[Troponins as biomarkers for myocardial injury and myocardial infarction]. / Troponine als Biomarker bei Myokardschaden und Myokardinfarkt.

Elevation of cardiac troponins above the 99th percentile of a healthy reference population is established as a marker for myocardial cell damage and is crucial for the diagnosis of myocardial infarction. In addition, corresponding clinical evidence of acute myocardial ischemia i.e. symptoms, changes in the electrocardiogram (ECG), wall motion abnormalities or suggestive angiographic findings are required for the diagnosis of myocardial infarction. Using modern highly sensitive assays myocardial infarction can be detected more frequently and earlier. On the other hand myocardial infarction can be ruled out with a higher diagnostic accuracy. Cardiac troponins are specific for myocardial cell damage but not for myocardial infarction and can be elevated in numerous other disease states. In these cases myocardial injury can be diagnosed independently of myocardial ischemia. Typical dynamics with rise and fall of troponin levels can distinguish acute myocardial injury (e. g. pericarditis/myocarditis and pulmonary embolism) from chronic myocardial injury (e. g. cardiomyopathy). Clinically, highly sensitive troponin assays are currently recommended in addition to the 0/3 h and 0/1 h algorithms for rapid inclusion or exclusion of myocardial infarction.

Minimally invasive direct coronary bypass surgery via distal mini-sternotomy : Promising clinical results with anaortic, multivessel, all-arterial technique.

BACKGROUND: Minimally invasive direct coronary artery bypass grafting (MIDCAB) was developed to decrease perioperative morbidity, some of which may be related to the use of cardiopulmonary bypass and to cross-clamping of the aorta. We report our initial experience with multivessel MIDCAB via distal mini-sternotomy (DIMS). DIMS is performed to gain access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery (LAD), diagonal branches, and right coronary artery (RCA). METHODS: Between January 2016 and January 2017, 12 patients with significant coronary artery disease of the LAD and the RCA underwent multivessel, all-arterial MIDCAB through a distal midline skin incision from the fourth intercostal space to the xyphoid process, with L­ or T­shaped division of the sternum. The mean age of the patients was 61.5 ± 5.2 years (range: 52-71 years). RESULTS: We performed all-arterial revascularization using the left internal mammary artery in 12 patients, the radial artery in ten, and the right internal mammary artery in two patients. The mean number of grafts per patient was 2.08 ± 0.4 (range: 2-3). The mean length of the skin incision was 8.5 ± 1.3 cm (range: 7-11 cm). There was no perioperative ischemia, postoperative bleeding, or arrhythmia events. No postoperative cognitive dysfunction occurred. The mean hospital stay was 5.6 days. No major adverse cardiac events (MACE) occurred at the 12-month follow-up. At follow-up, all patients were in New York Heart Association class I and there were no wound complications. CONCLUSION: Although MIDCAB-DIMS is technically more demanding than conventional procedures and our experience is limited, we conclude that this technique can be used safely in selected patients, with promising 12-month follow-up results.

In-hospital mortality after acute STEMI in patients undergoing primary PCI.

BACKGROUND: Acute myocardial infarction (AMI) is the main cause of global and in-hospital mortality in patients with cardiovascular diseases. We aimed to examine the association between the coronary artery involved and the in-hospital mortality in patients who underwent primary percutaneous coronary intervention (pPCI) after ST segment elevation myocardial infarction (STEMI). METHODS: The in-hospital mortality of STEMI patients who underwent pPCI was assessed at the Department of Cardiology, Harzklinik Goslar, Germany, which has no access to immediate mechanical circulatory support (MCS), between 2013 and 2017. RESULTS: We enrolled 312 STEMI patients, with a mean age of 67.1 ± 13.4 years, of whom 211 (68%) were male. In-hospital mortality was documented in 31 patients (10%). In-hospital mortality was associated with pre-hospital cardiopulmonary resuscitation (CPR; n = 39/12.5%), older age, lower systolic blood pressure, Killip class > 1, triple-vessel disease (each p < 0.0001), female gender (p = 0.0158), and with the localization of the treated culprit lesion in the left main coronary artery (LMCA; p = 0.0083) and in the ramus circumflexus (RCX; p = 0.0141). CONCLUSION: In this monocentric cohort, all-cause in-hospital mortality of STEMI patients after pPCI was significantly higher in those patients with culprit lesions in the LMCA and in the RCX, which may prove to be a substantial novel risk factor for STEMI-related mortality. Increasing age and female gender may be interdependent risk factors for mortality in this patient population. Furthermore, our data highlight the importance of the availability of MCS options in pPCI centers for patients after CPR.

