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Background Breath-hold (BH) requirement remains the limiting factor on the spatio-temporal resolution and coverage of the cine balanced steady-state free precession (bSSFP) cardiovascular magnetic resonance (CMR) imaging. In this prospective two-center clinical trial, we validated the performance of a respiratory triggered (RT) bSSFP cine sequence for evaluation of biventricular function. Methods Our study included 23 asymptomatic healthy subjects and 60 consecutive patients from Institute A (n = 39) and Institute B (n = 21) referred for a clinically indicated CMR study. We implemented a RT sequence with a respiratory synchronized drive to steady state (SS) of bSSFP signal, before the commencement of image data acquisition with prospective cardiac arrhythmia rejection and retrospectively cardiac gated reconstruction in real-time. Left (LV) and right (RV) ventricular function and LV mass were evaluated by using RT-bSSFP and conventional BH-bSSFP sequences with one cardiac cycle for SS preparation keeping all the imaging parameters identical. The performance of the sequences was evaluated by using quantitative and semi-quantitative metrics. Results Global LV and RV functional parameters and LV mass obtained from the RT-bSSFP and BH-bSSFP sequences were in good agreement. Quantitative metrics designed to capture fluctuation in SS signal intensity showed no significant difference between sequences. In addition, blood-to-myocardial contrast was nearly identical between sequences. The combined clinical score for image quality was excellent or good for 100% of cases with the BH-bSSFP and 83% of cases with the RT-bSSFP sequence. The de facto image acquisition time for RT-bSSFP was statistically significantly longer than that for conventional BH-bSSFP (7.9 ± 3.4 min vs. 5.1 ± 2.6 min). Conclusions Cine RT-bSSFP is an alternative for evaluating global biventricular function with contrast and spatio-temporal resolutions that are similar to those attained by using the BH-bSSFP sequence, albeit with a modest time penalty and a small reduction in image quality.

Background Mitral regurgitation (MR) is common in patients with ischemic cardiomyopathy (ICM) and independently associated with worse mortality. We sought to determine the impact of adverse LV remodeling, total myocardial infarct (MI) size, location and extent of regional MI, and mitral valve geometry on the severity of mitral regurgitation. Methods A total of 494 patients with LVEF ≤ 40% and ≥ 70% stenosis in ≥ 1 epicardial coronary artery and prior history of CABG or PCI were screened. Patients with transthoracic echocardiogram and CMR studies within 7 days were selected. Forty-two patients (9%) were excluded either due to prior mitral valve surgery, unavailable studies or organic mitral valve disease. Other 42 patients were excluded because of no mitral regurgitation noted on their study. Mitral regurgitation was assessed using semi-quantitative vena contracta method from a parasternal long axis zoomed view obtained of the mitral valve. LV volumes and EF were calculated from cine short axis CMR images. Mitral valve geometry was measured on end-systolic 2, 3, and 4 chamber cine views. LV scar was measured 10-15 minutes after gadolinium injection and using phase-sensitive inversion recovery sequence. Results The mean age of the cohort (n = 410) was 63 ± 11 years and males represented 75%. LVEF, LV end-systolic volume index, mean total infarct size, MV annulus index, MV tenting area index, and MV displacement index were: 23 ± 0.5%, 115 ± 2 ml/m2, 31 ± 17%, 1.7 ± 0.5 cm2/m2, 0.88 ± 0.48 cm2/m2, respectively. Mean inferior, lateral, anterior infarct size were: 27 ± 21%, 25 ± 20%, 37 ± 23%. MR was classified as: mild (63%), moderate (22%) or severe (15%). The mean vena contracta was 0.33 ± 0.24 cm. Multiple variable linear regression (R2 = 0.23) revealed that male gender, worsening GFR, increase extent of inferior LV scar, LV ESVi and MV tenting area index were independent predictors of MR severity, whereas overall scar extent, anterior or lateral location were not. (Figure 1). Conclusions Global LV remodeling, regional inferior myocardial scarring, and mitral valve geometry are more important predictors of worsening MR than total infarct size in patients with advanced ischemic cardiomyopathy. Funding None.

