Search

Objectives: To prospectively compare image quality and infarct sizing methods between magnetization-transfer "flow-independent dark-blood delayed enhancement" (MT-FIDDLE) and standard "bright-blood"-late gadolinium enhancement (LGE) cardiac-magnetic-resonance (CMR) sequence., Methods: "Bright-blood"-LGE and MT-FIDDLE sequence were acquired in 110 patients at 4 days (n = 33), 4 months (n = 39) and 12 months (n = 38) after acute ST-elevation myocardial infarction (STEMI). Subjective image quality, including confidence in infarct segmentation and blood-pool bordering, were each rated on a 4-point Likert scale. Objective image quality was assessed by the detectability index (DI). Infarct volumes derived via full-width at half-maximum (FWHM) and different number of standard deviations ("n-SD") methods on MT-FIDDLE images were compared with FWHM and reference 5-SD results from "bright-blood-LGE images., Results: Overall subjective median image quality was excellent for both LGE sequences. Qualitative analysis revealed a significantly higher confidence in infarct segmentation and in blood-pool bordering for MT-FIDDLE as compared to "bright-blood"-LGE (all p < 0.001). Infarct volumes assessed by the FWHM technique on MT-FIDDLE and "bright-blood"-LGE showed excellent agreement overall (Concordance correlation coefficient, CCC = 0.96). The 3-SD technique for MT-FIDDLE showed the best agreement with the 5-SD method for "bright-blood"-LGE overall (CCC = 0.94), as well as in the subgroup with excellent confidence in infarct segmentation on "bright-blood"-LGE (CCC = 0.96). DI of scar versus LV blood-pool was higher for MT-FIDDLE (8.9 ± 5.5) compared to "bright-blood"-LGE sequence (2.0 ± 1.5; p < 0.001)., Conclusion: MT-FIDDLE significantly optimizes the discrimination between myocardial infarction and adjacent blood-pool in STEMI patients. As compared to the established 5-SD technique on "bright-blood"-LGE, the 3-SD method on MT-FIDDLE results in consistent infarct volumes., Key Points: Question Does magnetization-transfer "flow-independent dark-blood delayed enhancement" (MT-FIDDLE) offer any benefits over standard "bright-blood"-late gadolinium enhancement (LGE) cardiac-magnetic-resonance (CMR) for identifying STEMI infarct borders? Findings MT-FIDDLE image quality was higher than LGE CMR and measured infarct volume comparability to the standard 5-SD-threshold-technique. Clinical relevance MT-FIDDLE facilitates the assessment of myocardial infarctions at the subendocardial border, improving the discrimination between myocardial infarction and adjacent blood-pool in STEMI patients., Competing Interests: Compliance with ethical standards. Guarantor: The scientific guarantor of this publication is Agnes Mayr, MD. Conflict of interest: One of the authors (Wolfgang G. Rehwald) is an employee of Siemens Medical Solutions. The remaining authors declare no relationships with any companies whose products or services may be related to the subject matter of the article. Statistics and biometry: One of the authors (Christian Kremser, PhD) has significant statistical expertise. Informed consent: Written informed consent was obtained from all subjects (patients) in this study. Ethical approval: Institutional Review Board approval was obtained. Study subjects or cohorts overlap: Some study subjects or cohorts have been not previously reported. Methodology: Prospective study, (© 2024. The Author(s).)

Background and Aims: In chronic ischaemic heart failure, revascularisation strategies control symptoms but are less effective in improving left ventricular ejection fraction (LVEF). The aim of this trial is to investigate the safety of cardiac shockwave therapy (SWT) as a novel treatment option and its efficacy in increasing cardiac function by inducing angiogenesis and regeneration in hibernating myocardium., Methods: In this single-blind, parallel-group, sham-controlled trial (cardiac shockwave therapy for ischemic heart failure, CAST-HF; NCT03859466) patients with LVEF ≤40% requiring surgical revascularisation were enrolled. Patients were randomly assigned to undergo direct cardiac SWT or sham treatment in addition to coronary bypass surgery. The primary efficacy endpoint was the improvement in LVEF measured by cardiac magnetic resonance imaging from baseline to 360 days., Results: Overall, 63 patients were randomized, out of which 30 patients of the SWT group and 28 patients of the Sham group attained 1-year follow-up of the primary endpoint. Greater improvement in LVEF was observed in the SWT group (Δ from baseline to 360 days: SWT 11.3%, SD 8.8; Sham 6.3%, SD 7.4, P = .0146). Secondary endpoints included the 6-minute walking test, where patients randomized in the SWT group showed a greater Δ from baseline to 360 days (127.5 m, SD 110.6) than patients in the Sham group (43.6 m, SD 172.1) (P = .028) and Minnesota Living with Heart Failure Questionnaire score on day 360, which was 11.0 points (SD 19.1) for the SWT group and 17.3 points (SD 15.1) for the Sham group (P = .15). Two patients in the treatment group died for non-device-related reasons., Conclusions: In conclusion, the CAST-HF trial indicates that direct cardiac SWT, in addition to coronary bypass surgery improves LVEF and physical capacity in patients with ischaemic heart failure., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Aortic stenosis (AS) is one of the most prevalent valvular heart-diseases in Europe. Currently, diagnosis and classification are not sex-sensitive; however, due to a distinctly different natural history of AS, further investigations of sex-differences in AS-patients are needed. Thus, this study aimed to detect sex-differences in severe AS, especially concerning flow-patterns, via phase-contrast cardiac magnetic resonance imaging (PC-CMR)., Methods: Forty-four severe AS-patients (20 women, 45 % vs. 24 men, 55 %) with a median age of 72 years underwent transthoracic echocardiography (TTE), cardiac catheterization (CC) and CMR. Aortic valve area (AVA) and stroke volume (SV) were determined in all modalities, with CMR yielding geometrical AVA via cine-planimetry and functional AVA via PC-CMR, the latter being also used to examine flow-properties., Results: Geometrical AVA showed no sex-differences (0.91 cm 2 , IQR: 0.61-1.14 vs. 0.94 cm 2 , IQR: 0.77-1.22, p = 0.322). However, functional AVA differed significantly between sexes in all three modalities (TTE: p = 0.044; CC/PC-CMR: p < 0.001). In men, no significant intermethodical biases in functional AVA-measurements between modalities were found (p = 0.278); yet, in women the particular measurements differed significantly (p < 0.001). Momentary flowrate showed sex-differences depending on momentary opening-degree (at 50 %, 75 % and 90 % of peak-AVA, all p < 0.001), with men showing higher flowrates with increasing opening-area. In women, flowrate did not differ between 75 % and 90 % of peak-AVA (p = 0.191)., Conclusions: In severe AS-patients, functional AVA showed marked sex-differences in all modalities, whilst geometrical AVA did not differ. Inter-methodical biases were negligible in men, but not in women. Lastly, significant sex-differences in flow-patterns fit in with the different pathogenesis of AS., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier B.V.)

