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Background Regional contractile dysfunction is a frequent finding in hypertrophic cardiomyopathy (HCM). We aimed to investigate the contribution of different tissue characteristics in HCM to regional contractile dysfunction. Methods We prospectively recruited 50 patients with HCM who underwent cardiovascular magnetic resonance (CMR) studies at 3.0 T including cine imaging, T1 mapping and late gadolinium enhancement (LGE) imaging. For each segment of the American Heart Association model segment thickness, native T1, extracellular volume (ECV), presence of LGE and regional strain (by feature tracking and tissue tagging) were assessed. The relationship of segmental function, hypertrophy and tissue characteristics were determined using a mixed effects model, with random intercept for each patient. Results Individually segment thickness, native T1, ECV and the presence of LGE all had significant associations with regional strain. The first multivariable model (segment thickness, LGE and ECV) demonstrated that all strain parameters were associated with segment thickness (P

Background In adults with prior arterial switch operation (ASO) for d-transposition of the great arteries, the need for routine coronary artery assessment and evaluation for silent myocardial ischemia is not well defined. In this observational study we aimed to determine the value of a comprehensive cardiovascular magnetic resonance (CMR) protocol for the detection of coronary problems in adults with prior ASO for d-transposition of the great arteries. Methods Adult ASO patients (≥18 years of age) were recruited consecutively. Patients underwent a comprehensive stress perfusion CMR protocol that included measurement of biventricular systolic function, myocardial scar burden, coronary ostial assessment and myocardial perfusion during vasodilator stress by perfusion CMR. Single photon emission computed tomography (SPECT) was performed on the same day as a confirmatory second imaging modality. Stress studies were visually assessed for perfusion defects (qualitative analysis). Additionally, myocardial blood flow was quantitatively analysed from mid-ventricular perfusion CMR images. In unclear cases, CT coronary angiography or conventional angiography was done. Results Twenty-seven adult ASO patients (mean age 23 years, 85% male, 67% with a usual coronary pattern; none with a prior coronary artery complication) were included in the study. CMR stress perfusion was normal in all 27 patients with no evidence of inducible perfusion defects. In 24 cases the coronary ostia could conclusively be demonstrated to be normal. There was disagreement between CMR and SPECT for visually-assessed perfusion defects in 54% of patients with most disagreement due to false positive SPECT. Conclusions Adult ASO survivors in this study had no CMR evidence of myocardial ischemia, scar or coronary ostial abnormality. Compared to SPECT, CMR provides additional valuable information about the coronary artery anatomy. The data shows that the asymptomatic and clinically stable adult ASO patient has a low pre-test probability for inducible ischemia. In this situation it is likely that routine evaluation with stress CMR is unnecessary.

Background Aortic stiffness is increasingly used as an independent predictor of adverse cardiovascular outcomes. We sought to compare the impact of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) upon aortic vascular function using cardiovascular magnetic resonance (CMR) measurements of aortic distensibility and pulse wave velocity (PWV). Methods and results A 1.5 T CMR scan was performed pre-operatively and at 6 m post-intervention in 72 patients (32 TAVI, 40 SAVR; age 76 ± 8 years) with high-risk symptomatic severe aortic stenosis. Distensibility of the ascending and descending thoracic aorta and aortic pulse wave velocity were determined at both time points. TAVI and SAVR patients were comparable for gender, blood pressure and left ventricular ejection fraction. The TAVI group were older (81 ± 6.3 vs. 72.8 ± 7.0 years, p

