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Role of cardiac magnetic resonance imaging in assessing ischemic and nonischemic cardiomyopathies

One of the diagnostic challenges in cardiology is the assessment of patients with suspected cardiomyopathies. The traditional approach involves clinical history and examination, followed by echocardiography and invasive angiography. Advances in cardiac MRI enable cardiologists to comprehensively assess both ischemic and nonischemic cardiomyopathies, providing information regarding cardiac anatomy, myocardial and valve functions, as well as tissue characterization.

Left ventricular morphology and response to beta-adrenergic stimulation in apical ballooning syndrome

AIMSnThe patho-physiology of apical ballooning syndrome (ABS) has not been clearly defined. The aim of this study was to determine whether patients with a history of ABS are more likely to develop left ventricular (LV) mid-cavity or outflow tract obstruction, or have a greater regional LV contractile response to an adrenergic stimulus compared with normal controls.nnnMETHODS AND RESULTSnTwenty patients who had recovered from ABS and 15 age-and sex-matched controls had dobutamine stress echocardiography with incremental doses up to 20 µg/kg/min. On average ABS subjects had slightly greater basal LV interventricular septal (1.1 ± 0.24 cm vs. 0.93 ± 0.12, P = 0.03) and posterior wall (1.04 ± 0.16 vs. 0.91 ± 0.11 cm, P = 0.02) diameters compared with controls but LV end-diastolic and end-systolic volumes and LV ejection fraction were similar both at rest and after dobutamine. Regional and global LV contractility, measured with the strain rate and tissue velocity imaging were also similar during the dobutamine infusion up to 10 µg/kg/min in ABS and controls. Mid-LV or LV outflow tract obstruction was not present at rest in any subjects, but was common during peak dobutamine infusion both in the ABS (45%) and controls (53%, P = 0.62).nnnCONCLUSIONSnDynamic LV obstruction with dobutamine is common in those with and without prior ABS. However, this study did not identify a greater individual predisposition to LV obstruction, or a different regional or global LV contractile response to dobutamine in patients with a history of ABS compared with control subjects.

The Significance of Equivocal Exercise Treadmill ECG for Intermediate Risk Chest Pain Assessment – Insight From Coronary CT Angiography Data

BACKGROUNDnExercise treadmill test (ETT) is commonly the first-line investigation in troponin-negative chest pain patients. Inconclusive results are common and often lead to repeated functional testings. Coronary computed tomographic angiography (CCTA) has excellent negative predictive value for coronary artery disease detection and may play an important role in their diagnostic workup. We aim to analyse ETT and CCTA findings to understand their modern roles in intermediate risk chest pain population with inconclusive ETT.nnnMETHODSnPatients who underwent both ETT and CCTA at our institution between August 2011 and February 2013 were retrospectively investigated. The ETTs were blindly reviewed, with equivocal ETTs defined as any indeterminate results not strictly adhering to ACC/AHA guidelines for positive ETT. Baseline demographics, clinical characteristics and investigation results were collated. Follow-up outcome data for subsequent investigations, representations, major cardiac adverse events (MACE) and unexpected revascularisations were also analysed.nnnRESULTSn346 consecutive patients were identified (age 57±10years, 53% females, body mass index (BMI) 28±4, Dukes Clinical Score 48±30%, mean follow-up 2.1±0.4years). The ETT was positive in 31%, equivocal in 54% and negative in 15%. Obstructive coronary artery disease (CAD) prevalence was 25% (29% males, 13% females). Those with negative ETTs had obstructive CAD in 8%, with no adverse outcomes during follow-up. Obstructive CAD was seen in 20% with equivocal ETTs and 29% with positive ETTs. In females, obstructive CAD prevalence was low, and similar in those with equivocal or positive ETT (16% and 11% respectively). In males, obstructive CAD was almost 50% in those with positive ETT (p=0.005).nnnCONCLUSIONSnObstructive CAD was found in one in five equivocal ETTs, hence, not all should be considered negative. Obstructive CAD was only found in one in three positive ETTs, hence not all should proceed to invasive angiography. CCTA may be an important gatekeeper test in those with low-intermediate pre-test probability of obstructive CAD.

Eventration of the Right Hemidiaphragm with Resultant Right Atrial Compression—A Rare Finding

A 77-year-old woman presented to hospital with nonlimiting subacute dyspnea. Cardiorespiratory examination was unremarkable including a normal JVP. Blood workup was normal apart from elevated troponin I without ischemic ECG changes. Chest x-ray was unremarkable. Well’s score for pulmonary embolism was 0. She was managed as an acute coronary syndrome. Echocardiogram (Figs. 1 and 2) demonstrated an LV ejection fraction of 60% with RCA territory hypokinesis. No valvular pathology seen. Surprisingly, there was an incidental large, uniformly echo dense mass compressing the right atrium (RA). Initial concern was of an extrinsic compression secondary to a tumor. Chest, abdomen, and pelvis computed tomography (Fig. 3) subsequently showed no malignancy. The marked abnormality was due to right hemidiaphragm eventration with the dome of the liver lying adjacent to the RA giving the appearance of a large mass compressing onto the RA. Coronary

Advanced 3D Imaging and Transcatheter Valve Repair/Implantation

In selected patient populations with valvular heart disease, minimally invasive surgical and transcatheter procedures are becoming an alternative to standard open surgical approaches. Because these procedures are characterized by limited or no direct exposure of the operative field, pre-procedural planning and intraoperative decision making rely heavily on image guidance.

Role of Echocardiography in Pulmonary Vein Ablation for Atrial Fibrillation

Pulmonary vein ablation is increasingly used for patients with difficult to manage atrial fibrillation. Echocardiography plays a central role in the assessment of patients undergoing ablation therapy, not only in the pre-ablation patient selection and post-ablation assessment, but also in the peri-procedural guidance. Newer echocardiographic techniques including atrial mechanics measurements are also reviewed.

Multicenter Studies on Cardiac Magnetic Resonance Perfusion and Delayed Enhancement Imaging

Perfusion and late gadolinium enhancement imaging sequences are commonly used in cardiac magnetic resonance imaging for the diagnosis of myocardial ischemia and infarction. The available literature has expanded from single-center studies to multiple multicenter studies that have established the clinical applicability of both imaging techniques in routine practice. In this article, these multicenter trials and their clinical implications are discussed, as well as the areas of interest that require further study.