Aim: The aim of this study was to investigate predictors of transthoracic echocardiography (TTE)-occult left ventricular (LV) thrombi (LVT) and to propose a clinical model for improved detection of TTE-occult LVT post-ST-elevation myocardial infarction (STEMI). Patients with acute STEMI are at significant risk for developing LVT. However, this complication often (up to 65%) remains undetected by using TTE, referred to as TTE-occult LVT., Methods and Results: In total, 870 STEMI patients underwent TTE and cardiac magnetic resonance (CMR), the reference method for LVT detection, 3 days after infarction. Clinical (body mass index, peak cardiac troponin T) and echocardiographic [ejection fraction, apical wall motion scores (AWMSs)] predictors were analysed. Primary endpoint was the presence of TTE-occult LVT identified by CMR imaging. From the overall cohort, 37 patients (4%) showed an LVT by CMR. Of these thrombi, 25 (68%) were not identified by TTE. Transthoracic echocardiography-occult thrombi did not significantly differ in volume (1.4 vs. 2.74 cm3), diameter (19.0 vs. 23.3 mm), and number of fragments or shape compared with TTE-apparent LVT (all P > 0.05). For predicting these TTE-occult LVT, the 16-segment AWMS (AWMS16Seg) showed highest validity {area under the curve: 0.91 [95% confidence interval (CI): 0.89-0.93]; P < 0.001}, with an association independent of ejection fraction and 17-segment AWMS (AWMS17Seg) [odds ratio: 1.68 (95% CI: 1.43-1.97); P < 0.001] and clinical (body mass index, peak troponin) and angiographic (culprit lesion, post-interventional thrombolysis in myocardial infarction flow) associates of TTE-occult LVT (all P < 0.05). Dichotomization at AWMS16Seg ≥ 8 (n = 260, 30%) allowed for a detection of all TTE-occult LVT (sensitivity: 100%), with a corresponding specificity of 77%., Conclusion: After acute STEMI, AWMS16Seg served as a simple and very robust predictor of TTE-occult LVT. An AWMS16Seg-based algorithm to identify patients for additional CMR imaging offers great potential to optimize detection of TTE-occult LVT following STEMI., Competing Interests: Conflict of interest: None., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Computed tomography (CT) is recommended for guiding transcatheter aortic valve replacement (TAVR). However, a sizable proportion of TAVR candidates have chronic kidney disease, in whom the use of iodinated contrast media is a limitation. Cardiac magnetic resonance imaging (CMR) is a promising alternative, but randomized data comparing the effectiveness of CMR-guided versus CT-guided TAVR are lacking., Methods: An investigator-initiated, prospective, randomized, open-label, noninferiority trial was conducted at 2 Austrian heart centers. Patients evaluated for TAVR according to the inclusion criteria (severe symptomatic aortic stenosis) and exclusion criteria (contraindication to CMR, CT, or TAVR, a life expectancy <1 year, or chronic kidney disease level 4 or 5) were randomized (1:1) to undergo CMR or CT guiding. The primary outcome was defined according to the Valve Academic Research Consortium-2 definition of implantation success at discharge, including absence of procedural mortality, correct positioning of a single prosthetic valve, and proper prosthetic valve performance. Noninferiority was assessed using a hybrid modified intention-to-treat/per-protocol approach on the basis of an absolute risk difference margin of 9%., Results: Between September 11, 2017, and December 16, 2022, 380 candidates for TAVR were randomized to CMR-guided (191 patients) or CT-guided (189 patients) TAVR planning. Of these, 138 patients (72.3%) in the CMR-guided group and 129 patients (68.3%) in the CT-guided group eventually underwent TAVR (modified intention-to-treat cohort). Of these 267, 19 patients had protocol deviations, resulting in a per-protocol cohort of 248 patients (121 CMR-guided, 127 CT-guided). In the modified intention-to-treat cohort, implantation success was achieved in 129 patients (93.5%) in the CMR group and in 117 patients (90.7%) in the CT group (between-group difference, 2.8% [90% CI, -2.7% to 8.2%]; P <0.01 for noninferiority). In the per-protocol cohort (n=248), the between-group difference was 2.0% (90% CI, -3.8% to 7.8%; P <0.01 for noninferiority)., Conclusions: CMR-guided TAVR was noninferior to CT-guided TAVR in terms of device implantation success. CMR can therefore be considered as an alternative for TAVR planning., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT03831087., Competing Interests: Disclosures None.

Aims: To determine the phase-contrast cardiovascular magnetic resonance imaging (PC-CMR) slice-position above aortic leaflet-attachment-plane (LAP) that provides flow-velocity, -volume and aortic valve area (AVA) measurements with best agreement to invasive and echocardiographic measurements in aortic stenosis (AS)., Methods and Results: Fifty-five patients with moderate/severe AS underwent cardiac catheterization, transthoracic echocardiography (TTE) and CMR. Overall, 171 image-planes parallel to LAP were measured via PC-CMR between 22 mm below and 24 mm above LAP. AVA via PC-CMR was calculated as flow-volume divided by peak-velocity during systole. Stroke volume (SV) and AVA were compared to volumetric SV and invasive AVA via the Gorlin-formula, respectively. Above LAP, SV by PC-CMR showed no significant dependence on image-plane-position and correlated strongly with volumetry (rho: 0.633, p < 0.001, marginal-mean-difference (MMD): 1 ml, 95 % confidence-interval (CI): -4 to 6). AVA assessed in image-planes 0-10 mm above LAP differed significantly from invasive measurement (MMD: -0.14 cm 2 , 95 %CI: 0.08-0.21). In contrast, AVA-values by PC-CMR measured 10-20 mm above LAP showed good agreement with invasive determination without significant MMD (0.003 cm 2 , 95 %CI: -0.09 to 0.09). Within these measurements, a plane 15 mm above LAP resulted in the lowest bias (MMD: 0.02 cm 2 , 95 %CI:-0.29 to 0.33). SV and AVA via TTE correlated moderately with volumetry (rho: 0.461, p < 0.001; bias: 15 ml, p < 0.001) and cardiac catheterization (rho: 0.486, p < 0.001, bias: -0.13 cm 2 , p < 0.001), respectively., Conclusion: PC-CMR measurements at 0-10 mm above LAP should be avoided due to significant AVA-overestimation compared to invasive determination. AVA-assessment by PC-CMR between 10 and 20 mm above LAP did not differ from invasive measurements, with the lowest intermethodical bias measured 15 mm above LAP., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Objectives: To investigate the prognostic value of pulmonary transit time (pTT) determined by cardiac magnetic resonance (CMR) after acute ST-segment-elevation myocardial infarction (STEMI)., Methods: Comprehensive CMR examinations were performed in 207 patients 3 days and 4 months after reperfused STEMI. Functional parameters and infarct characteristics were assessed. PTT was defined as the interval between peaks of gadolinium contrast time-intensity curves in the right and left ventricles in first-pass perfusion imaging. Cox regression models were calculated to assess the association between pTT and the occurrence of major adverse cardiac events (MACE), defined as a composite of death, re-infarction, and congestive heart failure., Results: PTT was 8.6 s at baseline and 7.8 s at the 4-month CMR. In Cox regression, baseline pTT (hazard ratio [HR]: 1.58; 95% CI: 1.12 to 2.22; p = 0.009) remained significantly associated with MACE occurrence after adjustment for left ventricular ejection fraction (LVEF) and cardiac index. The association of pTT and MACE remained significant also after adjusting for infarct size and microvascular obstruction size. In Kaplan-Meier analysis, pTT ≥ 9.6 s was associated with MACE (p < 0.001). Addition of pTT to LVEF resulted in a categorical net reclassification improvement of 0.73 (95% CI: 0.27 to 1.20; p = 0.002) and integrated discrimination improvement of 0.07 (95% CI: 0.02 to 0.13; p = 0.007)., Conclusions: After reperfused STEMI, CMR-derived pTT was associated with hard clinical events with prognostic information independent of and incremental to infarct size and LV systolic function., Key Points: • Pulmonary transit time is the duration it takes the heart to pump blood from the right chambers across lung vessels to the left chambers. • This prospective single-centre study showed inferior outcome in patients with prolonged pulmonary transit time after myocardial infarction. • Pulmonary transit time assessed by magnetic resonance imaging added incremental information to established prognostic markers., (© 2022. The Author(s).)

