Michel A. Galjee

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.)

Full pattern of transient apical ballooning of the left ventricle triggered by minor myocardial infarction

A 60-year-old female with a history of hypertension, hypercholesterolaemia, and diabetes mellitus presented two hours after sudden onset of severe persistent chest pain. Electrocardiography showed ST-segment elevation in the inferolateral leads (figure 1A). Coronary angiography revealed a subtotal occlusion of a small left marginal side branch (figure 1B; arrow) and a normal right coronary artery, which could not explain the full typical pattern of apical ballooning as demonstrated by left ventricular angiography (figure 1C and D; arrows).

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.

Cardiac imaging in a symptomatic patient with multiple coronary artery–left ventricular microfistulae

We present the case of a 44-year-old woman with acute coronary syndrome and multiple coronary artery–left ventricular microfistulae at angiography. To evaluate the clinical significance of this observation and to obtain further insights into this rare disease, the patient was further examined with echocardiography and both magnetic resonance imaging and single-photon emission computed tomography, which showed considerable abnormalities.

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.

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.