A Baritussio

Diagnostic yield of cardiovascular magnetic resonance in young-middle aged patients with high-grade atrio-ventricular block

BACKGROUNDnAtrio-ventricular block (AVB) is a rare finding in young or middle-aged adults, often leading to pacemaker implantation (PM) without further investigation. We sought to assess the diagnostic role of cardiovascular magnetic resonance (CMR) in young and middle-aged adults with high-grade AVB.nnnMETHODSnWe consecutively enrolled young-middle aged (18-65years) patients with high grade AVB referred to CMR after standard clinical assessment (history, electrocardiogram and cardiac rhythm monitoring) prior to PM implantation. Cine and post-contrast imaging were performed in a 1.5T scanner.nnnRESULTSn34 patients (59% male, mean age 42±12years) with high grade AVB were referred to CMR for suspected ischemic heart disease (IHD)(n=4) and non-ischemic heart disease (NIHD)(n=20); no clear cause was found in 9 patients prior to CMR and 1 patient had suspected lung disease. A pathologic substrate was found on CMR in 15 patients (44%), while a structurally normal heart was reported in 18 (53%). Non-specific findings were reported in 1 patient (3%). There was a fair agreement between CMR and echocardiographic findings (Cohens kappa 0.243), and CMR provided an entirely new diagnosis in 34% of patients. As compared to the standard clinical assessment, CMR had an additional role in 65% of patients and guided further testing (genetic testing, extra-cardiac imaging) in 9%.nnnCONCLUSIONSnCMR found a pathologic substrate in 44% of patients, mainly NIHD (32%). Half of the patients (53%) had a structurally normal heart. When added to the standard clinical assessment, CMR had an incremental diagnostic role in two thirds of patients.

7 Sex differences in late chemotherapy-induced cardiomyopathy in adult cancer survivors: a cardiovascular magnetic resonance study

Introduction Chemotherapy induced cardiomyopathy (CIC) carries significant morbidity and mortality in cancer survivors. Female sex is a recognised risk factor for CIC in paediatric populations but the effect of sex in adult patients has not been established. We investigated sex differences in CIC using cardiovascular magnetic resonance (CMR). Method 76 patients without abnormal left ventricular function prior to chemotherapy (30 male [59±15 years], and 46 female [58±13 years, p=0.86]) were included. Cumulative anthracycline dose (193±165 vs. 189±119 mg/m2, p=0.91) and follow-up interval (8.75±8.75 years vs. 8.75±9 years, p=0.99) were similar. All patients underwent contrast-enhanced CMR at 1.5T, including long and short axis cine imaging, mitral and tricuspid annular peak systolic excursion (MAPSE and TAPSE, respectively), and late gadolinium enhancement (LGE). Multivariate regression analysis was undertaken. Results Left (39±13 vs 46±10%; p=0.027) and right ventricular ejection fraction (50±10 vs. 55±8%; p=0.042) were significantly lower in males, largely driven by differences in LV (208±83 vs. 167±42, p=0.02) and RV end diastolic volume (150±44 vs. 120±31, p=0.002). MAPSE and LAVi correlated significantly with LVEF (p<0.001 in both cases), as did TAPSE with RVEF (p=0.02). LGE prevalence did not differ between males and females (37% vs. 20%, respectively, p=0.10). Conclusions Adult male cancer survivors developed comparably worse late biventricular CIC than their female counterparts despite receiving similar doses of cancer treatment. These findings need confirmation in larger cohort studies, and if confirmed, could inform bespoke monitoring strategies taking sex differences into account.