Background: Coronary artery disease (CAD) remains a severe socio-economic burden in the Western world. Coronary obstruction and subsequent myocardial ischemia result in the progressive replacement of contractile myocardium with dysfunctional, fibrotic scar tissue. Post-infarctional remodelling is causal for the concomitant decline of left-ventricular function and the fatal syndrome of heart failure. Available neurohumoral treatment strategies aim at the improvement of symptoms. Despite extensive research, therapeutic options for myocardial regeneration, including (stem)-cell therapy, gene therapy, cellular reprogramming or tissue engineering, remain purely experimental. Thus, there is an urgent clinical need for novel treatment options for inducing myocardial regeneration and improving left-ventricular function in ischemic cardiomyopathy. Shockwave therapy (SWT) is a well-established regenerative tool that is effective for the treatment of chronic tendonitis, long-bone non-union and wound-healing disorders. In preclinical trials, SWT regenerated ischemic myocardium via the induction of angiogenesis and the reduction of fibrotic scar tissue, resulting in improved left-ventricular function., Methods: In this prospective, randomized controlled, single-blind, monocentric study, 80 patients with reduced left-ventricular ejection fraction (LVEF≤ 40%) are subjected to coronary-artery bypass-graft surgery (CABG) surgery and randomized in a 1:1 ratio to receive additional cardiac SWT (intervention group; 40 patients) or CABG surgery with sham treatment (control group; 40 patients). This study aims to evaluate (1) the safety and (2) the efficacy of cardiac SWT as adjunctive treatment during CABG surgery for the regeneration of ischemic myocardium. The primary endpoints of the study represent (1) major cardiac events and (2) changes in left-ventricular function 12 months after treatment. Secondary endpoints include 6-min walk test distance, improvement of symptoms and assessment of quality of life., Discussion: This study aims to investigate the safety and efficacy of cardiac SWT during CABG surgery for myocardial regeneration. The induction of angiogenesis, decrease of fibrotic scar tissue formation and, thus, improvement of left-ventricular function could lead to improved quality of life and prognosis for patients with ischemic heart failure. Thus, it could become the first clinically available treatment strategy for the regeneration of ischemic myocardium alleviating the socio-economic burden of heart failure., Trial Registration: ClinicalTrials.gov NCT03859466. Registered on 1 March 2019., (© 2022. The Author(s).)

Background: Mitral annular disjunction (MAD) represents the detachment of the mitral leaflet hinge-point from the ventricular myocardium. Its role in patients with ST-segment-elevation myocardial infarction (STEMI) is unknown. This study aims to investigate the prevalence of MAD by cardiac magnetic resonance imaging (CMR) in STEMI-patients and its association with serious adverse events., Methods: STEMI-patients (n = 621) underwent CMR 4 days [interquartile range (IQR) 2-5] after percutaneous coronary intervention. Presence and longitudinal extent of MAD were obtained in long-axis cine-images, infarct characteristics in late gadolinium enhancement-images. During a median follow-up time of 366 days (IQR 136-454), patients were observed for the occurrence of major adverse cardiac events (MACE), comprising death, myocardial reinfarction, and congestive heart failure., Results: Overall, 307 patients (49 %) had MAD. Longitudinal MAD-distance was 4.6 ± 1.7 mm and the P3-segment was affected most frequently (n = 262, 85 % of MAD-patients). MAD-patients had a significantly smaller infarct size, lower prevalence of microvascular obstruction, and intramyocardial hemorrhage as well as a higher ejection fraction (all p < 0.03). During follow-up period, MACE occurred in 52 patients (8 %) and did not show significant difference between patients with and without MAD (7 % vs. 9 %, p = 0.424). Cardiovascular death occurred significantly more often in patients without MAD (n = 10, 3.2 % vs. n = 2, 0.7 %, p = 0.021)., Conclusion: MAD is a rather common finding in patients presenting with STEMI. Patients with MAD had less severe infarct characteristics, however, they were not more commonly affected by MACE. Further confirmation and longer follow-up intervals are necessary to define the exact role of MAD in STEMI patients., (Copyright © 2022. Published by Elsevier Ltd.)

Background: The standard procedure for the planning of transcatheter aortic valve replacement (TAVR) is the combination of echocardiography, coronary angiography, and cardiovascular computed tomography (TAVR-CT) for the exact determination of the aortic valve dimensions, valve size, and implantation route. However, up to 80% of the patients undergoing TAVR suffer from chronic renal insufficiency. Alternatives to reduce the need for iodinated contrast agents are desirable. Cardiac magnetic resonance (CMR) imaging recently has emerged as such an alternative. Therefore, we aim to investigate, for the first time, the non-inferiority of TAVR-CMR to TAVR-CT regarding efficacy and safety end-points., Methods: This is a prospective, randomized, open-label trial. It is planned to include 250 patients with symptomatic severe aortic stenosis scheduled for TAVR based on a local heart-team decision. Patients will be randomized in a 1:1 fashion to receive a predefined TAVR-CMR protocol or to receive a standard TAVR-CT protocol within 2 weeks after inclusion. Follow-up will be performed at hospital discharge after TAVR and after 1 and 2 years. The primary efficacy outcome is device implantation success at discharge. The secondary endpoints are a combined safety endpoint and a combined clinical efficacy endpoint at baseline and at 1 and 2 years, as well as a comparison of imaging procedure related variables. Endpoint definitions are based on the updated 2012 VARC-2 consensus document., Discussion: TAVR-CMR might be an alternative to TAVR-CT for planning a TAVR procedure. If proven to be effective and safe, a broader application of TAVR-CMR might reduce the incidence of acute kidney injury after TAVR and thus improve outcomes., Trial Registration: The trial is registered at ClinicalTrials.gov (NCT03831087). The results will be disseminated at scientific meetings and publication in peer-reviewed journals., (© 2022. The Author(s).)