Background Acute Coronary Syndromes account for 15% of deaths in the UK, and patients remain at significant risk of re-admission for future complications and death. Pathologically the underlying process of atherosclerosis is driven by inflammatory mechanisms, which are activated in ACS patients. Previous studies have investigated the role of inflammatory markers in this process, including interleukin 1 (IL-1) and C Reactive Protein (CRP). Pre-clinical studies indicate that IL-1 may be a primary driver of ACS and that the naturally occurring interleukin-1 receptor antagonist (IL-1ra) may inhibit the atherosclerotic process. This study will investigate the effects of IL-1ra on inflammatory markers in man. Methods/design Three centres in the UK are planning to recruit 186 Non-ST elevation myocardial infarction patients to receive either interleukin-1 receptor antagonist (Anakinra) or matching placebo. Patients will receive a daily subcutaneous injection of either study drug or placebo over a 14 day period. The primary outcome is area under the curve of high sensitivity C-Reactive Protein (CRP) over the first 7 days. Discussion The MRC-ILA-HEART Study is a proof of concept clinical trial investigating the effects of IL-1ra upon markers of inflammation in patients with Non-ST elevation myocardial infarction. It is hoped this will provide new and exciting information in relation to an "anti-inflammatory" strategy for patients with acute coronary syndrome. Trial registration ISRCTN89369318

volume (46±18 ml/m 2 vs. 41±17 ml/m 2 ,p=0 .02). The end-diastolic volume (95±18 ml/m 2 vs. 91±20 ml/m 2 , p = ns) and stroke volume (48±10 ml/m 2 vs. 50±10 ml/m 2 , p = ns) did not change.

Background Two-dimensional (2D) perfusion-CMR has been shown to have greater diagnostic accuracy than single-photon emission computed tomography but remains limited by a lack of complete myocardial coverage. Three-dimensional (3D) whole-heart myocardial perfusion CMR addresses this limitation and has recently been shown to be clinically feasible. However, the feasibility and potential clinical utility of quantitative 3D perfusion measurements, as already shown with 2D-perfusion-CMR and positron emission tomography, has yet to be evaluated. The purpose of this study was to establish the feasibility of quantitative 3Dperfusion-CMR to detect coronary artery disease (CAD). Additionally, as 3D-perfusion-CMR offers the opportunity to select the phase of acquisition, a secondary objective was to determine differences between systolic and diastolic estimates of myocardial blood flow (MBF).

Background Intramyocardial hemorrhage (IMH) identified by CMR is an established prognostic marker following acute myocardial infarction (AMI), but remains relatively underused in the clinical setting. Detection of IMH by T2-weighted or T2* CMR can be limited by long breath hold times and sensitivity to artefacts, especially at 3 Tesla. Alternative methods that can detect IMH with shorter breath hold times are therefore desirable. CMR is capable of detecting differences in the magnetic susceptibility of tissues. The paramagnetic properties of hemoglobin products within IMH cause local phase shifts relative to surrounding tissue. Phase data can be filtered and combined with magnitude data to generate susceptibility weighted MR images (SW MRI). SW imaging has been shown to be highly sensitive for the detection of cerebral hemorrhage, but typically uses long echo times, resulting in prolonged image acquisition. With the larger size of IMH, we hypothesized that SW MRI may be used with shorter echo times, leading to rapid imaging with breath hold times of approximately 4 seconds. We compared the image quality and diagnostic ability of this SW MRI pulse sequence with T2-weighted and T2* CMR to detect IMH at 3T. Methods

Background Left atrial (LA) size is a marker of poor prognosis in a variety of cardiovascular conditions. Severe aortic stenosis results in elevated LV afterload with compensatory hypertrophy and increased filling pressures. This is associated with progressive left atrial enlargement and dysfunction. Intervention for aortic stenosis results in LV reverse remodelling, however the effect of TAVI or SAVR upon LA function remains poorly understood and the two treatments have not been directly compared. We sought to accurately determine LA size and function using CMR in patients with severe symptomatic aortic stenosis and identify changes following TAVI compared to SAVR.

