Christoph J Jensen

Myocardial scar visualized by cardiovascular magnetic resonance imaging predicts major adverse events in patients with hypertrophic cardiomyopathy.

OBJECTIVES We sought to establish the prognostic value of a comprehensive cardiovascular magnetic resonance (CMR) examination in risk stratification of hypertrophic cardiomyopathy (HCM) patients. BACKGROUND With annual mortality rates ranging between 1% and 5%, depending on patient selection, a small but significant number of HCM patients are at risk for an adverse event. Therefore, the identification of and prophylactic therapy (i.e., defibrillator placement) in patients with HCM who are at risk of dying are imperative. METHODS Two-hundred forty-three consecutive patients with HCM were prospectively enrolled. All patients underwent initial CMR, and 220 were available for clinical follow-up. The mean follow-up time was 1,090 days after CMR. End points were all-cause and cardiac mortality. RESULTS During follow-up 20 of the 220 patients died, and 2 patients survived sudden cardiac death due to adequate implantable cardioverter-defibrillator discharge. Most events (n = 16) occurred for cardiac reasons; the remaining 6 events were related to cancer and accidents. Our data indicate that the presence of scar visualized by CMR yields an odds ratio of 5.47 for all-cause mortality and of 8.01 for cardiac mortality. This might be superior to classic clinical risk factors, because in our dataset the presence of 2 risk factors yields an odds ratio of 3.86 for all-cause and of 2.20 for cardiac mortality, respectively. Multivariable analysis also revealed the presence of late gadolinium enhancement as a good independent predictor of death in HCM patients. CONCLUSIONS Among our population of largely low or asymptomatic HCM patients, the presence of scar indicated by CMR is a good independent predictor of all-cause and cardiac mortality.

Right Ventricular Involvement in Acute Left Ventricular Myocardial Infarction: Prognostic Implications of MRI Findings

OBJECTIVE The purpose of this study was to investigate the prevalence and prognostic importance of the cardiac MRI finding of right ventricular involvement in patients with acute ST-segment elevation myocardial infarction (MI). SUBJECTS AND METHODS Fifty patients (41 men, nine women; mean age, 58 +/- 11 years) with first-ST-segment elevation MI underwent 1.5-T cardiac MRI immediately after successful percutaneous coronary intervention. The cardiac MRI protocol included steady-state free precession cine sequences for functional assessment of the left, right, and both ventricles and inversion recovery FLASH delayed enhancement sequences after contrast administration for the quantification of myocardial damage. The prevalence of right ventricular involvement detected with ECG and echocardiography was compared with the prevalence detected with cardiac MRI, which was the reference standard. Patients underwent follow-up for 32 +/- 8 months. RESULTS Right ventricular involvement was diagnosed with cardiac MRI in 27 patients (54%): 14 of 30 patients (47%) with inferior ST-segment elevation MI and 13 of 20 patients (65%) with anterior ST-segment elevation MI. ECG and echocardiographic findings showed only moderate agreement with cardiac MRI findings in the detection of right ventricular involvement in inferior acute MI (kappa = 0.38). Patients with right ventricular involvement in anterior ST-segment elevation MI had larger infarcts (delayed enhancement, 25.9% +/- 14.5% vs 11.4% +/- 10.1%; p = 0.030), lower left ventricular ejection fraction (34.3% +/- 8.2% vs 45.2% +/- 9.5%; p < 0.015), and lower right ventricular ejection fraction (39.8% +/- 6.6% vs 54.9% +/- 8.8%; p < 0.001) than those without right ventricular involvement. In a multivariate logistic regression model, right ventricular involvement was a strong independent predictor (odds ratio, 15.8; 95% CI, 4-63%) of major cardiac adverse events. CONCLUSION Right ventricular involvement in ST-segment elevation MI is detected more frequently with cardiac MRI than with ECG and echocardiography and is an independent prognostic indicator.