Clinical Issue: Smoking, which affects the whole cardiovascular system, primarily results in atheromatous plaques with risk of vascular stenosis or aneurysmatic vascular changes with risk of rupture., Standard Radiological Methods: Depending on location, sonography provides an initial assessment of alterations. Angiography in combination with computed tomography (CT) and magnetic resonance imaging (MRI) allows further evaluation and, if necessary, therapy planning. In smokers without clinical symptoms or additional risk factors, imaging only because of smoking is not recommended., Methodical Innovations: Recent guidelines of respective pathologies unanimously acknowledge smoking as modifiable risk factor for cardiovascular diseases; therefore, smoking cessation for prevention of secondary acute events is always recommended as the first step. In suspected chronic coronary syndrome, smoking increases clinical probability, which means that diagnostic imaging is often indicated earlier., Performance: Although smoking causes extensive changes to the entire cardiovascular system, it remains to be evaluated whether smokers might profit from modification of current guidelines regarding prevention and diagnosis in terms of specific clinical events., Practical Recommendations: Due to increased cardiovascular risk, smokers should be advised to stop smoking. Regarding specific diseases, smoking does not fundamentally result in modification of imaging evaluation; however, in intermediate risk patients, further imaging can be recommended earlier in smokers., (© 2022. The Author(s).)

Background: In patients with a first ST-segment elevation myocardial infarction (STEMI), the multi-annual evolution of myocardial tissue injury parameters, as assessed by cardiac magnetic resonance (CMR), has not yet been described., Objectives: This study examined myocardial tissue injury dynamics over a decade after STEMI., Methods: Sequential CMR examinations (within the first week after STEMI, and at 4, 12, months, and 9 years thereafter) were conducted in 74 patients with STEMI treated with primary percutaneous coronary intervention. Left ventricular function, infarct size (IS), and microvascular obstruction (MVO) were assessed at all time points. T2∗, T2, and T1 mapping (n = 59) were added at 9-year scan to evaluate the presence of iron and edema within the infarct core, respectively., Results: IS decreased progressively and significantly between all CMR time points (all P < 0.001), with an average reduction rate of 5.8% per year (IQR: 3.5%-8.8%) and a relative reduction of 49% (IQR: 39%-76%) over a decade. MVO was present in 61% of patients at baseline, but was not present at the follow-up examinations. At 9-year CMR, 17 of 59 (29%) patients showed iron deposition within the infarct core, whereas 82% had persistent edema. Persistent iron and edema were associated with greater IS on any occasion (all P < 0.001), as well as the presence of MVO (P < 0.001). Patients with persistent iron and edema showed a lower relative regression of IS (P = 0.005 and P = 0.032, respectively) and greater end-systolic volumes over a decade (all P < 0.012 and P > 0.023, respectively). A T1 hypointense infarct core without evidence of T2∗ iron deposition (14 of 59 [24%] patients) was attributed to lipomatous metaplasia of the infarct., Conclusions: The evolution of IS is a dynamic process that extends well beyond the first few months after STEMI. Persistence of iron and edema within the infarct core occurs up to a decade after STEMI and is associated with initial infarct severity and poor infarct healing., Competing Interests: Funding Support and Author Disclosures The study was supported by grants from the Austrian Science Fund (FWF): KLI 772-B (BM) and by the Austrian Society of Cardiology. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: Comparison of puncture deviation and puncture duration between computed tomography (CT)- and C-arm CT (CACT)-guided puncture performed by residents in training (RiT)., Methods: In a cohort of 25 RiTs enrolled in a research training program either CT- or CACT-guided puncture was performed on a phantom. Prior to the experiments, the RiT's level of training, experience playing a musical instrument, video games, and ball sports, and self-assessed manual skills and spatial skills were recorded. Each RiT performed two punctures. The first puncture was performed with a transaxial or single angulated needle path and the second with a single or double angulated needle path. Puncture deviation and puncture duration were compared between the procedures and were correlated with the self-assessments., Results: RiTs in both the CT guidance and CACT guidance groups did not differ with respect to radiologic experience (p = 1), angiographic experience (p = 0.415), and number of ultrasound-guided puncture procedures (p = 0.483), CT-guided puncture procedures (p = 0.934), and CACT-guided puncture procedures (p = 0.466). The puncture duration was significantly longer with CT guidance (without navigation tool) than with CACT guidance with navigation software (p < 0.001). There was no significant difference in the puncture duration between the first and second puncture using CT guidance (p = 0.719). However, in the case of CACT, the second puncture was significantly faster (p = 0.006). Puncture deviations were not different between CT-guided and CACT-guided puncture (p = 0.337) and between the first and second puncture of CT-guided and CACT-guided puncture (CT: p = 0.130; CACT: p = 0.391). The self-assessment of manual skills did not correlate with puncture deviation (p = 0.059) and puncture duration (p = 0.158). The self-assessed spatial skills correlated positively with puncture deviation (p = 0.011) but not with puncture duration (p = 0.541)., Conclusion: The RiTs achieved a puncture deviation that was clinically adequate with respect to their level of training and did not differ between CT-guided and CACT-guided puncture. The puncture duration was shorter when using CACT. CACT guidance with navigation software support has a potentially steeper learning curve. Spatial skills might accelerate the learning of image-guided puncture., Key Points: · The CT-guided and CACT-guided puncture experience of the RiTs selected as part of the program "Researchers for the Future" of the German Roentgen Society was adequate with respect to the level of training.. · Despite the lower collective experience of the RiTs with CACT-guided puncture with navigation software assistance, the learning curve regarding CACT-guided puncture may be faster compared to the CT-guided puncture technique.. · If the needle path is complex, CACT guidance with navigation software assistance might have an advantage over CT guidance.., Citation Format: · Meine TC, Hinrichs JB, Werncke T et al. Phantom study for comparison between computed tomography- and C-Arm computed tomography-guided puncture applied by residents in radiology. Fortschr Röntgenstr 2022; 194: 272 - 280., Competing Interests: Lorenz Biggemann: L. B. declares travel grant from Siemens Healthineers and speakers honorarium from Bristol Myer-Squibb unrelated to this project.Jan –Peter Grunz: J.-P. G. declares employment as “Research Consultant” at Siemens Healthineers unrelated to this project.Markus Kopp: M. B. declares participation at the Siemens Healthineers speakers’ bureau unrelated to this project.Simon Lennartz: S. L. declares institutional research support from Philips unrelated to this project.Timo C. Meine: T.C.M. declares passive participation at the BTG TheraSphere™ DACH Summit 2018 unrelated to this to this project.Bernhard C. Meyer: B.C.M. declares relationships with Siemens Healthcare and ProMedicus (outside the submitted work).Frank K. Wacker: F. K. W. declares relationships with Siemens Healthcare and ProMedicus (outside the submitted work).David Zopfs: D. Z. declares institutional research support from Philips Healthcare unrelated to this project., (Thieme. All rights reserved.)

