by imaging scarring and to assess iron level. Despite the existence of MRI units, CMR is identified as a complex test, with poor training and availability in developing countries.

Purpose
To assess the potential impact of a faster CMR protocol at a multicentre level in developing countries; implementing it with an education program, for the assessment cardiomyopathies.

Methods
An international partnership. A rapid CMR protocol for the evaluation of cardiac volumes, function and tissue characterization (Cardiac Iron T2* and LGE for scar) Figure 1a. We deployed the protocol as a multicentre study: Argentina, Peru, India and South Africa accompanied by a program of education. Pre-scan clinical information, scanning data: complications, image quality and post-scan follow-up of participants for the assessment on impact, between 3 to 24 months.

Results
510 scans (4 countries, 6 cities, 12 centres) were performed with the rapid CMR protocol. Contrast studies in 378 (74%). There were no scan-related complications. Quality of the studies was maintained in a high level as an average of 89%. 97% of studies responded referral's question. All patients with contrast CMR scan have had at least one 2D echocardiogram before CMR. Average scan duration was 21±6 mins for contrast studies and 12±3 for non-contrast T2* protocol. The most common underlying diagnoses were non-ischaemic cardiomyopathy in 73% of participants (including cardiac iron level assessment in 26%, HCM in 17%, DCM in 15%), 27% for ischaemic cardiomyopathy and 15% for other pathologies. 4 of the 12 participant centres started to incorporate CMR for the first time. Findings impacted management in 60% of patients, including new diagnosis in 21% of participants. See table 1, figure 1b. For just cardiac iron assessment: 1/3 of participants had iron deposited in the heart with 14% of patients in severe levels.

Conclusions
CMR can be delivered faster and easier. When this abbreviated protocol is enabled with education, it can be implemented in developing countries with existing technology. This protocol shows high quality exam, with an important impact on patient's management.
Characteristics and impact on management Contrast studies Non-contrast studies All patients (%) 378 (74) 132 (36) Age, mean (range) years 54 (16–93) 24 (13–41) Male (%) 151 (39) 64 (48) Pre-echocardiography exam (%) 370 (98) 42 (32) Scanning duration mean (SD) 21 (6) 12 (3) Good quality exam (%) 329 (87) 120 (91) Impact on management Total All patients (%) 510 (100) Completely new diagnosis (%) 105 (21) Change/Addition of Medication (%) 128 (25) Intervention/ Surgery (%) 31 (6) Invasive angiography/biopsy (%) 25 (5) Hospital discharge/admission (%) 15 (3) TOTAL 306 (60%) SD: Standard Deviation.

Acknowledgement/Funding
Global Engagement UCL, UK Foreign & Commonwealth Office and The Peruvian Scientific, Technological Development and Technological Innovation (FONDECYT)