Quantitative evaluation of aortic valve regurgitation in 4D flow cardiac magnetic resonance: at which level should we measure?

PURPOSE To find the best level to measure aortic flow for quantification of aortic regurgitation (AR) in 4D flow CMR. METHODS In 27 congenital heart disease patients with AR (67% male, 31 ± 16 years) two blinded observers measured antegrade, retrograde, net aortic flow volumes and regurgitant fractions at 6 levels in 4D flow: (1) below the aortic valve (AV), (2) at the AV, (3) at the aortic sinus, (4) at the sinotubular junction, (5) at the level of the pulmonary arteries (PA) and (6) below the brachiocephalic trunk. 2D phase contrast (2DPC) sequences were acquired at the level of PA. All patients received prior transthoracic echocardiography (TTE) with AR severity grading according to a recommended multiparametric approach. RESULTS After assigning 2DPC measurements into AR grading, agreement between TTE AR grading and 2DPC was good (κ = 0.88). In 4D flow, antegrade flow was similar between the six levels (p = 0.87). Net flow was higher at level 1-2 than at levels 3-6 (p < 0.05). Retrograde flow and regurgitant fraction at level 1-2 were lower compared to levels 3-6 (p < 0.05). Reproducibility (inter-reader agreement: ICC 0.993, 95% CI 0.986-0.99; intra-reader agreement: ICC 0.982, 95%CI 0.943-0.994) as well as measurement agreement between 4D flow and 2DPC (ICC 0.994; 95%CI 0.989 - 0.998) was best at the level of PA. CONCLUSION For estimating severity of AR in 4D flow, best reproducibility along with best agreement with 2DPC measurements can be expected at the level of PA. Measurements at AV or below AV might underestimate AR

Impact of myocardial injury on regional left ventricular function in the course of acute myocarditis with preserved ejection fraction: insights from segmental feature tracking strain analysis using cine cardiac MRI

The aim of this study was to provide insights into myocardial adaptation over time in myocyte injury caused by acute myocarditis with preserved ejection fraction. The effect of myocardial injury, as defined by the presence of late gadolinium enhancement (LGE), on the change of left ventricular (LV) segmental strain parameters was evaluated in a longitudinal analysis. Patients with a first episode of acute myocarditis were enrolled retrospectively. Peak radial (PRS), longitudinal (PLS) and circumferential (PCS) LV segmental strain values at baseline and at follow-up were computed using feature tracking cine cardiac magnetic resonance imaging. The change of segmental strain values in LGE positive (LGE+) and LGE negative (LGE−) segments was compared over a course of 89 ± 20 days. In 24 patients, 100 LGE+ segments and 284 LGE− segments were analysed. Between LGE+ and LGE− segments, significant differences were found for the change of segmental PCS (p < 0.001) and segmental PRS (p = 0.006). LGE + segments showed an increase in contractility, indicating recovery, and LGE− segments showed a decrease in contractility, indicating normalisation after a hypercontractile state or impairment of an initially normal contracting segment. No significant difference between LGE+ and LGE− segments was found for the change in segmental PLS. In the course of acute myocarditis with preserved ejection fraction, regional myocardial function adapts inversely in segments with and without LGE. As these effects seem to counterbalance each other, global functional parameters might be of limited use in monitoring functional recovery of these patients

Comparative analysis of late gadolinium enhancement assessment techniques for monitoring fibrotic changes in myocarditis follow-up

