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Background: Challenges remain in our understanding of implications of right ventricle (RV) dysfunction in heart failure. Cardiac magnetic resonance imaging (CMR) is the reference standard for RV quantification, but has seldomly been studied for this purpose in cardiomyopathy patients. We evaluated the predictors and outcomes of reduced CMR-derived right ventricle function in non-ischemic cardiomyopathy (NICM). Methods: Adult NICM patients undergoing CMR quantifying the RV during 2002-2017 were retrospectively studied. Multivariable linear and Cox proportional hazards regression were used to identify factors associated with reduced RV ejection fraction (RVEF) and adverse outcomes. The primary endpoint was all-cause mortality, heart transplant and/or left ventricular assist device implantation. Results: Amongst 624 NICM patients, mean age was 52.7±15.9 years, 253 (40.5%) were female, and RVEF was 43±13%. Factors independently associated with RVEF (beta-coefficients, P-values) were male (-3.26, P Conclusion: Reduced RVEF was prevalent in NICM patients, and was independently associated with worse prognosis in NICM. Important clinical and CMR factors associated with lower RVEF were identified, as well as the optimal prognostic RVEF thresholds.

Background: The impact of cardiomyopathy on left atrial function is currently unclear. The aim of this study was to assess the predictors of left atrial function in patients with non-ischemic dilated cardiomyopathy (NICM) utilizing cardiovascular magnetic resonance (CMR) assessment. Methods: We evaluated 251 NICM patients who underwent CMR in our study, between 12/2008 - 1/2014. LA volumes were measured by the modified biplane method from 2- and 4-chamber long axis views at end-systole and end-diastole. Left atrial ejection fraction (LAEF) was calculated. Multivariable linear regression was performed to determine significant covariate associations with LA EF. Results: We studied 251consecutive patients (61 % male), mean age of 52.5 ± 15.5 years . The results of the multivariable linear regression are provided in Figure 1. Younger age, female sex, and less myocardial fibrosis were significantly associated with higher LAEF (p=0.008, p= 0.004, and p= 0.031, respectively). Additionally, increasing left ventricular end diastolic volume index (LVEDVi) and left ventricular ejection fraction (LVEF) was significantly associated with increasing LAEF (both with a significance of p Conclusions: In patients with NICM, age, sex, LVEDVi, LVEF, myocardial fibrosis, and LAVi were independently associated with LAEF. Keywords: Nonischemic cardiomyopathy, left atrial ejection fraction, left atrial function, cardiovascular magnetic resonance

Background: Left atrial (LA) size has been shown to be predictive of adverse outcomes in patients with various cardiac conditions. However, the significance of left atrial function (LAF) is not clearly defined in patients with advanced ischemic cardiomyopathy (ICM). We assess the effect of cardiac magnetic resonance imaging (CMR) based LA ejection fraction (LAEF), LA volume index (LAVi) and total LA strain(Las) on outcomes in patients with ICM. Methods: Patients with ICM, who underwent cardiac magnetic resonance (CMR) between January 2002 and January 2017, were included in our study. Clinical characteristics and CMR parameters were collected and analyzed. Maximum and minimum left atrial volume (LAV) and LAEF were calculated using the biplane area-length method. Multi-variable Cox proportional hazards models were then built to test whether LAEF, LAs, and LAVi predict all-cause mortality or time to transplant. The proportionality assumption test and supremum test for functional form were used to verify the model. Results: LA functional data on 656 patients were analyzed. Patients were followed for a median of 1900 days (5.2 years). There were 336 deaths and 17 transplants. LAEF and Las were significant predictors of outcome: HR=0.98, 95% CI [0.97, 0.99], p Conclusion: Left atrial function is a more powerful predictor of adverse outcome than left atrial size and ischemic mitral regurgitation. Further studies are needed to assess impact of treatment on LA function.

Background: Transthoracic echocardiography (TTE) is the first-line imaging modality to evaluate isolated tricuspid regurgitation (TR), however comparisons with magnetic resonance imaging (MRI) measurements have seldomly been studied. We assessed the correlation, discriminative ability and derived a novel TTE-based algorithm using TR and right heart parameters to identify isolated severe TR by MRI. Methods: Isolated TR patients graded at least moderate-to-severe by TTE and undergoing MRI between January 2007-June 2019 were studied. TR and right heart parameters were analyzed by correlation, receiver-operative characteristics analysis and classification and regression tree algorithm for detection of severe TR by MRI (regurgitant volume > 45mL and/or fraction > 50%). Results: In 262 isolated TR patients, 108 (41.2%) had severe TR by MRI. There were moderate correlations and discrimination for most TTE-derived TR parameters and indexed right atrial volume (Pearson r=0.428-0.645) for TR quantification by MRI. This included a mean absolute and percentage difference of +10mL and +19% for regurgitant volume by TTE higher than MRI. However, there were none to modest correlations between TTE-derived right ventricle parameters with MRI-derived TR or right ventricle quantification. Key TTE parameters to identify severe TR by MRI in the decision tree regression algorithm were right atrial volume indexed >47cm 2 /m 2 , then effective regurgitant orifice area >0.45 cm 2 , and finally those with right ventricle free wall strain >-9.5% had the highest risk. Conclusion: TTE-derived TR and right atrial quantification had moderate correlation and discrimination of severe TR by CMR, from which a novel TTE-based decision tree algorithm was derived, while RV correlation was relatively poor between TTE and CMR.