An unusual cause of ‘dextrocardia’

A previously fit and well 37 year-old man was diagnosed with ESC grade 1 arterial hypertension. His personal medical history was only remarkable for longstanding chest wall asymmetry, never previously investigated. There was no relevant family history. An electrocardiogram was Sokolow-Lyon voltage criteria positive for left ventricular hypertrophy (LVH) ( Figure 1A ). Chest radiograph revealed apparent dextrocardia ( Figure 1B ). Cardiac magnetic resonance (CMR) was performed to: (i) confirm dextrocardia and exclude concomitant cardiac congenital abnormalities, (ii) confirm the presumptive diagnosis of hypertensive LVH and (iii) investigate for underlying causes of young-onset hypertension. nnnnFigure 1 n( A ) 12-lead ECG showing Sokolow-Lyon voltage …

1 Prevalence of extra-cardiac findings detected by cardiac MRI in inherited vs acquired cardiovascular diseases

Introduction With its large field of view, Cardiovascular Magnetic Resonance (CMR) allows the detection of extra-cardiac pathologies (ECP). Both cardiologists and radiologists should be able to recognise ECP and identify those requiring further investigation. The aim of our study is to assess the difference in prevalence of ECP in patients with suspected inherited cardiac conditions vs acquired heart disease. Materials and methods We reviewed 1.817 consecutive clinical CMR studies performed in the biggest CMR department in Southwest England to look for ECP. Demographic characteristics and scans indications were also recorded. For each scan the presence of ECP and its relevance (need for further investigation, i.e. suspected lung malignancy) was assessed. The internal record system (Picture Achievement and Communication System, PACS) was used to check whether the ECP were previously known, or whether it represents a new finding. Abstract 1 Figure 1 (A) Axial Haste showed a nodule (arrow) in the superior lobe of the right lung. (B) On the High Resolution Computed Tomography (HRCT), performed to further assess the ECP, the presence of the nodule in the superior lobe of the right lung was confirmed (head-arrow) Results We analysed 1,817 scans, referred for the assessment of inherited cardiac condition (Group A, n = 906) and acquired heart disease (Group B, n = 911). There was no significant difference in prevalence of ECP between the two groups (p = 0.63). ECP were found in 26% of patient in Group A, 4% of which requiring further assessment; 69% previously unknown (Figure 1). ECP were reported in 27% of patients in Group B, 5% requiring further assessment; 68% were previously unknown. Conclusion One in four patient has an extra-cardiac finding and the prevalence of ECP did not differ in patients presenting with inherited conditions vs acquired heart disease.

6 Prevalence and CMR characteristics of apical HCM

Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiac death in young adults. The 3 main phenotypes are asymmetric (most common), concentric and apical. Literature suggests apical HCM is rare and more benign, but data is scarce. We sought to describe prevalence and characteristics of apical HCM in a large CMR service. Methods We reviewed 3,100 scans (Jan 2014–Mar 2015). Protocol included cines, early and late gadolinium enhancement imaging. 114 consecutive HCM patients were identified. Asymmetric HCM defined as septal/ free wall thickness ratio > 1.3; apical HCM as apical wall thickness > 15mm or apical/basal wall thicknesses ≥ 1.3–1.5. Concentric HCM defined as symmetrical hypertrophy of ventricular wall without regional preferences. Non-apical HCM (asymmetric and concentric phenotypes) were compared with apical HCM. Fisher’s exact t-test and unpaired t-test were performed for statistical significance (P-value < 0.05, statistically significant). Univariate and multivariate logistic regression analyses were performed to determine CMR predictors of apical HCM. Results 10 patients were excluded, leaving 104 patients, median age 60years; 70% male. 70% had non-apical HCM (5 patients concentric HCM, the rest asymmetric HCM) and 30% apical HCM. Mean maximum LV wall thickness, indexed LV mass, stroke volume, prevalence of LVOTO and SAM were greater in non-apical group. Presence of LGE was high in both groups (>85%) and wasn’t statistically different. Univariate predictors of apical HCM included maximum LV wall thickness, indexed stroke volume, LVOT obstruction (Table 1). In the multivariate model, maximum wall thickness remained the only significant predictor. Abstract 6 Table 1 CMR characteristics of Apical vs non-Apical HCM CMR findings: Total Cohort (n = 104) Non-apical (n = 73) Apical (n = 31) P-value Mean LVEF (%) 69.7 68.4 72.6 0.0552 Mean LVEDVI (mL/m²) 73.7 76.7 66.8 0.0718 Mean LVESVI (mL/m²) 23.8 25.5 20.1 0.1177 Mean indexed stroke volume 53.1 55.9 46.4 0.0333 Mean max. LV wall thickness (mm) 18.2 19.3 15.6 0.0001 Mean indexed LV mass 93.5 98.4 82.4 0.0102 LVOTO 35.2 41.1 12.5 0.0403 SAM 31.4 38.9 6.25 0.0143 LGE (%) 86.9 85.7 89.7 0.8063 LVEF, left ventricular ejection fraction; LVEDVI, left ventricular end diastolic volume index; LVESVI, left ventricular end systolic volume index; LVOTO, Left ventricular outflow tract obstruction; SAM, systolic anterior valve motion; LGE, late gadolinium enhancement. Conclusions Our study suggests that prevalence of apical HCM is almost 1/3rd of all observed cases. It also demonstrates that prevalence of LGE was high in apical HCM, suggesting that better prognosis of apical HCM based on the absence of myocardial fibrosis, should be reconsidered. Further large trials are needed to better understand the pathophysiology.