Background: Transthoracic echocardiography (TTE) is the diagnostic routine standard for assessing aortic stenosis (AS). However, its inaccuracies in determining stroke volume (SV) and aortic valve area (AVA) call for a more precise and dependable method. Phase-contrast cardiovascular magnetic resonance imaging (PC-CMR) is a promising tool to push these boundaries. Thus, the aim of this study was to validate a novel approach based on PC-CMR against the gold-standard of invasive determination of AVA in AS compared to TTE., Methods: A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR. AVA via PC-CMR was determined by plotting momentary flow across the valve against flow-velocity. SV by CMR was measured directly via PC-CMR and volumetrically using cine-images. Invasive SV and AVA were determined via Fick-principle and Gorlin-formula, respectively. TTE yielded SV and AVA using continuity equation. Gradients were calculated via the modified Bernoulli-equation., Results: SV by PC-CMR (85 ± 31 ml) correlated strongly (r: 0.73, p < 0.001) with cine-CMR (85 ± 19 ml) without significant bias (lower and upper limits of agreement (LLoA and ULoA): - 41 ml and 44 ml, p = 0.83). In PC-CMR, mean pressure gradient correlated significantly with invasive determination (r: 0.36, p = 0.011). Mean AVA, as determined by PC-CMR during systole (0.78 ± 0.25 cm 2 ), correlated moderately (r: 0.54, p < 0.001) with invasive AVA (0.70 ± 0.23 cm 2 ), resulting in a small bias of 0.08 cm 2 (LLoA and ULoA: - 0.36 cm 2 and 0.55 cm 2 , p = 0.017). Inter-methodically, AVA by TTE (0.81 ± 0.23 cm 2 ) compared to invasive determination showed similar correlations (r: 0.58, p < 0.001 with a bias of 0.11 cm 2 , LLoA and ULoA: - 0.30 and 0.52, p < 0.001) to PC-CMR. Intra- and interobserver reproducibility were excellent for AVA (intraclass-correlation-coefficients of 0.939 and 0.827, respectively)., Conclusions: Our novel approach using continuous determination of flow-volumes and velocities with PC-CMR enables simple AVA measurement with no bias to invasive assessment. This approach highlights non-invasive AS grading through CMR, especially when TTE findings are inconclusive., (© 2021. The Author(s).)

Aim: We aimed to investigate the comparative prognostic value of left ventricular ejection fraction (LVEF), mitral annular plane systolic excursion (MAPSE), fast manual long-axis strain (LAS) and global longitudinal strain (GLS) determined by cardiac magnetic resonance (CMR) in patients after ST-segment elevation myocardial infarction (STEMI)., Methods and Results: This observational cohort study included 445 acute STEMI patients treated with primary percutaneous coronary intervention (pPCI). Comprehensive CMR examinations were performed 3 [interquartile range (IQR): 2-4] days after pPCI for the determination of left ventricular (LV) functional parameters and infarct characteristics. Primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as composite of death, re-infarction and congestive heart failure. During a follow-up of 16 [IQR: 12-49] months, 48 (11%) patients experienced a MACE. LVEF (p = 0.023), MAPSE (p < 0.001), LAS (p < 0.001) and GLS (p < 0.001) were significantly related to MACE. According to receiver operating characteristic analyses, only the area under the curve (AUC) of GLS was significantly higher compared to LVEF (0.69, 95% confidence interval (CI) 0.64-0.73; p < 0.001 vs. 0.60, 95% CI 0.55-0.65; p = 0.031. AUC difference: 0.09, p = 0.020). After multivariable analysis, GLS emerged as independent predictor of MACE even after adjustment for LV function, infarct size and microvascular obstruction (hazard ratio (HR): 1.13, 95% CI 1.01-1.27; p = 0.030), as well as angiographical (HR: 1.13, 95% CI 1.01-1.28; p = 0.037) and clinical parameters (HR: 1.16, 95% CI 1.05-1.29; p = 0.003)., Conclusion: GLS emerged as independent predictor of MACE after adjustment for parameters of LV function and myocardial damage as well as angiographical and clinical characteristics with superior prognostic validity compared to LVEF., (© 2021. The Author(s).)