Background Tetralogy of Fallot (TOF) repair and pulmonary valvotomy for pulmonary stenosis (PS) lead to progressive pulmonary insufficiency (PI), right ventricular enlargement and dysfunction. This study assessed whether pulmonary regurgitant fraction measured by cardiovascular magnetic resonance (CMR) could be reduced with inhaled nitric oxide (iNO). Methods Patients with at least moderate PI by echocardiography undergoing clinically indicated CMR were prospectively enrolled. Patients with residual hemodynamic lesions were excluded. Ventricular volume and blood flow sequences were obtained at baseline and during administration of 40 ppm iNO. Results Sixteen patients (11 with repaired TOF and 5 with repaired PS) completed the protocol with adequate data for analysis. The median age [range] was 35 [19–46] years, BMI was 26 ± 5 kg/m2 (mean ± SD), 50% were women and 75% were in NYHA class I. Right ventricular end diastolic volume index for the cohort was 157 ± 33 mL/m2, end systolic volume index was 93 ± 20 mL/m2 and right ventricular ejection fraction was 40 ± 6%. Baseline pulmonary regurgitant volume was 45 ± 25 mL/beat and regurgitant fraction was 35 ± 16%. During administration of iNO, regurgitant volume was reduced by an average of 6 ± 9% (p=0.01) and regurgitant fraction was reduced by an average of 5 ± 8% (p=0.02). No significant changes were observed in ventricular indices for either the left or right ventricle. Conclusion iNO was successfully administered during CMR acquisition and appears to reduce regurgitant fraction in patients with at least moderate PI suggesting a potential role for selective pulmonary vasodilator therapy in these patients. Trials registration ClinicalTrials.gov, NCT00543933

Background Mitral regurgitation (MR) and right ventricular dysfunction have been shown to be an independent predictors of mortality in patients with severe ischemic cardiomyopathy (ICM). However, it is unclear how right ventricular end systolic volume index (RVESVi) modifies risk in patients with ischemic mitral regurgitation. We sought to assess impact of RVESVi, MR, and the interaction of these variables on outcomes in patients with ICM.

News from the Society for Cardiovascular Magnetic Resonance Editorial The Society has begun 2011 on multiple highpoints, yet these have been tempered by a recent and particularly saddening low - the untimely death of Stefan Fischer. For those of you unaware, Stefan was the Director of Clinical Science for Philips Healthcare, North America, an important developer of CMR pulse sequences, tools and equipment that remain critical standards today; he was a longstanding member of SCMR with friends too numerous to count in our Society and field. I had known Stefan for well over a decade, and knew him as fiercely intelligent, strong-willed yet gently firm in his guidance, purposeful in increasing the benefits we impart to patients with our technology, and always practical. His passing leaves a gap that is impossible to fill, both in our Society, and in our hearts. I trust that the work we pursue in this Society will continue to live up to those characteristics and ideals that he embodied. To recap key Society events thus far, the year began with the 2011 SCMR Annual Scientific Sessions held in conjunction with the Euro CMR Working Group in Nice, France. It was a great success with a record number of participants from around the world. Much of that success can be attributed to the constant and hard work put forth by the Program and Abstract Chairs, Sven Plein, MD, and Raymond Kwong, MD, who put together an outstanding scientific program with a compelling array of scientific presentations, excellent posters, invited talks, and thought provoking case-sessions. The opening plenary was an important prelude to the thrust of the meeting where Michael Lauer, MD, of the NHLBI, emphasized the critical importance of CMR investigators and clinicians to design trials that alter patient outcome, as opposed to simply providing a superior diagnosis - a theme that was emphasized repeatedly as necessary to maximize CMR’s impact on clinical care. During the meeting, the Society awarded its first Gold Medal Award, given for distinguished and extraordinary service to the field of Cardiovascular Magnetic Resonance and to the Society. Fittingly, Gerald Pohost, MD, and Charles Higgins, MD, two long-standing and esteemed leaders in CMR and the Society were the inaugural winners of this annual award. Outside of the annual meeting fantastic news was

Methods Velocity encoded MRI was performed in 80 HCM and 35 normal control subjects. PWV was determined between the mid ascending and descending thoracic aorta. Delayed enhancement MRI was acquired for identification of myocardial fibrosis. Quantitative analysis of the scar was performed using advanced software package (Philips, The Netherlands). LV mass was evaluated by drawing endocardial and epicardial contours in cine-SSFP images. Diastolic function and LVOT gradients were evaluated by echocardiography. Diastolic function was graded from 03 and LVOT gradient was significant if > 30 mm Hg.