Background Left ventricular non‐compaction remains a poorly described entity, which has led to challenges of overdiagnosis. We aimed to evaluate if the presence of a thin compacted myocardial layer portends poorer outcomes in individuals meeting cardiac magnetic resonance criteria for left ventricular non‐compaction . Methods and Results This was an observational, retrospective cohort study involving individuals selected from the Cleveland Clinic Foundation cardiac magnetic resonance database (N=26 531). Between 2000 and 2018, 328 individuals ≥12 years, with left ventricular non‐compaction or excessive trabeculations based on the cardiac magnetic resonance Petersen criteria were included. The cohort comprised 42% women, mean age 43 years. We assessed the predictive ability of myocardial thinning for the primary composite end point of major adverse cardiac events (composite of all‐cause mortality, heart failure hospitalization, left ventricular assist device implantation/heart transplant, ventricular tachycardia, or ischemic stroke). At mean follow‐up of 3.1 years, major adverse cardiac events occurred in 102 (31%) patients. After adjusting for comorbidities, the risk of major adverse cardiac events was nearly doubled in the presence of significant compacted myocardial thinning (hazard ratio [HR], 1.88 [95% CI, 1.18‒3.00]; P =0.016), tripled in the presence of elevated plasma B‐type natriuretic peptide (HR, 3.29 [95% CI, 1.52‒7.11]; P =0.006), and increased by 5% for every 10‐unit increase in left ventricular end‐systolic volume (HR, 1.01 [95% CI, 1.00‒1.01]; P =0.041). Conclusions The risk of adverse clinical events is increased in the presence of significant compacted myocardial thinning, an elevated B‐type natriuretic peptide or increased left ventricular dimensions. The combination of these markers may enhance risk assessment to minimize left ventricular non‐compaction overdiagnosis whilst facilitating appropriate diagnoses in those with true disease.

Background: Cardiac magnetic resonance imaging (CMR) is central to the evaluation of cardiac amyloidosis (CA). Native T1 mapping and extracellular volume (ECV) are novel CMR techniques with evolving utility in cardiovascular diseases including CA. This study aims to meta-analyze the diagnostic and prognostic data of native T1 mapping and extracellular volume (ECV) techniques for assessing CA. Methods: Pubmed, Cochrane and Embase were searched until 31 March 2020 for studies reporting the accuracy of native T1 mapping and ECV for diagnosing CA or predicting all-cause mortality. Area under the receiver-operative characteristics curves (AUC) and hazards ratios (HR) with 95% confidence intervals (95% CI) respectively were pooled using random-effects models and Open-Meta(Analyst) software. Results: Amongst 459 records obtained from the literature search, 41 full-text articles were assessed and 10 studies were eligible totalling 2364 subjects and 1528 patients with confirmed CA. Pooled AUCs (95% CI) for diagnosing CA were 0.924 (0.889-0.959) for native T1 mapping and 0.963 (0.925-1.000) for ECV (Figure panel A/B). Both techniques had similarly high detection rates for AL- and ATTR CA (pooled AUCs of 0.935 and 0.916 for native T1 mapping and 0.980 and 0.952 for ECV). Pooled HRs (95% CI) for predicting all-cause mortality were 1.15 (1.08-1.22) for native T1 mapping as a continuous parameter, 1.19 (1.01-1.40) for ECV as a continuous parameter (Figure panel C/D), and 4.93 (2.64-9.20) for ECV as a binary threshold. Conclusion: Both native T1 mapping and ECV had high diagnostic performance for CA and predicted all-cause mortality after CA. These CMR techniques can play important roles in the multi-modality imaging assessment of CA, including when contrast administration is contraindicated.

