M. A. G. M. Olimulder

The importance of cardiac MRI as a diagnostic tool in viral myocarditis-induced cardiomyopathy

Myocarditis is an acute or chronic inflammatory disease of the myocardium which can be viral, postinfectious immune or primarily organ-specific autoimmune. Clinical manifestations of acute and chronic myocarditis are extremely varied, ranging from mild to severe. Affected patients may recover or develop (dilated) cardiomyopathy (DCM) with life-threatening symptoms including heart failure, conduction disturbances, arrhythmias, cardiogenic shock or sudden cardiac death.The diagnosis of myocarditis is a challenging process and not only because of a diverse presentation; other problems are limited sensitivity of endomyocardial biopsies (EMB) and overlapping symptoms. Furthermore, the diagnosis is not well defined. However, early diagnosis is mandatory to address specific aetiology-directed therapeutic management in myocarditis that influences patient morbidity and mortality.Currently, EMB remains the only way to confirm the presence of a viral genome and other histopathological findings allowing proper treatment to be implemented in cases of myocarditis. Increased recognition of the role of myocardial inflammatory changes has given rise to interest in noninvasive imaging as a diagnostic tool, especially cardiovascular magnetic resonance imaging (CMR). In this review we discuss the current role of CMR in the evaluation of myocarditis-induced inflammatory cardiomyopathies. (Neth Heart J 2009;17:481–6.)

Contrast-enhancement cardiac magnetic resonance imaging beyond the scope of viability

The clinical applications of cardiovascular magnetic resonance imaging with contrast enhancement are expanding. Besides the direct visualisation of viable and non-viable myocardium, this technique is increasingly used in a variety of cardiac disorders to determine the exact aetiology, guide proper treatment, and predict outcome and prognosis. In this review, we discuss the value of cardiovascular magnetic resonance imaging with contrast enhancement in a range of cardiac disorders, in which this technique may provide insights beyond the scope of myocardial viability.

Scar tissue and microvolt T-wave alternans

AbstractnMicrovolt T-wave alternans (MTWA) is an electrocardiographic marker for predicting sudden cardiac death. In this study, we aimed to study the relation between MTWA and scar assessed with cardiac magnetic resonance imaging (CMR) in patients with ischemic cardiomyopathy (ICM) or dilated cardiomyopathy (DCM). Sixty-eight patients with positive or negative MTWA and analysable CMR examination were included. Using CMR and the delayed enhancement technique, left ventricular ejection fraction (LVEF), volumes, wall motion and scar characteristics were assessed. Overall, positive MTWA (nxa0=xa040) was related to male gender (pxa0=xa00.04), lower LVEF (pxa0=xa00.04) and increased left ventricular end-diastolic volume (LVEDV) (pxa0<xa00.01). After multivariate analysis, male gender (pxa0=xa00.01) and lower LVEF remained significant (pxa0=xa00.02). Scar characteristics (presence, transmurality, and scar score) were not related to MTWA (all pxa0>xa00.5). In the patients with ICM (nxa0=xa040) scar was detected in 38. Positive MTWA (nxa0=xa018) was related to higher LVEDV (pxa0=xa00.05). In patients with DCM (nxa0=xa028), scar was detected in 11. Trends were found between positive MTWA (nxa0=xa015) and male gender (pxa0=xa00.10), lower LVEF (pxa0=xa00.10), and higher LVEDV (pxa0=xa00.09). In both subgroups, the presence, transmurality or extent of scar was not related to MTWA (all pxa0>xa00.45). In this small study, neither in patients with ICM or DCM a relation was found between the occurrence of MTWA and the presence, transmurality or extent of myocardial scar. Overall there was a significant relation between heart failure remodeling parameters and positive MTWA.