Relationship of T2-Weighted MRI Myocardial Hyperintensity and the Ischemic Area-At-Risk

RATIONALE After acute myocardial infarction (MI), delineating the area-at-risk (AAR) is crucial for measuring how much, if any, ischemic myocardium has been salvaged. T2-weighted MRI is promoted as an excellent method to delineate the AAR. However, the evidence supporting the validity of this method to measure the AAR is indirect, and it has never been validated with direct anatomic measurements. OBJECTIVE To determine whether T2-weighted MRI delineates the AAR. METHODS AND RESULTS Twenty-one canines and 24 patients with acute MI were studied. We compared bright-blood and black-blood T2-weighted MRI with images of the AAR and MI by histopathology in canines and with MI by in vivo delayed-enhancement MRI in canines and patients. Abnormal regions on MRI and pathology were compared by (a) quantitative measurement of the transmural-extent of the abnormality and (b) picture matching of contours. We found no relationship between the transmural-extent of T2-hyperintense regions and that of the AAR (bright-blood-T2: r=0.06, P=0.69; black-blood-T2: r=0.01, P=0.97). Instead, there was a strong correlation with that of infarction (bright-blood-T2: r=0.94, P<0.0001; black-blood-T2: r=0.95, P<0.0001). Additionally, contour analysis demonstrated a fingerprint match of T2-hyperintense regions with the intricate contour of infarcted regions by delayed-enhancement MRI. Similarly, in patients there was a close correspondence between contours of T2-hyperintense and infarcted regions, and the transmural-extent of these regions were highly correlated (bright-blood-T2: r=0.82, P<0.0001; black-blood-T2: r=0.83, P<0.0001). CONCLUSION T2-weighted MRI does not depict the AAR. Accordingly, T2-weighted MRI should not be used to measure myocardial salvage, either to inform patient management decisions or to evaluate novel therapies for acute MI.

Integrated 18F-FDG PET/MR Imaging in the Assessment of Cardiac Masses: A Pilot Study

The objective of the present study was to evaluate whether integrated 18F-FDG PET/MR imaging could improve the diagnostic workup in patients with cardiac masses. Methods: Twenty patients were prospectively assessed using integrated cardiac 18F-FDG PET/MR imaging: 16 patients with cardiac masses of unknown identity and 4 patients with cardiac sarcoma after surgical therapy. All scans were obtained on an integrated 3-T PET/MR device. The MR protocol consisted of half Fourier acquisition single-shot turbo spin-echo sequence, cine, and T2-weighted images as well as T1-weighted images before and after injection of gadobutrol. PET data were acquired simultaneously with the MR scan after injection of 199 ± 58 MBq of 18F-FDG. Patients were prepared with a high-fat, low-carbohydrate diet in a period of 24 h before the examination, and 50 IU/kg of unfractionated heparin were administered intravenously 15 min before 18F-FDG injection. Results: Cardiac masses were diagnosed as follows: metastases, 3; direct tumor infiltration via pulmonary vein, 1; local relapse of primary sarcoma after surgery, 2; Burkitt lymphoma, 1; scar/patch tissue after surgery of primary sarcoma, 2; myxoma, 4; fibroelastoma, 1; caseous calcification of mitral annulus, 3; and thrombus, 3. The maximum standardized uptake value (SUVmax) in malignant lesions was significantly higher than in nonmalignant cases (13.2 ± 6.2 vs. 2.3 ± 1.2, P = 0.0004). When a threshold of 5.2 or greater was used, SUVmax was found to yield 100% sensitivity and 92% specificity for the differentiation between malignant and nonmalignant cases. T2-weighted hyperintensity and contrast enhancement both yielded 100% sensitivity but a weak specificity of 54% and 46%, respectively. Morphologic tumor features as assessed by cine MR imaging yielded 86% sensitivity and 92% specificity. Consent interpretation using all available MR features yielded 100% sensitivity and 92% specificity. A Boolean ‘AND’ combination of an SUVmax of 5.2 or greater with consent MR image interpretation improved sensitivity and specificity to 100%. Conclusion: In selected patients, 18F-FDG PET/MR imaging can improve the noninvasive diagnosis and follow-up of cardiac masses.