Hemodynamic effects of left ventricular pacing site in an animal model of heart failure.

BACKGROUND: This study investigates how different left ventricular epicardial and endocardial pacing sites influence hemodynamic performance in an animal model of heart failure (HF). METHODS: In six adult sheep, dilated HF was induced by rapid pacing. Subsequently, endocardial left ventricular stimulation was performed using a 64-electrode basket catheter. Epicardial pacing was achieved with temporary electrodes. RESULTS: Baseline cardiac output (CO) was 2.7 +/- 0.4 l/min and improved significantly with lateral wall epicardial and endocardial stimulation (3.6 +/- 0.7 and 3.8 +/- 0.65 l/min), whereas right ventricular pacing led to lower CO (2.1 +/- 0.5 and 2.0 +/- 0.9 l/min). In the optimal pacing location arterial pressure, pulmonary capillary wedge pressure (pcwp) and LV diameters improved significantly. Right ventricular pacing impaired hemodynamics, while no change was observed in the LV inferior wall and apex pacing. CONCLUSION: Endocardial and epicardial pacing of the lateral wall led to an improvement in LV function while right ventricular pacing induced a further reduction of LV performance. As this optimal pacing site cannot always be reached via the coronary sinus, surgical implantation of epicardial electrodes should be considered in all non-responding patients.

Detection of vein graft disease using 4-row computed tomography. Evaluation of coronary bypass graft patency and correlation with the Ca-score.

BACKGROUND: Multi-row computed tomography (MDCT) is a promising non-invasive technique and capable of rapid imaging of cardiac structures, including coronary arteries and bypass grafts during a single held breath. In this study, we evaluated coronary artery bypass graft (CABG) patency by comparing 4-slice computed tomography with conventional contrast angiography. One disadvantage of MDCT is the limited diagnostic accuracy with + increased calcification of the grafts. Therefore, the correlation between Ca-grading and diagnostic accuracy was examined. METHODS: We examined 30 patients with 104 bypass grafts with a 4-row MDCT scanner. On the basis of the Ca-score, patients were divided into 3 groups. RESULTS: It was possible to assess the exact degree of stenosis in 25 of 32 > 50% stenoses with 4-row MDCT, 7 stenoses were underestimated. All occlusions in 21 patients were identified correctly, 33 graft segments were underestimated in MDCT, of which 28 were in the group with a Ca-score of > 800. CONCLUSIONS: MDCT allows non-invasive angiographic evaluation of coronary bypass grafts with a high diagnostic accuracy. However, the method strongly depends on the degree of vascular calcification and underrates the degree of stenosis subject to the Ca-score. This is a distinct limitation in distal vascular segments of small calibre which cannot be validly displayed. In patients with low or moderate Ca-score values, MDCT coronary angiography is promising new technique with a high diagnostic accuracy for the detection of graft stenosis or occlusions.

High-field MR angiography on an in vitro stenosis model determination of the spatial resolution on 1.5 and 3T in correlation to flow velocity and contrast medium concentration.

Since the first description of coronary magnetic angiography (MRA) in the early of 1990, this method seems to be shaped us a promising noninvasive modality to view the coronary arteries. Since several years dedicated high-field MR systems up to 4T are available for human use. The aim of the study was the evaluation of an in vitro vessel model with defined stenoses on 1.5T and 3T. For imaging at 3T, we used a 3d gradient-echo-sequence (fast SPGR). Furthermore, we examined the influence of the flow velocity and the contrast medium concentration on the spatial resolution. The accurate detection of in vitro stenoses was possible in segments up to 0.6 mm at 3T, the best results were obtained at a flow velocity of 40 ml/min and a contrast medium concentration of 0.2 mmol/l. The influence of the contrast medium concentration was statistically not significant. These results show that the spatial resolution can be increased by the use of a high-field MR scanner. Further in vivo studies are necessary to eliminate the method's limitation in visualizing small distal vessel segments.

Late improvement of regional wall motion after the subacute phase of myocardial infarction treated by acute PTCA in a 6-month follow-up.

