The utility of novel STE parameters in echocardiographic assessment of single ventricle after Fontan palliation.

Background and aims of the study A functionally single ventricle (FSV) refers to a group of congenital heart defects that are not amenable for biventricular correction. The Fontan operation is utilized as surgical treatment for most of FSV patients. The evaluation of FSV function is extremely difficult due to its unique pathophysiology. This study aimed to explore the efficacy of speckle tracking echocardiography (STE) parameters measured at rest and during exercise for comprehensive assessment of univentricular heart. METHODS: We enrolled 37 patients with a functionally single ventricle after the Fontan operation, hospitalized in the Department of Congenital Heart Defects between years 2019 and 2021.The echocardiographic stress tests were performed in the Echocardiography Laboratory of the Congenital Heart Defects Department. The study was conducted on a bicycle ergometer in a semi-recumbent position. The parameters obtained by speckle tracking echocardiography (STE): the longitudinal strain of the FSV free wall (Ɛ) and the longitudinal strain of myocardial layers: subendocardial, medial and subepicardial were analyzed. A transmural longitudinal strain gradient (TG) was calculated as the difference between longitudinal deformation of the subendocardial and subepicardial layers. Current results of cardiac magnetic resonance imaging (CMR) and cardio-pulmonary test (CPET) were also incorporated. Demographic data, past interventions, pharmacological treatment and comorbidities were extracted from medical records. RESULTS: Ɛ at rest and during exercise were not related to the parameters of physical capacity obtained on CPET nor to the CMR results. The transmural strain gradient was dependent on physical performance parameter- peak oxygen uptake- and related to the FSV ejection fraction calculated by magnetic resonance imaging. CONCLUSIONS: The transmural strain gradient and FSV free wall strain are readily measurable and suitable for evaluating single ventricle function. The TG is positively correlated with peak oxygen uptake during the cardiopulmonary test and with the ejection fraction derived from cardiac magnetic resonance imaging. The applicability of these findings in patients undergoing the Fontan procedure warrants further exploration.

Impact of Cardiac Magnetic Resonance on the Diagnosis of Left Ventricular Noncompaction-A 15-Year Experience.

The aim of this study was to assess the impact of cardiac magnetic resonance (CMR) on the diagnosis in patients with known or suspected left ventricular noncompaction (LVNC). We retrospectively reviewed the medical charts of 12,811 consecutive patients who had CMR studies between 2008 and 2022 in a large tertiary center. We included patients referred for CMR because of known or suspected LVNC. The study sample consisted of 333 patients, 193 (58.0%) male, median age 39.0 (26.8-51.0) years. Among 74 patients fulfilling the echocardiographic LVNC criteria, the diagnosis was confirmed in 54 (73.0%) cases. In 259 patients with ultrasound-based suspicion of LVNC, CMR led to an LVNC diagnosis in 82 (31.7%) patients. In both groups, CMR led to a new diagnosis in 89 cases (10 (13.5%) and 79 (30.5%)). A quantity of 38 (5.4%) patients were diagnosed with dilated cardiomyopathy, 11 (1.4%) patients were diagnosed with hypertrophic cardiomyopathy, and 21 (4.1%) patients were diagnosed with unclassified cardiomyopathy. In four patients with suspected LVNC, a myocardial trabeculation was a secondary result of dilatation due to coronary heart disease. In five cases, valvular heart disease was found. Four patients were diagnosed with athlete's heart. Other diagnoses (arrhythmogenic right ventricular cardiomyopathy, peripartum cardiomyopathy, hypokinetic non-dilated cardiomyopathy, sarcoidosis, amyloidosis, and ventricular septum defect) were found in six patients. CMR is a valuable tool in the evaluation of cardiac muscle and in differentiating LVNC and other cardiac diseases.

Magnetic resonance imaging in patients with implanted cardiac electrotherapy devices: a statement from experts of the Polish Medical Society of Radiology, the Polish Society of Cardiology, and the Polish Society of Electroradiology.