Prognostic impact of contrast-enhanced CMR early after acute ST segment elevation myocardial infarction (STEMI) in a regional STEMI network: results of the "Herzinfarktverbund Essen".

Background and Purpose:In acute ST segment elevation myocardial infarction (STEMI), rapid restoration of epicardial coronary blood flow and myocardial perfusion limits infarct size and improves survival. Primary percutaneous coronary intervention (PCI) is superior to systemic fibrinolysis when instantly performed by experienced operators. The “Herzinfarktverbund Essen” (HIVE) is an urban STEMI network supporting direct patient transfer for primary PCI to four PCI centers covering a city area of 600,000 inhabitants. Integrated health care is an optional part of the HIVE allowing for reimbursement of medical innovations such as the evaluation of infarct size and the presence and extent of microvascular obstruction by contrast-enhanced cardiac magnetic resonance (CMR). The aim of this study was to assess the prognostic impact of contrast-enhanced CMR in the patient cohort of a regional STEMI network.Patients and Methods:Within the 1st year (09/2004 to 08/2005) of the HIVE registry, 489 patients with acute myocardial infarction were treated in the four primary PCI centers. In one of the centers, including 143 patients, early CMR imaging using a standardized MR protocol for infarct quantification was performed whenever possible. Patients with hemodynamic instability, emergency coronary artery bypass grafting, resuscitation or death prior to CMR, claustrophobia, and other general contraindications to MRI had to be excluded, leaving 67 patients (54 male; mean age 61 ± 12 years) for final evaluation. CMR was performed 4.5 ± 2.5 days after admission on a 1.5-T MR scanner (Sonata, Siemens Medical Solutions, Erlangen, Germany) including steady-state free precession (SSFP) cine imaging for left ventricular function and single-shot inversion-recovery SSFP imaging for delayed enhancement (DE) and no-reflow (NR) evaluation following injection of 0.2 mmol/kg body weight gadodiamide (Omniscan®, GE Healthcare Buchler, Munich, Germany). NR and DE volumes were calculated from single-shot short-axis stacks taken within the 1st minute following gadodiamide infusion by manual planimetry and summation of disks. 1-year follow-up data (telephone interview) for major adverse cardiac events (MACE: cardiac death, myocardial infarction, and rehospitalization for congestive heart failure, angina pectoris, or revascularization) were available for all patients.Results:DE as a measure of infarct size was 9% ± 7% (range 0–33%) of left ventricular mass (LVM), and mean volume of microvascular obstruction was 2% ± 3% (range 0–17%). Microvascular obstruction was present in 61% of patients. 16 MACE (one cardiac death, one myocardial infarction, and 14 rehospitalizations for congestive heart failure or unstable angina pectoris with PCI in six cases) occurred within the follow-up period of 430 ± 63 days. Patients with MACE had larger infarcts (14% ± 10% vs. 8% ± 6% DE), lower left ventricular ejection fraction (LVEF 44% ± 17% vs. 48% ± 14%) and larger NR (3% ± 5% vs. 2% ± 3%). Using a stepwise logistic regression model, only NR > 0.5% of LVM was independently related to outcome (odds ratio = 3.9, confidence interval 1.1–13.9).Conclusion:NR as a correlate of microvascular obstruction remains