Objectives: To prospectively compare image-quality, reliability and graft sizing of a prototype self-navigated and a navigator-gated non-contrast three dimensional (3D) whole-heart magnetic-resonance-angiography (MRA) sequence with computed-tomography-angiography (CTA) for planning transcatheter-aortic-valve-implantation (TAVI)., Methods: Self- and navigator-gated 1.5 T MRA were performed in 27 patients (aged 83 ± 5 years, 41 % male) for aortic root sizing and coronary ostia height measurements; 15 (56 %) patients underwent additional CTA. Subjective-image quality was graded on a 4-point Likert scale, objective MRA image-quality was assessed by signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR). Continuous MRA and CTA measurements were analyzed with regression and Bland-Altman analysis, valve sizing by kappa statistics., Results: Median image-quality as rated by two observers was 1.5 [interquartile range (IQR) 1-3] for self-navigated MRA and 1 [IQR 1-2] for navigator-gated MRA (p = 0.059). SNR and CNR were comparable between MRA sequences (p = 0.471 and 0.445, respectively). Acquisition time was shorter for self-navigated MRA compared to navigator-gated MRA (5.5 ± 1 min vs, 6.5 ± 2 min, p = 0.029). Inter-observer correlation of aortic root measurements was high to very high for both self- and navigator-gated MRA (r = 0.75 to 0.94 and r = 0.85 to 0.96, respectively, all p < 0.0001). Theoretical prosthetic valve sizing of self-navigated MRA and CTA was equivalent (κ = 1). However, in four patients (15 %) one coronary ostium each (right coronary artery 3, left main artery 1) was not clearly definable on self-navigated MRA., Conclusion: Self-navigated MRA enables aortic annulus TAVI measurements without significant difference to navigator-gated MRA at shortened acquisition time. Prosthesis sizing by self-navigated MRA measurements is equivalent to navigator-gated MRA and CTA-based choice., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Purpose: To prospectively compare image quality and reliability of a non-contrast, self-navigated 3D whole-heart magnetic resonance angiography (MRA) sequence with contrast-enhanced computed tomography angiography (CTA) for sizing of thoracic aortic aneurysm (TAA)., Methods: Self-navigated 3D whole-heart 1.5 T MRA was performed in 20 patients (aged 67 ± 9 years, 75% male) for sizing of TAA; a subgroup of 18 (90%) patients underwent additional contrast-enhanced CTA on the same day. Subjective image quality was scored according to a 4-point Likert scale and ratings between observers were compared by Cohen's Kappa statistics. For MRA, subjective motion blurring and signal inhomogeneity was rated according to a 3-point scale, respectively. Objective signal inhomogeneity of MRA was quantified as standard deviation of the voxel intensities in a circular region of interest (ROI) placed in the ascending aorta divided by their mean value. Continuous MRA and CTA measurements were analyzed with regression and Bland-Altman analysis., Results: Overall subjective image quality as rated by two observers was 1 [interquartile range (IQR) 1-2] for self-navigated MRA and 1.5 [IQR 1-2] for CTA (p = 0.717). For MRA, perfect inter-observer agreement was found regarding presence of artefacts and subjective image sharpness (κ = 1). Subjective signal inhomogeneity agreed moderately between the observers (κ = 0.58, p = 0.007), however, it correlated strongly with objectively quantified inhomogeneity of the blood pool signal (r = 0.78, p < 0.0001). Maximum diameters of TAA as measured by self-navigated MRA and CTA showed very strong correlation (r = 0.99, p < 0.0001) without significant inter-method bias (bias -0.03 mm, lower and upper limit of agreement -0.74 and 0.68 mm, p = 0.749). Inter-observer correlation of aortic aneurysm as measured by MRA was very strong (r = 0.96) without significant bias (p = 0.695)., Conclusion: Self-navigated 3D whole-heart MRA enables reliable contrast- and radiation free aortic dilation surveillance without significant difference to standardized CTA while providing predictable acquisition time and offering excellent image quality., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The role of left ventricular (LV) myocardial strain by cardiac magnetic resonance feature tracking (CMR-FT) for the prediction of adverse remodeling following ST-elevation myocardial infarction (STEMI), as well as its prognostic validity compared to LV ejection fraction (LVEF) and CMR infarct severity parameters, is unclear. This study aimed to evaluate the independent and incremental value of LV strain by CMR-FT for the prediction of adverse LV remodeling post-STEMI., Methods: STEMI patients treated with primary percutaneous coronary intervention were enrolled in this prospective observational study. CMR core laboratory analysis was performed to assess LVEF, infarct pathology and LV myocardial strain. The primary endpoint was adverse remodeling, defined as ≥ 20% increase in LV end-diastolic volume from baseline to 4 months., Results: From the 232 patients included, 38 (16.4%) reached the primary endpoint. Global longitudinal strain (GLS), global radial strain, and global circumferential strain were all predictive of adverse remodeling (p < 0.01 for all), but only GLS was an independent predictor of adverse remodeling (odds ratio: 1.36[1.03-1.78]; p = 0.028) after adjustment for strain parameters, LVEF and CMR markers of infarct severity. A GLS > - 14% was associated with a fourfold increase in the risk for LV remodeling (odds ratio: 4.16[1.56-11.13]; p = 0.005). Addition of GLS to a baseline model comprising LVEF, infarct size and microvascular obstruction resulted in net reclassification improvement of 0.26 ([0.13-0.38]; p < 0.001) and integrated discrimination improvement of 0.02 ([0.01-0.03]; p = 0.006)., Conclusions: In STEMI survivors, determination of GLS using CMR-FT provides important prognostic information for the development of adverse remodeling that is incremental to LVEF and CMR markers of infarct severity., Clinical Trial Registration: NCT04113356.

Objectives: To prospectively compare unenhanced quiescent-interval single-shot MR angiography (QISS-MRA) with contrast-enhanced computed tomography angiography (CTA) for contrast-free guidance in transcatheter aortic valve intervention (TAVI)., Methods: Twenty-six patients (mean age 83 ± 5 years, 15 female [58%]) referred for TAVI evaluation underwent QISS-MRA for aortoiliofemoral access guidance and non-contrast three-dimensional (3D) "whole heart" MRI for prosthesis sizing on a 1.5-T system. Contrast-enhanced CTA was performed as imaging gold standard for TAVI planning. Image quality was assessed by a 4-point Likert scale; continuous MRA and CTA measurements were compared with regression and Bland-Altman analyses., Results: QISS-MRA and CTA-based measurements of aortoiliofemoral vessel diameters correlated moderately to very strong (r = 0.572 to 0.851, all p ≤ 0.002) with good to excellent inter-observer reliability (intra-class correlation coefficient (ICC) = 0.862 to 0.999, all p < 0.0001) regarding QISS assessment. Mean diameters of the infrarenal aorta and iliofemoral vessels differed significantly (bias 0.37 to 0.98 mm, p = 0.041 to < 0.0001) between the two modalities. However, inter-method decision for transfemoral access route was comparable (κ = 0.866, p < 0.0001). Aortic root parameters assessed by 3D whole heart MRI strongly correlated (r = 0.679 to 0.887, all p ≤ 0.0001) to CTA measurements., Conclusion: QISS-MRA provides contrast-free access route evaluation in TAVI patients with moderate to strong correlations compared with CTA and substantial inter-observer agreement. Despite some significant differences in minimal vessel diameters, inter-method agreement for transfemoral accessibility is strong. Combination with 3D whole heart MRI facilitates unenhanced TAVI guidance., Key Points: • QISS-MRA and CTA inter-method agreement for transfemoral approach is strong. • QISS-MRA is a very good alternative to CTA and MRA especially in patients with Kidney Disease Outcomes Quality Initiativestages 4 and 5. • Combination of QISS-MRA and 3D "whole heart" MRI facilitates fully unenhanced TAVI guidance.

Background: Coronary artery diseases (CAD) remains a severe socio-economic burden in the Western world. Coronary obstruction and subsequent myocardial ischemia result in progressive replacement of contractile myocardium with dysfunctional, fibrotic scar tissue. Post-infarctional remodeling is causal for the concomitant decline of left-ventricular function and the fatal syndrome of heart failure. Available neurohumoral treatment strategies aim at the improvement of symptoms. Despite extensive research, therapeutic options for myocardial regeneration, including (stem)-cell therapy, gene therapy, cellular reprogramming or tissue engineering, remain purely experimental. Thus, there is an urgent clinical need for novel treatment options for inducing myocardial regeneration and improving left-ventricular function in ischemic cardiomyopathy. Shockwave Therapy (SWT) is a well-established regenerative tool that is effective for the treatment of chronic tendonitis, long-bone non-union and wound-healing disorders. In preclinical trials, SWT regenerated ischemic myocardium via the induction of angiogenesis and the reduction of fibrotic scar tissue, resulting in improved left-ventricular function., Methods/design: In this prospective, randomized controlled, single-blind, monocentric study, 80 patients with reduced left-ventricular ejection fraction (LVEF≤ 40%) are subjected to coronary-artery bypass-graft surgery (CABG) surgery and randomized in a 1:1 ratio to receive additional cardiac SWT (intervention group; 40 patients) or CABG surgery with sham treatment (control group; 40 patients). This study aims to evaluate (1) the safety and (2) the efficacy of cardiac SWT as adjunctive treatment during CABG surgery for the regeneration of ischemic myocardium. The primary endpoints of the study represent (1) major cardiac events and (2) changes in left-ventricular function 12 months after treatment. Secondary endpoints include 6-min Walk Test distance, improvement of symptoms and assessment of quality of life., Discussion: This study aims to investigate the safety and efficacy of cardiac SWT during CABG surgery for myocardial regeneration. The induction of angiogenesis, decrease of fibrotic scar tissue formation and, thus, improvement of left-ventricular function could lead to improved quality of life and prognosis for patients with ischemic heart failure. Thus, it could become the first clinically available treatment strategy for the regeneration of ischemic myocardium alleviating the socio-economic burden of heart failure., Trial Registration: ClinicalTrials.gov, ID: NCT03859466. Registered on 1 March 2019.

