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Left atrium (LA) volume is a biomarker of cardiovascular outcomes. Three-dimensional echocardiography (3DE) provides an accurate LA evaluation, but data regarding the optimal 3DE method is scarce. We assessed the feasibility and reproducibility of LA measurements using different 3DE methods. One hundred and ninety-four patients were prospectively analyzed. Conventional 3DE and two semi-automatic 3DE algorithms (Tomtec™ and Dynamic Heart Model (DHM)) were used in 110 patients. Intra- and interobserver reproducibility and intervendor comparison were performed in additional patients’ subsets. Forty patients underwent cardiac magnetic resonance (CMR). Feasibility was 100% for Tomtec, 98.2% for DHM, and 72.8% for conventional 3DE. Tomtec volumes were higher than 3DE and DHM (p < 0.001). Reproducibility was better for DHM (intraobserver LA maximum volume (LAmax) ICC 0.99 (95% CI 1.0–0.99), LA minimum volume (LAmin) 0.98 (95% CI 0.95–0.99), LApreA 0.96 (95% CI 0.91–0.98); interobserver LAmax ICC 0.98 (95% CI 0.96–0.99), LAmin 0.99 (95% CI 0.99–1.00), and LApreA 0.97 (95% CI 0.94–0.99)). Intervendor comparison showed differences between left ventricle (LV) software adapted for LA (p < 0.001). Tomtec underestimated the least LA volumes compared to CMR. These findings emphasize that dedicated software should be used for LA assessment, for consistent clinical longitudinal follow-up and research.

Three-dimensional (3D) transesophageal echocardiography (TEE) is the gold standard for mitral valve (MV) anatomic and functional evaluation. Currently, dedicated MV analysis software has limitations for its use in clinical practice. Thus, we tested here a complete and reproducible evaluation of a new fully automatic software to characterize MV anatomy in different forms of mitral regurgitation (MR) by 3D TEE. Sixty patients were included: 45 with more than moderate MR (28 organic MR [OMR] and 17 functional MR [FMR]) and 15 controls. All patients underwent TEE. 3D MV images obtained using 3D zoom were imported into the new software for automatic analysis. Different MV parameters were obtained and compared. Anatomic and dynamic differences between FMR and OMR were detected. A significant increase in systolic (859.75 vs 801.83 vs 607.78 mm2; P = 0.002) and diastolic (1040.60 vs. 1217.83 and 859.74 mm2; P

Tissue characterisation capabilities are continuing to evolve and proving to be valuable in the non-invasive diagnosis of clinicallyheterogeneous manifestations of myocarditis. The authors investigate how cardiovascular magnetic resonance imaging offers an increasingly reliable alternative to invasive biopsy for clinically-stable patients, and how this tool – with further longitudinal study – will improve the overall understanding of the natural course of myocarditis.

The electrocardiographic (ECG) P-wave pattern, >120 ms, and bimodal (±) in inferior leads has been attributed to Bachmann's bundle block. We have mapped left atrial (LA) activation in a patient with mild mitral stenosis, displaying this pattern, and with history …

Background Hypertrophic cardiomyopathy (HCM) is associated with significant associated morbidity and mortality. Increased maximal left ventricular wall thickness (LVWT) has been postulated as major risk factor of sudden death; however, relatives with normal LVWT are also at risk. Genetically driven interstitial collagenesis has been proposed as a possible mechanism of diffuse myocardial fibrosis and increased extracellular volume fractions (ECV) has been demonstrated in genotype positive subjects. We investigated whether native T1 can also separate genotype positive subjects in the absence of increase in LVWT and how does it relate to ECV measurements.

