Matteo Gravina

Right ventricular assessment by cardiac magnetic resonance in Takotsubo cardiomyopathy

We would thank the colleagues for their kind interest in our work. We actually do agree that cardiac magnetic resonance (CMR) can be a useful tool for the assessment of the right ventricular (RV) function, in particular, of regional wall motion abnormalities and ejection fraction (EF), where echocardiography often fails. Different patterns of contraction may be found during the acute phase of Takotsubo cardiomyopathy (TTC), including apical, midventricular, basal, and biventricular ballooning. Eitel et al. [1] observed in their study that RV involvement may be present in one third of patients with TTC and reported an association with longer hospitalization, increased levels of heart failure markers, and older age. Consequently, biventricular ballooning may portend a more severe prognosis [2], when compared with isolated left ventricular (LV) involvement. Such findings have been confirmed also in other studies [3,4]. Cardiac magnetic resonance may improve our ability in assessing RV function and identifying the pattern of biventricular ballooning. The case 1 described in our paper [5] is a complex clinical case, where CMR shows its potential in the diagnostic workup of acute cardiac syndromes. The pattern of edema distribution and late gadolinium enhancementmay be useful in the differential diagnosis in acute cardiac setting. In this case, we found RV involvement, with anteroapical segment akinesis. The RVEF was normal (58%) with normal indexed volumes (indexed end-diastolic volume, 61 mL/m; indexed end-systolic volume, 25 mL/m). Our hypothesis is that the LV apical akinesis with hypokinesis of the remaining segments was because of myocardial stunning, probably secondary to microvascular dysfunction in the left anterior descending (LAD) coronary territory. In this case, the LAD was long, extending over the apex and supplying the apical region (so-called wrap around LAD), probably also the anteroapical RV segment. This may explain the regional and localized akinesis of the RV with normal EF. In case 2, instead, the clinical and instrumental data were suggestive for a TTC, further confirmed at CMR on the basis of typical localized edema to midapical LV segments, in the absence of late enhancement. The RV function was normal, without regional wall motion abnormalities (EF, 60%; indexed end-diastolic volume, 47 mL/m; indexed endsystolic volume, 19 mL/m). The assessment of RV abnormalities, when present, could therefore allow an early diagnosis of TTC [6]. We thus believe that a systematic evaluation of RV function by echocardiogram is recommended for an optimal management of patients with TTC [3].

Left ventricular fibroma: What cardiac magnetic resonance imaging may add?

Cardiac fibromas are benign connective tissue tumors derived fromfibroblaststhat occur predominantlyin children andconstitutethesec-ond most common type (after the rhabdomyoma) of primary cardiactumoroccurringinthepediatricagegroup[1].Mostaredetectedinchil-dren younger than 10 years, and about one-third are diagnosed in in-fants younger than 1 year. Males and females appear to be equallyaffected. Cardiac fibromas are typically large tumors ranging from 3 to10cmin diameter.They usuallyoccurwithintheventricularmyocardi-um and much more frequently within the anterior free wall of the leftventricular wall or the inter-ventricular septum than in the posteriorleft ventricular wall or right ventricle [2]. Approximately 70% of fibro-mas are symptomatic, causing mechanical interference with intra-cardiac flow (usually with bulky intra-cavitary left ventricular or rightventricular tumors), ventricular systolic function (usually with largeintra-myocardial left ventricular tumors), or conduction disturbances(usually with tumors arising in the inter-ventricular septum). Themost common clinical manifestations are congestive heart failure(21%), ventricular tachy-arrhythmias (13%) and atypical chest pain(3.5%)[3].Suddencardiacdeathoccursin14%ofpatientswithfibromas,typically in infants. Cardiac fibromas do not show spontaneous regres-sion and surgical resection generally remains the treatment of choicefor these tumors in children.A 51-year old man (C.R.) was referred to the emergency room fortypical dizziness, sweating and vomit. Electrocardiogram showedsinus rhythm with Q wave in D1, D2, aVL and from V4 to V6 with Twave inversion from V4 to V6. Blood pressure at admission was150/100mmHg,troponin-Ivalueswerenormal.Thepatientwasthere-fore admitted to the acute cardiac care unit with a diagnosis ofsuspected acute coronary syndrome. Echocardiography showed, in offaxis views, a heterogeneous oval mass of the left ventricular lateralwall (5 × 3 cm) without involvement of mitral valve apparatus(Fig. 1a–b). Coronary angiography was normal.Cardiacmagneticresonanceimaging(cMRI),performedwitha1.5-Tmagnet(PhilipsAchieva)andacardiacphased-arraymulti-coil,showedin the mid-apical left ventricular lateral wall and inferior-lateral wallsegments a nodular intra-myocardial formation (5.3 × 3.6 cm) iso-intense in the sequences T1-TSE (turbo spin echo Fig. 2 left) and inCINE-TFE sequences (turbo field echo Fig. 2 right; Videos 1–3), hypo-intense in the sequences T2-SPIRR BB (black-blood — T2-short-tau-in-version recovery Fig. 3a–b; Video 4). In the sequences for the dynamicstudy of first pass a minimal and inhomogeneous enhancement aftergadolinium was evident (Fig. 4 left; Video 5). In late enhancementPSIR-TFE (phase sensitive inversion recovery turbo field echo) se-quences, the nodular formation was hyper-intense (Fig. 5; Video 6).A diagnosis of cardiac fibroma was therefore based on such cMRIfindings (iso-intense mass in cine“bright blood” balanced fast field-echo images and in T1, hypo-intense in T2-STIR, minimal enhance-ment with gadolinium at the dynamicfirst pass and hyper-intensein PSIR sequences). The patient did not undergo endo-myocardialbiopsy and surgical excision because of the large dimension of themass.Thecardiac fibromaisararebenigntumoroftheheart.Thefirsttoolto assess such lesion is echocardiography, which can provide informa-tion on the tumors extent and on ventricular and valvular function.cMRImayimproveandhelpthediagnosisbythetissuecharacterizationof the lesion. cMRI allows the identification of cardiac and para-cardiacsuspicious masses; a precise definition of the extension and the rela-tionships as well as possible involvement of vascular and mediastinalstructures, the infiltration of the pericardium and relationships withnormal intra-cardiac structures may be obtained. Finally, the signalcharacteristics and contrast are useful for tissue characterization of