The year 2023 marks 60 years since the first pacemaker was implanted in Poland. The number of implantable cardiac electrotherapy devices (CIEDs), including pacemakers, cardioverter-defibrillators, and resynchronization therapy systems, has been systematically increasing in the subsequent decades. It is estimated that nearly 500,000 Poles have an implanted cardiac electrotherapy device, making optimal diagnostic imaging with the use of magnetic resonance imaging (MRI) a clinically and epidemiologically important issue. MRI has become a gold diagnostic standard in many disease states. In this situation, it is believed that 50-70% of patients who have a cardiac electrotherapy device may have indications for an MRI examination later in life. For many years, an implanted cardiac electrotherapy device was considered a definite contraindication to MRI. However, MRI has become possible in most patients with CIED if certain procedures and precautions are followed. In these guidelines, we describe the basic rules that should be followed in order to perform a safe MRI examination in patients with different CIEDs. Despite all the risks and organizational factors described in the text, it seems that for many MRI departments, MRI in patients with CIEDs is achievable and should be implemented immediately. A second important issue is the need for dedicated financial support for these procedures from public health insurance.

Strategy to optimize PeriproCeduraL AnticOagulation in structural transseptal interventions: Design and rationale of the STOP CLOT trial.

BACKGROUND: Both transcatheter edge-to-edge repair (TEER) of mitral regurgitation or left atrial appendage closure (LAAC) require periprocedural anticoagulation with unfractionated heparin (UFH) that is administered either before or immediately after transseptal puncture (TSP). The optimal timing of UFH administration (before or after TSP) is unknown. The Strategy To Optimize PeriproCeduraL AnticOagulation in Structural Transseptal Interventions trial (STOP CLOT Trial) was designed to determine if early anticoagulation is effective in reducing ischemic complications without increasing the risk of periprocedural bleeding. METHODS: The STOP CLOT trial is a multicenter, prospective, double-blind, placebo-controlled, randomized trial. A total of 410 patients scheduled for TEER or LAAC will be randomized 1:1 either early UFH administration (iv. bolus of 100 units/kg UFH or placebo, given after obtaining femoral vein access and at least 5 minutes prior to the start of the TSP) or late UFH administration (iv. bolus of 100 units/kg UFH or placebo given immediately after TSP). Prespecified preliminary statistical analysis will be performed after complete follow-up of the first 196 randomized subjects. To ensure blinding, a study nurse responsible for randomization and UFH/placebo preparation is not involved in the care of the patients enrolled into the study. The primary study endpoint is a composite of (1) major adverse cardiac and cerebrovascular events (death, stroke, TIA, myocardial infarction, or peripheral embolization) within 30 days post-procedure, (2) intraprocedural fresh thrombus formation in the right or left atrium as assessed with periprocedural transesophageal echocardiography, or (3) occurrence of new ischemic lesions (diameter ≥4 mm) on brain magnetic resonance imaging performed 2 to 5 days after the procedure. The safety endpoint is the occurrence of moderate or severe bleeding complications during the index hospitalization. CONCLUSIONS: Protocols of periprocedural anticoagulation administration during structural interventions have never been tested in a randomized clinical trial. The Stop Clot trial may help reach consensus on the optimal timing of initiation of periprocedural anticoagulation. CLINICAL TRIALS REGISTRATION NUMBER: The study protocol is registered at ClinicalTrials.gov, identifier NCT05305612.

Diagnostic Yield of Cardiac Magnetic Resonance in Athletes with and without Features of the Athlete's Heart and Suspected Structural Heart Disease.

Cardiac magnetic resonance (CMR) is a second-line imaging test in cardiology. Balanced enlargement of heart chambers called athlete's heart (AH) is a part of physiological adaptation to regular physical activity. The aim of this study was to evaluate the diagnostic utility of CMR in athletes with suspected structural heart disease (SHD) and to analyse the relation between the coexistence of AH and SHD. We wanted to assess whether the presence of AH phenotype could be considered as a sign of a healthy heart less prone to development of SHD. This retrospective, single centre study included 154 consecutive athletes (57 non-amateur, all sports categories, 87% male, mean age 34 ± 12 years) referred for CMR because of suspected SHD. The suspicion was based on existing guidelines including electrocardiographic and/or echocardiographic changes suggestive of abnormality but without a formal diagnosis. CMR permitted establishment of a new diagnosis in 66 patients (42%). The main diagnoses included myocardial fibrosis typical for prior myocarditis (n = 21), hypertrophic cardiomyopathy (n = 17, including 6 apical forms), other cardiomyopathies (n = 10) and prior myocardial infarction (n = 6). Athlete's heart was diagnosed in 59 athletes (38%). The presence of pathologic late gadolinium enhancement (LGE) was found in 41 patients (27%) and was not higher in athletes without AH (32% vs. 19%, p = 0.08). Junction-point LGE was more prevalent in patients with AH phenotype (22% vs. 9%, p = 0.02). Patients without AH were not more likely to be diagnosed with SHD than those with AH (49% vs. 32%, p = 0.05). Based on the results of CMR and other tests, three patients (2%) were referred for ICD implantation for the primary prevention of sudden cardiac death with one patient experiencing adequate intervention during follow-up. The inclusion of CMR into the diagnostic process leads to a new diagnosis in many athletes with suspicion of SHD and equivocal routine tests. Athletes with AH pattern are equally likely to be diagnosed with SHD in comparison to those without AH phenotype. This shows that the development of AH and SHD can occur in parallel, which makes differential diagnosis in this group of patients more challenging.