independently related to prognosis in patients with acute myocardial infarction treated by PCI.ZusammenfassungHintergrund und Ziel:Infarktgröße und Prognose eines akuten ST-Strecken-Hebungsinfarkt (STEMI) profitieren von einer schnellen Wiedereröffnung des Infarktgefäßes und einer effektiven Wiederherstellung der myokardialen Perfusion. Dabei ist die primäre perkutane Koronarintervention (PCI) der systemischen thrombolytischen Therapie (Lysetherapie) überlegen. Der Herzinfarktverbund Essen (HIVE), ein regionales STEMI-Netzwerk, sichert den ca. 600 000 Einwohnern des Stadtgebiets Essen durch vier Interventionszentren eine leitlinienkonforme, zeitlich optimierte Versorgung von STEMI-Patienten durch primäre PCI. Integrierte Versorgung als Option im HIVE ermöglicht die extrabudgetäre Finanzierung medizinischer Innovationen wie der Beurteilung von Infarktgröße und mikrovaskulärer Obstruktion durch kontrastverstärkte kardiale MRT (CMR). Untersucht werden sollte die prognostische Bedeutung der kontrastverstärkten CMR im Patientenkollektiv eines regionalen STEMI-Netzwerks.Patienten und Methodik:489 Patienten wurden im 1. Jahr (09/2004–08/2005) des HIVE durch die vier Interventionszentren versorgt. Für die 143 Patienten eines Zentrums stand eine standardisierte CMR-Diagnostik zur Infarktquantifizierung zur Verfügung. Nach Ausschluss hämodynamischer Instabilität, notfallmäßiger operativer Myokardrevaskularisation, Reanimation oder Tod vor CMR sowie Klaustrophobie und sonstiger MR-typischer Kontraindikationen verblieben 67 Patienten (54 Männer, mittleres Alter 61 ± 12 Jahre) zur Auswertung. Die CMR erfolgte 4,5 ± 2,5 Tage nach stationärer Aufnahme an einem 1,5-T-MR-Scanner (Sonata, Siemens Medical Solution, Erlangen) mit einem Protokoll aus „steady-state free precession“-(SSFP-)Sequenzen zur Analyse der Ventrikelfunktion und „single-shot inversion-recovery“-SSFP-Sequenzen nach Kontrastmittelgabe zur Quantifizierung von Delayed Enhancement (DE) und No-Reflow (NR) mittels manueller Planimetrie und Scheibchensummation. Für alle Patienten lagen 1-Jahres-Ergebnisse für kardiale Ereignisse (MACE: kardialer Tod, Reinfarkt, Rehospitalisation wegen Herzinsuffizienz, Angina pectoris oder Revaskularisation) vor.Ergebnisse:Bei einer Infarktgröße (DE) von 9% ± 7% (0–33%) der linksventrikulären Masse (LVM) zeigten 61% der Patienten eine mikrovaskuläre Obstruktion (NR) mit 2% ± 3% (0–17%) der LVM. In der Verlaufsbeobachtung von 430 ± 63 Tagen traten 16 kardiale Ereignisse auf (ein kardialer Tod, ein Reinfarkt und 14 Rehospitalisationen wegen Herzinsuffizienz oder instabiler Angina pectoris mit PCI in sechs Fällen). Patienten mit Ereignis zeigten größere Infarkte (14% ± 10% vs. 8% ± 6% DE), eine schlechtere linksventrikuläre Funktion (LVEF 44% ± 17% vs. 48% ± 14%) und mehr mikrovaskuläre Obstruktion (NR 3% ± 5% vs. 2% ± 3%). Nach stufenweiser logistischer Regression verblieb NR > 0,5% LVM als prognostisch unabhängiger Parameter (Odds-Ratio = 3,9, Konfidenzintervall 1,1–13,9).Schlussfolgerung:NR als Korrelat einer mikrovaskulären Obstruktion ist bei PCI-behandelten STEMIPatienten im regionalen STEMI-Netzwerk HIVE ein unabhängiger Marker für eine schlechte Prognose.

Assessment of left ventricular function and mass in dual-source computed tomography coronary angiography: influence of beta-blockers on left ventricular function: comparison to magnetic resonance imaging.