Background Mitral annular plane systolic excursion (MAPSE) is known to have prognostic importance in the risk stratification of patients with acute myocardial infarction (MI). In post-MI patients with MAPSE

Background The sensitivity of adenosine perfusion CMR is reduced by false negative scans, with up to 50% resulting from inadequate pharmacological stress. Without a robust physiological marker for adequate myocardial hyperaemia, this false negative rate is difficult to address. We observed that splenic perfusion is markedly attenuated with adenosine - compared both to rest and to myocardial perfusion. In this collaborative multi-center study, we investigate the pharmacology of‘splenic switch-off’, and evaluate its potential clinical utility as a marker of inadequate stress in adenosine perfusion imaging. Methods We assessed splenic perfusion in 4 cohorts acquired in 4 separate CMR units using 3 different pharmacological stressors. This study included:  Verification cohort of 50 adenosine perfusion scans (London, UK); to determine

Summary This study compared the diagnostic accuracy of highresolution and standard-resolution cardiovascular magnetic resonance (CMR) perfusion imaging in patients with suspected coronary artery disease (CAD). Background Although accelerated high-spatial-resolution CMR perfusion imaging has recently been shown to be clinically feasible, there has not yet been a direct comparison with standard-resolution methods. We hypothesised that higher spatial resolution detects more subendocardial ischemia and leads to greater diagnostic accuracy for the detection of angiographically defined CAD. Methods A total of 111 patients with suspected CAD were prospectively recruited. All patients underwent two separate perfusion CMR studies on a 1.5 Tesla CMR scanner (Intera CV, Philips Healthcare, Best, the Netherlands), one with standard-resolution (2.5 x 2.5mm in-plane resolution) and one with high-resolution (1.6 x 1.6mm in-plane resolution) acquisition. High-resolution acquisition was facilitated by eight-fold k-t broad linear speed up technique (BLAST) acceleration. Two observers visually graded perfusion in each myocardial segment on a 4-point scale. Segmental scores were summed to produce a perfusion score for each patient. All patients underwent invasive coronary angiography. Significant CAD was defined as a coronary artery stenosis of ≥ 50% diameter on quantitative coronary angiography. Results CMR data were successfully obtained in 100 patients. A typical example is shown in Figure 1. In patients with CAD (n=70), more segments were determined to have subendocardial ischemia with high-resolution acquisition than with standard-resolution acquisition (279 vs.108; p

Methods 10 volunteers (7 male, mean age 38 years) were studied on a 1.5 T Philips Intera system during adenosine induced hyperaemia (140 mcg/kg/min for 3 minutes, 0.05 mmol/ kg Gd-DTPA) and at rest. A pulse sequence optimised for acquisition of a single midventricular slice at systole was used (saturation recovery segmented gradient echo, 2 × SENSE TR/TE/flip 2.7 ms/1.0/15°, typical FOV 380 × 380 mm, matrix 160 × 160, slice thickness 10 mm, preparation pulse delay 150 ms, shot duration 130 ms). Endo and epicardial contours were drawn and the slice segmented into 6 equidistant sectors. These were further subdivided into epicardial, mid-myocardial and endocardial thirds. Based on LV and blood pool time intensity curves, an inhouse mathematical Fermi Function deconvolution algorithm was implemented to estimate absolute myocardial blood flow [2].

Left main stem (LMS) disease is found in approximately 5% of patients with stable angina and in approximately 7% of patients presenting with an acute myocardial infarction. Accurate assessment of the degree of left main stem stenosis has important prognostic and therapeutic implications. Clinically, angiographic LMS stenosis of 50% or more is considered significant. However, it is not known how accurately myocardial perfusion imaging detects LMS disease at this severity threshold.

Background The effect of transcatheter aortic valve implantation (TAVR) on left ventricular remodelling early following valve implantation has not previously been evaluated using cardiac magnetic resonance (CMR). Early left ventricular mass (LVM) regression (assessed using echocardiography) has been linked to a 50% reduction in rehospitalisation in the first year following TAVR. We sought to establish using CMR, the reference standard non-invasive imaging technique for LVM quantification, whether LVM regression occurs early post-TAVR.