Introduction Abnormal aortic stiffness implies an unfavorable prognosis in a variety of aortic diseases, and is considered an emerging biomarker for cardiovascular disease. In bicuspid aortic valve (BAV), aortic stiffness can be elevated as a result of intrinsic aortopathy, as well as geometrical, morphological and functional abnormalities. Aortic regurgitation (AR) is associated with LV dysfunction in approximately 4% of patients per year. It has been found that loss of vascular elasticity in patients with AR hastens the development of symptoms, as typically aortic regurgitation is compensated for by increased systolic volume, which is then further accommodated by compliant arteries.

Introduction ZOOM is a spin echo based technique with high spatial resolution [1]. ZOOM differs from traditional spin echo imaging in that the 180° refocusing radiofrequency pulse is applied perpendicular to the 90° excitation pulse, limiting the field of view to the intersection of these pulses. Turbo spin echo (TSE) black blood images are acquired routinely during MRI assessment of patients with arrhythomogenic right ventricular dysplasia (ARVD). High spatial resolution is necessary for characterizing the thin RV wall in suspected ARVD patients, which is typically only 23.5 mm thick.

ss Open Acce Oral presentation Degree of mitral regurgitation and left ventricular scarring are more powerful predictors of long-term outcomes than volumes and sphericity: a multi-modality imaging study in patients with severe ischemic cardiomyopathy Deborah Kwon*, Zoran B Popovic, Venugopal Menon, Carmel M Halley, Danielle Brennan, Randall C Starling, Scott D Flamm, Paul Schoenhagen, Bruce W Lytle, Brian P Griffin and Milind Y Desai

These reporting guidelines are recommended by the Society for Cardiovascular Magnetic Resonance (SCMR) to provide a framework for healthcare delivery systems to disseminate cardiac and vascular imaging findings related to the performance of cardiovascular magnetic resonance (CMR) examinations.

Beyond the morphologic and functional abnormalities of the bicuspid aortic valve (BAV) there is also intrinsic pathology of the aortic wall, manifested by potentially lethal complications such as aortic aneurysm or dissection. Aortic distensibility and compliance are impaired in atherosclerotic aortic aneurysms and Marfan syndrome. Similar abnormalities of compliance are felt to occur in the setting of BAV, though this has been little studied with velocity-encoded magnetic resonance imaging (VENC-MRI), and further there is no data on the influence of BAV morphology on this abnormality. VENC-MRI is a potent non-invasive technique to determine aortic distensibility via aortic pulse wave velocity (PWV) measurements; in addition these measurements do not depend on knowledge of central arterial pressure or geometrical assumptions that may limit alternative measurement tools.

Hypertrophic cardiomyopathy (HCM) is characterized by disproportionate left ventricular (LV) hypertrophy, which cannot be attributed to other concomitant cardiac or systemic diseases. HCM can result in accelerated cardiac remodelling; thus affecting the pathophysiology of the disease. Because of an increased utilization of cardiac magnetic resonance (CMR) in the diagnosis and management of HCM, we have observed that a subgroup of HCM patients had a steep LV to aortic root angle (LVARA, Figure ​Figure11). Open in a separate window Figure 1 Quantification of LVARA using the 5 chamber view.

Hypertrophic cardiomyopathy (HCM) patients with similar basal septal hypertrophy (BSH) can have significantly different degrees of dynamic obstruction, quantified by the left ventricular outflow tract gradient (LVOTG). Furthermore, an elevated LVOTG can be seen even with minimal BSH. Using advanced 3-dimensional whole-heart sequence on cardiac magnetic resonance (CMR), we observed a spectrum of acuity in the LV to aortic root angle (LVARA) in our study population of HCM patients (Figure ​(Figure11). Open in a separate window Figure 1 Quantification of the LVARA in the 5 chamber view.