Providing music therapy for people with dementia in an acute mental health setting.

As global figures for dementia are set to rise significantly, there has been a shift towards using non-pharmacological interventions such as music therapy to enhance the quality of life for people with the condition. Research into music therapy interventions for this patient group in acute mental health inpatient settings, however, is limited. This article describes a service evaluation that explored whether group music therapy was effective for people with dementia in such settings. Open group music therapy sessions were hosted weekly in two acute wards and the researchers examined the social and behavioural outcomes of participants pre and post-intervention. The results indicated that music therapy significantly improved patient outcomes following participation. The outcome measure developed for this service evaluation was found to be a reliable tool for measuring the effectiveness of music therapy on patient outcomes.

Role of cardiac magnetic resonance in heart failure of initially unknown etiology: A 10-year observational study.

BACKGROUND: The heart failure (HF) population is estimated to be 64.3 million people worldwide and continues to grow. Identifying the underlying cause of HF is crucial for patient management and prognosis. AIMS: We sought to evaluate the role of cardiac magnetic resonance (CMR) imaging to identify the etiology of HF and to evaluate the impact of CMR on diagnosis and patient management. METHODS: We retrospectively reviewed the medical charts of 8630 consecutive patients referred for CMR in a large tertiary center between 2008 and 2017 (10 years). In this study, we only included patients referred for CMR due to HF of unknown etiology whose diagnostic workup had not revealed suspicion of any specific cardiac disease leading to HF. We also analyzed changes in patient management that were guided by the CMR findings, which were defined as changes in treatment and/or the necessity of further tests. RESULTS: The study sample included 243 patients: 173 (71.2%) patients were male, and the mean (SD) age was 44.0 (15.2) years. All patients underwent contrast-enhanced CMR. Late gadolinium enhancement (LGE) was detected in 74.9% of cases. In 94 patients (38.7%), CMR led to a new diagnosis. In 41 patients (16.9%), patient management was changed by CMR. The latter group comprised patients with coronary artery disease, amyloidosis, valvular disease, and cardiomyopathies other than dilated, namely hypertrophic, restrictive, and left ventricular noncompaction. CONCLUSIONS: Our study strongly suggests that CMR imaging is a valuable tool for determining the etiology of HF and affects patient management.

Early Myocardial Changes in Patients with Rheumatoid Arthritis without Known Cardiovascular Diseases-A Comprehensive Cardiac Magnetic Resonance Study.