BACKGROUND: The aim of this follow-up study was to investigate the late effects of acute coronary angioplasty (PTCA) on regional wall motion after the subacute phase of myocardial infarction (MI). METHODS AND RESULTS: Seventeen patients were investigated initially at a median of 11 days and again at 6 months after acute PTCA for myocardial infarction (< 8 hours after onset of symptoms) by cardiac magnetic resonance imaging. Corresponding short-axis slices encompassing the left ventricle (LV) were acquired using a standard cine MR for regional wall motion analysis and using delayed contrast enhanced magnetic resonance imaging (ceMRI) for infarct size quantification. The infarct size was similar in the subacute phase and the 6 month follow-up (20.8 and 21.9%, respectively; n.s.). Regional wall motion improved significantly in the area of hyperenhancement [percentage wall thickening (PWT) 21.9% and 37.9%, p < 0.05] in contrast to remote normal myocardium (46.4% and 38.4%; n.s.). Regional wall motion was significantly poorer in transmural compared with nontransmural MI in the subacute stage, and a late improvement could only be observed in transmural MI. CONCLUSION: Transmural areas of hyperenhancement displayed significant late long-term improvement of regional wall motion after acute PTCA, possibly related to prolonged stunning compared with nontransmural areas.

[Evaluation of myocardial perfusion reserve in patients with CAD using contrast-enhanced MRI: a comparison between semiquantitative and quantitative methods]. / Bestimmung der myokardialen Perfusionsreserve bei KHK-Patienten mit der kontrastmittelverstärkten MRT: Ein Vergleich zwischen semiquantitativer und quantitativer Auswertung.

OBJECTIVE: Comparison between two semiquantitative methods and a quantitative evaluation of myocardial blood flow (MBF) for assessment of myocardial perfusion reserve (MPR) in patients with CAD. MATERIAL AND METHODS: 9 patients with coronary stenoses > 50 % were examined with an ECG-gated Saturation Recovery Turbo FLASH sequence by using Gd-DTPA as contrast agent (CA). The entive measurements were performed both during rest and hyperemia induced by adenosine. The up-slopes of the signal-time S(t) curves in the myocardium and left ventricular (LV) cavity were evaluated by a linear fit. MPR was calculated from the original up-slopes of the myocardial S(t) curves and from the up-slopes, which were normalized to the up-slopes of the LV S(t) curves, respectively. For quantification of MBF values, the mathematical model MMID 4 was used and MPR was evaluated from the MBF values. RESULTS: With all tested methods, MPR was reduced in myocardial regions subtended by arteries with stenoses >/= 70 % compared with remote regions. With MMID 4 and the normalized up-slope method, differences between severe ischemic and remote regions were statistically significant. CONCLUSION: The up-slope method with normalization and quantification with MMID 4 are more sensitive methods to differentiate between remote and ischemic myocardium than the up-slope method without normalization.

[MR angiography and flow measurement in coronary arteries and coronary bypass grafts]. / MR-Angiographie und Flussmessung in Koronararterien und koronaren Bypassgefässen.

Better MR image quality of coronary arteries and coronary grafts is the product of increased spatial and temporal resolution. Breathing artifacts could be reduced by implementing breath-holding and navigator techniques. With these developments normal coronary arteries can often be imaged reliably. Several trials have been performed in order to test the reliability of MR angiography to detect coronary artery stenosis. But up to now, sensitivity and specificity have proven to be too low to introduce these techniques in clinical routine. The patency of coronary grafts can be detected reliably using different MR techniques. Coronary flow reserve can be measured using the MR phase contrast technique. This noninvasive approach was tested in diseased coronary arteries and in graft stenoses. A reduced MR coronary flow reserve corresponded to reduced flow reserve measured invasively. Measurement of MR flow reserve in normal and diseased coronary grafts revealed significant differences (3.3 +/- 0.4 vs. 1.3 +/- 0.2).

[Flow quantification in coronary and bypass vessels with MR phase contrast technique]. / Flussquantifizierung in Koronar- und Bypassgefässen mit der MR-Phasenkontrasttechnik.