PURPOSE To quantify left ventricular (LV) function and mass (LVM) derived from dual-source computed tomography (DSCT) and the influence of beta-blocker administration compared to cardiac magnetic resonance imaging (CMR). METHODS Thirty-two patients undergoing cardiac DSCT and CMR were included, where of fifteen received metoprolol intravenously before DSCT. LV parameters were calculated by the disc-summation method (DSM) and by a segmented region-growing algorithm (RGA). All data sets were analyzed by two blinded observers. Interobserver agreement was tested by the intraclass correlation coefficient. RESULTS.: 1. Using DSM LV parameters were not statistically different between DSCT and CMR in all patients (DSCT vs. CMR: EF 63+/-8% vs. 64+/-8%, p=0.47; EDV 136+/-36 ml vs. 138+/-35 ml, p=0.66; ESV 52+/-21 ml vs. 52+/-22 ml, p=0.61; SV 83+/-22 ml vs. 87+/-19 ml, p=0.22; CO 5.4+/-0.9l/min vs. 5.7+/-1.2l/min, p=0.09, LVM 132+/-33 g vs. 132+/-33 g, p=0.99). 2. In a subgroup of 15 patients beta-blockade prior to DSCT resulted in a lower ejection fraction (EF), stroke volume (SV), cardiac output (CO) and increase in end systolic volume (ESV) in DSCT (EF 59+/-8% vs. 62+/-9%; SV 73+/-17 ml vs. 81+/-15 ml; CO 5.7+/-1.2l/min vs. 5.0+/-0.8 l/min; ESV 52+/-27 ml vs. 57+/-24 ml, all p<0.05). 3. Analyzing the RGA parameters LV volumes were not significantly different compared to DSM, whereas LVM was higher using RGA (177+/-31 g vs. 132+/-33 g, p<0.05). Interobserver agreement was excellent comparing DSM values with best agreement between RGA calculations. CONCLUSION Left ventricular volumes and mass can reliably be assessed by DSCT compared to CMR. However, beta-blocker administration leads to statistically significant reduced EF, SV and CO, whereas ESV significantly increases. DSCT RGA reliably analyzes LV function, whereas LVM is overestimated compared to DSM.

1-Year Outcomes of Everolimus-Eluting Bioresorbable Scaffolds Versus Everolimus-Eluting Stents: A Propensity-Matched Comparison of the GHOST-EU and XIENCE V USA Registries.

OBJECTIVES The purpose of this study was to compare the 1-year outcomes of the ABSORB everolimus-eluting bioresorbable scaffold (BRS) (Abbott Vascular, Santa Clara, California) and the XIENCE everolimus-eluting stent (EES) (Abbott Vascular) in patients undergoing percutaneous coronary intervention. BACKGROUND Randomized studies of the ABSORB BRS have been performed in selected patient and lesion scenarios. The available registries of the ABSORB BRS reflect real-world practice more closely compared with randomized studies, but most of them are limited by the small sample size and the lack of comparative outcomes versus second-generation drug-eluting stents. METHODS A total of 1,189 consecutive patients treated with ABSORB BRS from the GHOST-EU (Gauging coronary Healing with bioresorbable Scaffolding plaTforms in EUrope) registry and 5,034 patients treated with XIENCE EES from the XIENCE V USA registry were analyzed. Clinical outcomes were compared with the use of propensity-score matching techniques and reported as Kaplan-Meier estimates and absolute risk difference (D) with 95% confidence intervals (CIs). The primary endpoint was a device-oriented composite endpoint, including cardiac death, target vessel myocardial infarction, and ischemia-driven target lesion revascularization at 1-year follow-up. RESULTS After propensity score matching was performed for the entire population (N = 6,223), there were 905 matched pairs of patients. In the matched cohort (N = 1,810), there was no significant difference between ABSORB BRS and XIENCE EES in the risk of device-oriented composite endpoint at 1 year (5.8% vs. 7.6%, D = -1.8 [95% CI: -4.1 to 0.5]; p = 0.12). Cardiac death was less likely to occur in the ABSORB BRS group (0.7% vs. 1.9%, D = -1.2 [95% CI: -2.2 to 0.2]; p = 0.03), and a trend toward a reduction in myocardial infarction was noted with ABSORB BRS compared with XIENCE EES (2.4% vs. 4.0%, D = -1.6 [95% CI: -3.2 to 0.0]; p = 0.07). Conversely, no differences in ischemia-driven target lesion revascularization (4.6% vs. 3.5%, D = 1.1 [95% CI: -0.7 to 2.9]; p = 0.22) and definite or probable device thrombosis (1.8% vs. 1.1%, D = 0.7 [95% CI: -0.4 to 1.8]; p = 0.23) were detected between ABSORB BRS and XIENCE EES. CONCLUSIONS In a contemporary large cohort of patients undergoing percutaneous coronary intervention with ABSORB BRS, the combined rate of ischemic events at 1 year was low and nonsignificantly different compared with matched patients treated with XIENCE EES.

