The role of cardiac magnetic resonance imaging in the assessment, evaluation and management of patients with pulmonary hypertension

The aim of the present thesis was to investigate the additive value of right ventricular and right atrial deformation parameters on cardiac magnetic resonance, by the use of latest imaging techniques, and whether they can aid in the assessment of the prognosis in patients with pulmonary hypertension. Global longitudinal strain has emerged, according to the literature, as one of the most important strain parameter. Similarly, in our study we focused on this by the use of a novel technique, CMR-feature tracking, both for right ventricle (RV) and right atrium (RA). The main finding of our study was that RV and RA deformation parameters were significantly impaired in patients with pulmonary hypertension in comparison with healthy controls. Reduced right atrial and right ventricular GLS correlated significantly with increased risk of clinical failure. Adding RV GLS and RA GLS to the multivariate Cox model including NT-proBNP and WHO functional status had significant additive value. This study confirms the additional prognostic role of deformation assessment, especially for right ventricular early deterioration, in patients with pulmonary hypertension, as well as the important role of right atrial function preservation in this category of patients.Σκοπός της διατριβής ήταν η εκτίμηση της επιπρόσθετης συνεισφοράς των παραμέτρων που προκύπτουν από την ποσοτικοποίηση της παραμόρφωσης της δεξιάς κοιλίας και του δεξιού κόλπου, με τη χρήση προχωρημένων τεχνικών μαγνητικής τομογραφίας καρδιάς, στην πρόγνωση ασθενών με πνευμονική υπέρταση. Το global longitudinal strain (GLS) έχει αναδειχθεί βιβλιογραφικά από τους σημαντικότερους παράγοντες εξ αυτών. Παρομοίως στα πλαίσια της μελέτης μας, δόθηκε ιδιαίτερη έμφαση σε αυτή την παράμετρο, όπως αυτή ποσοτικοποιείται με την νεότερη τεχνική CMR-feature tracking, τόσο στην δεξιά κοιλία όσο και στο δεξιό κόλπο. Το κύριο εύρημα της παρούσας μελέτης είναι ότι οι παράμετροι παραμόρφωσης του δεξιού κόλπου (RA) και της δεξιάς κοιλίας (RV) επηρεάζονται σημαντικά στους ασθενείς των ομάδων πνευμονικής υπέρτασης που μελετήσαμε σε σύγκριση με υγιή δείγματα ελέγχου. Η ελάττωση του RV και RA GLS σχετίστηκε σημαντικά με αυξημένο κίνδυνο κλινικής επιδείνωσης, ενώ είχε επιπρόσθετη αξία στην πρόγνωση κλινικής επιδείνωσης σε ένα πολυπαραγοντικό μοντέλο που συμπεριλάμβανε τη λειτουργική κατάταξη κατά WHO και τις τιμές NT-proBNP. Η παρούσα μελέτη καταδεικνύει την συνεισφορά της εκτίμησης της πρώιμης έκπτωσης των παραγόντων παραμόρφωσης, ιδιαίτερα της δεξιάς κοιλίας, στην πρόγνωση ασθενών με πνευμονική υπέρταση, όσο και τον σημαντικό ρόλο της διατήρησης της συσταλτικότητας του δεξιού κόλπου σ’ αυτή την κατηγορία των ασθενών

Right ventricular myxoma in a patient with tetralogy of Fallot

INTRODUCTION: Cardiac myxoma is the most common primary cardiac tumour in adulthood and may present in the context of Carney's complex. PRESENTATION OF CASE: A 32-year-old male with a history of repaired tetralogy of Fallot in childhood was admitted with severe pulmonary valve regurgitation and a mobile mass in the right ventricle. The patient underwent pulmonary valve replacement and mass excision. Pathology examination showed myxoma. DISCUSSION: In the majority of cases myxomas originate in the atria, nevertheless they can also be found in a ventricular cavity. Myxoma is a prevalent feature of Carney's complex, an inherited, autosomal disease, characterised by multiple tumours in several organs. Tetralogy of Fallot has also been described in association with Carney's complex. CONCLUSION: Coexistence of tetralogy of Fallot with a cardiac ventricular myxoma in a patient not affected from Carney's complex or other familial syndrome

The Interplay between Myocardial Fibrosis, Strain Imaging and Collagen Biomarkers in Adults with Repaired Tetralogy of Fallot

