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Pectus excavatum (PE) is a congenital malformation with a funnel-shaped depression of the sternum that can lead to cardiac symptoms. However, there are patients with thoracic constriction (defined as elevated Haller-Index > 3.25 determined by cardiac magnetic resonance imaging (CMR)) without visible evidence of PE, leading to similar complaints. Between January 2004 till June 2020, patients who underwent CMR for further evaluation of the heart, due to cardiac symptoms were enrolled and compared to controls. Biventricular global strain analysis was assessed using feature tracking (CMR-FT). ECG and/or Holter recordings were performed to detect rhythm events. Cardiac symptoms were evaluated in detail using a questionnaire. Finally, 88 patients (male 35, female 53) with elevated Haller-Index (3.9 ± 0.8) were included and compared to CMR data from 25 individuals with confirmed PE and 25 healthy controls (HC). Mean age at time of CMR was 35 ± 16 years. The most common symptoms at presentation were palpitations (41%), followed by dyspnea (24%) and atypical chest pain (14%). Three patients (3%) had atrial fibrillation or atrial flutter. Concomitant phenomena were pericardial effusion in 39% and mitral valve prolapse (MVP) in 27% of the study cohort. While there were no differences in left ventricular function or volumes, right ventricular function (RVEF) was significantly lower in patients with internal PE compared to HC (RVEF (%) 50 ± 5 vs 59 ± 4, p < 0.01). Strain analysis revealed only discrete changes in RV strain, implying a purely mechanical problem in the absence of structural changes. RV dimensions were negatively correlated with the size of thoracic indices (r = 0.41), reflecting the extent of thoracic constriction. MVP was more prevalent in patients with greater thoracic indices (r = 0.24). The described cohort, referred to as internal PE because of the absence of external changes, showed similar CMR morphologic findings as patients with real PE (especially altered dimensions of the right heart and a lower RVEF). In addition, there was a high incidence of rhythm disturbances, such as extrasystoles or arrhythmias. In one-third of the study cohort additional abnormalities such as pericardial effusion or MVP were present, with MVP being found more frequently in patients with larger thoracic indices, suggesting a possible common pathogenesis.Trial registration: ISRCTN registry, ISRCTN15355937, retrospectively registered 03.06.2022, https://www.isrctn.com/ISRCTN15355937?q=15355937&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10 ., (© 2023. The Author(s).)

We hypothesized that myocardial septal scarring, assessed by cardiac magnetic resonance (CMR) using late gadolinium enhancement (LGE), at the site of cardiac contractility modulation (CCM) lead placement may predict treatment response. Eligible heart failure (HF) patients underwent LGE CMR imaging before CCM device implantation. The response to CCM therapy at follow-up was determined by a change in NYHA class and echocardiographic left ventricular ejection fraction (LVEF) assessment. Patients were classified as responders, if they showed an improvement in either NYHA class or improvement of LVEF by ≥ 5%. 58 patients were included. 67% of patients were classified as responders according to improved NYHA; 55% according to LVEF improvement. 74% of patients were responders if either NYHA class or LVEF improvement was observed. 90% of responders (according to NYHA class) showed septal LGE < 25% at septal position of the leads, while 44% of non-responders showed septal LGE > 25% (p < 0.01). In patients treated with CCM, an improvement of NYHA class was observed when leads were placed at myocardial segments with a CMR- LGE burden less than 25%., (© 2022. The Author(s).)

Myocardial T 1 -mapping, a cardiac magnetic resonance imaging technique, facilitates a quantitative measure of fibrosis which is linked to numerous cardiovascular symptoms. To overcome the problems of common techniques, including lack of accuracy and robustness against partial-voluming and heart-rate variability, we introduce a systolic saturation-recovery T 1 -mapping method. The Saturation-Pulse Prepared Heart-rate independent Inversion-Recovery (SAPPHIRE) T 1 -mapping method was modified to enable imaging during systole. Phantom measurements were used to evaluate the insensitivity of systolic T 1 -mapping towards heart-rate variability. In-vivo feasibility and accuracy were demonstrated in ten healthy volunteers with native and post-contrast T 1 -mappping during systole and diastole. To show benefits in the presence of RR-variability, six arrhythmic patients underwent native T 1 -mapping. Resulting systolic SAPPHIRE T 1 -values showed no dependence on arrhythmia in phantom (CoV < 1%). In-vivo, significantly lower T 1 (1563 ± 56 ms, precision: 84.8 ms) and ECV-values (0.20 ± 0.03) than during diastole (T 1  = 1580 ± 62 ms, p = 0.0124; precision: 60.2 ms, p = 0.03; ECV = 0.21 ± 0.03, p = 0.0098) were measured, with a strong correlation of systolic and diastolic T 1 (r = 0.89). In patients, mis-triggering-induced motion caused significant imaging artifacts in diastolic T 1 -maps, whereas systolic T 1 -maps displayed resilience to arrythmia. In conclusion, the proposed method enables saturation-recovery T 1 -mapping during systole, providing increased robustness against partial-voluming compared to diastolic imaging, for the benefit of T 1 -measurements in arrhythmic patients.