Background: Functional mitral regurgitation (MR) grading by echocardiography is often challenging, and cardiac magnetic resonance (CMR) may provide more accurate and reproducible assessment, however optimal CMR thresholds have not been established. We aimed to determine clinically significant thresholds of MR-volume and MR-fraction by CMR in patients with non-ischemic cardiomyopathy (NICM). Methods: All patients having CMR with confirmed NICM between 2001/4/1-2019/3/31 were retrospectively studied. Time to death, heart transplant and/or left ventricular assist device is the primary endpoint, and receiver-operative (ROC) characteristics analyses were used to identify significant cut-points for MR-volume and MR-fraction. Results: Mean MR-volume was 11±12% and MR-fraction 14±13% in 840 NICM patients. C-statistics for the primary endpoint (141 events) were MR-volume 0.629 (95%CI: 0.577-0.691) and MR-fraction 0.594 (95%CI 0.542-0.647). Thresholds of MR-volume≥10mL and MR-fraction≥15% had the highest products of sensitivities and specificities (57.4%, 56.8%; and 54.6%, 63.4% respectively) reflecting elevated risk. MR-volume≥35mL and MR-fraction≥40% were associated the best combination of positive and negative predictive values (40.1%, 84.2%; and 38.4%, 84.6% respectively) representing severe risk. The figure illustrates Kaplan-Meier curves of the primary endpoint, categorized into three subgroups based on aforementioned MR-volume and MR-fraction thresholds. Conclusion: Adverse prognosis are observed when MR-volume≥10mL or MR-fraction≥15%, with increasing risk of adverse outcomes as functional MR severity increased in NICM. The proposed MR thresholds from this study for elevated and severe risk are lower than current valvular regurgitation guidelines, suggesting the need for separate classification schema for functional MR.

Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery. Methods: Of 833 consecutive patients with surgically proven IE during 5/1/2014-5/1/2019 at Cleveland Clinic, 155 underwent both pre-operative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II. Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients respectively. CT identified an additional 11% of vegetations, 13% of pseudoaneurysms or abscesses, 5% of dehiscences and 14% of fistulae when TEE was negative. Thirty-day mortality occurred in 3 (1.9%) patients, and composite mortality and/or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality and/or morbidities in-hospital, with odds ratio (95%CI) of 3.66 (1.76-7.59), P=0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95%CI) of 3.82 (1.25, 11.7), P Conclusion: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.

Background: Functional mitral regurgitation (MR) is associated with poor outcomes and the prognostic role of cardiac magnetic resonance imaging (CMR) quantification of secondary MR has rarely been studied. We evaluated the associations between CMR-derived MR-fraction and adverse outcomes in non-ischemic cardiomyopathy (NICM) patients. Methods: We retrospectively studied 840 consecutive NICM patients undergoing CMR during 2001/4/1-2019/3/31. Multivariable Cox proportional hazards regression was performed for MR-fraction and two composite endpoints: primary (time to death, heart transplant and/or left ventricular assist device) and secondary (primary endpoint plus heart failure hospitalizations). Results: The cohort had mean age of 53.0±15.9 years, 319 (38.0) were female, and mean MR-fraction of 14±13% by CMR. There were 141 (16.8%) primary and 223 (26.5%) secondary endpoints over a mean follow-up of 3.6±3.0 years. Multivariable analyses results are shown in the Table. MR-fraction was independently associated with the primary and secondary endpoints with hazards ratios of 1.13 (95%CI 1.07-1.20) and 1.13 (95%CI 1.07-1.19) respectively per 5% increase in MR-fraction. MR-fraction provided stronger prognostic power compared to late gadolinium enhancement (LGE) in both models. Older age and diabetes were independently associated with both composite endpoints, while lower LVEF was independently associated with the secondary endpoint only. Conclusion: CMR quantification of functional MR is a powerful predictor of adverse outcomes and demonstrated stronger associations with poor prognosis compared to LGE and left ventricular remodeling in a large cohort of patients with NICM.

Background: Cardiac computed tomography (CT) is emerging as an adjunctive modality to echocardiography in the evaluation of infective endocarditis (IE) and surgical planning. CT studies in IE have, however, focused on its diagnostic rather than prognostic utility, the latter of which is important in high-risk diseases like IE. We evaluated the associations between cardiac CT and transesophageal echocardiography (TEE) findings and adverse outcomes after IE surgery. Methods: Of 833 consecutive patients with surgically proven IE during May 1, 2014 to May 1, 2019, at Cleveland Clinic, 155 underwent both preoperative ECG-gated contrast-enhanced CT and TEE. Multivariable analyses were performed to identify CT and TEE biomarkers that predict adverse outcomes after IE surgery, adjusting for EuroSCORE II (European System for Cardiac operative Risk Evaluation II). Results: CT and TEE were positive for IE in 123 (75.0%) and 124 (75.6%) of patients, respectively. Thirty-day mortality occurred in 3 (1.9%) patients and composite mortality or morbidities in 72 (46.5%). Pseudoaneurysm or abscess detected on TEE was the only imaging biomarker to show independent association with composite mortality or morbidities in-hospital, with odds ratio (95% CI) of 3.66 (1.76–7.59), P =0.001. There were 17 late deaths, and both pseudoaneurysm or abscess detected on CT and fistula detected on CT were the only independent predictors of total mortality during follow-up, with hazards ratios (95% CI) of 3.82 (1.25–11.7), P P =0.007, respectively. Conclusions: We identified cardiac CT and TEE features that predicted separate adverse outcomes after IE surgery. Imaging biomarkers can play important roles incremental to conventional clinical factors for risk stratification in patients undergoing IE surgery.

