Hassan Abdel-Aty

Reference values for left and right ventricular trabeculation and non-compacted myocardium

BACKGROUND Since the differentiation between physiological and pathological trabeculation is challenging, we assessed its distribution in a reference population of selected healthy volunteers. METHODS We studied 117 subjects (58 males) stratified into age tertiles and by gender. Cardiovascular magnetic resonance images were acquired using a standard SSFP-sequence. Left and right ventricular (LV/RV) end-diastolic (EDV), end-systolic (ESV) and trabeculated volumes indexed to the body surface area as well as ejection fraction (EF) were quantified in short-axis views. The maximum non-compacted-to-compacted (NC/C) ratio was measured in long-axis views. RESULTS The trabeculated volumes were significantly larger in men than in women and decreased with age. The correlation between both was moderate (r=0.46; p<0.001). LV trabeculated volume was positively associated with EDV and ESV (r=0.74; r=0.59; both p<0.001) and negatively with EF (r=-0.27; p<0.005). It was no independent predictor for EF. The maximum NC/C ratio was >2.3 in 46.2% and >2.5 in 37.6% of the subjects, which is regarded as abnormal in current literature. The fraction of subjects with a maximum NC/C ratio >2.3 and the mean maximum NC/C ratio differed significantly between gender but not between age groups. An increasing NC/C ratio was associated with a significant decrease in EF (r=-0.21; p<0.05). CONCLUSION A considerable amount of healthy volunteers fulfils the current diagnostic criteria of LV noncompaction with female subjects showing a higher fraction of false-positive results than males. LV trabeculated volume is more pronounced in young subjects and declines with age. The use of age- and gender-specific reference values as provided in this study may facilitate the delineation of physiological and pathological findings.

Epicardial Adipose Tissue Is Associated with Plaque Burden and Composition and Provides Incremental Value for the Prediction of Cardiac Outcome. A Clinical Cardiac Computed Tomography Angiography Study

Objectives We sought to investigate the association of epicardial adipose tissue (eCAT) volume with plaque burden, circulating biomarkers and cardiac outcomes in patients with intermediate risk for coronary artery disease (CAD). Methods and Results 177 consecutive outpatients at intermediate risk for CAD and completed biomarker analysis including high-sensitive Troponin T (hs-TnT) and hs-CRP underwent 256-slice cardiac computed tomography angiography (CCTA) between June 2008 and October 2011. Patients with lumen narrowing ≥50% exhibited significantly higher eCAT volume than patients without any CAD or lumen narrowing <50% (median (interquartile range, IQR): 108 (73–167) cm3 vs. 119 (82–196) cm3, p = 0.04). Multivariate regression analysis demonstrated an independent association eCAT volume with plaque burden by number of lesions (R2 = 0.22, rpartial = 0.29, p = 0.026) and CAD severity by lumen narrowing (R2 = 0.22, rpartial = 0.23, p = 0.038) after adjustment for age, diabetes mellitus, hyperlidipemia, body-mass-index (BMI), hs-CRP and hs-TnT. Univariate Cox proportional hazards regression analysis identified a significant association for both increased eCAT volume and maximal lumen narrowing with all cardiac events. Multivariate Cox proportional hazards regression analysis revealed an independent association of increased eCAT volume with all cardiac events after adjustment for age, >3 risk factors, presence of CAD, hs-CRP and hs-TnT. Conclusion Epicardial adipose tissue volume is independently associated with plaque burden and maximum luminal narrowing by CCTA and may serve as an independent predictor for cardiac outcomes in patients at intermediate risk for CAD.

Comparison of parameters for left ventricular volumes and function between echocardiography and cardiovascular magnetic resonance in a large group of cardiac patients

Background Left ventricular (LV) volumes and function are of paramount importance for the correct diagnosis finding, cardiovascular risk stratification and assessment of future cardiac events as well as for therapeutic guidance. In clinical routine, echocardiography (EC) is the method of choice due to its wide availability and its straight-forward examination. However, cardiovascular magnetic resonance (CMR) is the gold-standard for the evaluation of cardiac volumes and function. In this study we compared the LV volumes and functional parameters obtained by EC with CMR results in a large group of cardiac patients. Methods

Prevalence of cardiac morphological and functional alterations in systemic lupus erythematosus patients with a low disease activity.