OBJECTIVES To compare the repeatability and interrelation of various late gadolinium enhancement (LGE) assessment techniques for monitoring fibrotic changes in myocarditis follow-up. MATERIALS AND METHODS LGE extent change between baseline and 3-month cardiovascular magnetic resonance (CMR) was compared in patients with acute myocarditis using the full width at half maximum (FWHM), gray-scale thresholds at 5 and 6 standard deviations (SD5 and SD6), visual assessment with threshold (VAT) and full manual (FM) techniques. In addition, visual presence score (VPS), visual transmurality score (VTS), and a simplified visual change score (VCS) were assessed. Intraclass-correlation (ICC) was used to evaluate repeatability, and methods were compared using Spearman's correlation. RESULTS Forty-seven patients (38 male, median age: 27 [IQR: 21; 38] years) were included. LGE extent change differed among quantitative techniques (p < 0.01), with variability in the proportion of patients showing LGE change during follow-up (FWHM: 62%, SD5: 74%, SD6: 66%, VAT: 43%, FM: 60%, VPS: 53%, VTS: 77%, VCS: 89%). Repeatability was highest with FWHM (ICC: 0.97) and lowest with SD5 (ICC: 0.89). Semiquantitative scoring had slightly lower values (VPS ICC: 0.81; VTS ICC: 0.71). VCS repeatability was excellent (ICC: 0.93). VPS and VTS correlated with quantitative techniques, while VCS was positively associated with VPS, VTS, VAT, and FM, but not with FWHM, SD5, and SD6. CONCLUSION FWHM offers the least observer-dependent LGE follow-up after myocarditis. VPS, VTS, and VCS are practical alternatives, showing reliable correlations with quantitative methods. Classification of patients exhibiting either stable or changing LGE relies on the assessment technique. CLINICAL RELEVANCE STATEMENT This study shows that LGE monitoring in myocarditis is technique-dependent; the FWHM method yields the most consistent fibrotic tracking results, with scoring-based techniques as reliable alternatives. KEY POINTS Recognition of fibrotic changes during myocarditis follow-up is significantly influenced by the choice of the quantification technique employed. The FWHM technique ensures highly repeatable tracking of myocarditis-related LGE changes. Segment-based visual scoring and the simplified visual change score offer practical, reproducible alternatives in resource-limited settings

Comparison of 3D and 2D late gadolinium enhancement magnetic resonance imaging in patients with acute and chronic myocarditis

We compared a fast, single breath-hold three dimensional LGE sequence (3D LGE) with an established two dimensional multi breath-hold sequence (2D LGE) and evaluated image quality and the amount of myocardial fibrosis in patients with acute and chronic myocarditis. 3D LGE and 2D LGE (both spatial resolution 1.5 × 1.5 mm$^{2}$, slice-thickness 8 mm, field of view 350 × 350 mm$^{2}$) were acquired in 25 patients with acute myocarditis (mean age 40 ± 18 years, 7 female) and 27 patients with chronic myocarditis (mean age 44 ± 22 years, 9 female) on a 1.5 T MR system. Image quality was evaluated by two independent, blinded readers using a 5-point Likert scale. Total myocardial mass, fibrotic mass and total fibrotic tissue percentage were quantified for both sequences in both groups. There was no significant difference in image quality between 3D und 2D acquisitions in patients with acute (p = 0.8) and chronic (p = 0.5) myocarditis. No significant differences between 3D and 2D acquisitions could be shown for myocardial mass (acute p = 0.2; chronic p = 0.3), fibrous tissue mass (acute p = 0.7; chronic p = 0.1) and total fibrous percentage (acute p = 0.4 and chronic p = 0.2). Inter-observer agreement was substantial to almost perfect. Acquisition time was significantly shorter for 3D LGE (24 ± 5 s) as compared to 2D LGE (350 ± 58 s, p < 0.001). In patients with acute and chronic myocarditis 3D LGE imaging shows equal diagnostic quality compared to standard 2D LGE imaging but with significantly reduced acquisition time

Parametric mapping CMR for the measurement of inflammatory reactions of the pericardium

Objectives Although cardiovascular magnetic resonance (CMR) is increasingly used to diagnose pericardial inflammation, imaging can still be challenging using conventional CMR techniques. Parametric mapping (T1/T2 mapping) techniques have emerged as novel methods to quantify focal and global changes of the myocardium without contrast agent. The aim of the present study was to implement parametric mapping to facilitate diagnostic decision-making in pericardial inflammation. Methods Twenty patients with pericardial inflammation underwent CMR (1.5T system) including T1-weighted/T2-weighted imaging, T1/T2 mapping and late gadolinium enhancement. T1/T2 mapping was performed in end-diastole covering three short-axis slices. Diagnosis of pericardial inflammation was made according to recent guidelines. T1/T2 measurements were pursued by manually drawing regions of interest (ROIs) in the thickened, diseased pericardium carefully avoiding contamination by other cardiac structures. Parametric values were correlated to further markers of pericardial inflammation, such as pericardial thickening and inflammatory parameters. Results On average, the pericardium displayed a thickness of 4.8±1.0 mm. Mean T1 value was 1363.0±227.1 ms and T2 value was 123.3±52.6 ms, which were above patient’s myocardial values (myocardial T1: 998.7±81.0 ms, p<0.001, median 1014.46 ms; T2: 68.0±28.9 m,p<0.001) and the values of a group of four patients with chronic pericarditis (T1: 953.0±16.7 ms; T2: 63.2±10.1 ms). T1 and T2 showed a correlation to the extent of the thickened pericardium (R=0.64, p=0.002 for T1, R=0.72, p=0.005 for T2). There was no correlation of pericardial T1/T2 to blood markers of inflammation, myocardial injury (C reactive protein, troponin, creatine kinase) or further CMR parameters. Conclusions In patients with pericardial inflammation, parametric mapping showed elevated T1 and T2 values. Parametric mapping may help to facilitate diagnosis of pericardial inflammation if conventional parameters such as pericardial hyperintensity in T1-weighted or T2-weighted imaging or contrast agent uptake are heterogeneous