A 75-year-old man presented with dyspnea requiring home oxygen, on a background of partial colectomy for colon cancer, chronic renal failure, and coronary artery bypass graft surgery in 1978 (left internal mammary artery to left anterior descending graft and saphenous vein grafts [SVG] to the right coronary artery [RCA] and left circumflex artery). Clinically, he had jugular venous distension and bibasal crepitations, without overt ascites or peripheral edema. Chest x-ray demonstrated remote postoperative changes, cardiomegaly, mild pericardial calcification, and other radiographic findings of congestive heart failure, without apparent mediastinal mass (Figure 1). However, echocardiography revealed a large (9.4×8.7 cm), apparently extracardiac, mass compressing the right ventricle with severe functional tricuspid stenosis (mean gradient, 10 mm Hg) and turbulence of forward transtricuspid flow on color Doppler imaging (Figures 2A, 2B, and 3; Movie IA and IB in the online-only Data Supplement). Noncontrast cardiac MRI revealed a large (10.9×7.4×6.5 cm), relatively homogenous structure adjacent to the atrioventricular groove anteriorly, which was compressing the right heart and obstructing the tricuspid valve. The mass was distinct from adipose tissue, well circumscribed by overlying pericardium, and had no invasive characteristics. Cine imaging demonstrated flow within the mass. The structure location and characteristics were consistent with a partially thrombosed SVG aneurysm (Figure 4; Movie II …

The aims of the current statement are to refine the definition of quality in cardiovascular imaging and to propose novel methodological approaches to inform the demonstration of quality in imaging in future clinical trials and registries. We propose defining quality in cardiovascular imaging using an analytical framework put forth by the Institute of Medicine whereby quality was defined as testing being safe, effective, patient-centered, timely, equitable, and efficient. The implications of each of these components of quality health care are as essential for cardiovascular imaging as they are for other areas within health care. Our proposed statement may serve as the foundation for integrating these quality indicators into establishing designations of quality laboratory practices and developing standards for value-based payment reform for imaging services. We also include recommendations for future clinical research to fulfill quality aims within cardiovascular imaging, including clinical hypotheses of improving patient outcomes, the importance of health status as an end point, and deferred testing options. Future research should evolve to define novel methods optimized for the role of cardiovascular imaging for detecting disease and guiding treatment and to demonstrate the role of cardiovascular imaging in facilitating healthcare quality.

During the past 30 years, there has been a significant decrease in cancer mortality rates, predominantly attributable to improvements in treatment options.1 However, survivors are at increased risk of premature cardiac disease,2 both because of the overlap in risk factors for cancer and cardiovascular disease3 and the cardiotoxic effects of cancer chemotherapy. Two chemotherapeutic agent classes that are commonly associated with cardiotoxicity are the anthracyclines and tyrosine kinase inhibitors, both of which can cause left ventricular (LV) dysfunction and heart failure (HF).4,5 Mechanisms of cardiac injury from cancer therapy have been summarized elsewhere.4,6 Briefly, anthracycline cardiotoxicity has been attributed to reactive oxygen species formation, transcriptional changes in intracellular adenosine triphosphate production in cardiac myocytes, and, more recently, through interaction with cardiac topoisomerase IIβ.4,6 Trastuzumab cardiotoxicity seems to be because of inhibition of cardiomyocyte human epidermal growth factor receptor 2, resulting in ATP depletion and contractile dysfunction.4 Other proposed mechanisms include immune-mediated destruction of cardiomyocytes.4,6 At the tissue level, early anthracycline toxicity has been associated with myocardial inflammation,7–9 vacuolization,9–12 and cell swelling/edema.11,13 These changes seem to occur before myocardial functional abnormalities.11,13 Later stages of toxicity are associated with myocardial fibrosis.14,15 Unfortunately, the use of myocardial biopsy is not feasible for diagnostic purposes in this setting. However, once HF manifests, the 2-year mortality can be as high as 60%.16 This emphasizes the importance of early recognition of cardiac injury and institution of cardioprotective therapy in an effort to prevent development of HF and allow uninterrupted completion of cancer therapy.17 Thus, the diagnosis is dependent on either direct evidence of myocardial damage or functional disturbance. Either signal may be identified …