Clinically silent cardiac disease is frequently observed in rheumatoid arthritis (RA), and cardiovascular complications are the leading cause of mortality in RA. We sought to evaluate the myocardium of young RA patients without known cardiac disease using cardiac magnetic resonance (CMR), including T1/T2 mapping sequences. Eighteen RA patients (median age 41 years, 83% females) mainly with low disease activity or in remission and without any known cardiovascular disease were prospectively included to undergo CMR. A control group consisted of 10 sex- and age-matched patients without RA or any known structural cardiovascular disease. Heart chambers size and left/right ventricular systolic function were similar in patients with RA and controls. Signs of myocardial oedema were present in up to 39% of RA patients, including T2 time above cut-off value in 7 patients (39%) in comparison to none of the controls (p = 0.003) and T2 signal intensity ratio above the cut-off value in 6 patients (33%) and in none of the controls (p = 0.06). Extracellular volume was similar in both groups signifying a lack of diffuse fibrosis in studied group of RA patients. There were also no signs of late gadolinium enhancement (LGE) in either group except for one patient with RA who was found to have prior silent myocardial infarction. No correlation was found between markers of disease severity and markers of oedema observed on CMR in patients with RA. Nevertheless, patients with increased T2 time (≥50 ms) were more likely to have X-ray erosions (p = 0.02) and a longer duration between symptom onset and diagnosis (p = 0.02). Finally, there were no significant arrhythmias on 24-h ECG Holter monitoring in RA patients. CMR features of myocardial oedema without signs of myocardial fibrosis were found in 39% of young RA patients without known heart disease or cardiac symptoms. Presence of myocardial oedema was associated with X-ray erosions and a longer duration between symptom onset and diagnosis. The clinical significance of the observed early myocardial changes accompanying RA requires additional studies.

Cardiovascular Magnetic Resonance in Peripartum Cardiomyopathy: Comparison with Idiopathic Dilated Cardiomyopathy.

BACKGROUND: Peripartum (PPCM) and dilated (DCM) cardiomyopathies are distinct forms of cardiac disease that share certain aspects in clinical presentation. AIM: We hypothesized that different cardiac structural changes underlie PPCM and DCM, and we aimed to investigate them with cardiovascular magnetic resonance (CMR). METHODS: We included 21 PPCM patients (30.5 ± 5.9 years) and 30 female DCM patients (41.5 ± 16.8 years) matched for left ventricular ejection fraction. Biventricular and biatrial volumetric and functional parameters were assessed along with ventricular and atrial strain indices based on feature-tracking techniques. The presence of late gadolinium enhancement (LGE) was also assessed. RESULTS: In PPCM, the left ventricular (LV) stroke volume index was lower (p = 0.04), right atrial (RA) minimal and pre-systolic volumes were higher (p < 0.01 and p = 0.02, respectively), and the total RA ejection fraction was lower (p = 0.02) in comparison to DCM. Moreover, in PPCM, the LV global longitudinal strain (p = 0.03), global circumferential strain rate (p = 0.04), and global longitudinal strain rate (p < 0.01) were less impaired than in DCM. Both PPCM and DCM patients with LGE had more dilated ventricles and more impaired LV and left atrial function than in PPCM and DCM patients without LGE. CONCLUSIONS: Subtle differences appear on CMR between PPCM and DCM. Most importantly, the RA is larger and more impaired, and LV global longitudinal strain is less reduced in PPCM than in DCM. Furthermore, similarly to DCM, PPCM patients with LGE have more dilated and impaired ventricles than patients without LGE.

Comparison of mitral regurgitation severity assessments based on magnetic resonance imaging and echocardiography in patients with hypertrophic cardiomyopathy.

Mitral regurgitation (MR), which is one of the factors responsible for heart failure symptoms and the development of atrial fibrillation, is an important feature of hypertrophic cardiomyopathy (HCM), and its presence affects which treatment options are chosen. Although cardiac magnetic resonance imaging (MRI) is considered the reference standard for assessing the regurgitant volume (RV) and fraction (RF), echocardiography is the most common method for assessing MR severity. Accordingly, the aim of this study was to compare the results of echocardiography and cardiac MRI for assessing MR severity in a cohort of patients with HCM. MR severity was assessed in 53 patients using cardiac MRI by determining the mitral RV (MRV) and mitral RF (MRF). The results were graded according to thresholds recommended in current guidelines. MR severity assessed by echocardiography was graded by integrating indices of severity. Greater than mild MR, as assessed using echocardiography, was present in 22 patients (41.5%) with HCM and in none of the control patients (p = 0.001). In all, 31 patients (58.5%) had no more than mild MR. When MR severity was assessed using different methods, either moderate (kappa = 0.44, 95% confidence interval = 0.21-0.67), poor or no agreement was found between MRI-derived and echocardiography-derived grades. HCM patients with echocardiography-derived moderate and severe MR had similar median MRVs and MRFs (p = 0.59 and p = 0.11, respectively). In HCM patients, cardiac MRI and echocardiography were at most in modest agreement in assessing MR severity. Importantly, echocardiography-derived moderate and severe MR were not distinguishable by either MRV or MRF.