22 Intra-ventricular myocardial deformation strain analysis in healthy volunteers: regional variation and implications for regional myocardial disease processes

Ejection fraction (EF) is a traditional marker of systolic function. However, it may not detect early, subtle cardiac disease with regional predilection. The aim of this study was to define regional intra-ventricular variation in myocardial strain in a cohort of healthy volunteers using Tissue-tracking cardiac magnetic resonance (CMR). Methods Healthy volunteers were recruited (n = 94, age range 20–79 years, 54% male). CMR at 1.5T was performed. Tissue-tracking software (CVI42, Circle Cardiovascular Imaging Inc.) estimated myocardial strain from the long-axis and the short-axis steady-state free precession (SSFP) cine images (Figure 1). The entire cohort was analysed by two independent readers. Inter-observer variability was also assessed. Myocardial segments were defined in accordance to the American Heart Association 16-segment model. Regional variations in circumferential and radial strain between basal, mid-cavity and apical segments as well as between left ventricle walls were assessed. Statistical analysis was performed using paired t test (p < 0.05). Results Inter-observer reproducibility analyses were excellent for mid-cavity and apical radial and circumferential strain values. On the other hand, reproducibility was not as good for basal segments for both deformation directions. Regional variations in strain (Table 1) revealed a statistically significant increase in deformation of the apical segments compared to the basal and mid-cavity ones for both radial and circumferential strain. Analysis of the different LV walls deformations indicated lowest values in the septum in all subjects, as well as across all age and gender subgroups. Conclusion This is the first study to demonstrate that there is a positive gradient toward the apex in both circumferential and radial strain using CMR-derived myocardial strain analysis. Furthermore, we also showed that the interventricular septum is the segment with lowest deformation values. These findings are important, as a comprehensive understanding of normal intra-ventricular regional variation is needed before this new tool can be implemented in routine clinical practice. Abstract 22 Table 1 Regional strain values Strain% Subgroup Basal Mid-cavity Apical P-value * Septal Lateral Anterior Inferior P-value ** Circumferential Gender Male (n = 51) −19 ± 2 −20 ± 2 −24 ± 2 <0.001 −16 ± 2 −24 ± 3 −22 ± 3 −22 ± 2 <0.001 Female (n = 43) −20 ± 2 −21 ± 3 −24 ± 3 <0.001 −17 ± 3 −24 ± 3 −23 ± 3 −22 ± 2 <0.001 Age (years) 20–39 (n = 28) −19 ± 2 −19 ± 2 −23 ± 3 <0.001 −15 ± 3 −23 ± 3 −22 ± 3 −21 ± 2 <0.001 40–59 (n = 35) −19 ± 2 −20 ± 2 −24 ± 2 <0.001 −16 ± 3 −24 ± 2 −22 ± 3 −22 ± 2 <0.001 60–79 (n = 31) −20 ± 2 −22 ± 2 −25 ± 3 <0.001 −17 ± 2 −26 ± 2 −24 ± 2 −23 ± 2 <0.001 Radial Gender Male (n = 51) 39 ± 6 37 ± 7 51 ± 9 <0.001 28 ± 6 52 ± 11 46 ± 9 44 ± 8 <0.001 Female (n = 43) 43 ± 8 39 ± 9 52 ± 11 <0.001 30 ± 8 52 ± 11 48 ± 11 45 ± 8 <0.001 Age (years) 20–39 (n = 28) 39 ± 7 34 ± 7 48 ± 10 <0.001 27 ± 7 47 ± 9 45 ± 10 42 ± 6 <0.001 40–59 (n = 35) 40 ± 6 37 ± 6 52 ± 10 <0.001 28 ± 8 50 ± 9 44 ± 10 42 ± 9 <0.001 60–79 (n = 31) 44 ± 9 43 ± 9 55 ± 11 <0.001 32 ± 5 60 ± 11 51 ± 9 49 ± 8 <0.001 * p-values between basal and apical ** p-values between septal and all the other walls Abstract 22 Figure 1 Definition of longitudinal, circumferential and radial myocardial strain, calculated by SSFP long-axis and short-axis cine images

