Cardiac MRI in this Era

Abstract Cardiac MRI (CMR) in this era is fast emerging as an invaluable tool in assessment of a large gamut of cardiac pathologies to not only ascertain the diagnosis but also assess severity, enable prognostication of disease process, guide management, and follow-up patients. CMR is today the gold standard for accurate and reproducible cardiac functional assessment, with excellent soft-tissue contrast, and ability to evaluate myocardial involvement even without contrast objectively via mapping techniques. CMR is thus fast emerging as the modality of choice and exponentially growing for cardiac assessment.

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Thoracic aortic imaging

Cardiovascular Computed Tomography ◽

10.1093/med/9780198809272.003.0025 ◽

2019 ◽

pp. 439-454

Keyword(s):

Clinical Practice ◽

Cardiac Imaging ◽

Cardiac Mri ◽

Gold Standard ◽

Imaging Techniques ◽

Imaging Procedures ◽

Mri Angiography ◽

Aortic Pathology ◽

Cardiovascular Ct

The type of imaging performed on the thoracic aorta is usually dependent on the clinical presentation, local clinical practice, and availability of imaging techniques. Cardiovascular CT remains the gold standard for aortic assessment, but increasingly cardiac MRI angiography is used, particularly in patients who are young and require serial follow-up. Other standard cardiac imaging procedures are also used in the assessment of aortic pathology, including the PA chest radiograph, TTE, and TOE. Invasive aortography is occasionally also used.

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Prospective, Comprehensive Cardiac Assessment in Patients Receiving BTK Inhibitor Therapy

Blood ◽

10.1182/blood-2019-129808 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 4301-4301

Author(s):

Chloe Pek Sang Tang ◽

Andre La Gerche ◽

Julie McMullen ◽

Erin Howden ◽

Sasanka M. Handunnetti ◽

...

Keyword(s):

Cardiac Mri ◽

Left Atrial ◽

Research Funding ◽

Cardiopulmonary Exercise Testing ◽

Vo2 Max ◽

Ventricular Ejection Fraction ◽

Holter Monitor ◽

Cardiopulmonary Exercise ◽

Cardiac Assessment

The development of Bruton Kinase Inhibitors (BTKi) has been a major advance in the treatment of chronic lymphocytic leukaemia and related B cell malignancies, but atrial fibrillation (AF) and sudden cardiac deaths are emerging as unique side effects of BTKi. The pathophysiology of cardiac side effects in BTKi treated patients is not known, and an excess of cardiac diseases is not exhibited in the congenital BTK deficiency population. Our group has previously shown in cell models that ibrutinib inhibits the phosphoinositide 3-kinase (PI3K)-AKT pathway in the heart, providing a potential explanation for cardiotoxicity. The PI3K pathway is the major cardioprotective mechanism in the heart under stress conditions, and mice with cardiomyopathy and reduced PI3K can display AF, ventricular arrhythmias and develop severe cardiomyopathy. Concerningly, given the above information, cardiac surveillance has not been routinely incorporated in BTKi trials. We therefore sought to prospectively and systemically assess cardiac function and rhythm in patients commencing BTKi therapy. Method: This is a prospective, multicentre study with the aim of conducting comprehensive cardiac assessment of patients commencing BTKi. This assessment involved 2 domains: 1) detection of subclinical arrhythmias by performing baseline and 3 month follow-up Holter Monitor testing, 2) quantification of subclinical structural changes including dynamic atrial and ventricular contractile function using transthoracic echocardiogram (TTE) and exercise cardiac magnetic resonance imaging (MRI) at baseline and 3 months. The primary outcome assessed was significant reduction in left atrial(LA) volume as a measure of ibrutinib-induced myocardial dysfunction. A 12.5% difference in LA volume is clinically meaningful given that it has been associated with greater AF risk in predisposed individuals. A sample size of 40 provides adequate power of 0.8, α = 0.05 for detecting a 12.5% increase in LA volume from an expected baseline of -18±3. Secondary outcomes measured were: 1) Reduction in ventricular ejection fraction during exercise cardiac MRI, 2) reduction in VO2 max on cardiopulmonary exercise testing. Results: A total number of 40 patients with median age of 68 years were recruited over median follow-up of 12 months (Table 1). 6/40 patients demonstrated significant reduction in left atrial volume at 3 month follow-up. They were not clinically symptomatic and did not have co-existing history of AF. Functional testing with VO2 max on cardiopulmonary exercise testing showed significant reduction in VO2 max in 8/40 patients. There were no significant reduction in ventricular ejection fraction during exercise cardiac MRI. 1/40 patients developed symptomatic AF 257 days after commencing ibrutinib and symptoms were controlled with a beta blocker. He had normal baseline TTE but was found to have enlargement of LA volume during follow-up. One patient with Waldenstrom Macroglobulinameia with normal baseline cardiac testing died from presumed ventricular tachycardia 3 months after commencing trial drug, before reassessment could be conducted. Overall, our data indicated that despite thorough cardiac surveillance, no significant cardiac abnormalities were detected at 3 month follow-up. Conclusion: This prospective and comprehensive cardiac study demonstrated no significant evidence of functional, structural or rhythm abnormalities at 3 month follow-up of patients commencing BTKiinhibitor, as assessed by Holter monitor, exercise cardiac MRI, cardiopulmonary testing and transthoracic echocardiography. Longer follow-up and additional electrophysiological studies may be required to further delineate the cause of BTKi induced cardiotoxicity. Disclosures McMullen: CLL Global Research Funding: Research Funding. Handunnetti:Gilead: Honoraria; Abbvie: Other: Travel Grant. Tam:Abbvie, Janssen: Research Funding; Abbvie, Janssen, Beigene, Roche, Novartis: Honoraria.

