Chrysanthos Grigoratos

Pericardial agenesis as a rather unusual cause of palpitations: We only see what we know

Cardiac palpitations secondary to ventricular ectopic beats are a frequent clinical indication for a cardiac magnetic resonance (CMR) scan. CMR has already demonstrated its additive diagnostic value in patients with frequent arrhythmias even when echocardiogram appears normal. Hereby, we describe a case of a middle-aged male patient referred to our laboratory because of frequent ventricular ectopic beats and an inconclusive echocardiogram due to an extremely poor acoustic window. A diagnosis of pericardial agenesis (PA) was made explaining patient symptoms and arrhythmias previously detected. Furthermore, at the case report description, PA prevalence, associated cardiac pathologies, and novel CMR diagnostic criteria are being described.

Role of right ventricular involvement in acute myocarditis, assessed by cardiac magnetic resonance

OBJECTIVES Right ventricular (RV) myocarditis (MY) is unrecognized, and its prevalence is unknown. We evaluated the prevalence of RV involvement in acute MY and its association with cardiac events (cardiac death, cardiac arrest, ventricular assist device, transplantation, and appropriate ICD intervention). METHODS We enrolled 151 patients who underwent cardiac magnetic resonance for clinical suspicion of acute MY. The CMR protocol included T2-STIR images for edema detection, post-contrast cine-SSFP for hyperemia detection and late gadolinium enhancement (LGE) images. RESULTS Signs of RV MY were found in 27 patients (17.8%): RV edema at T2-STIR in all of these 27 patients; RV LGE was detected in 11 patients (7.3%). The median RV myocardial segment involved was 2 (1-3). In 13 patients, RV edema was in direct continuity with LV edema of septum and inferior wall or with anterior septum and anterior wall. In 2 patients RV myocarditis was found without any signs of LV involvement. Patients with RV MY had higher RV end-diastolic volume index (p = 0.04) and RV mass index (p = 0.03), and lower RV ejection fraction (p < 0.001) than others. At Kaplan-Meier survival curve patients with RV MY had more cardiac events than those without RV involvement (p = 0.015). RV involvement, anteroseptal LGE and RV LGE were associated with cardiac events. CONCLUSION RV involvement in acute MY is more frequent than previously hypothesized. RV MY was associated with cardiac events.

Late gadolinium enhancement as a predictor of functional recovery, need for defibrillator implantation and prognosis in non-ischemic dilated cardiomyopathy

BACKGROUND Aim of the study was to investigate whether late gadolinium enhancement (LGE) at cardiac magnetic resonance (CMR) predict reverse remodeling (RR) in non-ischemic dilated cardiomyopathy (NIDCM). METHODS Seventy-one NIDCM patients (age 57±14years, 43 males, median left ventricular ejection fraction [LVEF] 35%, [interquartile range 27-41%]) with two CMR scans within 5years were included. RR was defined as ≥10% reduction in left ventricular (LV) end-diastolic volume and ≥10% LVEF increase. The end-point was a composite of all-cause death, cardiovascular hospitalization or appropriate defibrillator discharge. LGE was assessed both visually and as percentage of LV mass (LGE%). RESULTS LGE was present in 42 patients (59%). During the interval between the 2 CMR scans (median 28 [15-44]months), 22 patients (31%) displayed RR. LGE absence predicted RR irrespectively of baseline LV volumes and LVEF. Over a median 42[15-73]-month follow-up, the endpoint occurred in 36 patients (51%). LGE absence was associated with better prognosis (P=0.043), with best quantitative LGE cut-point <7% at ROC analysis (P=0.017), but RR was the strongest prognostic predictor. Among 35 patients with baseline LVEF <35%, 25 (69%) crossed the 35% LVEF threshold. Both LGE absence and quantitative LGE <7% were associated with crossing of the 35% LVEF threshold for defibrillator implantation; patients with either LGE or quantitative LGE≥7% had a worse prognosis. CONCLUSIONS In NIDCM, the absence of LGE at baseline CMR is associated with RR. When baseline LVEF is <35%, LGE absence is associated with more frequent crossing of the 35% LVEF threshold for defibrillator implantation.