Sudden cardiac death risk in hypertrophic cardiomyopathy: comparison between echocardiography and magnetic resonance imaging.

In hypertrophic cardiomyopathy (HCM) patients, left ventricular (LV) maximal wall thickness (MWT) is one of the most important factors determining sudden cardiac death (SCD) risk. In a large unselected sample of HCM patients, we aimed to simulate what changes would occur in the calculated SCD risk according to the European HCM Risk-SCD calculator when MWT measured using echocardiography was changed to MWT measured using MRI. All consecutive patients with HCM who underwent cardiac MRI were included. MWT measured with echocardiography and MRI were compared, and 5-year SCD risk according to the HCM Risk-SCD calculator was computed using four different models. The final population included 673 patients [389 (57.8%) males, median age 50 years, interquartile range (36-60)]. The median MWT was lower measured by echocardiography than by MRI [20 (17-24) mm vs 21 (18-24) mm; p < 0.0001]. There was agreement between echocardiography and MRI in the measurement of maximal LV wall thickness in 96 patients (14.3%). The largest differences between echo and MRI were - 13 mm and + 9 mm. The differences in MWT by echocardiography and MRI translated to a maximal difference of 8.33% in the absolute 5-year risk of SCD, i.e., the echocardiography-based risk was 8.33% lower than the MRI-based estimates. Interestingly, 13.7% of patients would have been reclassified into different SCD risk categories if MRI had been used to measure MWT instead of echocardiography. In conclusion, although there was high general intermodality agreement between echocardiography and MRI in the MWT measurements, the differences in MWT translated to significant differences in the 5-year risk of SCD.

Deformation Parameters of the Heart in Endurance Athletes and in Patients with Dilated Cardiomyopathy-A Cardiac Magnetic Resonance Study.

A better understanding of the left ventricle (LV) and right ventricle (RV) functioning would help with the differentiation between athlete's heart and dilated cardiomyopathy (DCM). We aimed to analyse deformation parameters in endurance athletes relative to patients with DCM using cardiac magnetic resonance feature tracking (CMR-FT). The study included males of a similar age: 22 ultramarathon runners, 22 patients with DCM and 21 sedentary healthy controls (41 ± 9 years). The analysed parameters were peak LV global longitudinal, circumferential and radial strains (GLS, GCS and GRS, respectively); peak LV torsion; peak RV GLS. The peak LV GLS was similar in controls and athletes, but lower in DCM (p < 0.0001). Peak LV GCS and GRS decreased from controls to DCM (both p < 0.0001). The best value for differentiation between DCM and other groups was found for the LV ejection fraction (area under the curve (AUC) = 0.990, p = 0.0001, with 90.9% sensitivity and 100% specificity for ≤53%) and the peak LV GRS diastolic rate (AUC = 0.987, p = 0.0001, with 100% sensitivity and 88.4% specificity for >-1.27 s-1). The peak LV GRS diastolic rate was the only independent predictor of DCM (p = 0.003). Distinctive deformation patterns that were typical for each of the analysed groups existed and can help to differentiate between athlete's heart, a nonathletic heart and a dilated cardiomyopathy.

Right-ventricular mechanics assessed by cardiovascular magnetic resonance feature tracking in children with hypertrophic cardiomyopathy.

BACKGROUND: Although hypertrophic cardiomyopathy (HCM) is considered a disease of the left ventricle (LV), right ventricular (RV) abnormalities have also been reported on. Cardiovascular magnetic resonance feature tracking (CMR-FT) accurately and reproducibly quantifies RV myocardial deformation. AIM: To investigate RV deformation disorders in childhood HCM using CMR-FT. MATERIAL AND METHODS: Consecutive subjects aged <18 years with echocardiographic evidence of HCM were enrolled. Cardiovascular magnetic resonance (CMR) was performed including RV volumetric and functional assessment, and late gadolinium enhancement (LGE) imaging. RESULTS: We included 54 children (37 males, 68.5%) with HCM, of which 28 patients (51.8%; mean extent of 2.18 ± 2.34% of LV mass) had late gadolinium enhancement. LV outflow tract obstruction (LVOTO) was detected in 19 subjects (35.2%). In patients with LVOTO, RV global longitudinal strain (RVGLS) (-16.1±5.0 vs. -20.7±5.3, p<0.01), RVGLS rate (-1.05±0.30 vs. -1.26±0.40, p = 0.03), RV radial strain (RVR) (15.8±7.7 vs. 22.1±7.0, p<0.01) and RVR rate (0.95±0.35 vs. 1.6±0.44, p<0.01) were lower than in patients without LVOTO. The RVR rate (p<0.01) was lower in patients with LGE in comparison to patients without LGE. CONCLUSIONS: Children with HCM, especially with LVOTO, have significantly reduced indices of RV mechanics despite normal RV systolic function. It seems that the degree of LVOT obstruction is responsible for compromising the RV dynamics, rather than either mass or the amount of LV fibrosis.