Rapid MR assessment of left ventricular systolic function after acute myocardial infarction using single breath-hold cine imaging with the temporal parallel acquisition technique (TPAT) and 4D guide-point modelling analysis of left ventricular function

We compared four-dimensional guide-point modelling left ventricular function analysis (4DVF) results of cine images in four short-axis and two long-axis slices acquired in a single breath-hold, obtained with the temporal parallel acquisition technique (TPAT), with standard left ventricular function (LVF) analysis results determined by the summation of discs method, in patients who had recently suffered myocardial infarction. Despite wall motion abnormalities, 4DVF yields results for left ventricular ejection fractions and end-diastolic and end-systolic volumes that are in excellent agreement with standard LVF analysis results in these patients. A shortened cardiac magnetic resonance (CMR) protocol using single breath-hold cine image acquisition could facilitate the assessment of left ventricular function soon after myocardial infarction in critically ill patients who are unable to comply with the multiple breath-holds required for standard LVF analysis.

Flow-Independent Dark-blood DeLayed Enhancement (FIDDLE): validation of a novel black blood technique for the diagnosis of myocardial infarction

Background A fundamental component of the CMR exam is contrast enhanced imaging, which is crucial for delineating diseased from normal tissue. Unfortunately, diseased tissue adjacent to vasculature often remains hidden since there is poor contrast between hyperenhanced tissue and bright blood-pool. Conventional black-blood double-IR methods are not a solution; these were not designed to function after contrast administration since they rely on the long native T1 of blood (~2s at 3T) and adequate blood flow within this time period. We introduce a novel Flow-Independent Dark-blood DeLayed Enhancement technique (FIDDLE) that allows visualization of tissue contrast-enhancement while suppressing blood-pool signal. We validate FIDDLE in an animal model of myocardial infarction (MI) and demonstrate feasibility in patients.

Accuracy and variability of right ventricular volumes and mass assessed by dual-source computed tomography: influence of slice orientation in comparison to magnetic resonance imaging

ObjectiveTo evaluate the accuracy and variability of right ventricular (RV) volumes and mass using dual-source computed tomography (DSCT) and the influence of slice orientation in comparison to cardiac magnetic resonance imaging (CMR).MethodsIn 33 patients undergoing cardiac DSCT and CMR, RV parameters were calculated using the short-axis (DSCT, CMR) and axial orientation (DSCT). Intra- and interobserver variability were assessed by Bland-Altman analysis.ResultsShort-axis orientation: RV parameters of the two techniques were not statistically different. Axial orientation: RV volumes and mass were significantly overestimated compared with short-axis parameters whereas EF was similar. The short-axis approach resulted in low variability, although the axial orientation had the least amount of intra- and interobserver variability.ConclusionRV parameters can be more accurately assessed by DSCT compared with CMR using short-axis slice orientation. RV volumes and mass are significantly higher using axial compared with short-axis slices, whereas EF is unaffected. RV parameters derived from both approaches yield high reproducibility.