Constanze Merten

Use of cardiovascular magnetic resonance for risk stratification in chronic heart failure: prognostic value of late gadolinium enhancement in patients with non-ischaemic dilated cardiomyopathy

Objective Owing to its variable clinical course, risk stratification is of paramount importance in non-ischaemic dilated cardiomyopathy (DCM). The goal of this study was to investigate the long-term prognostic significance of late gadolinium enhancement (LGE) as detected by contrast-enhanced cardiovascular magnetic resonance (CE-CMR) in patients with DCM. Design Observational cohort study. Setting University hospital. Patients 184 consecutive patients with DCM. Measurements CE-CMR was performed on a 1.5 T clinical scanner. Presence, extent and patterns of LGE were determined by two independent observers. Outcome measures Patients were followed for the composite end point of cardiac death, hospitalisation for decompensated heart failure, or appropriate implantable cardioverter defibrillator discharge for a mean±SEM of 685±30 days. Results LGE was detected in 72/184 patients (39%) and was associated with a lower left ventricular (LV) ejection fraction (31% (20.9–42.2%) vs 44% (33.1–50.9%), p<0.001), higher LV end-diastolic volume index (133 (116–161) ml/m2 vs 109 (92.7–137.6) ml/m2, p<0.001) and higher LV mass (80 (67.1–94.8) g/m2 vs 65.8 (55.2–82.9) g/m2, p<0.001). Patients in whom LGE was present were more likely to experience the composite end point (15/72 vs 6/112, p=0.002). Receiver operating characteristic curve analysis revealed a LGE of >4.4% of LV mass as optimal discriminator for the composite end point. When entered into multivariate Cox regression analysis, LGE retained its independent predictive value, yielding an associated HR of 3.4 (95% CI 1.26 to 9). Conclusion The presence of LGE in this large DCM patient cohort is associated with pronounced LV remodelling, functional impairment and an adverse outcome. Further research is necessary to determine whether these findings will aid the clinical management of DCM patients.

Prevalence of Different Gadolinium Enhancement Patterns in Patients After Heart Transplantation

OBJECTIVES Transplant coronary artery disease (TCAD) limits long-term survival after heart transplantation (HTX). We hypothesized that contrast-enhanced magnetic resonance imaging (CE-MRI) detects chronic TCAD-related myocardial infarctions (MIs), even in patients with angiographically classified mild TCAD. BACKGROUND Coronary angiography underestimates the TCAD-degree, subsequently missing occluded small coronary arteries and resulting MI. CE-MRI as a noninvasive imaging technique identifies infarct-typical MI and myocardial fibrosis. METHODS CE-MRI (gadolinium: 0.2 mmol/kg/bw) was performed in 53 HTX patients on a 1.5-T MRI scanner (Philips, Best, the Netherlands). Infarct-typical CE-MRI areas were classified as: I=<or=25%, II=25% to 50%, III=50% to 75% and IV=>or=75%. Infarct-atypical forms were divided into diffuse, spotted, intramural, and infero-septal. Coronary angiography results were reviewed qualitatively with the TCAD score (TCAD I=mild evidence; II=30% to 75%, III=>or=75% stenosis). Groups were compared with analysis of variance (statistically significant p values<or=0.05). RESULTS Infarct-typical CE-MRI was already present in TCAD I+II, increased significantly between groups (I=23%, II=33%, III=84%, p<0.05), and involved only single coronary territories in TCAD I but multiple vessels in TCAD II+III. Infarct-atypical CE-MRI was equally distributed across all TCAD stages (I=50% vs. II=58% vs. III=42%, p=NS) without relation to a coronary territory. Patients with only infarct-atypical CE-MRI were associated with significantly better left ventricular function compared with patients with infarct-typical or combined CE-MRI patterns (ejection fraction=66+/-6% vs. 45+/-16% or 60+/-13%; end-diastolic volume=139+/-32 ml vs. 148+/-27 ml or 164+/-43 ml; end-systolic volume=47+/-15 ml vs. 81+/-27 ml or 69+/-38 ml, p<or=0.05). CONCLUSIONS CE-MRI allows identification of silent MI in apparently event-free HTX patients and is able to disclose myocardial fibrosis already in patients with absent or mild angiographic TCAD. CE-MRI might be helpful to establish an earlier TCAD diagnosis and to intensify medical treatment. Future studies are necessary to test prognostic implications associated with CE-MRI patterns.

Relative role of NT-pro BNP and cardiac troponin T at 96 hours for estimation of infarct size and left ventricular function after acute myocardial infarction.

