Cardiac magnetic resonance imaging in dilated cardiomyopathy in adults--towards identification of myocardial inflammation.

OBJECTIVE: To assess active myocardial inflammation by cardiovascular magnetic resonance (CMR) and endomyocardial biopsy (EMB) amongst adult patients with dilated cardiomyopathy (DCM). METHODS: We evaluated 23 adults with chronic DCM, who had successfully undergone both CMR and EMB within 3.5 ± 2.6 days. EMB was considered the gold standard. CMR assessment of myocardial inflammation used the following parameters as recommended by the recently published "Lake Louise Criteria": global myocardial oedema, global relative enhancement (RE), and late gadolinium enhancement (LGE). According to "Lake Louise Criteria", myocardial inflammation was diagnosed if two or more of the three above-mentioned parameters were positive. RESULTS: Myocardial inflammation was confirmed by immunohistology in 12 patients (52.2%). Sensitivity, specificity, and diagnostic accuracy of CMR to detect immunohistologically confirmed myocardial inflammation were 75.0%, 72.7%, and 73.9%, respectively. Sensitivity, specificity, and diagnostic accuracy of the individual CMR parameters to detect myocardial inflammation were as follows: global myocardial oedema, 91.7%, 81.8%, and 87.0%, respectively; global RE, 58.3%, 63.6%, and 60.9%, respectively; LGE, 58.3%, 45.4%, and 52.2%, respectively. CONCLUSION: Global myocardial oedema was identified as a promising CMR parameter for assessment of myocardial inflammation in patients with DCM. In these patients, global myocardial oedema yielded superior diagnostic performance compared to "Lake Louise Criteria".

Elasticity-based determination of isovolumetric phases in the human heart.

UNLABELLED: BACKGROUND/MOTIVATION: To directly determine isovolumetric cardiac time intervals by magnetic resonance elastography (MRE) using the magnitude of the complex signal for deducing morphological information combined with the phase of the complex signal for tension-relaxation measurements. METHODS: Thirty-five healthy volunteers and 11 patients with relaxation abnormalities were subjected to transthoracic wave stimulation using vibrations of approximately 25 Hz. A k-space-segmented, ECG-gated gradient-recalled echo steady-state sequence with a 500-Hz bipolar motion-encoding gradient was used for acquiring a series of 360 complex images of a short-axis view of the heart at a frame rate of less than 5.2 ms. Magnitude images were employed for measuring the cross-sectional area of the left ventricle, while phase images were used for analyzing the amplitudes of the externally induced waves. The delay between the decrease in amplitude and onset of ventricular contraction was determined in all subjects and assigned to the time of isovolumetric tension. Conversely, the delay between the increase in wave amplitude and ventricular dilatation was used for measuring the time of isovolumetric elasticity relaxation. RESULTS: Wave amplitudes decreased during systole and increased during diastole. The variation in wave amplitude occurred ahead of morphological changes. In healthy volunteers the time of isovolumetric elasticity relaxation was 75 ± 31 ms, which is significantly shorter than the time of isovolumetric tension of 136 ± 36 ms (P < 0.01). In patients with relaxation abnormalities (mild diastolic dysfunction, n = 11) isovolumetric elasticity relaxation was significantly prolonged, with 133 ± 57 ms (P < 0.01), whereas isovolumetric tension time was in the range of healthy controls (161 ± 45 ms; P = 0.053). CONCLUSION: The complex MRE signal conveys complementary information on cardiac morphology and elasticity, which can be combined for directly measuring isovolumetric tension and elasticity relaxation in the human heart.

Cardiac magnetic resonance elastography: toward the diagnosis of abnormal myocardial relaxation.

AIM: To assess the potential of cardiac magnetic resonance elastography (MRE) for elasticity-based detection of abnormal left ventricular (LV) relaxation. MATERIALS AND METHODS: Cardiac MRE was performed in 3 groups: young volunteers (n = 11; mean age, 31.7 years), older volunteers (n = 5; mean age, 54.8 years), and a group with relaxation abnormalities (n = 11; mean age, 58 years) identified by transthoracic echocardiography. Cine MR imaging served to measure LV volumes and global LV systolic function. Wave-amplitude-sensitive electrocardiograph-gated steady-state MRE was performed using an extended piston driver attached to the anterior chest wall. Phase contrast shear wave images were acquired in all 3 Cartesian components and combined to generate amplitude maps. This was done using the time-gradient operator for linear high-pass filtering and phase unwrapping followed by temporal Fourier transformation for extracting externally induced 24.13-Hz shear oscillations from intrinsic motion and blood flow. Amplitudes were evaluated in the left ventricle and normalized by wave amplitudes outside the heart, adjacent to the right ventricle. RESULTS: One patient and 1 young volunteer had to be excluded from final analysis because of considerable body movement during the acquisition of the MRE scans. Mean wave amplitudes in the remaining subjects were 0.22 ± 0.05 mm in young volunteers, 0.23 ± 0.09 in older volunteers, and 0.14 ± 0.03 mm in patients. The mean ratio of amplitudes inside the ventricle to the anterior chest wall was 0.62 ± 0.15 for young volunteers, 0.50 ± 0.09 for older volunteers, and 0.33 ± 0.08 for patients. CONCLUSION: MRE identifies significantly reduced LV shear wave amplitudes in patients with mild relaxation abnormality. Thus, cardiac MRE provides a promising modality for an elasticity-based diagnosis of dysfunctional myocardial relaxation.