Prognostic value of microvolt T-wave alternans in a real-world ICD population. Twente ICD Cohort Studie (TICS)

IntroductionSurvival benefit from ICD implantation is relatively low in primary prevention patients. Better patient selection is important to maintain maximum survival benefit while reducing the number of unnecessary implants. Microvolt T-wave alternans (MTWA) is a promising risk marker. In this study, we aimed to evaluate the predictive value of MTWA in ICD patients.Methods and resultsThis study was a substudy of the Twente ICD Cohort Study (TICS). Patients with ischaemic or non-ischaemic left ventricular dysfunction who received an ICD following current ESC guidelines were eligible for inclusion. Exercise-MTWA was performed and classified as non-negative or negative. The primary endpoint was the composite of mortality and appropriate shock therapy. Analysis was performed in 134 patients (81xa0% male, mean age 62xa0years, mean ejection fraction 26.5xa0%). MTWA was non-negative in 64xa0%. There was no relation between non-negative MTWA testing and mortality and/or appropriate shock therapy (all p-values >0.15). Due to clinical conditions, 24xa0% were ineligible for testing. These patients experienced the highest risk for mortality (pu2009<u20090.01).ConclusionNon-negative MTWA testing did not predict mortality and/or appropriate shock therapy. Furthermore, MTWA testing is not feasible in a large percentage of patients. These ineligible patients experience the highest risk for mortality.

Relationship between Framingham Risk Score and Left Ventricular Remodeling after Successful Primary Percutaneous Coronary Intervention in Patients with First Myocardial Infarction and Single Vessel Disease

Background: Limited data is available on the potential value of estimated cardiovascular event risk for prediction of left ventricular (LV) remodeling and size of infarcted tissue after ST-elevation myocardial infarction (STEMI). Methods: Therefore, we assessed in a consecutive series of patients with first STEMI, successful primary percutaneous coronary intervention (PCI), and single-vessel disease the potential relationship between the Framingham Risk Score and parameters of both LV remodeling and infarct tissue characteristics, as determined with contrast-enhanced (CE) cardiovascular magnetic resonance (CMR) 6 months after the index event. Parameters of LV remodeling were end-diastolic and end-systolic volumes, ejection fraction, and wall motion score index; infarct tissue characteristics comprised core, peri, and total infarct size, and transmural extent. Results: A total of 25 patients (21 men, 56 ± 10 years) were studied, and the mean Framingham Risk Score was 14.1 ± 5.8%. There was a significant relation between Framingham Risk Score and multiple parameters of LV remodeling: LV ejection fraction, end-diastolic volume, end-systolic volume, and wall motion score index after 6 months (r=-0.55-0.76; p=0.000 for all). Framingham Risk Score showed no relation with various infarct tissue characteristics (ns). Male gender was the only component of the Framingham Risk Score that correlated individually with a few parameters of LV remodeling: LV end-diastolic volume and end-systolic volume (p=0.000 for both). Conclusion: In a series of consecutive patients with first STEMI, successful primary PCI, and single-vessel coronary artery disease, we observed a significant relation between the Framingham Risk Score and several CMRbased parameters of LV remodeling. The results of our small hypothesis-generating study underline the supremacy of multifactorial risk scores as tools for prediction of unfavorable cardiovascular outcome. Additionally, the data support the hypothesis that there might be a future role for a novel and specific multifactorial risk score in predicting unfavorable LV remodeling, which finally could trigger risk-adjusted preventive measures.

Chronic fatigue syndrome in women assessed with combined cardiac magnetic resonance imaging