Background Cardiac magnetic resonance (CMR) increasingly adds to clinical conformation of the diagnosis in patients with suspected myocarditis. The proposed Lake Louise Consensus Criteria ("any-two” approach) can separate from chronic forms of myocardial inflammation. However, both global enhancement ratio (GRE) and T2-weighted imaging are underutilized, due to poor reproducibility and high susceptibility to artefacts. T1 and T2 mapping by CMR projects tissue-dependent relaxation times. T2 mapping has been recently proposed as a robust and accurate technique to identify areas of focal myocardial oedema. Our aim was to investigate the value of quantitative T2 values in discrimination between health and disease, and separation between active/acute myocarditis and chronic convalescent stage of the disease. Methods Twenty-four patients with acute presentation of viral myocarditis and twenty-three subjects in clinical convalescence were recruited. Thirty-three healthy subjects were served as controls. All subjects underwent CMR study for routine assessment of myocardial oedema, function and scar by at 3-Tesla scanner. T2 values were acquired in midventricular short-axis slice (mSAX) using GraSE sequence. We examined regional T2 values in patients and controls. T2 values are presented as an average of the six segments per mSAX. Secondly we investigated the differences between visually involved and remote myocardium (involved myocardium = areas by LGE, remote = areas with no LGE) Results Patients with acute myocarditis and chronic myocarditis showed significantly raised T2 values [controls vs. acute vs. chronic myocarditis, T2 myocardium (msec): 48 ± 3 vs. 59 ± 9 vs. 53 ± 5, p < 0.0001). Compared to controls, T2 values in remote myocardium were significantly different for acute myocarditis only (T2, msec: 48 ± 3 vs. 51 ± 5 vs. 49 ± 2, p < 0.01), whereas T2 values in involved myocardium differed between all groups (T2, msec: 48 ± 3 vs. 69 ± 13 vs. 57 ± 8, p < 0.0001]. Using T2 values of complete mSAX or involved were identified as the independent discriminators between active and chronic myocarditis. T2 values were concordant with T2 oedema ratio (T2 involved, r = 0.42, p < 0.0001) and with native T1 (r = 0.55, p < 0.001). Conclusions We demonstrate that quantitative T2 values are increased in patients with myocarditis. We further demonstrate that average mSAX and involved T2 values can discriminate between acute and chronic stage of the disease. Funding

Background T1 mapping by cardiovascular magnetic resonance (CMR) provides tissue-dependent relaxation times in line with the underlying myocardial composition. In this study, we examined the value of native T1 in differentiation between acute viral myocarditis and chronic stages of healing. Methods Fifty-three patients with a clinical diagnosis of acute viral myocarditis were compared to fifty-six subjects in clinical convalescence. All subjects underwent assessment of myocardial oedema, function and scar by CMR at 1.5 and 3-Tesla. T1 values were measured in midventricular short-axis slice prior to and after administration of 0.2 mmol/kg of gadobutrol. Results Compared to controls (n = 40), native T1 values were increased in both acute and chronic myocarditis at both field strengths (controls vs. acute vs. chronic myocarditis; 1.5T: native T1 (msec): 940 ± 17 vs. 1070 ± 34 vs. 998 ± 28, p < 0.001; 3T: 1045 ± 18 vs. 1182 ± 66 vs. 1094 ± 15, p < 0.001). Native T1 values were significantly higher in acute vs. chronic myocardium (p < 0.001). Native T1 was identified as the independent discriminator between health and disease, as well as acute and chronic myocarditis (Figure 1). Native T1 showed gradual reduction of values between acute and chronic stage of myocardial inflammation.

Background Aortic stiffness, measured by pulse way velocity (PWV), is an independent predictor of cardiovascular events over and above traditional risk factors. Previous evidence revealed moderately raised PWV in the presence of presence of systemic inflammatory diseases, such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Changes in aortic stiffness in response to acute systemic inflammation, such as systemic viral myocarditis, remain unknown.

Background Hypertrophic cardiomyopathy (HCM) has a wide clinical spectrum. An important subgroup of patients are at risk of major complications and sudden cardiac death. However risk stratification in these patients is still a challenge. The degree of hypertrophy and myocardial fibrosis are important predictors of prognosis. There are several papers showing the possibility of areas of abnormal left ventricular (LV) perfusion in patients with HCM. Some studies focused on stress-induced perfusion defects (Petersen SE, et al. Circulation 2007;115:2418-2425), demonstrating the presence of epi-endocardial gradients of perfusion in the LV due to microvascular dysfunction. Some other studies (Matsunaka T MRSM 2003;2:61-9 Melacini P, Int J Cardiol 2008;128:364-73) have focused the attention on LGE-related rest perfusion abnormalities. These are due to areas of microvascular disruption and do not contribute necessarily towards the LV ischemic burden. Mixed defects are also possible. The aim of the study was to analyse in retrospective a group of patients with HCM that underwent stress perfusion and LGE-CMR and to describe the prevalence of perfusion defects of each type.