21 Feature tracking cardiac magnetic resonance to assess LV mechanics in different cardiac overload caused by aortic valve disease

Background In aortic valve disease, left ventricular (LV) dimensions and ejection fraction are important parameters for decision making. However, the effects of pressure overload caused by aortic stenosis or/and volume overload, due to aortic regurgitation, lead to different LV remodelling, concentric and eccentric hypertrophy, respectively, which may differently alter LV mechanics. We aimed to characterise LV mechanics, in terms of longitudinal strain/deformation using feature tracking cardiac magnetic resonance (FT-CMR) in patients with various degree of aortic stenosis and aortic regurgitation and preserved LV ejection fraction (LVEF). Methods Seventy-one patients (14 with normal valve function, 29 with aortic stenosis and 28 with aortic regurgitation), mean age 45 ± 19 years, 70% men, who underwent clinically indicated CMR and showed preserved LVEF (>50%) were included. LV volumes, LVEF and mass were measured on steady-state free precession (SSFP) cine images. FT-CMR analysis was performed offline using tissue-tracking software (CVI42, Circle Cardiovascular Imaging Inc.) to estimate LV global longitudinal strain (GLS) from two long-axis SSFP cine images (Figure 1). To correct for the LV remodelling process, LV GLS was corrected for LV end-diastolic volume. Results There were significant differences in LV volumes, mass and ejection fraction across the 3 groups of patients (Table 1): patients with aortic regurgitation showed significantly larger LV volumes, and lower LVEF compared to patients with normal aortic valve function and patients with aortic stenosis. There were no differences in LV GLS across the groups. However, after correcting for LV end-diastolic volume, patients with aortic regurgitation showed more impaired LV GLS as compared to the other groups. Abstract 21 Table 1 CMR characteristics Normal valve function (n = 14) Aortic stenosis (n = 29) Aortic regurgitation (n = 28) ANOVA p-value Heart rate (beats/min) 71 ± 8 70 ± 12 64 ± 13 0.132 LVEDV (ml) 135 ± 33 138 ± 33 186 ± 50 * <0.001 LVESV (ml) 46 ± 15 43 ± 16 70 ± 22 * <0.001 LVEF (%) 65 ± 5 69 ± 6 62 ± 5† <0.001 LV mass (gr) 120 ± 29 # 153 ± 36 157 ± 35 0.005 GLS (%) −19.2 ± 3.4 −19.3 ± 3.6 −19.8 ± 3.0 0.813 LV GLS/LVEDV −0.15 ± 0.05 −0.14 ± 0.04 −0.12 ± 0.04 * 0.01 * p < 0.001 vs. Aortic stenosis and normal; †p < 0.001 vs. Aortic stenosis; # p < 0.001 vs. Aortic regurgitation and Aortic stenosis. Conclusions LV mechanics significantly differ across normal functioning and different type of aortic valve dysfunction (stenosis and regurgitation), with aortic regurgitation showing the most impaired LV GLS corrected for LV end-diastolic volume, despite preserved LVEF. Abstract 21 Figure 1 Assessment of LV GLS with FT-CMR. From two long-axis SSFP cine images, the time-GLS curve is obtained and peak LV GLS is determined

2 Clinical application of cardiovascular magnetic resonance in patients with MR-conditional devices: safety, feasibility and clinical impact