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The FUSION iENA Study: Comparison of I-124-PET/US Fusion Imaging with Conventional Diagnostics for the Functional Assessment of Thyroid Nodules by Multiple Observers

Nuklearmedizin ◽

10.1055/a-1031-9832 ◽

2019 ◽

Vol 58 (06) ◽

pp. 434-442 ◽

Cited By ~ 3

Author(s):

Thomas Winkens ◽

Philipp Seifert ◽

Christian Hollenbach ◽

Christian Kühnel ◽

Falk Gühne ◽

...

Keyword(s):

Functional Assessment ◽

Thyroid Nodules ◽

Radioiodine Therapy ◽

Fusion Imaging ◽

Needle Aspiration ◽

Patient Case ◽

Positron Emission ◽

Thyroid Medication ◽

Case Files

Abstract Aim To investigate the value of I-124 positron emission tomography (PET) / ultrasound (US) fusion imaging in comparison to conventional diagnostics (CD) of Thyroid nodules (TN) by multiple observers. Methods Digital patient case files (PCF) of patients that received CD and I-124-PET/US in clinical routine were prepared containing cine-loops of the examinations. All physicians with nuclear medicine specialty from Germany, Austria, and Switzerland were invited to participate. 106 acquired observers completed 7.2 ± 1.8 (median: 8, range: 4–14) randomly assigned PCF (CD only or CD+PET/US). They assessed the TN function, stated their confidence in functional assessment, and suggested a treatment course for each TN. Results 68 PCF of 34 patients comprising 66 TN ≥ 1 cm (= 1.94 TN/patient) were created. A total of 748 (11.2/TN), and 751 ratings (11.4/TN) were recorded for CD only, and CD+PET/US, respectively. The functional assessment revealed more hyper- or hypofunctioning (524 vs. 320, p < 0.0001) and less indifferent or not rateable (209 vs. 428, p < 0.0001) TN in CD+PET/US vs. CD only. The observers’ confidence in functional assessment was superior in CD+PET/US (p < 0.0001). Furthermore, the ratings were carried out more homogeneous in CD+PET/US (p < 0.0001). Fewer suggestion of follow up (p < 0.0001), and more (p < 0.0001) suggestion of invasive treatments (fine-needle aspiration & surgery) was observed in CD+PET/US. Radioiodine therapy was more often (p = 0.0036), and thyroid medication less often (p = 0.0167) advised in CD+PET/US. Conclusion Functional assessment of equivocal TN shows frequent failures in CD, underestimating the incidence of hyper- and hypofunctioning lesions. Confidence in functional assessment significantly increases with additional PET/US. This influences the proposed treatment course.