Methods 349 patients (24% women) with severe ICM >/= 70% stenosis in >/= 1 epicardial vessel on angiography and mean LV ejection fraction (EF) 23%], that underwent DHE-MRI (Siemens 1.5 T scanner, Erlangen, Germany) from 2003– 6 were studied. DHE-MR images were obtained in standard long and short axis orientations (covering the entire LV), after injection of Gadolinium dimenglumine using an inversion recovery spoiled gradient echo sequence: TE 4 msec, TR 8 msec, flip angle 300, bandwidth 140 Hz/ pixel, 23 k-space lines acquired every other RR-interval, field of view (varied from 228–330 in the x-direction and 260–330 in the y-direction) and matrix size (varied from 140–180 in the x-direction and 256 in the y-direction). For DHE-MRI analysis, a custom analysis package (VPT software, Siemens, Erlangen, Germany) was used to manually delineate endocardial and epicardial myocardial edges. Scar was defined (as % of myocardium in a 17-segment model on custom software, Siemens Research) on DHE-MR images, as intensity > 2 standard deviation above viable myocardium. Transmurality score was recorded in all segments as follows: 0 = no scar, 1 = 1– 25% scar, 2 = 26–50%, 3 = 51–75% and 4 = > 75%. Global LV scar burden was calculated as transmurality score for all segments/17. LV volumes, EF, demographic/clinical data, history of cardiac transplantation and all-cause mortality were recorded.

Methods 349 patients with severe ICM >/= 70% coronary artery disease in >/= 1 epicardial vessel on angiography, mean LV ejection fraction (EF) of 24%] that underwent DHE-MRI (Siemens 1.5 T scanner, Erlangen, Germany) from 2003– 6 were studied. (Siemens, Erlangen, Germany) from 2005–6. DHE-MR images were obtained in standard long and short axis orientations (covering the entire LV), after injection of Gadolinium dimenglumine using an inversion recovery spoiled gradient echo sequence: TE 4 msec, TR 8 msec, flip angle 300, bandwidth 140 Hz/pixel, 23 kspace lines acquired every other RR-interval, field of view (varied from 228–330 in the x-direction and 260–330 in the y-direction) and matrix size (varied from 140–180 in the x-direction and 256 in the y-direction). For DHE-MRI analysis, a custom analysis package (VPT software, Siemens, Erlangen, Germany) was used to manually delineate endocardial and epicardial myocardial edges. Scar was defined (as % of myocardium in a 17-segment model on custom software, Siemens Research) on DHE-MR images, as intensity > 2 standard deviation above viable myocardium. Transmurality score was recorded in all segments as follows: 0 = no scar, 1 = 1–25% scar, 2 = 26–50%, 3 = 51– 75% and 4 = > 75%. Total scar score was calculated as transmurality score for all segments/17. LV volumes, EF, demographics, risk factors, need for cardiac transplantation (CTx) and all-cause mortality were recorded. Figure 1.

Background T1 mapping is increasingly employed for evaluation of diffuse fibrosis within the left ventricular (LV) myocardium. Physiological confounders require correction of raw data prior to analysis. T1 values have been inversely correlated with LV systolic and diastolic function. We sought to evaluate the feasibility of right ventricular (RV) T1 mapping and to assess its relationship with RV function.

Methods 5 control patients (4M/1F, age 44±21 y) with normal left ventricular (LV) function and no history of heart disease, 5 patients with ICM (3M/2F, 63±2 y), and 16 patients with HCM (10M/6F, age 51±15y) were recruited into an IRB approved protocol. All subjects were imaged at 1.5T (Achieva XR, Philips). T1 mapping was performed using MOLLI and LL at 2 LV short axis levels (basaland midcavity) before and after contrast agent injection (Magnevist; 0.2 mmol/kg). Post gadopentetate dimeglumine (Magnevist; 0.2 mmol/kg) injection time was about 15 min for HCM and ICM patients and was shorter (about 5 min) for the controls due to organizational reasons. For each subject, TI measurements were made in 6 ROIs per level.

Methods We performed CMR in 24 patients with idiopathic nonischemic cardiomyopathy (16 men, mean age 58±11 years) and also in 12 healthy volunteers as control subjects. T1 mapping was performed with post-contrast Look-Locker gradient echo. Baseline echocardiography as well as hemodynamic and metabolic data were collected at the time of CMR. Patients were followed over a median time of 8 months for LVRR which was defined as a left ventricular ejection fraction (LVEF) increase of ≥10 U and a decrease in indexed left ventricular end-diastolic diameter (LVEDD) of ≥10% or indexed LVEDD of < 33 mm/m at 24 months. A multivariable logistic regression analysis was performed to identify associations with LVRR.