Comparison of non-gated vs. electrocardiogram-gated 64-detector-row computed tomography for integrated electroanatomic mapping in patients undergoing pulmonary vein isolation.

AIMS: To compare non-gated vs. electrocardiogram (ECG)-gated 64-detector-row computed tomography (MDCT) of the left atrium (LA) for integrated electroanatomic mapping (EAM) in patients with paroxysmal atrial fibrillation (AF). METHODS AND RESULTS: Twenty-nine consecutive patients with paroxysmal AF underwent MDCT prior to pulmonary vein isolation (PVI). All patients were in sinus rhythm both during CT imaging and PVI. Multi-detector-row computed tomography was performed in 15 patients without ECG-gating (non-gated MDCT) and in 14 patients with retrospective ECG-gating (ECG-gated MDCT). Image quality of LA reconstructions from MDCT was rated on a five-point scale (from 1 = excellent to 5 = segmentation failed). Registration error between LA geometry obtained from EAM and MDCT was calculated as the mean distance between EAM points and MDCT surface. In all patients, LA was successfully segmented from MDCT data. The segmentation process took 2:31 +/- 0:54 min for non-gated MDCT and 2:36 +/- 0:47 min for ECG-gated MDCT (P = 0.8). Image quality scores of LA reconstructions from non-gated and ECG-gated MDCT were 1.3 +/- 0.6 and 1.4 +/- 0.7, respectively (P = 0.76). There was no significant difference in the registration error between non-gated and ECG-gated MDCT (1.8 +/- 0.2 vs. 1.9 +/- 0.3 mm, respectively; P = 0.6). The radiation dose of non-gated MDCT was significantly lower compared with ECG-gated MDCT (4.6 +/- 1.4 vs. 13.4 +/- 3.6 mSv, respectively; P < 0.001). CONCLUSION: Non-gated MDCT depicts LA with appropriate image quality for integrated EAM, while exposing patients to substantially lower radiation dose compared with ECG-gated MDCT.

Gadofosveset trisodium-enhanced magnetic resonance angiography of the left atrium--a feasibility study.

AIM: Imaging of the left atrium is regularly performed prior to pulmonary vein isolation. The aim of the study was to evaluate the feasibility of contrast-enhanced high-resolution magnetic resonance angiography (MRA) of the left atrium using the blood-pool contrast agent gadofosveset trisodium in comparison to noncontrast MRA. MATERIALS AND METHODS: Twenty consecutive patients were examined by free-breathing electrocardiogram-gated whole-heart MRA (reconstructed spatial resolution, 0.7mm x 0.6mm x 0.8mm) with a noncontrast T2-prepared steady state free precession sequence (T2-prep SSFP) and a gadofosveset trisodium-enhanced inversion-recovery SSFP sequence (CE IR-SSFP). Contrast-to-noise ratio (CNR) of blood in the left atrium was determined. Depiction of the left atrium was rated by two radiologists in consensus. A cardiologist segmented the MR data sets and rated depiction of the left atrium. RESULTS: Five of 20 patients had irregular breathing patterns with navigator efficiency less than 35% and were excluded from evaluation. CNR was significantly higher for CE IR-SSFP compared with T2-prep SSFP (18.4+/-5.3 vs. 11.7+/-3.5, p<0.01). Depiction of the left atrium by T2-prep SSFP was rated as good in four patients, moderate in ten patients, and poor in one patient, whereas depiction of the left atrium by CE IR-SSFP was rated as excellent in nine patients, good in four patients, and moderate in two patients. CE IR-SSFP allowed for semiautomated segmentation of the left atrium in 15 patients, whereas T2-prep SSFP allowed for segmentation only in ten patients. CONCLUSION: Gadofosveset trisodium-enhanced MRA of the left atrium is feasible with significantly improved image quality compared to noncontrast MRA.

Myocardial tissue Doppler echocardiography and N-terminal B-type natriuretic peptide (NT-proBNP) in diastolic and systolic heart failure.