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Multislice imaging of gastrointestinal stromal tumors

10.32512/jmr.1.1.2018/3.14 ◽

2018 ◽

pp. 3-14

Keyword(s):

Computed Tomography ◽

Key Words ◽

Gold Standard ◽

Gastrointestinal Stromal Tumors ◽

Mesenchymal Tumors ◽

Stromal Tumors ◽

Preferential Localization ◽

Multislice Imaging ◽

Computed Tomography Diagnosis

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the digestive tract (1%). These tumors express the CD 117 in 95% of cases. The stomach is the preferential localization (70%). Diagnosis is difficult and sometimes late. Progress of imaging has greatly improved the management and the prognosis. Computed tomography (CT) is the gold standard for diagnosis, staging, and treatment follow-up. The increasing recognition of GIST’s histopathology and the prolonged survival revealed some suggestive imaging aspects. Key words: gastro-intestinal stromal tumors; computed tomography; diagnosis

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Cardiac Amyloidosis with Discordant QRS Voltage between Frontal and Precordial Leads

Medicina ◽

10.3390/medicina57070660 ◽

2021 ◽

Vol 57 (7) ◽

pp. 660

Author(s):

Csilla-Andrea Eötvös ◽

Roxana-Daiana Lazar ◽

Iulia-Georgiana Zehan ◽

Erna-Brigitta Lévay-Hail ◽

Giorgia Pastiu ◽

...

Keyword(s):

Left Ventricular Hypertrophy ◽

Cardiac Amyloidosis ◽

Ventricular Hypertrophy ◽

Low Voltage ◽

Disease Process ◽

Left Ventricular ◽

Clinical Suspicion ◽

Immunoglobulin Light Chain ◽

Different Types

Among the different types, immunoglobulin light chain (AL) cardiac amyloidosis is associated with the highest morbidity and mortality. The outcome, however, is significantly better when an early diagnosis is made and treatment initiated promptly. We present a case of cardiac amyloidosis with left ventricular hypertrophy criteria on the electrocardiogram. After 9 months of follow-up, the patient developed low voltage in the limb leads, while still maintaining the Cornell criteria for left ventricular hypertrophy as well. The relative apical sparing by the disease process, as well as decreased cancellation of the opposing left ventricular walls could be responsible for this phenomenon. The discordance between the voltage in the frontal leads and precordial leads, when present in conjunction with other findings, may be helpful in raising the clinical suspicion of cardiac amyloidosis.

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Detection of adverse drug events in e-prescribing and administrative health data: a validation study

BMC Health Services Research ◽

10.1186/s12913-021-06346-y ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Bettina Habib ◽

Robyn Tamblyn ◽

Nadyne Girard ◽

Tewodros Eguale ◽

Allen Huang

Keyword(s):