A standardized imaging algorithm by cardiac computed tomography angiography (cCTA) (LOVE-view) was used in 30 patients to evaluate the influence of different left atrial appendage (LAA) morphologies on development of thrombosis in the LAA 6 months after implantation of an occlusion device (Watchman or Amplatzer-Cardiac-Plug) in patients with non-valvular atrial fibrillation, CHA 2 DS 2 -VASc-Score >1 and a contraindication for oral anticoagulation. The distribution of different LAA morphologies was 40% windsock, 17% broccoli and 43% chicken wing type. There was no significant difference in the level of thrombosis regarding LAA morphology or the type of chosen occlusion device. The rates of complete LAA thrombosis was 40% in broccoli type, 33% in windsock and 15% in chicken wing type. Independently of LAA type, 13% had none and 60% incomplete thrombosis. The ratio of density (LA/LAA) was 0.14 in patients with complete thrombosis and 0.67 in those with none or incomplete thrombosis. cCTA and the LOVE-view-imaging-algorithm were shown to be a valuable method for standardized imaging in clinical routine in a greater set of patients. Surprisingly thrombosis of the occluded LAA was still in progress in most cases at 6 months, whereas further studies are needed defining its clinical consequences, especially for the selection of the optimal post-procedural antithrombotic treatment strategy.

Hypertrophic cardiomyopathy (HCM) has a low risk for sudden cardiac death (SCD). The ESC clinical risk prediction model estimates the risk of SCD using clinical and echocardiographical parameters without taking into account cardiac magnetic resonance (CMR) parameters. Therefore, we compared the CMR characteristics of 149 patients with low, intermediate and high ESC risk scores. In these patients left and right ventricular ejection fraction and volumes were comparable. Patients with a high ESC risk score revealed a significantly higher extent of late gadolinium enhancement (LGE) compared to patients with intermediate or a low risk scores. During follow-up of 4 years an extent of LGE ≥20% identified patients at a higher risk for major adverse cardiac arrhythmic events in the low and intermediate ESC risk group whereas an extent of LGE <20% was associated with a low risk of major adverse cardiac arrhythmic events despite a high ESC risk score ≥6%. Hence, we hypothesize that the extent of fibrosis might be an additional risk marker.

To generate a patient-friendly, time-efficient cardiac MRI examination protocol, a highly accelerated real-time CINE MR sequence (SSIR) was acquired in the idle time in between contrast injection and late gadolinium enhancement phase. 20 consecutive patients underwent a cardiac MRI examination including a multi-breath-hold sequence as gold standard (Ref) as well as SSIR sequences with (SSIR-BH) and without breath-hold (SSIR-nonBH). SSIR sequences were acquired 4 minutes after gadolinium injection. Right- (RV) and left-ventricular (LV) volumetric functional parameters were evaluated and compared between Ref and SSIR sequences. Despite reduced contrast between myocardium and intra-ventricular blood, volumetric as well as regional wall movement assessment revealed high agreement between both SSIR sequences and Ref. Excellent correlation and narrow limits of agreements were found for both SSIR-BH and SSIR-nonBH when compared to Ref for both LV (mean LV ejection fraction [EF] Ref: 52.8 ± 12.6%, SSIR-BH 52.3 ± 12.9%, SSIR-nonBH 52.5 ± 12.6%) and RV (mean RV EF Ref: 52.7 ± 9.4%, SSIR-BH 52.0 ± 8.1%, SSIR-nonBH 52.2 ± 9.3%) analyses. Even when acquired in the idle time in between gadolinium injection and LGE acquisition, the highly accelerated SSIR sequence delivers accurate volumetric and regional wall movement information. It thus seems ideal for very time-efficient and robust cardiac MR imaging protocols., Competing Interests: MS is full time employee of Siemens Healthcare GmbH. The Department of Clinical Radiology and Nuclear Medicine has research agreements with Siemens Healthcare. The other authors have no competing financial interests.