PURPOSE: To evaluate accuracy of velocity encoded cine MR imaging for determination of blood flow in coronary arteries and coronary bypass grafts. MATERIALS AND METHODS: 12 patients with 22 coronary bypass grafts underwent intraoperative flow quantification using the transit time ultrasound method. These values were compared to postoperative MR phase shift measurements. Flow measurements were performed preoperatively in 28 coronary arteries of 20 patients. For flow measurement, we used a velocity-encoded k-space segmented gradient echo sequence with a temporal resolution of 110 or 125 ms, respectively. 6-8 pase shift images could be acquired during one cardiac cycle. RESULTS: There was a significant correlation between intraoperative and flow measurements using velocity-encoded MR imaging (r = 0.74, p < 0.0001, t-test). Flow volumes determined by MR imaging were systematically larger than those determined by the transit time ultrasound method. Mean flow in coronary arteries was reduced in severely stenosed vessels (> 70%) compared to normal vessels. Intra- and interobserver variability were 10.5 and 15% (coronary bypass grafts), and 12.3 and 15.8% (coronary arteries), respectively. CONCLUSIONS: Velocity-encoded MR imaging enables determination of flow in coronary artery bypass grafts and coronary arteries. Future developments should aim at the improvement of spatial and temporal resolution of the method.

[Noninvasive evaluation of coronary bypass grafts by magnetic resonance imaging. Comparison of the Haste and Fisp-3-D sequences with the conventional coronary angiography]. / Kernspintomographische Darstellung koronarer Bypassgefässe - Vergleich der Haste- und Fisp-3-D-Angiographiesequenz mit der konventionellen Koronarangiographie.

The aim of the study was to evaluate the patency of coronary artery bypass grafts (CABG) with the 2D and 3D magnetic resonance (MR) imaging techniques. 29 patients with 74 bypass grafts and a total of 91 distal anastomoses were studied on a 1.5 Tesla scanner using a phased array body coil. A 2D T-2 weighted breathhold turbo spin echo sequence (Haste) and a 3D breath hold contrast enhanced MR angiography sequence (Fisp-3-D) were performed. With the Haste and Fisp-3-D sequences 55 of the 58 patent and 15 of the 16 occluded grafts were recognized; the sensitivity and specificity were 95% and 94%, respectively. With the Haste sequence 74% (47/63) and with the Fisp-3-D sequence 64% (40/63) of the distal anastomoses were seen in good image quality. Only 3 of 8 significant grafts stenoses were detected. The patency of CABGs can be evaluated non-invasively with the Haste and the Fisp-3-D angiography sequences. Better results can be expected with the development of a blood-pool contrast medium and the combination of MR flow measurements with imaging techniques.

[Intraoperative flow measurement of coronary bypass grafts using the ultrasound transit time flowmeter]. / Intraoperative Flussmessung koronarer Bypassgefässe mit der Ultraschall-Transit-Zeit-Methode.

The aim of the study was to compare the mean and maximum flow and the flow pattern of coronary vein grafts (SVG) supplying target vessels of the inferior and lateral wall with internal mammary (IMA) grafts to the left anterior descending artery (LAD). In 21 patients 25 bypass grafts (13/25 SVG, 12/25 IMA) were investigated. Using the transit time ultrasound method, flow was measured every 5 ms and the flow data of 60 s were acquired. The flow pattern showed significant differences between both graft types during their cycle. IMA grafts showed only one peak occurring after 22.1+/-12.3% and the second after 63.4+/-15.5% of their cycle. The mean flow was not different in both graft types (IMA: 45.3+/-27.0 ml/min and SVG: 41.8+/-26.7 ml/min, p = n. s.) as it was the case for the maximum flow (IMS: 98. 4+/-45.2 ml/min and SVG: 75.7+/-55.4 ml/min, p = n. s.). In conclusion, there is a different flow pattern for both graft types concerning the number and the occurrence of flow-peaks in the bypass cycle. The mean and peak flow showed no significant difference.

A nonhealing ulcer diagnosed as extramedullary plasmocytoma of the limb eight years after cardiac transplantation.

A 63-year-old man was hospitalized for a nonhealing ulcer of the left lower leg that appeared 8 years after orthotopic cardiac transplantation under immunosuppressive therapy including cyclosporine. Serum protein electrophoresis, immunofixation, and urinalysis revealed a monoclonal gammopathy IgG kappa. The final diagnosis of an extramedullary plasmocytoma was made by biopsy of the ulcer, which showed formations of plasmablastic cells. We report a rare case of extramedullary plasmocytoma as a posttransplantational malignancy.