ObjectiveIn chronic fatigue syndrome (CFS), only axa0few imaging and histopathological studies have previously assessed either cardiac dimensions/function or myocardial tissue, suggesting smaller left ventricular (LV) dimensions, LV wall motion abnormalities and occasionally viral persistence that may lead to cardiomyopathy. The present study with cardiac magnetic resonance (CMR) imaging is the first to use axa0contrast-enhanced approach to assess cardiac involvement, including tissue characterisation of the LV wall.MethodsCMR measurements of 12xa0female CFS patients were compared with data of 36 age-matched, healthy female controls. With cine imaging, LV volumes, ejection fraction (EF), mass, and wall motion abnormalities were assessed. T2-weighted images were analysed for increased signal intensity, reflecting oedema (i.u2009e. inflammation). In addition, the presence of contrast enhancement, reflecting fibrosis (i.u2009e. myocardial damage), was analysed.ResultsWhen comparing CFS patients and healthy controls, LVEF (57.9xa0± 4.3u2009% vs. 63.7xa0± 3.7u2009%; pxa0< 0.01), end-diastolic diameter (44xa0± 3.7xa0mm vs. 49xa0± 3.7xa0mm; pxa0< 0.01), as well as body surface area corrected LV end-diastolic volume (77.5xa0± 6.2xa0ml/m2 vs. 86.0xa0± 9.3xa0ml/m2; pxa0< 0.01), stroke volume (44.9xa0± 4.5xa0ml/m2 vs. 54.9xa0± 6.3xa0ml/m2; pxa0< 0.001), and mass (39.8xa0± 6.5xa0g/m2 vs. 49.6xa0± 7.1xa0g/m2; pxa0= 0.02) were significantly lower in patients. Wall motion abnormalities were observed in four patients and contrast enhancement (fibrosis) in three; none of the controls showed wall motion abnormalities or contrast enhancement. None of the patients or controls showed increased signal intensity on the T2-weighted images.ConclusionIn patients with CFS, CMR demonstrated lower LV dimensions and axa0mildly reduced LV function. The presence of myocardial fibrosis in some CFS patients suggests that CMR assessment of cardiac involvement is warranted as part of the scientific exploration, which may imply serial non-invasive examinations.

The Use of Contrast-Enhancement Cardiovascular Magnetic Resonance Imaging in Cardiomyopathies

The clinical applications of cardiovascular magnetic resonance imaging (CMR), are expanding as the result of the development in hardware, pulse sequence and the ability of post-processing techniques. As the result of the flexibility of CMR to use different pulsesequences, with or without the use of Gadolinium, CMR has developed as a powerful tool for clinical relevant tissue characterization. CMR in combination with the contrastenhancement (CE) technique was initially developed to distinguish viable from non-viable myocardium following myocardial infarction. Nowadays, CE-CMR is increasingly used for tissue characterization in ischemic as well as non-ischemic cardiomyopathies to determine the exact etiology, guide proper treatment, and predict outcome and prognosis. In this chapter, we would like to discuss and illustrate the value of CE-CMR imaging in various cardiomyopathies.

Preservation of the relation between infarct characteristics and left ventricular remodeling following successful early revascularization for myocardial infarction: an observational study with contrast-enhanced cardiovascular MRI

Left ventricular (LV) remodeling following myocardial infarction (MI) is the result of complex interactions between various factors, including presence or absence of early revascularization. Cardiovascular Magnetic Resonance (CMR) imaging with contrast-enhancement (CE) permits assessment of myocardial tissue and LV dimensions and function, but the impact of early revascularization on the relationship between infarct tissue characteristics and LV remodeling has not yet been investigated.

Infarct tissue characteristics of patients with versus without early revascularization for acute myocardial infarction: a contrast enhancement cardiovascular magnetic resonance imaging study

Histopathological studies have suggested that early revascularization for acute myocardial infarction (MI) limits the size, transmural extent, and homogeneity of myocardial necrosis. However, the long-term effect of early revascularization on infarct tissue characteristics is largely unknown. Cardiovascular magnetic resonance (CMR) imaging with contrast enhancement (CE) allows non-invasive examination of infarct tissue characteristics and left ventricular (LV) dimensions and function in one examination. A total of 69 patients, referred for cardiac evaluation for various clinical reasons, were examined with CE-CMR >1 month (median 6, range 1–213) post-acute MI. We compared patients with (n = 33) versus without (n = 36) successful early revascularization for acute MI. Cine-CMR measurements included the LV end-diastolic and end-systolic volumes (ESV), LV ejection fraction (LVEF, %), and wall motion score index (WMSI). CE images were analyzed for core, peri, and total infarct size (%), and for the number of transmural segments. In our population, patients with successful early revascularization had better LVEFs (46 ± 16 vs. 34 ± 14%; P 0.05 for all comparisons); only transmural extent (P = 0.07) and infarct age (P = 0.06) tended to be larger in patients without early revascularization. CMR wall motion abnormalities are significantly better after revascularization; these differences are particularly marked later after infarction. The difference in scar size is more subtle and does not reach significance in this study.