BACKGROUND: The aim of this prospective study was to assess the diagnostic value of NT-proBNP and the concordance with Tissue Doppler Echocardiography (including strain and longitudinal displacement) in diastolic and systolic heart failure. METHODS AND RESULTS: 137 consecutive clinically stable patients were included (42 healthy controls, 43 with diastolic heart failure, 52 with systolic heart failure). In diastolic heart failure, basal septal strain was reduced (-24.8 +/- 8.1% vs. controls. -18.5 +/- 5.3%, p < 0.0001). In all patients with preserved systolic function, septal basal longitudinal displacement was impaired in patients with increased left-ventricular filling pressures (E/E' < 8: 13.5 mm +/- 3.3 mm vs. E/E' > 15: 8.5 mm +/- 2.3 mm, p = 0.001) parallel to NT-proBNP elevation (E/E' < 8: 45.8 pg/ml, IQR: 172.5 pg/ml vs. E/E' > 15: 402.0 pg/ml, IQR: 1337.2 pg/ml; p = 0.0007). In ROC analysis, NT-proBNP could detect patients with reduced left ventricular systolic function (LVEF >or= 55%) with a good diagnostic accuracy. However, the diagnostic accuracy of NT-proBNP to detect diastolic dysfunction was lower. CONCLUSION: Subtle changes of longitudinal myocardial function begin in diastolic heart failure and are further increased in systolic heart failure. In patients with preserved LV function, a complex approach with the integration of multiple parameters including Tissue Doppler echocardiography and NT-proBNP is necessary to classify patients.

Noninvasive monitoring of myocardial function after surgical and cytostatic therapy in a peritoneal metastasis rat model: assessment with tissue Doppler and non-Doppler 2D strain echocardiography.

OBJECTIVE: We sought to evaluate the impact of different antineoplastic treatment methods on systolic and diastolic myocardial function, and the feasibility estimation of regional deformation parameters with non-Doppler 2D echocardiography in rats. BACKGROUND: The optimal method for quantitative assessment of global and regional ventricular function in rats and the impact of complex oncological multimodal therapy on left- and right-ventricular function in rats remains unclear. METHODS: 90 rats after subperitoneal implantation of syngenetic colonic carcinoma cells underwent different onclogical treatment methods and were diveded into one control group and five treatment groups (with 15 rats in each group): group 1 = control group (without operation and without medication), group 2 = operation group without additional therapy, group 3 = combination of operation and photodynamic therapy, group 4 = operation in combination with hyperthermic intraoperative peritoneal chemotherapy with mitomycine, and group 5 = operation in combination with hyperthermic intraoperative peritoneal chemotherapy with gemcitabine, group 6 = operation in combination with taurolidin i.p. instillation. Echocardiographic examination with estimation of wall thickness, diameters, left ventricular fractional shortening, ejection fraction, early and late diastolic transmitral and myocardial velocities, radial and circumferential strain were performed 3-4 days after therapy. RESULTS: There was an increase of LVEDD and LVESD in all groups after the follow-up period (P = 0.0037). Other LV dimensions, FS and EF as well as diastolic mitral filling parameters measured by echocardiography were not significantly affected by the different treatments. Values for right ventricular dimensions and function remained unchanged, whereas circumferential 2D strain of the inferior wall was slightly, but significantly reduced under the treatment (-18.1 +/- 2.5 before and -16.2 +/- 2.9 % after treatment; P = 0.001) without differences between the single treatment groups. CONCLUSION: It is feasible to assess dimensions, global function, and regional contractility with echocardiography in rats under different oncological therapy. The deformation was decreased under overall treatment without influence by one specific therapy. Therefore, deformation assessment with non-Doppler 2D strain echocardiography is more sensitive than conventional echocardiography for assessing myocardial dysfunction in rats under oncological treatment.

Long-term results after partial left ventriculectomy.

BACKGROUND: Long-term clinical, echocardiographic and hemodynamic effects after partial left ventriculectomy (PLV) and predictors of outcome have been determined. METHODS: Between January 1995 and July 1999, PLV was performed in 39 patients. In 15 patients the etiology of heart failure was idiopathic dilated cardiomyopathy (DCMP), 19 patients had ischemic cardiomyopathy (ICMP) and five patients had valvular cardiomyopathy. Concomitant procedures included coronary artery bypass grafting in 16 patients, mitral valve repair in 33 patients and aortic valve replacement in five patients. All patients belonged in New York Heart Association (NYHA) functional class III or IV. Mean follow-up was 663+/-514 days. Clinical, echocardiographic and hemodynamic assessments and metabolic stress testing were performed preoperatively, within 30 days postoperatively and 6, 12 and 24 months after the operation. RESULTS: Actuarial survival was 64% after 1 year, 55% after 2 years and 44% 3 years after the operation. In patients with ICMP as well as in patients with DCMP actuarial 1 year survival was 60%. At 2-year follow-up NYHA functional class was improved significantly (P<0.05), but LV ejection fraction, LV end-diastolic diameter, cardiac index and peak oxygen consumption did not differ significantly from preoperative values. Analysis of factors influencing postoperative outcome indicated that decreased left ventricular wall thickness and a failure to increase the stroke volume index as a response to preoperative dobutamine administration were associated with postoperative mortality. CONCLUSIONS: PLV is associated with considerable postoperative mortality and lacking long-term improvement of cardiac performance.