Background Patients with systemic inflammatory diseases are at risk of heart failure due to sustained systemic inflammation leading to diffuse myocardial injury and left ventricular remodelling. Because native T1 and T2 values are raised in the presence of diffuse fibrosis and oedema, T1 and T2 mapping by cardiovascular magnetic resonance (CMR) are emerging as potential tools to assess diffuse myocardial involvement. In this study, we examined native T1 and T2 values in patients with systemic inflammatory diseases. Methods 79 patients with a clinical diagnosis of systemic inflammatory disease (systemic lupus erythematosus (SLE, n = 46), rheumatoid arthritis (RA, n = 17), systemic sclerosis (SS, n = 9) and Wegener’ sg ranulomatosis (WG, n=7 ) underwent CMR study for routine assessment of oedema, function and scar at 3-Tesla. 36 healthy subjects served as controls. Native T1 values were acquired using 3’3’5 MOLLI and measured conservatively within septal myocardium of midventricular short-axis slice (mSAX). T2 values were recorded from T2 maps based on GraSE sequence using equivalent cardiac geometry. We compared regional T2 values between patients and controls, and assessed associations with native T1 values. Results Patients showed impaired global LV systolic function compared to controls (control vs. SLE vs. RA vs. SS vs. WG, % = 62 ± 5 vs. 54 ± 12 vs. 60 ± 8 vs. 53 ± 8 vs. 56, p = 0.02). There were no differences in LV volumes and LV mass between controls and patients’ group. Patients showed LGE (SLE: n = 19 (41%); RA: n = 2 (12%); SS:n = 5(56%); WG: n = 4 (57%), which was of non-ischaemic pattern in presentation. Oedema ratio was increased in all systemic inflammatory conditions (p < 0.0001). Native T1 values were significantly raised in patients compared to controls (controls vs. SLE vs. RA vs. SS Vs. WG, native T1 (msec): 1048 ± 26 vs. 1170 ± 52 vs. 1118 ± 52 vs. 1199 ± 81 vs. 1151 ± 57, p < 0.0001). There were no significant regional variations in T2 values between the segments of the mSAX slice in controls with concordant SD between the segments. Patients showed raised native T2 values (native T2 (msec, average of all segments per mSAX): 48 ±3v s. 58 ±7v s. 54 ±5v s. 53 ±3v s. 57 ±8 , p < 0.001). Patients also showed regional differences in T2 values (range of native T2 values within mSAX, maximum vs. minimum (msec): SLE: 61 ± 6 vs 54 ± 8; RA: 58 ± 6 vs. 49 ± 3, SS: 59 ± 3 vs 51 ± 3, p < 0.01). There was a linear relationship between native T1 and average T2 (r = 0.63, p < 0.001) (Figure 1). Quantitative native T1 and T2 values were concordant with oedema ratio (r = 0.56 and r = 0.52 respectively, p < 0.001) and the presence of LGE (r = 0.28 and r = 0.34 respectively, p < 0.01). Conclusions We demonstrate that native T1 and T2 values are increased in patients with systemic inflammation compared to controls. We also demonstrate that T2 values have regional differences in the presence of diffuse involvement. Native T1 and T2 values may serve as an early marker of myocardial injury due to diffuse fibrosis and low grade of oedema.

Background The differential diagnosis of hypertrophic phenotype remains challenging in clinical practice, in particular between hypertrophy cardiomyopathy (HCM) and increased left ventricular wall thickness (LVWT) due to systemic hypertension. Diffuse myocardial fibrosis is the characteristic feature in HCM, whereas hypertensive response is underpinned by addition of myofibrils in otherwise normal myocardial tissue. Late gadolinium enhancement (LGE) imaging provided important new way of differentiation between these two entities by separating those cases with evidence of regional fibrosis. Whereas approximately 60% of patients with HCM reveal visually discernable LGE, T1 mapping is highly discriminative, irrespective of the presence of LGE. Methods Sixty patients with diagnosis of unequivocally hypertrophic cardiomyopathy and fifty patients with hypertensive cardiomyopathy underwent routine cardiac MRI protocol including assessment of function and scar (3-Tesla). T1 values were measured conservatively within septal myocardium in midventricular short-axis slice prior to administration of 0.2 mmol/kg of gadobutrol. Results HCM group showed higher LV mass and maximum LVWT than the hypertensive group (HCM vs. hypertensive: LVmass, g/m2: 97 ± 31 vs. 69 ± 22; maximum LVWT 18.4 ± 3 vs. 13.3 ± 1.4, p < 0.0001). There was LGE in 20% of hypertensive (n = 10, 4 of them with an ischaemic pattern) and in 84% of hypertrophic cardiomyopathy (n = 50, 3 of them with an ischaemic pattern) (p < 0.001). Patients with HCM showed significantly higher T1 values compared to hypertensive patients (HCM vs. hypertensive, msec: 1164 ± 45 vs. 1049 ± 31, < 0.0001). Native T1 values were concordant to LVWT and LV mass (r = 0.52 and r = 0.46, p < 0.001, respectively). T1native held superior diagnostic accuracy compared to conventional functional parameters and the presence of LGE to discriminate between hypertrophic or hypertensive cardiomyopathy (Figure 1). T1 native was identified as an independent discriminator between the two conditions. Conclusions We demonstrate that native T1 values can reliably discriminate between hypertrophic and hypertensive