Background: For patients suffering from acute ST-elevation myocardial infarction (STEMI), it is controversial whether infarct location predicts worse clinical outcome independently of infarct size. We therefore aimed to investigate the prognostic relevance of infarct location in relation to infarct size in STEMI patients treated with contemporary primary percutaneous coronary intervention (PCI)., Methods: Cardiac magnetic resonance was performed in 355 patients with acute STEMI 3 (interquartile range [IQR]: 2-4) days after primary PCI. Infarct location, infarct size, and microvascular obstruction were assessed by late gadolinium enhancement (LGE). Patients were followed for major adverse cardiac events (MACE) at a median follow-up of 35 (IQR: 12-52) months., Results: One hundred and sixty five patients (47%) had anterior STEMI. These patients had a greater infarct size as compared to non-anterior STEMI patients (19 vs. 12% of left ventricular myocardial mass, p < .001), but no significant differences in microvascular obstruction occurrence and extent (p = .26 and p = .09, respectively). MACE occurred in 39 patients (11%). Patients with anterior STEMI had a higher risk of MACE (hazard ratio: 2.01; 95% confidence interval: 1.05-3.83; p = .03). In multivariable analysis, infarct severity by LGE imaging but not its location was independently associated with an increased risk of MACE (hazard ratio: 1.03; 95% confidence interval: 1.01-1.06; p = .01)., Conclusions: The higher rate of medium-term MACE in anterior STEMI treated with contemporary primary PCI is explained by a larger extent of myocardial damage as determined by CMR imaging without any further contribution of infarct location., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background In survivors of acute ST-segment-elevation myocardial infarction (STEMI), increased aortic stiffness is associated with worse clinical outcome; however, the underlying pathomechanisms are incompletely understood. We aimed to investigate associations between aortic stiffness and infarct healing using comprehensive cardiac magnetic resonance imaging in patients with acute STEMI. Methods and Results This was a prospective observational study including 103 consecutive STEMI patients treated with primary percutaneous coronary intervention. Pulse wave velocity (PWV), the reference standard for aortic stiffness assessment, was determined by a validated phase-contrast cardiac magnetic resonance imaging protocol within the first week after STEMI. Infarct healing, defined as relative infarct size reduction from baseline to 4 months post-STEMI, was determined using late gadolinium-enhanced cardiac magnetic resonance. Median infarct size significantly decreased from 17% of left ventricular mass (interquartile range 9% to 28%) at baseline to 12% (6% to 17%) at 4-month follow-up ( P <0.001). Relative infarct size reduction was 36% (interquartile range 15% to 52%). Patients with a reduction >36% were younger ( P =0.01) and had lower baseline NT-proBNP (N-terminal pro-B-type natriuretic peptide) concentrations ( P =0.047) and aortic PWV values ( P =0.003). In a continuous (odds ratio 0.64 [95% CI, 0.49-0.84]; P =0.001) as well as categorical (PWV <7 m/s; odds ratio 4.80 [95% CI, 1.89-12.20]; P =0.001) multivariable logistic regression model, the relation between aortic PWV and relative infarct size reduction remained significant after adjustment for baseline infarct size, age, NT-proBNP, and C-reactive protein. Conclusions Aortic PWV independently predicted infarct size reduction as assessed by cardiac magnetic resonance, revealing a novel pathophysiological link between aortic stiffness and adverse infarct healing during the early phase after STEMI treated with contemporary primary percutaneous coronary intervention.

Objectives: The purpose of this study was to assess the comparative prognostic value of mitral annular plane systolic excursion (MAPSE) versus left ventricular ejection fraction (LVEF), measured by cardiac magnetic resonance (CMR) imaging in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI)., Methods: CMR was performed in 255 STEMI patients within 2 days (interquartile range (IQR) 2-4 days) after infarction. CMR included MAPSE measurement on CINE 4-chamber view. Patients were followed for major adverse cardiovascular events (MACE)-death, non-fatal myocardial re-infarction, stroke, and new congestive heart failure., Results: Patients with MACE (n = 35, 14%, median follow-up 3 years [IQR 1-4 years]) showed significantly lower MAPSE (8 mm [7-8.8] vs. 9.6 mm [8.1-11.5], p < 0.001). The association between decreased MAPSE (< 9 mm, optimal cut-off value by c-statistics) remained significant after adjustment for independent clinical and CMR predictors of MACE. The AUC of MAPSE for the prediction of MACE was 0.74 (CI 95% 0.65-0.82), significantly higher than that of LVEF (0.61 [CI 95% 0.50-0.71]; p < 0.001)., Conclusions: Reduced long-axis function assessed with MAPSE measurement using CINE CMR independently predicts long-term prognosis following STEMI. Moreover, MAPSE provided significantly higher prognostic implication in comparison with conventional LVEF measurement., Key Points: • MAPSE determined by CMR independently predicts long-term prognosis following STEMI. • MACE-free survival is significantly higher in patients with MAPSE ≥ 9 mm than < 9 mm. • MAPSE provides significantly higher prognostic implication than conventional LVEF.

Background: Sarcopenia is an established risk factor predicting survival in chronically ill and trauma patients. We herein examine the assessment and clinical implication of sarcopenia in liver transplantation (LT)., Methods: Computerized tomography scans from 172 patients waitlisted for LT were analyzed by applying 6 morphometric muscle scores, including 2 density indices (psoas density [PD] and skeletal muscle density [SMD]) and 4 scores based on muscle area (total psoas area, psoas muscle index, skeletal muscle area, and skeletal muscle index)., Results: The prevalence of sarcopenia in our cohort ranged from 7.0% to 37.8%, depending on the score applied. Only sarcopenia as defined by the density indices PD and SMD (but not total psoas area, psoas muscle index, skeletal muscle area, or skeletal muscle index) revealed clinical relevance since it correlates significantly with postoperative complications (≥Grade III, Clavien-Dindo classification) and sepsis. Furthermore, sarcopenia predicted inferior patient and graft survival, with low muscle density (PD: <38.5 HU or SMD: <30 HU) representing an independent risk factor in a multivariate regression model (P < 0.05). Importantly, the widely used Eurotransplant donor risk index had a predictive value in nonsarcopenic patients but failed to predict graft survival in patients with sarcopenia., Conclusions: Sarcopenia revealed by low muscle density correlates with major complications following LT and acts as an independent predictor for patient and graft survival. Therefore, the application of a simple computerized tomography-morphologic index can refine an individual recipient's risk estimate in a personalized approach to transplantation.