BACKGROUND N-terminal brain-type natriuretic peptide (NT-pro BNP) and cardiac troponin T (cTnT) after acute myocardial infarction (AMI) have proven useful for prediction of prognosis and may be valuable for assessment of left ventricular function and infarct size. The aim of the present study was to correlate infarct size and left ventricular function determined by cine and late gadolinium enhanced CMR with plasma levels of TNT and NT-pro BNP levels after AMI. METHODS We studied 44 patients (pts) with first ST- and non-ST-segment elevation myocardial infarction (STEMI=23 pts.,NSTEMI=21 pts.). We measured NT-pro BNP and cTnT on a single occasion at 96 hours after onset of symptoms. RESULTS There was a moderate inverse correlation between NT-pro BNP and LV-EF in STEMI (r=-0.67, p=0.0009) and NSTEMI (r=-0.85, p<0.0001). Likewise, cTnT showed a significant inverse correlation with LV-EF in STEMI (r=-0.54, p=0.014) but not in NSTEMI. With cTnT there was a strong linear correlation with infarct mass and relative infarct size in STEMI (r=0.92, p<0.0001) and NSTEMI (r=0.59, p<0.0093). NT-pro BNP demonstrated a good relationship with infarct mass (r=0.79, p<0.0001) and relative infarct size (r=0.75, p<0.0001) in STEMI, but not in NSTEMI. CONCLUSION A single NT-pro BNP and cTnT value at 96 hours after onset of symptoms proved useful for estimation of LV-EF and infarct size. In direct comparison, NT-pro BNP disclosed a better performance for estimation of LV-EF whereas cTnT was superior for assessment of infarct mass and relative infarct size, suggesting an implementation of a dual marker strategy for diagnostic and prognostic work-up.

Aortic Regurgitation and Left Ventricular Remodeling After Transcatheter Aortic Valve Implantation A Serial Cardiac Magnetic Resonance Imaging Study

Background—Aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) has been associated with poor outcomes, but little is known about how it evolves over time. We evaluated left ventricular (LV) function, remodeling, and the occurrence and evolution of AR after TAVI by using cardiac MRI. Methods and Results—Forty-three patients treated with transfemoral TAVI underwent cardiac MRI 1 week and 6 months after TAVI. LV volumes and function were assessed by using standard cine MRI sequences. Phase-contrast imaging was performed to quantify the degree of AR. The mean age of the evaluated patients was 80 years, and 65% of patients were women. At baseline MRI, the median LV ejection fraction was 58.1%, which improved significantly at follow-up to 63.4% (P<0.0001). A significant reduction of LV end-diastolic volume (149.7±41.4–140.1±43.9 mL; P=0.014) and of LV mass (156.3±32.8–142.7±39.3 g; P<0.001) was observed. Over time, aortic regurgitant fraction increased slightly but significantly from 5.2% to 7.8% (P=0.04). Subgroup analysis revealed that significant changes of LV ejection fraction, volumes, and mass only occurred in patients with no or mild AR at baseline MRI, whereas those parameters remained unchanged in patients with AR more than or equal to grade II. Conclusions—By using cardiac MRI in patients with TAVI, a significant improvement of LV function, volume, and mass can be documented. Mild-to-moderate AR is commonly seen, and AR shows a small increase over time. More-than-mild AR seems to prevent LV functional and structural recovery after TAVI.

A Rare Form of Midventricular Tako-Tsubo After Emotional Stress Followed up With Magnetic Resonance Imaging

A 62-year-old woman was admitted to our emergency room with acute onset of typical chest pain that started during an emotionally stressful psychotherapeutic treatment. The patient’s history revealed no cardiovascular risk factors and the initial ECG was unspecific. Blood tests performed concomitantly revealed mild elevation of cardiac troponin T and creatinine kinase levels. Consequently, the patient was referred to our catheter laboratory for treatment of a suspected acute coronary syndrome. Coronary luminography …