Background— Ischemic mitral regurgitation (IMR) is associated with poor outcomes. It is unknown what factors contribute to progression of IMR and how progressive IMR affects outcomes. We sought to determine imaging predictors of IMR progression and to determine if progressive IMR is an independent predictor of survival in patients with advanced ischemic cardiomyopathy. Methods and Results— Consecutive advanced ischemic cardiomyopathy patients who underwent cardiac magnetic resonance and echocardiograms at baseline with echocardiographic follow-up were studied. Cardiac magnetic resonance was used to assess left ventricular volumes, infarct size, and mitral valve geometry. The effective regurgitant orifice area (EROA) was calculated from the proximal isovelocity surface area by echocardiography. Repeated measures mixed effects and Cox proportional hazards regression models were built to identify predictors of IMR progression and survival. We evaluated 336 patients (age, 62±11 years) over a median follow-up time of 54 months: 154 patients were subsequently revascularized, and 182 patients were medically treated. Ninety-eight patients (29%) demonstrated an increase in EROA values of ≥0.1 cm 2 . There were 87 adverse events (death or transplant). On multivariable analysis, infarct size ( P P =0.008), age ( P =0.003), and baseline EROA ( P =0.010) were independently associated with adverse events. Independent predictors of IMR progression were as follows: baseline EROA ( P P =0.014), and total scar ( P =0.036). Conclusions— IMR frequently increases in severity, and progression is independently associated with adverse left ventricular remodeling and infarct size, as assessed by cardiac magnetic resonance. Furthermore, IMR progression is a powerful independent predictor of adverse events, even after controlling for the severity of IMR at baseline.

Background— Left ventricular ejection fraction is a powerful independent predictor of survival in cardiac patients, especially those with coronary artery disease. Delayed-enhancement magnetic resonance imaging (DE-MRI) can accurately identify irreversible myocardial injury with high spatial and contrast resolution. To date, relatively limited data are available on the prognostic value of DE-MRI, so we sought to determine whether DE-MRI findings independently predict survival. Methods and Results— The medical records of 857 consecutive patients who had complete cine and DE-MRI evaluation at a tertiary care center were reviewed regardless of whether the patients had coronary artery disease. The presence and extent of myocardial scar were evaluated qualitatively by a single experienced observer. The primary, composite end point was all-cause mortality or cardiac transplantation. Survival data were obtained from the Social Security Death Index. The median follow-up was 4.4 years; 252 patients (29%) reached one of the end points. Independent predictors of mortality or transplantation included congestive heart failure, ejection fraction, and age ( P P =0.033). Similarly, in subsets of patients with or without coronary artery disease, scar index also independently predicted mortality or transplantation (hazard ratio, 1.33; 95% confidence interval, 1.05 to 1.68; P =0.018; and hazard ratio, 5.65; 95% confidence interval, 1.74 to 18.3; P =0.004, respectively). Cox regression analysis showed worse outcome in patients with any DE in addition to depressed left ventricular ejection fraction ( Conclusion— The degree of DE detected by DE-MRI appears to strongly predict all-cause mortality or cardiac transplantation after adjustment for traditional, well-known prognosticators.

Advances in magnetic resonance (MR) imaging over the past 2 decades have led to MR becoming an increasingly attractive imaging modality. With the growing number of patients treated with permanent implanted or temporary cardiovascular devices, it is becoming ever more important to clarify safety issues in regard to the performance of MR examinations in patients with these devices. Extensive, although not complete, ex vivo, animal, and clinical data are available from which to generate recommendations regarding the safe performance of MR examination in patients with cardiovascular devices, as well as to ascertain caveats and contraindications regarding MR examination for such patients. Safe MR imaging involves a careful initial patient screening, accurate determination of the permanent implanted or temporary cardiovascular device and its properties, a thoughtful analysis of the risks and benefits of performing the examination at that time, and, when indicated, appropriate physician management and supervision. This scientific statement is intended to summarize and clarify issues regarding the safety of MR imaging in patients with cardiovascular devices.

Background— Delayed hyperenhancement (DHE) of the pericardium usually represents ongoing inflammation and may identify patients with constrictive pericarditis that will improve with anti-inflammatory therapy. However, a quantitative assessment of pericardial DHE has not been performed, and the hierarchical relationship among clinical factors, inflammatory markers, and pericardial DHE is unknown. Methods and Results— We identified 41 consecutive patients with constrictive pericarditis who had a cardiovascular magnetic resonance study with DHE prior to the initiation of anti-inflammatory medications. Pericardial inflammation was quantified on short-axis DHE sequences by contouring the pericardium, selecting normal septal myocardium as a reference region, and then quantifying the pericardial signal that was >6 SD above the reference. Our primary outcome was clinical improvement with anti-inflammatory therapy. The mean age of our patients was 58 years, most patients were male (83%) with New York Heart Association Class II or III (59%) heart failure, and the median follow-up was 1 year. Chest pain, lower New York Heart Association class, higher Westergren sedimentation rates, and increased pericardial DHE were all significantly associated with clinical improvement ( P 2 improved significantly ( P =0.04 for DHE), and the area under the receiver operating characteristic curve was 0.96. Conclusions— In patients with constrictive pericarditis treated with anti-inflammatory therapy, a quantitative assessment of pericardial DHE can provide incremental information to predict clinical improvement when added to clinical factors and Westergren sedimentation rates.