[The assessment of the patency of coronary bypass vessels with a 2D T2-weighted turbo-spin-echo sequence (HASTE) in the breath-hold technic]. / Beurteilung der Durchgängigkeit von koronaren Bypassgefässen mit einer 2D T2-gewichteten Turbo-Spin-Echo-Sequenz (HASTE) in Atemanhaltetechnik.

AIM: To evaluate the patency of coronary artery bypass grafts with a 2D T2-weighted breath-hold turbo-spin-echo sequence. METHODS: 38 patients with 97 grafts (19 internal mammary artery and 78 saphenous vein grafts) and a total of 120 distal anastomoses were studied at 1.5 Tesla in supine position using a phased array body coil. An ECG gated 2D T2-weighted breath-hold turbo-spin-echo sequence (HASTE) was performed. Reference method was selective coronary angiography. The image material was evaluated independently by two radiologists (observer one, a radiological fellow and the second a staff radiologist). RESULTS: Observer 1 reached a sensitivity of 96% (72/75) and a specificity of 91% (20/22), positive predictive value was 97%, negative predictive value 87%. 79 of the 97 (81%) patent distal anastomoses were correctly identified. Observer 2 achieved a sensitivity of 92% (69/75) and a specificity of 82% (18/22), positive and negative predictive values were 95% and 75% respectively. From 97 patent distal anastomoses 59 (61%) were recognized. The interobserver agreement was good (Cohen's kappa = 68%, p-value [McNemar] = 58%). CONCLUSION: Using the HASTE sequence a reliable assessment of graft patency is possible. This sequence is a helpful tool for planning flow measurements and 3D MR angiography.

Assessment of coronary artery bypass grafts: value of different breath-hold MR imaging techniques.

OBJECTIVE: Our aim was to evaluate the patency of coronary artery bypass grafts and to detect graft stenosis using different breath-hold MR imaging techniques. SUBJECTS AND METHODS: Twenty-two patients with 59 grafts (14 internal mammary artery grafts and 45 saphenous vein grafts) and 76 distal anastomoses (singular and sequential grafts) were studied using a 1.5-T scanner. A two-dimensional T2-weighted breath-hold half-Fourier acquisition single-shot turbo spin echo (HASTE) sequence and a three-dimensional breath-hold contrast-enhanced MR angiography sequence (fast imaging with steady-state free precession) were performed. For MR angiography, a bolus of 20 ml of gadopentetate dimeglumine was used. Time delay for contrast injection was calculated by a test bolus. The gold standard was coronary angiography performed within 14 days of MR imaging. All images were evaluated independently by two radiologists. RESULTS: With the HASTE sequence, 95% of the patent grafts were recognized (42/44); specificity was 93% (14/15). MR angiography had both a sensitivity (41/44) and specificity (14/15) of 93%. Interobserver agreement for both sequences was good (Cohen's kappa = 87%; McNemar test, p = 56%). Forty-nine (83%) of 59 patent distal graft anastomoses were revealed with the HASTE sequence; 38 (64%) of 59 were seen on contrast-enhanced angiography. With HASTE imaging, only two of eight hemodynamically significant graft stenoses were detected. MR angiography revealed only four of eight significant graft stenoses. CONCLUSION: The HASTE sequence and three-dimensional MR angiography proved to be useful MR techniques when evaluating the patency of coronary artery bypass grafts. However, reliable detection of graft stenosis does not yet seem possible with these imaging techniques.

[Diagnosis of an intramyocardial hematoma via MRI after a traumatic myocardial infarct]. / Diagnose eines intramyokardialen Hämatoms nach traumatischem Myokardinfarkt durch Magnetresonanztomographie.

Traumatic cardiac lesions occur in about 30% of all traumatized patients, in most cases they are due to traffic accidents. We report a patient who suffered from a traumatic anterior wall infarction following a ski accident. Consecutively, an extended intramyocardial hemorrhage occurred. A left ventricular pseudoaneurysm was considered first by echocardiography. Using MRI, an intramyocaridal hemorrhage could be diagnosed because of a thin myocardial border surrounding the hematoma. Consecutively, the patient underwent CABG surgery as well as a resection of the intramyocardial hematoma. This diagnosis could be manifested surgically and histologically.