Background Implanted cardiac devices were previously considered unsuitable for CMR. With the development of MR-conditional devices, access to CMR has increased, despite concerns regarding image quality and diagnostic accuracy. We aimed to assess the clinical application of CMR in patients wearing MR-conditional devices. Materials and methods We retrospectively enrolled patients wearing MR-conditional devices undergoing a comprehensive CMR protocol (cine, early and late gadolinium enhancement, LGE) in a 1.5T scanner (June 2012–November 2015). Every sequence was analysed by two independent observers and scored according to the effect of artefacts on image quality and interpretation (no, minor and major artefacts). Inter-observer agreement was assessed per sequence and as overall judgement on scan quality and interpretation. Clinical impact of CMR was defined as a change in diagnosis and in management. All devices were interrogated before and after CMR. Abstract 2 Table 1 Cohen’s kappa for inter-observer agreement on image quality and interpretation per sequence and as overall judgement Cohen’s kappa p HASTE 0.378 0.001 Long Axis Cine 0.356 0.001 Short Axis Cine 0.532 <0.001 EGE 0.398 0.003 Long Axis LGE 0.284 0.005 Short Axis LGE 0.516 <0.001 Overall Judgement 0.454 <0.001 EGE, early gadolinium enhancement; LGE, late gadolinium enhancement. Results We enrolled 46 consecutive patients (28 male, mean age 56 ± 16 years) wearing MR-conditional pacemaker (22, 48%) and implantable loop recorder (24, 52%). All CMR scans were successfully completed and diagnostic: minor artefacts were recorded in 17 scans (37%), major artefacts in 7 (15%), and no artefacts in 22 (48%). Additional FLASH sequences were performed in 9 patients (20%) to overcome artefacts. Inter-observer agreement on image quality and interpretation was moderate, both overall (kappa 0.454, p < 0.0001) and per sequence, with the exception of long-axis LGE sequences, for which it was fair (kappa 0.284, p = 0.005) (Table 1). Cine sequences were most affected by artefacts, mainly in the mid-apical left ventricular anterior wall and anteroseptum (Figure 1). No change in device parameters was reported after the scan. CMR had a clinical impact in 26 patients (57%), determining a change in diagnosis in 16 (35%), in management in 5 (11%) and a change in both in 5 patients (11%). Conclusion With dedicated protocols and under strict monitoring of cardiac devices, CMR is safe and feasible in patients wearing MR-conditional devices, and it also has major clinical impact. Abstract 2 Figure 1 Left ventricular segmental analysis to assess artefacts interference. Sixteen-segment model showing that artefacts mostly affect the mid-apical left ventricular anterior and anteroseptal walls, on cine and post-contrast sequences, respectively