Background Increased ventricular and arterial stiffness is associated with diastolic dysfunction (DDFx) in patients with heart failure and preserved systolic function. Limited information is available regarding the impact of aortic biomechanics and the ventricular-vascular coupling (VVC) on DDFx in those patients with advanced ischemic cardiomyopathy (ICM). In addition, it is not known if cardiac magnetic resonance (CMR) measurements of LV remodeling (sphericity and scar burden) can also contribute to prediction of DDFx in these patients. We sought to examine the relationship between aortic biomechanical properties (ascending and descending distensibility, arch pulse wave velocity), ventricular-ventricular coupling (defined as the ratio between LV end-systolic elastance and effective arterial elastance), LV remodeling assessed by CMR and diastolic function assessed by echocardiography in patients with advanced ICM. Methods Patients were selected if they had undergone TTE and CMR studies within 7 days (median=1 day). 354 patients with LVEF ≤ 40% and ≥ 70% stenosis in ≥ 1c oronary artery but without prior mitral valve surgery, fused E/A waves, atrial fibrillation or > moderate mitral regurgitation were screened. Of those, 84 patients were excluded due to poor CMR image quality from artifacts and/or suboptimal temporal resolution. A total 270 charts were reviewed for demographic and laboratorial data. Diastolic function assessment was performed as per guidelines. Aortic biomechanics were measured using previously validated software (ARTFUN, INSERM U678, Paris, France) using semi-automated tracing of aortic contours with phase-contrast images and through-plane velocity encoding of the ascending and descending aorta. CMR evaluation also included long and short axis assessment of LV sphericity and function respectively on balanced steady state free precession images along with assessment of myocardial scar (on phase-sensitive inversion recovery DHE-CMR sequence ~ 10-20 minutes). Multivariate linear regression analysis was done to identify the independent predictors of DDFx. Results Males represented 76% of the cohort with a mean age of 62 ± 10 years. Mean LVEF was 23 ± 5% and DDFx was classified as either: stage 1 (44%), stage 2 (25%) or stage 3 (31%). The independent predictors of impaired diastolic function (stage > 1) are listed on Table 1. Conclusions In patients with advanced ICM, CMR assessment of VVC, LV sphericity and scar burden are independent predictors of DDFx. Aortic biomechanical properties are not independently associated with diastolic dysfunction. Funding None.

With mounting data on its accuracy and prognostic value, cardiovascular magnetic resonance (CMR) is becoming an increasingly important diagnostic tool with growing utility in clinical routine. Given its versatility and wide range of quantitative parameters, however, agreement on specific standards for the interpretation and post-processing of CMR studies is required to ensure consistent quality and reproducibility of CMR reports. This document addresses this need by providing consensus recommendations developed by the Task Force for Post Processing of the Society for Cardiovascular MR (SCMR). The aim of the task force is to recommend requirements and standards for image interpretation and post processing enabling qualitative and quantitative evaluation of CMR images. Furthermore, pitfalls of CMR image analysis are discussed where appropriate.

Introduction In HCM, with progression of disease, there is often a reduction in exercise capacity, likely due to diastolic dysfunction, mitral regurgitation (MR) and dynamic left ventricular outflow tract obstruction (LVOTO). However, there is considerable variation in exercise capacity despite similar diastolic dysfunction, LVOTO and MR. Aortic stiffness could be a possible contributor in HCM pathophysiology. Pulse wave velocity (PWV), measured by cardiac magnetic resonance (CMR), is a marker of aortic stiffness and is abnormal in HCM vs. controls.