Diagnostic and prognostic role of cardiac magnetic resonance in acute myocarditis

Acute myocarditis (AM) is commonly found in everyday clinical practice. Differential diagnosis between various causes of myocardial damage with non-obstructive coronary arteries can be cumbersome for clinician. Moreover, AM may be provoked by a number of different causes and clinical presentation can be heterogeneous with potential overlap going from asymptomatic or subclinical to severe heart failure, arrhythmias, and death. Cardiac magnetic resonance (CMR) over the last decades has proven to be the diagnostic technique of choice since it allows identifying AM with excellent diagnostic accuracy. Latest technological advancement with parametric imaging such as T1 and T2 mapping further increases sensitivity and provides additional help towards a correct diagnosis. CMR however is no longer to be considered as a mere diagnostic tool but also as a powerful source of prognostic information. Scientific evidence has corroborated CMR’s role beyond diagnosis demonstrating how late gadolinium enhancement (LGE) presence is a powerful predictor of cardiac events and how the presence of septal LGE is to be considered of worst prognosis regardless of LGE extension even in patients with preserved global systolic function. CMR should be routinely performed in all patients with AM suspicion since its diagnostic and prognostic role is of paramount important and could modify therapeutic strategy and subsequent clinical decisions.

The multi-modality cardiac imaging approach to cardiac sarcoidosis

BACKGROUND Sarcoidosis is a multisystem granulomatous disease with a neglected but high prevalence of life-threatening cardiac involvement. DISCUSSION The clinical presentation of Cardiac Sarcoidosis (CS) depends upon the location and extent of the granulomatous inflammation, with left ventricular free wall the most common location followed by interventricular septum. The lack of a diagnostic gold standard and the unpredictable risk of sudden cardiac death pose serious challenges for the validation of accurate and effective screening test and the management of the disease. In the last few years advanced cardiac imaging modalities such as Cardiac Magnetic Resonance (CMR) and Positron Emission Tomography (PET) have significantly improved our knowledge and understanding of CS, and have also contributed in risk stratification, assessment of inflammatory activity and therapeutic monitoring of the disease. CONCLUSION In this review, we will discuss the state of the art in the diagnosis of CS focusing on the role and importance of multi-modality cardiac imaging.

Magnetic Resonance Imaging Correlates of Left Bundle Branch Disease in Patients With Nonischemic Cardiomyopathy.

The pathologic correlates of intraventricular conduction delays in patients with nonischemic cardiomyopathy (NIC) have been scarcely investigated. We assessed left ventricular (LV) structural, functional, and tissue abnormalities associated with intraventricular conduction left bundle disease (LBD), including left anterior hemiblock or complete left bundle branch block, in a cohort of patients with NIC submitted to cardiovascular magnetic resonance. Twelve-lead electrocardiogram and cardiovascular magnetic resonance were performed in 196 consecutive patients with NIC. The presence and extent of myocardial fibrosis was evaluated with late gadolinium enhancement (LGE) technique. Compared with normal intraventricular conduction patients, those with LBD were older (66 vs 59 years, p = 0.001), had greater LV volumes (p = 0.035 for end-diastolic and p = 0.009 for end-systolic volume) and mass (p = 0.034), and showed lower LV ejection fraction (33% vs 40%, p = 0.008). LGE was observed more commonly in LBD than in normal intraventricular conduction patients and was more often located in the ventricular septum (p < 0.001). On multivariate analysis, septal LGE was independently associated with a higher likelihood of LBD (odds ratio 6.1, 95% confidence interval 2.9 to 12.7, p < 0.001), even after correction for LV volumes, mass, and ejection fraction. In conclusion, in NIC, the presence of LBD is associated with worse LV remodeling and dysfunction than normal intraventricular conduction. Septal fibrosis yielded a 6-fold greater likelihood of LBD, independently of the degree of LV dilatation and systolic dysfunction.

Shortness of breath on exertion: A (Cardiac Magnetic Resonance) picture is worth a thousand words

This is the case of a 78-year-old male patient that underwent a cardiac magnetic resonance (CMR) due to shortness of breath. An unanticipated diagnosis of a giant pseudoaneurysm with a “guitar-like” appearance was made and patient was sent for urgent ventriculoplasty. CMR offered striking illustrative images allowing for previously unsuspected diagnosis to be made and patients therapeutic management modified. Moreover, in this case, we emphasize the paramount importance of differentiating between true aneurysms, pseudoaneurysms, clefts, and diverticuli since each pathology has completely different management and prognosis that vary from benign to potentially fatal if not immediately treated.