Cardiovascular disease is the leading cause of mortality for women in the United States. Coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction, acute coronary syndromes, and angina, is the largest subset of this mortality, with >240 000 women dying annually from the disease. Atherosclerotic coronary artery disease (CAD) is the focus of this consensus statement. Research continues to report underrecognition and underdiagnosis of CAD as contributory to high mortality rates in women. Timely and accurate diagnosis can significantly reduce CAD mortality for women; indeed, once the diagnosis is made, it does appear that current treatments are equally effective at reducing risk in both women and men. As such, noninvasive diagnostic and prognostic testing offers the potential to identify women at increased CAD risk as the basis for instituting preventive and therapeutic interventions. Nevertheless, the recent evidence-based practice program report from the Agency for Healthcare Research and Quality noted the paucity of women enrolled in diagnostic research studies. Consequently, much of the evidence supporting contemporary recommendations for noninvasive diagnostic studies in women is extrapolated from studies conducted predominantly in cohorts of middle-aged men. The majority of diagnostic and prognostic evidence in cardiac imaging in women and men has been derived from observational registries and referral populations that are affected by selection and other biases. Thus, a better understanding of the potential impact of sex differences on noninvasive cardiac testing in women may greatly improve clinical decision making. This consensus statement provides a synopsis of available evidence on the role of the exercise ECG and cardiac imaging modalities, both those in common use as well as developing technologies that may add clinical value to the diagnosis and risk assessment of the symptomatic and asymptomatic woman with suspected CAD.

Dysfunctional myocardium that remains viable has the potential for contractile recovery after reperfusion.1 Dysfunctional but viable myocardium has been broadly divided into 2 closely linked pathophysiological states, myocardial hibernation and stunning. Stunned myocardium is the result of an ischemic insult leading to contractile dysfunction despite adequate reperfusion. Hibernating myocardium describes downregulation of myocyte metabolism as a result of prolonged reduction in perfusion, or, in some cases, repetitive episodes of myocardial stunning.2 The exact nature of structural changes in hibernating myocardium remains controversial.3 However, a spectrum of histological alterations has been noted, ranging from cellular dedifferentiation (fetal phenotype) to cellular degeneration (with more extensive fibrosis) with loss of contractile and cytoskeletal proteins. Worsening histological perturbations correlate with increasing duration of chronically low perfusion. Thus, accurate and early detection of viable myocardium has become an increasingly important guide to prognosis and therapy. Until recently, scintigraphic techniques and stress echocardiography were the mainstay of diagnosis.4,5 The focus of the present article is on the rapidly emerging clinical role of cardiovascular MRI (CMR) in the detection of viable myocardium. In patients with chronic ischemic left ventricular dysfunction, improvements in ejection fraction and exercise capacity after revascularization have been well documented.6–10 The prognostic importance of detecting myocardial viability hinges on 2 major considerations. First, medically treated viable myocardium is a harbinger of further nonfatal ischemic events and higher overall mortality. In patients with significant viable myocardium, the annual mortality rate is more than 4-fold greater in those treated medically compared with those patients who have had successful revascularization.11 Second, discrimination between viable and nonviable dysfunctional myocardium allows patients to avoid the risks associated with revascularization when they are unlikely to benefit. Although limited by the lack of large randomized studies, a recent meta-analysis indicated that the annual mortality rate …

Introduction: Ischemic mitral regurgitation (IMR) is associated with poor outcomes. Determining risk for the presence and progression of IMR may be critical for risk stratification. Hypothesis: We hypothesize that a multi-modality approach can evaluate the progression of IMR in patients with advanced ischemic cardiomyopathy (ICM) and create a risk model for the prediction of IMR progression. Methods: Consecutive ICM patients who underwent cardiac magnetic resonance (CMR) and echocardiograms at baseline with echocardiographic follow-up were included. CMR was used to assess global and regional left ventricular (LV) remodeling, myocardial scarring, and mitral valve geometry. The effective regurgitant orifice area (EROA) was calculated from the proximal isovelocity surface area by echocardiography. We identified the best performing model for prediction of worsening IMR based on the c-index. Results: We evaluated 693 patients (age 62±11). The following factors were independently predictive of an increased EROA at baseline (n=693): higher total scar% (p=0.002) and higher ESVi (p Conclusions: The variables which predict IMR at baseline and progression of IMR over time slightly differ. Higher total scar% and higher ESVi are independently associated with increasing IMR at baseline. However, higher EROA at baseline, lower tenting area, higher ESVi and total scar% * treatment type were associated with progression of IMR over time. The risk model of IMR progression was moderately predictive in this cohort.