Background T1 Mapping has emerged as a new marker to quantify myocardial extracellular volume (ECV), which is typically increased in the setting of diffuse fibrosis or infiltrative heart diseases. However the reproducibility of the technique is largely unknown. We sought to identify the interobserver, intraobserver variability of different T1 mapping techniques as well as validation of one technique against the standard technique for ECV quantification. Methods We selected 10 patients with the diagnosis of cardiomyopathy (5 with delayed contrast enhancement and 5 without). The Look-Locker (LL) and Modified Look-Locker both precontrast (MOLLI_Pre) and postcontrast (MOLLI_Post) T1 time were measured by 3 investigators blinded to clinical data at 2 different time points. Interobserver and Intraobserver reproducibility were assessed using 2-way ANOVA approach. The ECV was calculated using pre and post contrast T1 and hematocrit. Results There was a strong correlation between LL T1 and Postcontrast MOLLI(MOLLI_Post) (R2 0.82, p < 0.001) and a modest correlation between MOLLI_post and ECV (R2 = 0.42, p < 0.001). The interobserver and intraobserver variability of the measurements were expressed as standard errors of measurements (SEM) and 95% CI and were summarized in table 1. MOLLI_Post had the lowest intraobserver and intraobserver variability with minimal detectable change in T1 of 13.8 and 26.1 respectively. ECV showed minimal both interobserver and intraobserver variability. Conclusions Both LL and MOLLI are highly reproducible technique. LL was strongly correlated with post-contrast MOLLI which is moderately correlated to ECV. Funding None.

Background Scar burden has been shown to be an independent predictor of mortality in patients with severe ischemic cardiomyopathy (ICM). However, it is unclear how both scar burden and end systolic volume (ESV) impact outcomes in patients with severe ischemic (ICM). Purpose In patients with severe ICM, we sought to assess the association of ESV and scar burden with outcomes in severe ICM. Methods 450 patients with > 70% stenosis in ≥1 epicardial coronary artery (75% men, median age 63 years, median LV ejection fraction (EF) 22%, median ESVi 106ml, median scar % of 29%) underwent delayed hyperenhancementMRI (Siemens 1.5-T scanner, Erlangen, Germany) between 2003-2007. CMR evaluation included long and short axis assessment of LV function on balanced steady state free precession images along with assessment of myocardial scar (on phase-sensitive inversion recovery DHE-CMR sequence ~ 10-20 minutes after injection of 0.2 mmol/kg of Gadolinium dimenglumine). Scar was identified as regions of interest > 2 SD above normal myocardium. LV scar was was recorded as a percentage of the total myocardium and transmural extent (0 = none, 1 = 1-25%, 2 = 26-50%, 3 = 51-75%, and 4 = > 75%). Total scar score was determined from the summed scar score of 17 segments per patient divided by 17. Cox proportional hazards survival modeling, using a primary end-point of all-cause mortality, was used to risk-adjust comparisons. Results

Background The cine steady-state free-precession (SSFP) is the standard sequence for left ventricular (LV) function evaluation. However, SSFP mandates uninterrupted RF excitations to maintain steady-state (SS) during suspended respiration. In patients who cannot perform breath-holds (BH), a respiratory triggered (RT) free breathing (FB) retrospectively cardiac gated cine SSFP sequence that drives the magnetization to SS before commencing cine acquisition may be an alternative [1]. In this work, we validate the RT FB SSFP sequence by comparing it to the BH SSFP sequence for LV function evaluation.

Address: 1Baylor College of Medicine, Houston, TX, USA, 2St Luke's Episcopal Hospital – THI, Houston, TX, USA, 3Catharina Ziekenhuis Hospital, Eindhoven, The Netherlands, 4Leeds General Infirmary, Leeds, UK, 5Siriraj Hospital, Bangkok, Thailand, 6Skejby University Hospital, Aarhus, Denmark, 7Guy's Hospital, London, UK, 8Hygeia Hospital, Maroussi, Greece, 9German Heart Institute Berlin, Berlin, Germany and 10Cleveland Clinic Foundation, Cleveland, OH, USA * Corresponding author

Introduction Evaluation of chronic aortopathies requires repeated follow-up imaging studies to assess stability. MRI/MRA routinely has been used as the imaging modality of choice for its multiple advantages over competing modalities. However, recently there is heightened concern over gadolinium-enhanced MRA in patients with significant renal insufficiency as a result of nephrogenic systemic fibrosis (NSF). Development of a robust non-gadolinium enhanced MRI/MRA technique is needed for evaluation of aortopathies, particularly in patients with renal insufficiency.

Background Right ventricular ejection fraction (RVEF) has been shown to be an independent predictor of mortality after myocardial infarction. However, the predictive value of right ventricluar (RV) assessment in patients with severe ischemic cardiomyopathy (ICM) is unknown. Purpose In patients with severe ICM, we sought to assess the association of RVEF, RV end systolic and diastolic volumes (RV ESVi/RV ESDVi), right ventricular systolic pressure (RVSP) with outcomes in severe ICM. Methods