Parametric mapping CMR for the measurement of inflammatory reactions of the pericardium

OBJECTIVES Although cardiovascular magnetic resonance (CMR) is increasingly used to diagnose pericardial inflammation, imaging can still be challenging using conventional CMR techniques. Parametric mapping (T1/T2 mapping) techniques have emerged as novel methods to quantify focal and global changes of the myocardium without contrast agent. The aim of the present study was to implement parametric mapping to facilitate diagnostic decision-making in pericardial inflammation. METHODS Twenty patients with pericardial inflammation underwent CMR (1.5T system) including T1-weighted/T2-weighted imaging, T1/T2 mapping and late gadolinium enhancement. T1/T2 mapping was performed in end-diastole covering three short-axis slices. Diagnosis of pericardial inflammation was made according to recent guidelines. T1/T2 measurements were pursued by manually drawing regions of interest (ROIs) in the thickened, diseased pericardium carefully avoiding contamination by other cardiac structures. Parametric values were correlated to further markers of pericardial inflammation, such as pericardial thickening and inflammatory parameters. RESULTS On average, the pericardium displayed a thickness of 4.8±1.0 mm. Mean T1 value was 1363.0±227.1 ms and T2 value was 123.3±52.6 ms, which were above patient's myocardial values (myocardial T1: 998.7±81.0 ms, p<0.001, median 1014.46 ms; T2: 68.0±28.9 m,p<0.001) and the values of a group of four patients with chronic pericarditis (T1: 953.0±16.7 ms; T2: 63.2±10.1 ms). T1 and T2 showed a correlation to the extent of the thickened pericardium (R=0.64, p=0.002 for T1, R=0.72, p=0.005 for T2). There was no correlation of pericardial T1/T2 to blood markers of inflammation, myocardial injury (C reactive protein, troponin, creatine kinase) or further CMR parameters. CONCLUSIONS In patients with pericardial inflammation, parametric mapping showed elevated T1 and T2 values. Parametric mapping may help to facilitate diagnosis of pericardial inflammation if conventional parameters such as pericardial hyperintensity in T1-weighted or T2-weighted imaging or contrast agent uptake are heterogeneous

Association between ECG parameters and late gadolinium enhancement along the course of myocarditis

Purpose: Numerous electrocardiogram (ECG) abnormalities and late gadolinium enhancement (LGE) in cardiac magnetic resonance imaging (CMR) have been related to poor prognosis in acute myocarditis. We evaluated whether ECG parameters are associated with the distribution and dynamic of LGE along the course of myocarditis. Methods: Fifty-one patients with CMR confirmed acute myocarditis were included who underwent CMR with LGE and 12-lead ECG at baseline and 3-month follow-up at our institution. The association between the presence, regional distribution and change of ECG parameters and LGE was investigated using linear regression analysis. LGE was quantified as visual presence score (VPS) and visual transmurality score (VTS). Results: Among many ECG parameters only > 1 mm ST-elevation (STE) was associated with VPS and VTS at baseline (beta = 3.08 [95%CI: 1.75; 4.41], p = < 0.001 and beta = 5.40 [95%CI: 1.92; 8.88], p = 0.004; respectively). STE was most frequent in lateral and inferior ECG-leads (48% and 31%) and it was associated with VPS and VTS in these localizations (p < 0.05 all), however no association between anterior-septal STE and LGE could be confirmed. At follow-up the regression of STE was associated with the regression of VPS and VTS in univariate analysis (beta=-1.49 [95%CI: -2.41; -0.57], p = 0.003 and beta=-4.87 [95%CI: -7.18; -2.56], p = 0.001, respectively), which remained significant for VTS using a multivariate model (beta=-2.39 [95%CI: -3.32; -0.47], p = 0.019). Conclusion: Although we demonstrated some promising associations between STE and LGE, the usability of ECG to estimate the territorial involvement and dynamical changes of LGE along the course of myocarditis is generally limited and cardiac magnetic resonance should be considered for this purpose.ISSN:1875-8312ISSN:1569-579