Methods Ninety-three patients with first acute myocardial infarction (AMI) were studied. 22 patients had diabetes mellitus (DM) based on prior history or admission blood glucose ≥ 11.1 mmol/l. 13 patients had dysglycaemia (admission blood glucose ≥ 7.8 mmol/l but

BACKGROUND: Myocardial blood flow (MBF) varies throughout the cardiac cycle in response to phasic changes in myocardial tension. The aim of this study was to determine if quantitative myocardial perfusion imaging with cardiovascular magnetic resonance (CMR) can accurately track physiological variations in MBF throughout the cardiac cycle. \ud \ud METHODS: 30 healthy volunteers underwent a single stress/rest perfusion CMR study with data acquisition at 5 different time points in the cardiac cycle (early-systole, mid-systole, end-systole, early-diastole and end-diastole). MBF was estimated on a per-subject basis by Fermi-constrained deconvolution. Interval variations in MBF between successive time points were expressed as percentage change. Maximal cyclic variation (MCV) was calculated as the percentage difference between maximum and minimum MBF values in a cardiac cycle. \ud \ud RESULTS: At stress, there was significant variation in MBF across the cardiac cycle with successive reductions in MBF from end-diastole to early-, mid- and end-systole, and an increase from early- to end-diastole (end-diastole: 4.50 ± 0.91 vs. early-systole: 4.03 ± 0.76 vs. mid-systole: 3.68 ± 0.67 vs. end-systole 3.31 ± 0.70 vs. early-diastole: 4.11 ± 0.83 ml/g/min; all p values

Background First pass myocardial perfusion CMR allows quantification of myocardial blood flow (MBF). MBF estimation with whole-heart tissue response may be useful in a variety of systemic diseases, but can be limited by suboptimal imaging in one or more segments. The interventricular septum (IVS) offers an attractive target for MBF imaging, as it offers higher signal and less partial volume artefact from blood pool. It has been proposed that T1 measurements taken from the IVS are more reliable than measurements from an entire short axis slice. We hypothesised that MBF estimation from the IVS would be similar to whole-heart estimation.

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

Background First pass myocardial perfusion imaging by CMR may permit the detection of myocardial ischaemia with greater accuracy than single photon emission computed tomography (SPECT). Technical developments have led to improvements in myocardial perfusion CMR, particularly through accelerated data acquisition methods. These permit the acquisition of data at higher spatial resolution than conventional CMR techniques, though it is unknown whether this improves diagnostic performance.

Myocardial Perfusion Reserve but not fibrosis predicts outcomes in initially asymptomatic patients with moderate to severe aortic stenosis: the PRognostic Importance of MIcrovascular Dysfunction in AS studyPRIMID AS Anvesha Singh, Michael Jerosch-Herold, John P Greenwood, Colin Berry, Dana K Dawson, Chim C Lang, Damian J Kelly, David Sprigings, Jeffrey P Khoo, Kai Hogrefe, Richard P Steeds, Vijay Anand Dhakshinamurthy, Gerry P McCann

Background Myocardial ischaemic burden is an important marker of outcome in stable ischaemic heart disease with a 10% ischaemic burden suggested as a clinically relevant threshold for revascularisation. Standard CMR stress perfusion imaging utilises 3 short axis slices, each acquired in different phases of the cardiac cycle. Recently proposed 3D myocardial perfusion CMR allows the entire myocardium to be sampled within the same cardiac phase and therefore should allow more accurate quantification of ischaemic burden without extrapolation. In this study we compared visual ischaemia detection and quantification by 2D high resolution and 3D whole heart myocardial perfusion CMR.

Methods 11 volunteers (6 males, mean age 33 ± 7 years) underwent CMR perfusion on 2 separate days (mean interstudy delay = 84 ± 111 days, median delay = 7 days) on a 1.5 T Philips Intera system during adenosine-induced hyperaemia (140 mcg/kg/min, 0.05 mmol/kg Gd-DTPA) and rest. A pulse sequence optimised for acquisition of a single midventricular slice at systole was used (saturation recovery segmented gradient echo, 2 × SENSE TR/TE/flip 2.7 ms/1.0/ 15°, typical FOV 380 × 380 mm, matrix 160 × 160, slice thickness 10 mm, preparation pulse delay 150 ms, shot duration 130 ms). Endoand epicardial contours were drawn. "Semi"-quantitative analysis calculated maximal upslopes of myocardial signal intensity of the entire slice, normalised to the LV blood-pool (Myocardial perfusion index, MPI) using MASS 6.0 (Medis, Leiden, The Netherlands). The myocardial perfusion reserve index (MPRI) was calculated as the ratio of hyperaemic over rest MPI.

