Role of cardiovascular magnetic resonance imaging in cardio-oncology

Advances in cancer therapy have led to significantly longer cancer-free survival times over the last 40 years. Improved survivorship coupled with increasing recognition of an expanding range of adverse cardiovascular effects of many established and novel cancer therapies has highlighted the impact of cardiovascular disease in this population. This has led to the emergence of dedicated cardio-oncology services that can provide pre-treatment risk stratification, surveillance, diagnosis, and monitoring of cardiotoxicity during cancer therapies, and late effects screening following completion of treatment. Cardiovascular imaging and the development of imaging biomarkers that can accurately and reliably detect pre-clinical disease and enhance our understanding of the underlying pathophysiology of cancer treatment-related cardiotoxicity are becoming increasingly important. Multi-parametric cardiovascular magnetic resonance (CMR) is able to assess cardiac structure, function, and provide myocardial tissue characterization, and hence can be used to address a variety of important clinical questions in the emerging field of cardio-oncology. In this review, we discuss the current and potential future applications of CMR in the investigation and management of cancer patients

Temporary device malfunction of an MR conditional cardiac resynchronization defibrillator when undergoing MRI without appropriate re-programming: a case report

Background Magnetic resonance (MR) imaging (MRI) for patients with implantable cardiac devices is becoming more routine, with the development of MR conditional devices allowing more patients access to the imaging they need. However, for this to be performed safely, strict protocols must be followed necessitating close collaboration between cardiology and radiology departments. We present a case where mandatory device re-programming of a cardiac resynchronization therapy defibrillator device into MRI mode was not performed pre-scan leading to temporary device dysfunction with no clinical consequences. Case summary A 72-year-old man presented to a device clinic for a routine device interrogation. An atrial tachycardia response episode was recorded at the same time as the patient reported having undergone an MRI scan at a local centre. The electrogram demonstrated temporary right ventricular loss of capture with standard output programming, and a short episode of oversensing on the atrial and ventricular channel which was not sustained for long enough to meet tachycardia detection. Discussion We demonstrate two potential electrophysiological effects of MRI on pacemakers, where the device had not been appropriately re-programmed pre-procedure. This illustrates that whilst MRI in patients with implantable cardiac devices is safe, strict protocols must be followed requiring robust multidisciplinary communication

Evidence that conflict regarding size of haemodynamic response to interventricular delay optimization of cardiac resynchronization therapy may arise from differences in how atrioventricular delay is kept constant.

Aims: Whether adjusting interventricular (VV) delay changes haemodynamic efficacy of cardiac resynchronization therapy (CRT) is controversial, with conflicting results. This study addresses whether the convention for keeping atrioventricular (AV) delay constant during VV optimization might explain these conflicts. / Method and results: Twenty-two patients in sinus rhythm with existing CRT underwent VV optimization using non-invasive systolic blood pressure. Interventricular optimization was performed with four methods for keeping the AV delay constant: (i) atrium and left ventricle delay kept constant, (ii) atrium and right ventricle delay kept constant, (iii) time to the first-activated ventricle kept constant, and (iv) time to the second-activated ventricle kept constant. In 11 patients this was performed with AV delay of 120 ms, and in 11 at AV optimum. At AV 120 ms, time to the first ventricular lead (left or right) was the overwhelming determinant of haemodynamics (13.75 mmHg at ±80 ms, P < 0.001) with no significant effect of time to second lead (0.47 mmHg, P = 0.50), P < 0.001 for difference. At AV optimum, time to first ventricular lead again had a larger effect (5.03 mmHg, P < 0.001) than time to second (2.92 mmHg, P = 0.001), P = 0.02 for difference. / Conclusion: Time to first ventricular activation is the overwhelming determinant of circulatory function, regardless of whether this is the left or right ventricular lead. If this is kept constant, the effect of changing time to the second ventricle is small or nil, and is not beneficial. In practice, it may be advisable to leave VV delay at zero. Specifying how AV delay is kept fixed might make future VV delay research more enlightening

Non-invasive Imaging in Women With Heart Failure — Diagnosis and Insights Into Disease Mechanisms

PURPOSE OF REVIEW: To summarise the role of different imaging techniques for diagnosis and investigation of heart failure in women. RECENT FINDINGS: Although sex differences in heart failure are well recognised, and the scope of imaging techniques is expanding, there are currently no specific guidelines for imaging of heart failure in women. SUMMARY: Diagnosis and stratification of heart failure is generally performed first line using transthoracic echocardiography. Understanding the aetiology of heart failure is central to ongoing management, and with non-ischaemic causes more common in women, a multimodality approach is generally required using advanced imaging techniques including cardiovascular magnetic resonance imaging, nuclear imaging techniques, and cardiac computed tomography. There are specific considerations for imaging in women including radiation risks and challenges during pregnancy, highlighting the clear unmet need for cardiology and imaging societies to provide imaging guidelines specifically for women with heart failure

Graft-versus-host disease: a case report of a rare but reversible cause of constrictive pericarditis

BACKGROUND: Constrictive pericarditis (CP), although an uncommon cause of heart failure, requires specialist multidisciplinary input and multi-modality imaging to identify the underlying aetiology and treat potentially reversible causes. CASE SUMMARY: We report the case of a 74-year-old gentleman referred for assessment of progressive exertional dyspnoea and peripheral oedema, 30 months following treatment of acute myeloid leukaemia with high-dose chemotherapy and allogeneic stem cell transplantation. Clinical examination and cardiac imaging revealed a small pericardial effusion and pericardial thickening with constrictive physiology; however, no aetiology was identified despite diagnostic pericardiocentesis. The patient required recurrent hospital admissions for intravenous diuresis, therefore, following multidisciplinary discussions, surgical partial pericardectomy was performed. Histology suggested graft-vs.-host disease (GvHD) and post-operatively, the patient improved clinically. Following immunomodulatory therapy with ruxolitinib for both pericardial and pulmonary GvHD, his functional status improved further with no subsequent hospital admissions. DISCUSSION: Although pericardial disease in cancer patients is common, CP is unusual. Determining the underlying aetiology is important for subsequent management, and here, we describe the use of multi-modality imaging to diagnose a rare cause, GvHD, which responded to surgical treatment and immunomodulatory therapy