Background: We sought to assess the interplay between right ventricle (RV) fibrosis, biventricular dysfunction based on global longitudinal strain (GLS) analysis, and biomarkers such as Galectin-3 (Gal-3), procollagen type III (PCIII), and NTproBNP. Methods: We studied 35 adult patients with rToF. All patients underwent a cardiac magnetic resonance (CMR) scan including feature tracking for deformation imaging. Blood biomarkers were measured. Results: LGE RV was detected in all patients, mainly at surgical sites. Patients with the highest RV LGE scoring had greater RV dilatation and dysfunction whereas left ventricular (LV) function was preserved. LV GLS correlated with RV total fibrosis score (p = 0.007). A LV GLS value of −15.9% predicted LGE RV score > 8 (AUC 0.754 (p = 0.02)). Neither RV GLS nor biomarker levels were correlated with the extent of RV fibrosis. A cut-off value for NTproBNP of 145.25 pg/mL predicted LGE RV score > 8 points (AUC 0.729, (p = 0.03)). A cut-off value for Gal-3 of 7.42 ng/mL predicted PR Fraction > 20% [AUC 0.704, (p = 0.05)]. Conclusions: A significant extent of RV fibrosis was mainly detected at surgical sites of RV, affecting RV performance. CMR-FT reveals subtle LV dysfunction in rToF patients, due to decreased performance of the fibrotic RV. Impaired LV function and elevated NTproBNP in rToF reflect a dysfunctional fibrotic RV

Cardiovascular magnetic resonance for the evaluation of patients with cardiovascular disease: An overview of current indications, limitations, and procedures

Cardiovascular disease (CVD) is the most common cause of morbidity/mortality worldwide. Early diagnosis is the key to improve CVD prognosis, and cardiovascular imaging plays a crucial role in this direction. Echocardiography is the most commonly used imaging modality. However, the need for early diagnosis/treatment favors the development of modalities providing information about tissue characterization beyond echocardiography. In this context, the rapid evolution of cardiovascular magnetic resonance (CMR) led to the coexistence of cardiologists and radiologists in the CMR field. Our aim was to provide an overview of indications, sequences, and reporting of CMR findings in various CVDs. The indications/limitations of CMR as well as the pathophysiological significance of various sequences in adult/pediatric CVDs are presented and discussed in detail. The role of CMR indices in the evaluation of the most common clinical scenarios in cardiology and their impact on CVD diagnosis/prognosis were analyzed in detail. Additionally, the comparison of CMR versus other imaging modalities is also discussed. Finally, future research directions are presented. CMR can provide cardiac tissue characterization and biventricular/biatrial functional assessment in the same examination, allowing for early and accurate identification of important subclinical abnormalities, before clinically overt CVD takes place

Role of cardiac CT in the diagnostic evaluation and risk stratification of patients with myocardial infarction and non-obstructive coronary arteries (MINOCA): rationale and design of the MINOCA-GR study

INTRODUCTION Myocardial infarction with non-obstructive coronary arteries (MINOCA) occurs in 5%-15% of all patients with acute myocardial infarction. Cardiac MR (CMR) and optical coherence tomography have been used to identify the underlying pathophysiological mechanism in MINOCA. The role of cardiac CT angiography (CCTA) in patients with MINOCA, however, has not been well studied so far. CCTA can be used to assess atherosclerotic plaque volume, vulnerable plaque characteristics as well as pericoronary fat tissue attenuation, which has not been yet studied in MINOCA. METHODS AND ANALYSIS MINOCA-GR is a prospective, multicentre, observational cohort study based on a national registry that will use CCTA in combination with CMR and invasive coronary angiography (ICA) to evaluate the extent and characteristics of coronary atherosclerosis and its correlation with pericoronary fat attenuation in patients with MINOCA. A total of 60 consecutive adult patients across 4 participating study sites are expected to be enrolled. Following ICA and CMR, patients will undergo CCTA during index hospitalisation. The primary endpoints are quantification of extent and severity of coronary atherosclerosis, description of high-risk plaque features and attenuation profiling of pericoronary fat tissue around all three major epicardial coronary arteries in relation to CMR. Follow-up CCTA for the evaluation of changes in pericoronary fat attenuation will also be performed. MINOCA-GR aims to be the first study to explore the role of CCTA in combination with CMR and ICA in the underlying pathophysiological mechanisms and assisting in diagnostic evaluation and prognosis of patients with MINOCA. ETHICS AND DISSEMINATION The study protocol has been approved by the institutional review board/independent ethics committee at each site prior to study commencement. All patients will provide written informed consent. Results will be disseminated at national meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT4186676