Scott D. Flamm

Coronary Anomalies Incidence, Pathophysiology, and Clinical Relevance

Coronary artery anomalies are some of the most confusing, neglected topics in cardiology. Although the medical community and general public are increasingly aware that coronary anomalies can be fatal (typically in young, previously “healthy” athletes),1 the reasons for the sudden fatal event and the frequency with which it occurs are generally unclear. To promote a less casual approach to this subject, we review some basic, substantive, and methodological questions about coronary anomalies. According to the literature, coronary anomalies affect ≈1% of the general population; this percentage is derived from cineangiograms performed for suspected obstructive disease.2–4⇓⇓ Necropsies yield an even lower incidence: in 18 950 necropsies, Alexander and Griffith5 observed only 54 coronary anomalies (0.3%). Unfortunately, these studies are limited by entry biases and a lack of clear diagnostic criteria. Angelini and coworkers6 propose that, because of its substantial variability, normal and anomalous coronary anatomy should be characterized. Accordingly, an anomaly should be defined as any coronary pattern with a feature (number of ostia, proximal course, termination, etc) “rarely” encountered in the general population. By determining the incidence of anatomic variants in a large population, acceptable definitions of normal and anomalous anatomy could be established and the clinical importance of anomalous variants ascertained. Ideally, this effort would be overseen by an expert ad hoc committee and would generate a rational paradigm, perhaps along the lines of Table 1⇓. Previous authors have proposed a preemptive anatomo-clinical classification that considers anomalies as “major” or “minor” (ie, incapable of causing relevant clinical consequences)2,7–10⇓⇓⇓⇓; in view of our inadequate knowledge of the pathophysiology and clinical consequences of coronary anomalies, this scheme seems inappropriate.11 View this table: Table 1108690. Classification of Coronary Anomalies Observed in (Normal) Human Hearts View this table: Table 1A108690. (Continued) Additional studies examining the incidence of coronary …

Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

Cardiac dysfunction resulting from exposure to cancer therapeutics was first recognized in the 1960s, with the widespread introduction of anthracyclines into the oncologic therapeutic armamentarium. Heart failure (HF) associated with anthracyclines was then recognized as an important side effect. As a result, physicians learned to limit their doses to avoid cardiac dysfunction. Several strategies have been used over the past decades to detect it. Two of them evolved over time to be very useful: endomyocardial biopsies and monitoring of left ven- tricular (LV) ejection fraction (LVEF) by cardiac imaging. Examination of endomyocardial biopsies proved to be the most sensitive and spe- cific parameter for the identification of anthracycline-induced LV dysfunction and became the gold standard in the 1970s. However, the interest in endomyocardial biopsy has diminished over time because of the reduction in the cumulative dosages used to treat ma- lignancies, the invasive nature of the procedure, and the remarkable progress made in noninvasive cardiac imaging. The noninvasive evaluation of LVEF has gained importance, and notwithstanding the limitations of the techniques used for its calculation, has emerged as the most widely used strategy for monitoring the changes in cardiac function, both during and after the administration of potentially car- diotoxic cancer treatment.

MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial.

AIMS To determine in a multicentre, multivendor trial the diagnostic performance for perfusion-cardiac magnetic resonance (perfusion-CMR) in comparison with coronary X-ray angiography (CXA) and single-photon emission computed tomography (SPECT). METHODS AND RESULTS Of 241 eligible patients from 18 centres, 234 were randomly dosed with 0.01, 0.025, 0.05, 0.075, or 0.1 mmol/kg Gd-DTPA-BMA (Omniscantrade mark, GE-Healthcare) per stress (0.42 mg/kg adenosine) and rest perfusion study. Coronary artery disease (CAD) was defined as diameter stenosis > or =50% on quantitative CXA. Five CMR and eight SPECT studies (of 225 complete studies) were excluded from analyses due to inadequate quality (three blinded readers scored per modality). The comparison of CMR vs. SPECT was based on receiver operating characteristic (ROC) analysis. Perfusion-CMR at the optimal CM dose (0.1 mmol/kg) had similar performance as SPECT, if only the SPECT studies of the 42 patients with this dose were considered [area under ROC curve (AUC): 0.86 +/- 0.06 vs. 0.75 +/- 0.09 for SPECT, P = 0.12]; however, diagnostic performance of perfusion-CMR was better vs. the entire SPECT population (AUC: 0.67 +/- 0.05, n = 212, P = 0.013). CONCLUSIONS In this multicentre, multivendor trial, ROC analyses suggest perfusion-CMR as a valuable alternative to SPECT for CAD detection showing equal performance in the head-to-head comparison. Comparing perfusion-CMR with the entire SPECT population suggests CMR superiority over SPECT, which warrants further evaluation in larger trials.

Standardized cardiovascular magnetic resonance imaging (CMR) protocols, society for cardiovascular magnetic resonance: board of trustees task force on standardized protocols

AbstractIndex1. General techniques 1.1. Stress and safety equipment1.2. Left ventricular (LV) structure and function module1.3. Right ventricular (RV) structure and function module1.4. Gadolinium dosing module.1.5. First pass perfusion1.6. Late gadolinium enhancement (LGE) 2. Disease specific protocols2.1. Ischemic heart disease 2.1.1. Acute myocardial infarction (MI)2.1.2. Chronic ischemic heart disease and viability2.1.3. Dobutamine stress2.1.4. Adenosine stress perfusion 2.2. Angiography: 2.2.1. Peripheral magnetic resonance angiography (MRA)2.2.2. Thoracic MRA2.2.3. Anomalous coronary arteries2.2.4. Pulmonary vein evaluation 2.3. Other 2.3.1. Non-ischemic cardiomyopathy2.3.2. Arrhythmogenic right ventricular cardiomyopathy (ARVC)2.3.3. Congenital heart disease2.3.4. Valvular heart disease2.3.5. Pericardial disease2.3.6. Masses

ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents

Robert A. Harrington, MD, FACC, FAHA, Chair Jeffrey L. Anderson, MD, FACC, FAHA[††][1] Eric R. Bates, MD, FACC Charles R. Bridges, MD, MPH, FACC, FAHA Mark J. Eisenberg, MD, MPH, FACC, FAHA Victor A. Ferrari, MD, FACC, FAHA Cindy L. Grines, MD, FACC[††][1] Mark A. Hlatky, MD, FACC,

Standardized image interpretation and post processing in cardiovascular magnetic resonance: Society for Cardiovascular Magnetic Resonance (SCMR) Board of Trustees Task Force on Standardized Post Processing

With mounting data on its accuracy and prognostic value, cardiovascular magnetic resonance (CMR) is becoming an increasingly important diagnostic tool with growing utility in clinical routine. Given its versatility and wide range of quantitative parameters, however, agreement on specific standards for the interpretation and post-processing of CMR studies is required to ensure consistent quality and reproducibility of CMR reports. This document addresses this need by providing consensus recommendations developed by the Task Force for Post Processing of the Society for Cardiovascular MR (SCMR). The aim of the task force is to recommend requirements and standards for image interpretation and post processing enabling qualitative and quantitative evaluation of CMR images. Furthermore, pitfalls of CMR image analysis are discussed where appropriate.

Safety of Magnetic Resonance Imaging in Patients With Cardiovascular Devices An American Heart Association Scientific Statement From the Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Council on Cardiovascular Radiology and Intervention: Endorsed by the American College of Cardiology Foundation, the North American Society for Cardiac Imaging, and the Society for Cardiovascular Magnetic Resonance

Advances in magnetic resonance (MR) imaging over the past 2 decades have led to MR becoming an increasingly attractive imaging modality. With the growing number of patients treated with permanent implanted or temporary cardiovascular devices, it is becoming ever more important to clarify safety issues in regard to the performance of MR examinations in patients with these devices. Extensive, although not complete, ex vivo, animal, and clinical data are available from which to generate recommendations regarding the safe performance of MR examination in patients with cardiovascular devices, as well as to ascertain caveats and contraindications regarding MR examination for such patients. Safe MR imaging involves a careful initial patient screening, accurate determination of the permanent implanted or temporary cardiovascular device and its properties, a thoughtful analysis of the risks and benefits of performing the examination at that time, and, when indicated, appropriate physician management and supervision. This scientific statement is intended to summarize and clarify issues regarding the safety of MR imaging in patients with cardiovascular devices.

Expert Consensus DocumentACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents

American College of Cardiology Foundation Representative; †North merican Society for Cardiovascular Imaging Representative; ‡Society or Cardiovascular Magnetic Resonance Representative; §American cademy of Pediatrics; American College of Radiology Representaive; ¶ACCF Task Force Liaison; #American Heart Association epresentative. **The findings and conclusions in this expert consensus ocument reflect ACCF policy and do not necessarily represent the iews of the Uniformed Services University of the Health Sciences, the .S. Department of Defense, or the U.S. Government, by whom Dr.

Standardized cardiovascular magnetic resonance (CMR) protocols 2013 update.

This document is an update to the 2008 publication of the Society for Cardiovascular Magnetic Resonance (SCMR) Board of Trustees Task Force on Standardized Protocols. Since the time of the original publication, 3 additional task forces (Reporting, Post-Processing, and Congenital Heart Disease) have published documents that should be referred to in conjunction with the present document. The section on general principles and techniques has been expanded as more of the techniques common to CMR have been standardized. There is still a great deal of development in the area of tissue characterization/mapping, so these protocols have been in general left as optional. The authors hope that this document continues to standardize and simplify the patient-based approach to clinical CMR. It will be updated at regular intervals as the field of CMR advances.

Expert consensus for multimodality imaging evaluation of adult patients during and after cancer therapy: a report from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

### A. Definition, classification, and mechanisms of toxicity Cardiac dysfunction resulting from exposure to cancer therapeutics was first recognized in the 1960s, with the widespread introduction of anthracyclines into the oncological therapeutic armamentarium.1 Heart failure (HF) associated with anthracyclines was then recognized as an important side effect. As a result, physicians learned to limit their doses to avoid cardiac dysfunction.2 Several strategies have been used over the past decades to detect it. Two of them evolved over time to be very useful: endomyocardial biopsies and monitoring of left ventricular (LV) ejection fraction (LVEF) by cardiac imaging. Examination of endomyocardial biopsies proved to be the most sensitive and specific parameter for the identification of anthracycline-induced LV dysfunction and became the gold standard in the 1970s. However, the interest in endomyocardial biopsy has diminished over time because of the reduction in the cumulative dosages used to treat malignancies, the invasive nature of the procedure, and the remarkable progress made in non-invasive cardiac imaging. The non-invasive evaluation of LVEF has gained importance, and notwithstanding the limitations of the techniques used for its calculation, has emerged as the most widely used strategy for monitoring the changes in cardiac function, both during and after the administration of potentially cardiotoxic cancer treatment.3–5 The timing of LV dysfunction can vary among agents. In the case of anthracyclines, the damage occurs immediately after the exposure;6 for others, the time frame between drug administration and detectable cardiac dysfunction appears to be more variable. Nevertheless, the heart has significant cardiac reserve, and the expression of damage in the form of alterations in systolic or diastolic parameters may not be overt until a substantial amount of cardiac reserve has been exhausted. Thus, cardiac damage may not become apparent until years or even decades after receiving the cardiotoxic treatment. This is particularly applicable to …