Introduction Ischemic mitral regurgitation (MR) bodes worsened prognosis and increased mortality in patients with ischemic cardiomyopathy. Various mechanisms of ischemic MR have been purposed, resulting in a spectrum of surgical strategies with varying success rates. Papillary muscle infarction may contribute to ischemic MR, but could not be identified non-invasively until the recent development of chronic infarction specific imaging (delayed-enhancement, or DE-MRI). Hypothesis We hypothesized that papillary muscle infarction, determined by DE-MRI, was correlated with the presence of ischemic MR. Methods Contrast-enhanced cardiac MRI for viability assessment was performed in 100 patients with ischemic cardiomyopathy (67 male, mean age 65 years). Papillary muscle infarction was determined from DE-MRI, and left ventricular (LV) functional parameters were calculated from contiguous short-axis cine-MRI images using the disc-summation technique. Results MR by echocardiography was present in 67%: 30% with mild MR (1+), 27% moderate MR (2+), and 10% severe MR (3– 4+). In patients with no, mild, moderate, and severe MR, there was a positive correlation with the prevalence of posterior papillary muscle infarction (15%, 40%, 52%, and 70%, respectively), but there was no association with anterior papillary muscle infarction (p=NS). There was a significant inverse relationship with LV ejection fraction (LVEF) (29%, 26%, 24%, and 20%, respectively). Both LVEF (p=0.013) and posterior papillary muscle infarction (p=0.006) were significantly associated with ischemic MR on univariate analysis. Using multiple logistic regression analysis, both posterior papillary muscle infarction and LVEF remained independent determinants of MR presence and severity (p Conclusions Patients with ischemic cardiomyopathy demonstrate a significant and positive correlation between the severity of MR and prevalence of posterior, but not anterior papillary muscle infarction identified by DE-MRI, and an inverse relationship with LVEF. The identification of papillary muscle infarction may provide insights into alternative approaches for repair of ischemic MR.

Background: Both renal dysfunction and severe left ventricular (LV) systolic dysfunction lead to reduced survival. Delayed hyperenhancement magnetic resonance imaging (DHE-MRI) accurately detects myocardial fibrosis (scar), seen commonly in patients with severe left ventricular (LV) dysfunction. We sought to determine the association of myocardial scar and renal dysfunction on survival in patients with severe LV dysfunction. Methods: We studied 176 consecutive patients (61 ± 13 years, 73 % men) with severe LV systolic dysfunction (mean ejection fraction (24 ± 8 %) who underwent DHE-MRI (Siemens 1.5 T scanner, Erlangen, Germany) from 2005–6. Myocardial scar was determined visually on DHE-MR images, using custom software (Siemens Research), and defined as intensity >2 standard deviation above viable myocardium. Clinical and laboratory information, along with all-cause mortality, were recorded. Glomerular filtration rate (GFR, ml/min/1.73 m 2 ) was calculated using the following formula: 186 × (serum creatinine −1.154 ) × (age −0.203 ) × 1.212 (if black) × 0.742 (if female). We divided patients into 4 groups: GFR > 60, no scar (n = 28) GFR > 60 with scar (n = 85) GFR ≤ 60, no scar (n = 9) and GFR ≤ 60 with scar (n = 53). Results: There were 24 deaths in the group and 14 patients (65 %) had myocardial scar. Mean GFR was 70 ± 29 and 62 (35 %) patients had at-least moderate renal dysfunction (GFR < 60). Frequency of myocardial scar was higher in patients with GFR ≤ 60 vs. those with GFR > 60 (92 % vs. 79 %, p = 0.02). On multiple regression (including GFR, myocardial scar, coronary artery disease, hypertension, diabetes and coronary bypass), GFR and myocardial scar were associated with mortality (both p value < 0.05, overall model p value < 0.001). There were no deaths in group 1, 7 in group 2, 3 in group 3 and 14 in group 4 (p < 0.001). One year survival was significantly worse for groups 2, 3 and 4, compared to group 1 (log rank p value < 0.001). Conclusion: Renal dysfunction is associated with a higher frequency of myocardial fibrosis in patients with severe LV dysfunction. Presence of renal dysfunction, myocardial fibrosis or both is associated with worse survival in such patients. The mechanistic association between renal dysfunction and myocardial fibrosis needs to be further defined.