Administrative Data ◽

Gold Standard ◽

Adverse Drug Events ◽

Study Drug ◽

Health Data ◽

Diagnostic Code ◽

Administrative Health Data ◽

Potential Ades ◽

Patient Reported

Abstract Background Administrative health data are increasingly used to detect adverse drug events (ADEs). However, the few studies evaluating diagnostic codes for ADE detection demonstrated low sensitivity, likely due to narrow code sets, physician under-recognition of ADEs, and underreporting in administrative data. The objective of this study was to determine if combining an expanded ICD code set in administrative data with e-prescribing data improves ADE detection. Methods We conducted a prospective cohort study among patients newly prescribed antidepressant or antihypertensive medication in primary care and followed for 2 months. Gold standard ADEs were defined as patient-reported symptoms adjudicated as medication-related by a clinical expert. Potential ADEs in administrative data were defined as physician, ED, or hospital visits during follow-up for known adverse effects of the study medication, as identified by ICD codes. Potential ADEs in e-prescribing data were defined as study drug discontinuations or dose changes made during follow-up for safety or effectiveness reasons. Results Of 688 study participants, 445 (64.7%) were female and mean age was 64.2 (SD 13.9). The study drug for 386 (56.1%) patients was an antihypertensive, and for 302 (43.9%) an antidepressant. Using the gold standard definition, 114 (16.6%) patients experienced an ADE, with 40 (10.4%) among antihypertensive users and 74 (24.5%) among antidepressant users. The sensitivity of the expanded ICD code set was 7.0%, of e-prescribing data 9.7%, and of the two combined 14.0%. Specificities were high (86.0–95.0%). The sensitivity of the combined approach increased to 25.8% when analysis was restricted to the 27% of patients who indicated having reported symptoms to a physician. Conclusion Combining an expanded diagnostic code set with e-prescribing data improves ADE detection. As few patients report symptoms to their physician, higher detection rates may be achieved by collecting patient-reported outcomes via emerging digital technologies such as patient portals and mHealth applications.

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Follow-up magnetic resonance imaging of Löffler endocarditis: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa381 ◽

2020 ◽

Author(s):

Shinya Ito ◽

Akihiro Isotani ◽

Kyohei Yamaji ◽

Kenji Ando

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Corticosteroid Therapy ◽

Cardiac Mri ◽

High Intensity ◽

Left Ventricular ◽

Eosinophil Infiltration ◽

Resonance Imaging ◽

T2 Weighted Images

Abstract Background Löffler endocarditis is a condition characterized by cardiac infiltration of eosinophils. Cardiac magnetic resonance imaging (MRI) is a modality for the diagnosis of myocardial damage. Case summary This is the case of a 77-year-old man with acute decompensated heart failure who was admitted. Transthoracic echocardiography showed preserved left ventricular (LV) systolic function along with LV thrombi attached to the septo-apical wall and the posterior wall, consistent with Löffler endocarditis. Cardiac MRI revealed obliteration of the LV apex and partial filling of the LV cavity, as well as near circumferential subendocardial late gadolinium enhancement (LGE) in the mid- and apical segments. T2-weighted images showed a near circumferential high-intensity area of the LV subendocardial muscle in the mid- and apical segments. High-dose corticosteroids and intravenous heparin were initiated, followed by maintenance warfarin therapy. At 18 months, follow-up cardiac MRI revealed the disappearance of the LV thrombi, and a reduction of LGE, as well as high-intensity areas in the T2-weighted images. Discussion The high-intensity area of T2-weighted images indicate the presence of subendocardial oedema. Eosinophil-mediated heart damage evolves through three stages: (i) acute necrotic, (ii) thrombotic, and (iii) fibrotic stages. Since the deposition of toxic eosinophil granule proteins and eosinophil infiltration injured the endocardium, the first-line treatment for Löffler endocarditis is corticosteroid therapy. In this case, LGE in the subendocardium and the high-intensity area in the T2-weighted images were reduced at 18 months. High-intensity areas of T2-weighted images in the acute phase might indicate the possibility of therapeutic response to corticosteroid therapy.

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Role of myocardial inflammation and fibrosis in the development of ventricular arrythmias in patients with inflammatory cardiomyopathy (results of 1-year follow-up)

European Heart Journal ◽

10.1093/ehjci/ehaa946.2054 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

V Kovalenko ◽

E Nesukay ◽

S Cherniuk ◽

R Kirichenko ◽

A Kozliuk ◽

...