Association between ECG parameters and late gadolinium enhancement along the course of myocarditis

PURPOSE: Numerous electrocardiogram (ECG) abnormalities and late gadolinium enhancement (LGE) in cardiac magnetic resonance imaging (CMR) have been related to poor prognosis in acute myocarditis. We evaluated whether ECG parameters are associated with the distribution and dynamic of LGE along the course of myocarditis. METHODS: Fifty-one patients with CMR confirmed acute myocarditis were included who underwent CMR with LGE and 12-lead ECG at baseline and 3-month follow-up at our institution. The association between the presence, regional distribution and change of ECG parameters and LGE was investigated using linear regression analysis. LGE was quantified as visual presence score (VPS) and visual transmurality score (VTS). RESULTS: Among many ECG parameters only > 1 mm ST-elevation (STE) was associated with VPS and VTS at baseline (β = 3.08 [95%CI: 1.75; 4.41], p = < 0.001 and β = 5.40 [95%CI: 1.92; 8.88], p = 0.004; respectively). STE was most frequent in lateral and inferior ECG-leads (48% and 31%) and it was associated with VPS and VTS in these localizations (p < 0.05 all), however no association between anterior-septal STE and LGE could be confirmed. At follow-up the regression of STE was associated with the regression of VPS and VTS in univariate analysis (β=-1.49 [95%CI: -2.41; -0.57], p = 0.003 and β=-4.87 [95%CI: -7.18; -2.56], p = 0.001, respectively), which remained significant for VTS using a multivariate model (β=-2.39 [95%CI: -3.32; -0.47], p = 0.019). CONCLUSION: Although we demonstrated some promising associations between STE and LGE, the usability of ECG to estimate the territorial involvement and dynamical changes of LGE along the course of myocarditis is generally limited and cardiac magnetic resonance should be considered for this purpose

Reproducibility of aortic valve calcification scoring with computed tomography - An interplatform analysis

BACKGROUND To investigate whether aortic valve calcification (AVC) scoring performed with different workstation platforms generates comparable and thus software-independent results. METHODS In this IRB-approved retrospective study, we included 100 consecutive patients with symptomatic aortic stenosis undergoing CT prior to transcatheter aortic valve implantation. Two independent observers performed AVC scoring on non-enhanced images with commercially available software platforms of four vendors (GE, Philips, Siemens, 3mensio). Gender-specific Agatston score cut-off values were applied according to current recommendations to assign patients to different likelihood categories of aortic stenosis (unlikely to very likely). Comparative analysis of Agatston scores between the four platforms were performed by using Kruskal-Wallis analysis, Spearman rank correlation, linear regression analysis, and Bland-Altman analysis. Differences in category assignment were compared using Fisher's exact test and Cohen's kappa. RESULTS For both observers, each workstation platform produced slightly different numeric AVC Agatston scores, however, without statistical significance (p = 0.96 and p = 0.98). Excellent correlation was found between platforms, with r = 0.991-0.996 (Spearman) and r = 0.981-0.992 (regression analysis) for both observers. Bland-Altman analyses revealed small mean differences with narrow limits of agreement between platforms (mean differences: 6 ± 128 to 100 ± 179), for inter-observer (mean differences: 1 ± 43 to 12 ± 70), and intra-observer variability (mean differences: 9 ± 42 to 20 ± 96). Observer 1 assigned 11 (kappa: 0.85-0.97) and observer 2 assigned 10 patients (kappa: 0.88-0.95) to different likelihood groups of severe aortic stenosis with at least one platform. Overall, there was no significant difference of likelihood assignment between platforms (p = 0.98 and p = 1.0, respectively). CONCLUSION While absolute values differ slightly, common commercially available software platforms produce comparable results for AVC scoring, which indicates software-independence of the method