7 Clinical impact of cardiovascular magnetic resonance on the management of acutely hospitalised patients

Background Cardiac Magnetic Resonance (CMR) is invaluable for assessing ischaemic and non-ischaemic cardiomyopathies. However, evidence regarding the incremental impact of CMR in acutely hospitalised patients is scarce. We evaluated the impact of CMR on diagnosis and clinical decision-making in this cohort. Methods We evaluated 2481 consecutive scans (Jan 2014-Dec 2014) at a large tertiary cardiothoracic centre, identifying 283 patients referred for inpatient scans. Protocol included short axis-long axis cines, T2-weighted oedema sequences, early and late gadolinium enhancement (LGE) images. Definitions for “significant clinical impact” of CMR included change in pre-CMR diagnosis, influence on hospitalisation period, change in medication and on decision making for invasive medical procedures (CABG, angiography, ICD implantation). Results Of the 283 patients, 8 were excluded due to poor image quality, leaving 275 patients (66% male, mean age 59yrs), mean ejection fraction of 46% ± 19. Patients underwent CMR for further assessessment of ischaemic heart disease, cardiomyopathy or congenital heart disease. CMR demonstrated significant clinical impact on 68% of patients. This included a completely new diagnosis in 27% of patients, change in management in 31% and 10% of patients that had both a new diagnosis and change in management. CMR results promoted invasive procedures on 27%, avoided invasive procedures on 16%; and influenced on hospital discharge on 15% of the patients (Figure 1). 84% of the patients had echocardiography prior to CMR. CMR confirmed echo diagnosis in 11%, complemented echo findings with significant new information in 41% and changed the echo diagnosis in 30% of the cases. In a multivariable model that included clinical/imaging parameters, age and presence of LGE were the only independent predictors of “significant clinical impact” (LGE p-value .007, OR 2.782, CI 1.328–5.828) (Table 1). Conclusions CMR had significant impact in patient’s diagnosis and management in 68% of acutely hospitalised patients. Presence of LGE was the only independent predictor of significant clinical impact following CMR. Abstract 7 Table 1 Logistic Regression Variables in the Equation Sig. Odds ratio 95 Conf. Interval Lower Upper Sex .486 .766 .361 1.622 Age .028 1.026 1.003 1.050 Troponin .469 1.000 1.000 1.000 LVEF .945 .999 .972 1.027 iEDV .827 1.001 .989 1.014 RWMA .053 2.440 .987 6.033 LGE .007 2.782 1.328 5.828 Oedema .672 .904 .566 1.444 Variable(s): Sex, Age, Troponin, LVEF, iEDV, RWMA, LGE, Oedema. Abstract 7 Figure 1 Change in diagnosis after performing CMR in patients admitted with chest pain (A), shortness of breath (B) and arrhythmias-out of hospital cardiac arrest (C). (D) Overall significant clinical impact of CMR in change in management and new diagnosis

3 Clinical utility of cardiac MRI in young-middle aged patients with high-grade atrio-ventricular block

Background Atrio-ventricular (AV) block is a rare event in young-middle aged adults, often leading to pacemaker implantation without further investigation. We sought to assess the clinical utility of CMR in young-middle aged adults with high-grade AV block. Methods We retrospectively analysed the CMR registry to collect data on consecutive high-grade AV block patients (18–60yrs) referred for CMR (September 2012–November 2015). High-grade AVB was defined as Mobitz II 2nd degree or complete AVB. All patients underwent a transthoracic echocardiogram (TTE) and a comprehensive CMR protocol (cine and late gadolinium enhancement, LGE). A change in diagnosis was defined as a new diagnosis compared to a multi-parametric pre-CMR diagnosis (based on clinical, ECG and TTE data). Results We identified 34 patients (20 male, mean age 44 ± 12 years); 12 patients (34%) had II degree AVB and 22 (66%) complete AVB. Patients were referred to CMR for suspected ischaemic heart disease (IHD) in 4 patients (11%) and non ischaemic heart disease (NIHD) in 24 (71%); in 6 patients (18%) pre-CMR diagnosis was unclear. CMR showed IHD in 3 patients (9%) and NIHD in 11 patients (32%); a structurally normal heart was found in 18 patients (53%) and non-specific findings in 2 (6%) (Table 1) (Figure 1). LGE was found in 12 patients (34%), with predominant mid-wall pattern (58%). There was moderate agreement between CMR and TTE final diagnosis (Cohen’s kappa 0.435, p 0.001). CMR determined a change in diagnosis in 14 patients (40%). Abstract 3 Figure 1 CMR findings. Post-contrast four chamber long-axis (1A) and short-axis (1B) view showing structurally normal heart. Post-contrast four chamber long-axis (2A) and short-axis (2B) view showing epicardial LGE in the basal to mid-cavity lateral wall (white arrow) in a patient with myocarditis. Post-contrast four chamber long-axis (3A) and short-axis (3B) view showing transmural myocardial LGE in the basal to apical lateral wall in a patient with left ventricular non compaction Conclusions CMR was diagnostic in 94% of young-middle aged patients presenting with high grade AVB. As compared to a multi-parametric pre-CMR diagnosis, CMR led to a change in diagnosis in 40% of patients. Abstract 3 Table 1 CMR diagnosis CMR diagnosis n = 3 4 Ischaemic Heart Disease, n (%) 3 (9) Non-ischaemic Heart Disease, n (%) 11 (32) Structurally Normal Heart, n (%) 18 (53) Non-specific Findings, n (%) 2 (6)