The Indices of Cardiovascular Magnetic Resonance Derived Atrial Dynamics May Improve the Contemporary Risk Stratification Algorithms in Children with Hypertrophic Cardiomyopathy.

INTRODUCTION: The most efficient risk stratification algorithms are expected to deliver robust and indefectible identification of high-risk children with hypertrophic cardiomyopathy (HCM). Here we compare algorithms for risk stratification in primary prevention in HCM children and investigate whether novel indices of biatrial performance improve these algorithms. METHODS AND RESULTS: The endpoints were defined as sudden cardiac death, resuscitated cardiac arrest, or appropriate implantable cardioverter-defibrillator discharge. We examined the prognostic utility of classic American College of Cardiology/American Heart Association (ACC/AHA) risk factors, the novel HCM Risk-Kids score and the combination of these with indices of biatrial dynamics. The study consisted of 55 HCM children (mean age 12.5 ± 4.6 years, 69.1% males); seven had endpoints (four deaths, three appropriate ICD discharges). A strong trend (DeLong p = 0.08) was observed towards better endpoint identification performance of the HCM Risk-Kids Model compared to the ACC/AHA strategy. Adding the atrial conduit function component significantly improved the prediction capabilities of the AHA/ACC Model (DeLong p = 0.01) and HCM Risk-Kids algorithm (DeLong p = 0.04). CONCLUSIONS: The new HCM Risk-Kids individualised algorithm and score was capable of identifying high-risk children with very good accuracy. The inclusion of one of the atrial dynamic indices improved both risk stratification strategies.

Cardiac involvement in consecutive elite athletes recovered from Covid-19: A magnetic resonance study.

Magnetic resonance (MR) studies suggested cardiac involvement post-Covid-19 in a significant subset of affected individuals, including athletes. This brings serious clinical concerns regarding the potential need for in-depth cardiac screening in athletes after Covid-19 before return to play. The aim of this study was to gain further insight into the relation between Covid-19 and cardiac involvement in professional athletes. This was a retrospective cohort study, in which 26 consecutive elite athletes (national team, Olympians, top national league players; median age 24 years, interquartile range [IQR] 21-27, 81% female) were included. At 1.5 T including balanced steady-state free precession cine imaging, T1 and T2-mapping using Myomaps software (Siemens), dark-blood T2-weighted images with fat suppression, and late gadolinium enhancement (LGE) with phase-sensitive inversion recovery sequence were used. The athletes had mainly asymptomatic or mild course of the disease (77%). They were scanned after a median of 32 days (IQR 22-62 days) from the diagnosis. MR data were reviewed by three independent observers, each with >10 years cardiac MR experience. Native T1, T2, extracellular volume, and T2 signal intensity ratio were calculated. Diagnosis of acute myocarditis was based on modified Lake Louise criteria. Statistical analyses used were Pearson correlation and Bland-Altman repeatability analysis. At the time of MR the athletes had no pathologic electrocardiogram abnormalities or elevated troponin levels. MR did not reveal any case of acute myocarditis. Cardiac abnormalities were found in five (19%) athletes, including four athletes presenting borderline signs of isolated myocardial edema and one athlete showing nonischemic LGE with pleural and pericardial effusion. Another athlete had signs of persistent lung congestion without cardiac involvement. We have shown that in a small group of elite athletes with mainly asymptomatic to mild Covid-19, lack of electrocardiographic changes, and normal troponin concentration 1-2 months after the diagnosis, there were no signs of acute myocarditis, but 19% of athletes had some abnormalities as assessed by cardiac MR. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.