Background: The high accuracy of feature-tracking cardiac magnetic resonance (CMR) imaging qualifies this novel modality as potential gold standard for myocardial strain analyses in ST-elevation myocardial infarction patients; however, the incremental prognostic validity of feature-tracking-CMR over left ventricular ejection fraction (LVEF) and myocardial damage remains unclear. This study therefore aimed to determine the value of myocardial strain measured by feature-tracking-CMR for the prediction of clinical outcome following ST-elevation myocardial infarction., Methods: This prospective observational study enrolled 451 revascularized ST-elevation myocardial infarction patients. Comprehensive CMR investigations were performed 3 (interquartile range, 2-4) days after infarction to determine LVEF, global longitudinal strain (GLS), global radial strain, and global circumferential strain as well as myocardial damage. Primary end point was a composite of death, re-infarction, and congestive heart failure (major adverse cardiac events [MACE])., Results: During a follow-up of 24 (interquartile range, 11-48) months, 46 patients (10%) experienced a MACE event. All 3 strain indices were impaired in patients with MACE (all P <0.001). However, GLS emerged as the strongest MACE prognosticator among strain parameters (area under the curve, 0.73 [95% CI, 0.69-0.77]) and was significantly better ( P =0.005) than LVEF (area under the curve, 0.64 [95% CI, 0.59-0.68]). The association between GLS and MACE remained significant ( P <0.001) after adjustment for global radial strain, global circumferential strain, and LVEF as well as for infarct size and microvascular obstruction. The addition of GLS to a risk model comprising LVEF, infarct size, and microvascular obstruction led to a net reclassification improvement (0.35 [95% CI, 0.14-0.55]; P <0.001)., Conclusions: GLS by feature-tracking-CMR strongly and independently predicted the occurrence of medium-term MACE in contemporary revascularized ST-elevation myocardial infarction patients. Importantly, the prognostic value of GLS was superior and incremental to LVEF and CMR markers of infarct severity.

Background Acute complete occlusion of a coronary artery results in progressive ischemia, moving from the endocardium to the epicardium (ie, wavefront). Dependent on time to reperfusion and collateral flow, myocardial infarction ( MI ) will manifest, with transmural MI portending poor prognosis. Late gadolinium enhancement cardiac magnetic resonance imaging can detect MI with  high diagnostic accuracy. Primary percutaneous coronary intervention is the preferred reperfusion strategy in patients with ST -segment-elevation MI with <12 hours of symptom onset. We sought to visualize time-dependent necrosis in a population with ST -segment-elevation MI by using late gadolinium enhancement cardiac magnetic resonance imaging (STEMI-SCAR project). Methods and Results ST -segment-elevation MI patients with single-vessel disease, complete occlusion with TIMI (Thrombolysis in Myocardial Infarction) score 0, absence of collateral flow (Rentrop score 0), and symptom onset <12 hours were consecutively enrolled. Using late gadolinium enhancement cardiac magnetic resonance imaging, the area at risk and infarct size, myocardial salvage index, transmurality index, and transmurality grade (0-50%, 51-75%, 76-100%) were determined. In total, 164 patients (aged 54±11 years, 80% male) were included. A receiver operating characteristic curve (area under the curve: 0.81) indicating transmural necrosis revealed the best diagnostic cutoff for a symptom-to-balloon time of 121 minutes: patients with >121 minutes demonstrated increased infarct size, transmurality index, and transmurality grade (all P<0.01) and decreased myocardial salvage index ( P<0.001) versus patients with symptom-to-balloon times ≤121 minutes. Conclusions In MI with no residual antegrade and no collateral flow, immediate reperfusion is vital. A symptom-to-balloon time of >121 minutes causes a high grade of transmural necrosis. In this pure ST -segment-elevation MI population, time to reperfusion to salvage myocardium was less than suggested by current guidelines.

Purpose: To compare agreement between conventional B-mode ultrasound (US) and compression sonoelastography (SEL) of the common extensor tendons of the elbow with histological evaluation., Materials and Methods: Twenty-six common extensor tendons were evaluated in 17 cadavers (11 females, median age 85 years and 6 males, median age 80 years). B-mode US was graded into: Grade 1, homogeneous fibrillar pattern; grade 2, hypoechoic areas and/or calcifications <30%; and grade 3 > 30%. SEL was graded into: Grade 1 indicated blue (hardest) to green (hard); grade 2 yellow (soft); and grade 3 red (softest). B-mode US, SEL, and a combined grading score incorporating both were compared to histological findings in 76 biopsies., Results: Histological alterations were detected in 55/76 biopsies. Both modalities showed similar results (sensitivity, specificity, and accuracy 84%, 81%, and 83% for B-mode US versus 85%, 86%, and 86% for SEL, respectively, P > 0.3). However, a combination of both resulted in significant improvement in sensitivity (96%, P < 0.02) without significant change in specificity (81%, P < 0.3), yielding an improved overall accuracy (92%)., Conclusion: Combined imaging of the extensor tendons with both modalities is superior to either modality alone for predicting the presence of pathologic findings on histology., Key Points: • Combination of B-mode US and SEL proved efficiency in diagnosing lateral epicondylitis. • Combination of B-mode US and SEL in lateral epicondylitis correlates to histology. • Combination of both modalities provides improved sensitivity without loss of specificity.

Background: Recent studies have described the presence of the anterolateral ligament (ALL). However, there is still no consensus regarding the anatomy of this structure with the topic controversially discussed. The aim of this study was to provide an anatomical description of the ligamentous structures on the anterolateral side of the knee with special emphasis on the ALL., Methods: Forty-four human cadaveric knees were dissected to reveal the ALL and other significant structures in the anterolateral compartment of the knee joint. The ALL was defined as a firm structure running in an oblique direction from the lateral femoral epicondyle to a bony insertion at the anterolateral tibia., Results: The ALL was identified in 45.5% (n=20) of the dissected knee joints. The structure originates together with the fibular collateral ligament (45%) or just posterior and proximal to it (55%). The ligament has an extra-capsular, anteroinferior, oblique course to the anterolateral tibia with a bony insertion between Gerdy's tubercle and the fibular head. The ALL had its greatest extend at 60° of knee flexion and maximal internal rotation., Conclusion: The ALL is a firm ligamentous structure in the anterolateral part of the knee present in 45.5% of the cases. Given the course and characteristics of this structure, a function in providing rotational stability by preventing internal rotation of the knee is likely., Clinical Relevance: The ALL might be an important stabilizer in the knee and may play a significant role in preventing excessive internal tibial rotation and subluxation of the knee joint., (Copyright © 2015 Elsevier B.V. All rights reserved.)