[Determination of left ventricular mass by transthoracic three-dimensional echocardiography in patients with dilated cardiomyopathy]. / Linksventrikuläre Muskelmassenbestimmung bei Patienten mit dilatativer Kardiomyopathie mittels transthorakaler dreidimensionaler Echokardiographie.

Conventional echocardiographic methods of measuring left ventricular mass (LVM) are limited by assumptions of ventricular geometry and image plane positioning. Three-dimensional (3D) echocardiography offers a promising new approach for more accurate determination of LVM. This study was performed to compare LVM measurement by one- (1D), two- (2D), and 3D echocardiography with magnetic resonance imaging (MRI) in patients (pts) with dilated cardiomyopathy (DCM). 36 pts (age 18-74) with DCM underwent imaging by conventional 1D and 2D echocardiography as well as transthoracic 3D echocardiographic data acquisition. Also, pts were imaged with cardiac MRI. Due to echocardiographic and MRI quality and because of exclusion criteria's for MRI, it was not possible to accomplish each LVM determination method for each patient. LVM was determined by Devereux and area-length algorithm for the conventional echocardiography. 3D echocardiographic data was calculated after manual delineation of endo- and epicardial boundaries--slice by slice (5 mm)--in 3 perpendicular cut planes. LVM was determined by multiplying the myocardial volume by the specific density of the myocardium. To determine LVM in MRI, the even summation of slices method for myocardial volume measurement was used defined by the endo- and epicardium in short axis images. There was no significant correlation (r = 0.42) for measuring LVM between 1D echocardiography and MRI in pts with DCM. A significant correlation was obtained between 2D (r = 0.64, p < 0.01) echocardiography and MRI as well between 3D (r = 0.78, p < 0.01) and MRI in determination of LVM. Compared with 1D and 2D echocardiography, the 3D analysis achieved a significantly higher agreement with the results of the MRI (1D: 399.2 g, 2D: 285.9 g, 3D: 172.6 g versus MRI: 199.1 g). Interobserver variability was 5.1% for measuring LVM by 3D echocardiography (1D: 11.2%, 2D: 9.1%). In conclusion, in pts with DCM the determination of LVM was incompletely characterized by 1D and 2D echocardiography compared with results of MRI. The best correlation and high agreement for determination of LVM was obtained with 3D echocardiography compared with MRI.

[Flow quantification of intracardiac shunt volumes using MR phase contrast technique in the breath holding phase]. / Flussquantifizierung von intrakardialen Shuntvolumina unter Verwendung der MR-Phasenkontrast-Technik in Atemanhaltephase.

PURPOSE: Comparison of a breath-hold, velocity-encoded, phase-difference magnetic resonance (MR) sequence for intracardiac shunt flow measurement with the invasive shunt size determination by oximetry. PATIENTS AND METHODS: 10 patients with different cardiac shunts (6 ASD/3 VSD/1 PDA) and four healthy individuals were investigated using a 1.5 Tesla Siemens Vision system. For flow measurements a breath-hold, velocity-encoded, phase-difference magnetic resonance (MR) sequence was used ('through plane', FLASH 2D-sequence, TR/TE 110/5 ms, 'velocity encoding' 250 cm/s). Mean flow (ml/R-R interval) in the ascending aorta, the pulmonary trunk, and the right and left pulmonary arteries was determined. The ratio of the mean flow in the pulmonary circulation (Qp: sum of the mean flows in the right and left pulmonary arteries) and the systemic circulation (Qs: mean flow in the proximal aorta) was compared with the Qp/Qs ratios determined by the invasive oxymetric technique. Oximetry was performed within 24 hours after MR imaging. RESULTS: In the 4 healthy individuals MR flow measurement yielded a Qp/Qs ratio of 0.96 +/- 0.15. In the 10 patients with the various shunt defects, the non-invasive shunt determination by MR gave a Qp/Qs ratio of 2.09 +/- 0.67. The percentage of the calculated shunt sizes was 47.05 +/- 17.45%. In the comparison with the results determined by the invasive oxymetric technique, the MR data showed a strong correlation of r = 0.87. CONCLUSIONS: Breath-hold, velocity-encoded, phase-difference MR-technique enables a reliable quantification of cardiac shunts within a short acquisition time.