Background: There is a high prevalence of myocardial fibrosis in hypertrophic cardiomyopathy (HCM) patients, despite preserved left ventricular ejection fraction (LVEF). Association of myocardial fibrosis and longitudinal strain (LS) in such patients is not well understood. Methods: We studied 46 consecutive HCM patients (mean age 43±14 years, 30 men) who had transthoracic echocardiography (TTE, GE Medical, USA) and delayed hyper-enhancement magnetic resonance imaging (DHE-MRI, Siemens 1.5 T scanner, Germany), 20 minutes after injection of 0.2 mmol/kg of Gadolinium. Speckle tracking TTE was used to assess LS in LV (segmental and global) (EchoPac, GE Medical, USA). Fibrosis was determined semi-automatically on DHE-MR images, in a 12-segment short-axis model (apex, mid and base) of LV using custom software (Siemens Research) & defined as intensity >2 standard deviation above viable myocardium. Results: Global end-systolic LS correlated with number of fibrotic segments (r = 0.50, p = 0.0004; Figure ) and total myocardial fibrosis % (r = 0.43, p = 0.001). Association of fibrosis and regional LS is shown in Table . In a multivariate analysis, predictors of lower segmental LS were presence of fibrosis and basal segment location (both p < 0.001). Conclusion: Myocardial fibrosis is associated with depressed global and regional LS in HCM patients, despite preserved global LVEF. Table

Introduction: Redo cardiothoracic surgery (CTS) is associated with increased morbidity and mortality, compared to first-time CTS. Multi-detector computed tomography angiography (MDCTA) reliably delineates the course of previous coronary artery bypass grafts (CABG) and proximity of mediastinal structures to chest wall. We sought to determine if high risk preoperative MDCTA findings impacted use of preventive surgical strategies in patients with prior CABG undergoing re-CTS. Methods: We studied 167 patients (mean age 69 ± 9 years, 79% men) with prior CABG referred for re-CTS who underwent contrast-enhanced MDCTA (16 – 64 MDCT, 2 mm slice thickness) to assess CABG location and relationship of aorta/right ventricle (RV) to chest wall. Demographic, laboratory, and clinical data were used to determine the Higgins preoperative risk score. Prevalence of high risk MDCTA findings, use of preventive surgical strategies, frequency of severe intraoperative bleeding and postoperative mortality were recorded. Results: Mean preoperative risk score was high (7.5 ± 3) and 49% patients underwent combined redo CABG plus valve surgery. Incidences of 2 nd , 3 rd and 4 th operations were 78%, 19% and 3%, respectively. High-risk CT findings were as follows: adherence/ proximity (≤ 1 cm) of RV/aorta to chest wall (24%) or bypass graft crossing midline (≤ 1 cm antero-posteriorly) (38%). Preventive surgical strategies included: surgery cancelled (4%), non-midline incision (8%), deep hypothermic circulatory arrest (5%), initiation of peripheral cardiopulmonary bypass (11%), and extrathoracic vascular exposure prior to incision (53%). These surgical strategies were used at a significantly higher frequency in patients with high risk MDCTA findings compared to those without (88% vs. 28%, p Conclusions: In high risk re-CTS patients with prior CABG, use of preoperative MDCTA plays a significant role in planning and performance. Impact of preoperative MDCTA on outcomes requires further evaluation.

The patient is a 68-year-old man who had heterotopic heart transplantation (HHTx) performed 8 years ago for ischemic dilated cardiomyopathy. The patient presented for noninvasive evaluation of transplant cardiac function and patency of anastomotic connections. A contrast-enhanced 3D-magnetic resonance angiogram (MRA) was performed, and the data reconstructed …

A 44-year-old man was hospitalized after a syncopal episode. A thrill and loud systolic ejection murmur were present over the left border of the sternum. A 12-lead ECG and chest x-rays were normal. A 2D echocardiogram and Doppler studies documented normal cardiac chambers and a peak systolic pulmonary transvalvular gradient of 80 mm Hg. Biplane right ventriculography revealed a large mobile …

A 54-year-old man with a known history of hypertension, obesity, coronary artery disease, and prior coronary artery bypass grafting in 1988 presented to the hospital complaining of a recent onset of chest pain. He was admitted and treated for an acute coronary syndrome. Myocardial infarction was ruled out on the basis of serial ECGs and cardiac enzyme analysis. A chest x-ray demonstrated a widened mediastinum (Figure 1⇓). MRI was performed to elucidate the cause of this radiological finding. Perfusion imaging performed in the short …

A 44-year-old Hispanic man underwent a routine cardiac evaluation for kidney transplantation. He had a history of polycystic kidney disease and had been receiving hemodialysis for 2 years. A 2-dimensional echocardiogram revealed large trabeculations and deep recesses in the endocardial wall of both ventricles (Movie I; see Data Supplement). Cardiac …