Background Cardiac involvement in systemic lupus erythematosus (SLE) is a common complication and is associated with a considerable morbidity and mortality in these patients. As affected individuals often present with subclinical or nonspecific symptoms the betimes confirmation of cardiac manifestations is challenging. Cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) is the current gold-standard for non-invasive tissue characterization as well as for the evaluation of systolic and diastolic function. In this study we assessed the cardiac morphology and function in SLE patients with low disease activity. Methods We studied twenty-nine SLE patients (3 male, 26 female) fulfilling the SLE diagnostic criteria of the American College of Rheumatology and compared them to thirty agematched healthy volunteers. All patients were in a stable clinical condition and only patients with a low disease activity (SLEDAI Index < 5) were included. All of them received an individually optimized medication. CMR images were acquired on a 1.5 T whole-body MRI (Achieva, Philips Healthcare, Best, The Netherlands) using a 32-element cardiac phased-array coil. Short and long axis views were obtained applying a standard clinical steady-state free-precession sequence and LGE CMR imaging was performed (Gadolinium-DTPA 0.2 mmol/kg body weight, Magnevist, Schering, Berlin, Germany) in 27 patients. Left and right ventricular (LV, RV) end-diastolic and end-systolic volumes (EDV, ESV), stroke volume (SV), ejection fraction (EF) as well as the mitral/tricuspid annular plane systolic excursion (M/TAPSE) and LV wall mass were measured. Results

Cardiac Hydatidosis A Follow-Up With Cardiovascular Magnetic Resonance

We present a case of a 38-year–old Turkish patient with a previously diagnosed cardiac hydatidosis, which is a parasitic infection most commonly induced by Echinococcus granulosus and with only rare cardiac involvement (0.5%– 2.0%). In 1998, the patient survived a cardiogenic shock caused by the rupture of 1 hydatic cyst and concomitant cardiac tamponade. Postsurgery, the patient was treated pharmacologically with albendazole. In 2006, a cardiac magnetic resonance and a computed tomography examination showed recurrent myocardial cystic formations (Figure 1). Disadvantageously, the largest cyst was located in the inferior wall of the left ventricle in close vicinity to the mitral valvular apparatus. An interdisciplinary conference came to the conclusion to neither treat the patient surgically, because of an extensive myocardial and perivalvular defect, nor pharmacologically with albendazole, because even anthelmintic medical intervention would have borne the risk of weakening the cystic wall and causing wall rupture. From 2006 to 2012, noninvasive clinical follow-up showed no major complications. In the last evaluation in 2012, the patient was asymptomatic, the ECG showed Q waves in the inferior wall (Figure 2), and the echocardiogram revealed the presence of the lesion, without clear demonstration of its morphology, however (Figure 3). In contrast, cardiac magnetic resonance illustrated morphological features of the cyst in greater detail and gave clear evidence of a cyst transformation from a World Health Organization (Table) type1 CE2, an active cyst with multivesicular, multiseptated, rosette-like or honeycomb-like aspect (Figure 4A through 4F), into a CE3B cyst, a transitional cyst with daughter cysts in a solid matrix (Figure 4G through 4J). Rapidly, only within 8 weeks, the lesion showed a marked cyst regression into an almost inactive CE4 form. Moreover, late gadolinium enhancement images showed a fibrous capsule surrounding the lesion, which might represent an inflammatory response contributing to the favorable evolution of the disease (Figure 5). With this report, we demonstrate a follow-up of a patient with cardiac hydatidosis in whom neither the published previously surgical treatment nor an anthelminthic therapy2 could be performed, but who nevertheless showed cystic

Assessment of left and right ventricular trabeculation and non-compacted myocardium in a large selected healthy reference population

Background The differentiation of left ventricular non-compaction (LVNC) from physiological trabeculation is still challenging as it may be overdiagnosed by current criteria. Therefore, we sought to investigate the effect of age and gender on both the LV and RV trabeculation in a large group of proven healthy subjects to provide adjusted reference values. Furthermore, we examined the correlation between the amount of non-compacted myocardium and the global ventricular function. Methods We studied a selected reference population of 117 healthy volunteers (58 male, 59 female) stratified into age tertiles (group 1 = 20-34 years, group 2 = 35-50 years, group 3 > 50 years) and by gender. Cardiac diseases were meticulously ruled out by taken medical history, physical examination, electrocardiography, oral glucose tolerance test and lab tests. Cardiovascular magnetic resonance images were acquired in a 1.5T whole-body MRI (Achieva, Philips Heathcare) using a standard SSFP sequence. Enddiastolic (EDV), end-systolic (ESV), stroke and trabeculated volumes as well as ejection fraction (EF) were quantified in short-axis views from base to apex. Volumes were indexed to body surface area (BSA). The noncompacted-to-compacted (NC/C)-ratio was measured in 4-chamber view. Results The left and right ventricular (LV/RV) trabeculated volumes were significantly larger in men than in women and decreased with age (LV: s = -0.1262, R 2 = 0.04450, p 2.3 in 28 of 117 subjects (23.9%) and > 2.5 in 26 of 117 subjects (22.2%), which is regarded as pathologic in current literature. The fraction of subjects with a NC/C ratio > 2.3 differed significantly between age but not between gender groups (p < 0.05, p = n.s). Likewise the mean NC/C ratio showed no significant differences between gender groups (1.9 ± 0.7 vs. 2.1 ± 0.8, p = n.s.) whereas subjects of the first tertile showed significant higher values than the volunteers of the second tertile (2.2 ± 0.8 vs. 1.8 ± 0.6, p < 0.05). An increasing NC/C