Keyword(s):

Myocardial Fibrosis ◽

Cardiac Mri ◽

Inflammatory Process ◽

Delayed Enhancement ◽

Myocardial Inflammation ◽

Inflammatory Cardiomyopathy ◽

Initial Examination ◽

Inflammatory Lesions ◽

Clinical Onset

Abstract Background Myocardial inflammatory and fibrotic changes are the most frequent and significant causes of ventricular rhythm disorders that could result in development of life threatening arrythmias and increase the risk of sudden cardiac death, especially in young patients with inflammatory cardiomyopathy (ICM). The purpose – to estimate association of myocardial inflammation and fibrosis with development of ventricular arrythmias in patients with ICM during 12-months of follow-up. Material and methods The study was performed on 70 patients with ICM, average age was (35,2±2,7) years. Initially all patients had cardiomegaly with reduced left ventricular (LV) ejection fraction - <40% and absolute value of longitudinal global systolic strain <9,0%. By 24-hour ECG monitoring we studied frequency of ventricular premature beats (VPB) and incidence of non-sustained ventricular tachycardia (NSVT) paroxysms. All patients underwent for cardiac MRI with evaluation of early T1- and T2-weighted images for the detection of inflammatory changes and T1-weighted delayed images for detection of myocardial fibrosis. Results of cardiac MRI were estimated by Lake Louise criteria and also we performed quantification of segments involved according to standard 17-segment LV model. Initial examination was carried out within the 1st month from the clinical onset of disease and subsequent evaluation of studied parameters was performed after 12 months of follow-up. Results After 12 months of follow-up average frequency of VPB reduced to (1,42±0,14) % from (2,32±0,27) % on initial examination (p<0,01), similarly reduced the incidence of NSVT paroxysms – to 11,4% after 12 months from 28,6% initially. Mean quantity of LV segments, affected by inflammatory process and characterized by presence of edema and/or hyperemia, reduced to (2,12±0,22) segm. after 12 months of follow up from (6,12±0,71) segm. on the 1st month (p<0,01). Also we observed increase of LV segments amount with the presence of delayed enhancement which indicates myocardial fibrosis – from (2,04±0,21) segm. on initial examination to (4,79±0,38) segm. after 12 months (p<0,01). Using binary regression analysis we defined that initial presence of inflammatory lesions in ≥5,0 LV segments was associated with frequent VPB (≥1,0%) and NSVT paroxysms. Wherein, after 12 months presence of inflammatory lesions had no association with ventricular rhythm disorders but the same relation was observed between the presence of delayed enhancement in ≥4,0 LV segments and frequent VPB (≥1,0%) as also with NSVT paroxysms. Conclusion At the time of clinical onset of inflammatory cardiomyopathy ventricular rhythm disorders (particularly VPB and NSVT paroxysms) were associated with larger quantity of LV segments involved into inflammatory process. After 12 months of follow-up ventricular rhythm disorders were associated predominantly with the presence of fibrotic lesions in several (≥4,0) segments of LV. Funding Acknowledgement Type of funding source: None

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Chronic Constrictive Pericarditis

Case Reports in Cardiology ◽

10.1155/2013/957497 ◽

2013 ◽

Vol 2013 ◽

pp. 1-4

Author(s):

Hossein Doustkami ◽

Afshin Hooshyar ◽

Nasrollah Maleki ◽

Zahra Tavosi ◽

Iraj Feizi

Keyword(s):

Cardiac Catheterization ◽

Constrictive Pericarditis ◽

Gold Standard ◽

Elevated Serum ◽

Disease Process ◽

Clinical Suspicion ◽

Rare Clinical Entity ◽

Good Recovery ◽

Prompt Treatment ◽

High Degree

Constrictive pericarditis (CP) is a rare clinical entity that can pose diagnostic problems. The diagnosis of CP requires a high degree of clinical suspicion. The gold standard for diagnosis is cardiac catheterization with analysis of intracavitary pressure curves, which are high and, in end diastole, equal in all chambers. We present a patient with unexplained dyspnea, recurrent right-side pleural effusion, and ascites. Analysis of the ascitic fluid revealed a high protein content and an elevated serum-ascites gradient. Echocardiography, computed tomography, and cardiac catheterization revealed the diagnosis of CP. He underwent complete pericardiectomy and to date has made a good recovery. The diagnosis of CP is often neglected by admitting physicians, who usually attribute the symptoms to another disease process. This case exemplifies the difficulty in diagnosing this condition, as well as the investigation required, and provides a discussion of the benefit and outcomes of prompt treatment.

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