Acute phase reaction to gadolinium-DTPA in dialysis patients

BACKGROUND Several late sequelae of the administration of gadolinium (Gd)-containing MRI contrast agents have been described in patients with advanced renal failure. In an observational series, we found a remarkable frequency of peracute reactions after administration of Gd-DTPA used for cardiovascular evaluation before renal transplantation. METHODS In a 26-month observational period, 13 of 136 haemodialyzed or CAPD patients exhibited onset of fever, chills and nausea within hours after administration of Gd-DTPA peracute. A minority showed persistent cessation of residual diuresis. We performed blood cultures in most patients and evaluated white blood cell (WBC) counts, eosinophils, CRP, heart rate and blood pressure. RESULTS Within an average of 12 h (range 12-36 h) after Gd administration, the 13 patients (9 males, 4 females; median age 61 years, range 47-79) developed consistent symptomatology with fever (median 39.0 degrees C, range 37.5-39.5), chills, malaise, hypotension, vomiting, dyspnoea-initially raising suspicion of septicaemia. Subsequent blood cultures on bacterial contamination of the injected product remained negative throughout; bacterial or endotoxin contamination of the reagent was excluded. Steroids were tried in the first two patients without a noticeable effect. In all subsequent patients, symptoms were attenuated during the first 5 h dialysis (F60HPS with 280 ml/min blood flow) and disappeared within 72 h. CRP levels remained markedly elevated up to 14 days. Lymphopenia was seen in all patients, and polymorphic neutrophils (PMN) remained normal. Two polyuric patients developed persistent anuria. After a median of 16 months, none of these patients developed nephrogenic systemic fibrosis. CONCLUSION This series with unusually severe acute phase reactions was caused by one specific preparation. Such peracute reactions may be relevant for the so-far largely unresolved pathogenesis of the skin reaction to some Gd products in end-stage renal disease (ESRD) patients. It remains unresolved whether the reaction observed with Gd-DTPA do in principle also occur with other Gd reagents.

1113 MAPSE and TAPSE measured by MRI correlate with left and right ventricular ejection fraction and NTproBNP in patients with in dilated cardiomyopathy

Background MRI is the current reference-standard for quantification of systolic left and right ventricular (LV/RV-) function. However, the conventional three-dimensional quantitative assessment of LV and RV-ejection fraction (EF), is time consuming and operator-dependant. The mitral/tricuspid annular plane systolic excursion (MAPSE/TAPSE) towards the apex, on the other hand, can be easily and promptly quantified on MR-images and has been previously shown to, correlate with LVand RVEF and with the prognosis of patients with heart failure in echocardiographic studies. The aim of this study was to compare the value of MAPSE and TAPSE to the conventional LVEF and RVEF assessment and to the well established biomarker NTproBNP in heart failure.

Cardiac involvement in hypereosinophilic syndromes detected by cardiac magnetic resonance imaging

Background The Hypereosinophilic Syndromes (HES) are a heterogeneous group of rare diseases characterized by blood hypereosinophilia and eosinophil-related organ damage with the Churg-Strauss syndrome as the vasculitic form of disease. Cardiac involvement was reported in 20-50% in earlier series. Yet, with improved diagnostic methods, the frequency of cardiac involvement is expected to be even higher. We therefore sought to evaluate the frequency and different forms of presentation of cardiac manifestations of HES using cardiac MRI.

Long-term prognostic significance of late gadolinium enhancement in non-ischemic dilated cardiomyopathy: further evidence from 184 patients

Introduction Non-ischemic dilated cardiomyopathy (DCM) is a major cause for cardiovascular morbidity and premature mortality. Due to the variable clinical course, risk stratification is of paramount importance in these patients to identify those most likely to benefit from aggressive treatment strategies. There is emerging evidence for the prognostic significance of late gadolinium enhancement (LGE) in patients with DCM.

Visualization of a coronary fistula with pulmonary drainage.

A 57-year-old Turkish woman with known arteriovenous coronary drainage who had had a history of a nonmalignant hemorrhagic pleural effusion in the past presented again with unclear weight loss and fatigue lasting for a couple of weeks. A computer tomographic scan revealed an unclear tumorous process near the left anterior coronary artery. On the MRI there was clear evidence of an aneurysmatic left anterior coronary artery in connection with a circular and defined partly thrombosed supra-cardiac mass (diameter 4.8 cm, Fig. 1 A and B), which was fed via the left coronary artery and seemed to be connected to the right pulmonary artery without invasion into mediastinal organs. Cardiac catheterization confirmed the coronary fistula to the right pulmonary artery but greatly underestimated the size of the partly thrombosed mass (Fig. 1 C and D). To prevent future symptoms and taking into consideration the size of the partly thrombosed supra-cardiac structure seen on MRI and the former history of hemorrhagic pleural effusion, it was decided to excise the thrombosed supracardiac mass and to close the coronary fistula. The surgeon confirmed the diagnosis, histology of the mass showed a thrombus with no evidence of malignancy. Patient recovery was without complications and on inquiry the patient no longer reported about her initial symptoms. Coronary fistulas draining into the pulmonary arteries are extremely rare and most often closed even in asymptomatic patients to prevent future complications like large left-to-right shunt, heart failure or infective endocarditis.