Discrepancies in ejection fraction measurements between echocardiography and cardiovascular magnetic resonance lead to different clinical classifications

Background The left ventricular (LV) ejection fraction (EF) is a crucial parameter for the diagnosis and therapeutic management of heart failure. Due to its wide availability and its comprehensive use, echocardiography (EC) is the standard method for the assessment of the LV function in clinical routine. As fundamental clinical decisions, e.g. initiation of medical heart failure therapy or implantation of an ICD, are based on the EF, methods like the Simpsons or Teichholz formulas have been developed for its quantification in EC. Cardiovascular magnetic resonance (CMR) is the gold-standard for the evaluation of cardiac function but comparative data between CMR and EC is scarce. Therefore, we sought to compare the agreement of functional EC and CMR measurements in a daily routine clinical setting.

Comparison of the amount of affected myocardium quantified by late gadolinium enhancement and the degree of myocardial necrosis measured by cardiac troponin T in patients with myocarditis

Background The diagnosis of myocarditis is challenging due to its often subclinical or unspecific course. Yet, myocardial focal late gadolinium enhancement (LGE) patterns, which represent focal myocardial necrosis and imply negative clinical outcomes, can be assessed by cardiovascular magnetic resonance (CMR). Serologically, not only focal but also diffuse myocardial cell necrosis can be highly accurately detected by the cardiac-specific release of cardiac troponin T (cTnT) which has shown to have also prognostic value in these patients. However, data regarding the relationship between the focal necrosis size visualized by LGE-CMR and the serum marker of myocardial cell damage measured by cTnT are scarce. Therefore, we sought to investigate the relationship between focal LGE-CMR patterns, applying different standard deviations (std) of the LGE signal intensity, and serum levels of cTnT. Methods We retrospectively included 44 myocarditis patients (39 male, 5 female). CMR images were acquired on a 1.5 T whole-body MRI (Achieva, Philips Healthcare) and LGE imaging was performed (Gadolinium-DTPA (Magnevist, Bayer Schering Pharma), 0.2 mmol/kg body weight) using an inversion-recovery SSFP sequence. Short-axis LGE images were analyzed with a dedicated scar software (cmr42, Circle Cardiovascular Imaging) which allowed the measurement of the myocardial mass affected by focal LGE applying different std of contrast enhancement (2, 3, 4, 5, 6, 8, 10 std). Values for cTnT or high-sensitive cardiac troponin T (hscTnT) where applicable were retrieved from the patients’ records. Correlation analysis was performed using Pearson’s r or Spearman’s rho where applicable (p-value<0.05 was regarded significant).

Bio-imaging: late gadolinium enhancement in dilated cardiomyopathy and its relation to novel biomarkers of fibrosis and remodeling

Background Focal myocardial fibrosis is frequently observed in dilated cardiomyopathy (DCM) and predicts future major adverse cardiovascular events and patient outcome. However, the pathogenesis of fibrosis in DCM remains poorly understood. Novel serum biomarkers of fibrosis such as Endoglin have been recently identified as a trigger of myocardial fibrosis in heart failure. Accordingly, we sought to investigate the relationship between myocardial tissue fibrosis as identified by noninvasive late gadolinium contrast enhancement (LGE) CMR and serum biomarkers of fibrosis/ remodeling in a cohort of DCM patients.

Characteristics and clinical associations of late gadolinium enhanced cardiovascular magnetic tesonance in lamin A/C, cardiac troponin T and myosin binding protein C gene mutation related cardiomyopathies

Background Dilated cardiomyopathy (DCM) is a common cause of heart failure (HF) and the most common diagnosis in patients referred for cardiac transplantation. Genetic studies in DCM have identified mutations in over 30 genes. To date, there is only scarce data regarding the interdependencies between the various genotypes and their impact on cardiac morphology and myocardial tissue appearance. Since non-contrast cardiac magnetic resonance (CMR) is considered the reference method for morpho-functional analysis and late gadolinium enhanced (LGE) CMR method of choice for myocardial tissue assessment, we sought to investigate the characteristics of LGE in asymptomatic and symptomatic carriers of known cardiomyopathy mutations and their clinical associations.