Early recurrence of atrial fibrillation after catheter ablation with left atrial fibrosis identified at cardiac magnetic resonance by late gadolinium enhancement

In patients with atrial fibrillation (AF), extensive atrial tissue fibrosis identified by delayed enhancement magnetic resonance imaging has been associated with early recurrence of AF after catheter ablation. We present a case of a patient with extensive atrial fibrosis and AF recurrence. The study of late gadolinium enhancement with cardiac magnetic resonance imaging in patients with AF could be a valuable noninvasive tool for the selection of patients suitable for successful catheter ablation.

Don’t stop at first glance: pulmonary artery angiosarcoma mimicking chronic thromboembolic pulmonary hypertension

We report the case of an incomplete diagnosis of chronic thromboembolic pulmonary hypertension, with relevant prognostic implications, missing the presence of a primary pulmonary artery angiosarcoma. After the late neoplasm diagnosis, the patient, treated for months with riociguat, was considered inoperable and died soon after. This case highlights the need to manage patients with suspected pulmonary arterial hypertension by expert referral centers with specific and multi-professional expertise (heart and thoracic imaging) in order to avoid incomplete or delayed diagnoses.

Incidental Extracardiac Findings and Their Characterization on Cardiac MRI

Background Cardiac magnetic resonance imaging (cMRI) has recently emerged as a new noninvasive imaging modality that offers superior structural and functional assessment of the heart. cMRI benefits from a large field of view but, consequently, may capture incidental extracardiac findings (IEFs). We aimed to evaluate the frequency and significance of IEFs reported from clinically indicated cMRI scans. Methods 742 consecutive patients (402 males and 340 females) referred to the Cardiac Magnetic Resonance Center of our University Hospital between January 2015 and December 2016 for clinically indicated cMRI were retrospectively enrolled for the evaluation of IEF prevalence and relevance. The median age of the subjects was 51 years (range: 5–85 years). Results A significant number of patients who underwent cMRI had incidental and clinically significant IEFs (2% of the population, 11.4% of cases). cMRI allowed a correct diagnosis in 116/131 cases with a diagnostic accuracy value of 88.5%. Conclusions IEFs on cMRI are not uncommon and lesions with mild or no clinical significance represent the most frequent findings. cMRI can characterize incidental findings with high accuracy in most cases.

Prolonged QT and myocardium recovery after primary PCI: a cMRI study.

The presence of viable stunned myocardium recovering after primary angioplasty is not easy to identify in the early phase of acute myocardial infarction (AMI) by noninvasive bed‐side methods. We therefore aimed to assess whether a simple electrocardiogram parameter may be of help in identifying the presence of stunned viable myocardium recovering after reperfusion with primary angioplasty.