Background The CPT induces endothelial-dependent vasodilation with increased myocardial blood flow (MBF) in normal coronary arteries. It has been used to demonstrate abnormal coronary vasomotion by invasive (angiography) and non-invasive techniques (SPECT and PET). Cardiovascular Magnetic Resonance (CMR) allows the assessment of MBF in separate myocardial layers due to its high spatial resolution, but has not previously been used to measure physiological responses to CPT.

Background Longitudinal motion of the mitral valve, known as the mitral annular plane of systolic excursion (MAPSE), correlates well with LV systolic function. Similarly, tricuspid annular plane systolic excursion (TAPSE) correlates well with RV systolic function. Echocardiographically, the absolute value of TAPSE was greater than MAPSE, by 54.5% in a recent study of normal subjects and the MAPSE/TAPSE ratio is 0.66±0.14 (1). However, the interventricular systolic relationship has not been accurately defined in the presence of regional wall motion abnormalities. We hypothesised that the interventricular systolic relationship, measured by the ratio of averagedMAPSE and TAPSE, changes in the presence of acute myocardial infarction with regional wall motion abnormality.

The perceived clinical benefits of undertaking revascularisation to coronary artery chronic total occlusions (CTO) relate to improvements in angina symptoms and prognosis1,2. Long term survival benefits from CTO revascularisation has been suggested in several large observational studies despite a significant failure rate1,3. Data about the physiological consequences of successful opening of a CTO are limited and heterogeneous4. CMR imaging can provide quantitative information on MBF (myocardial blood flow) in this context.

Background Myocardial perfusion cardiovascular magnetic resonance (CMR) with vasodilator stress has high diagnostic accuracy for detecting coronary artery disease (CAD). Current CMR perfusion pulse sequences use largely fixed acquisition parameters designed to acquire at least three slices every heart beat, optimized for the heart rates that typically occur during pharmacological stress. In patients with lower heart rates there can be a significant amount of unused potential imaging time [Figure 1]. In those with higher heart rates, acquisition with fixed parameters may not be possible at every heart beat. A more flexible acquisition scheme could optimize acquisition parameters specifically for each patient and heart rate with potential improvements in image quality or temporal resolution. We aimed to assess the feasibility of a perfusion pulse sequence which adapts to the heart rate, maximizing imaging time and acquired spatial resolution.

The CE-MARC study is the largest, prospective evaluation of cardiovascular magnetic resonance (CMR) in patients with suspected coronary artery disease (CAD). This predefined CE-MARC substudy compared the diagnostic performance of CMR and single-photon emission computed tomography (SPECT) in the female cohort.

Background Aberrant coronary arteries represent a diverse group of congenital disorders. Post-mortem studies reveal a high risk of exercise-related sudden cardiac death in those with an anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with an inter-arterial course. There is little documentation of lifetime history and long-term follow-up of patients with coronary artery anomalies. Methods Patients with anomalous coronary arteries undergoing cardiovascular magnetic resonance over a 15-year period were identified and classified by anatomy and course. Medical records were reviewed for major adverse cardiovascular events (MACE). Revascularisation or myocardial infarction counted only if occurring in the distribution of the anomalous artery. Results Consecutive patients with coronary artery anomalies were retrospectively identified (n = 172). Median follow-up time was 4.3 years (IQR 2.5–7.8, maximum 15.6). 116 patients had ACAOS of which 64 (55%) had an inter-arterial course (IAC) and 52 (45%) did not. During follow up 110 ACAOS patients were alive, 5 died and 1 lost to follow-up. ACAOS patients experienced 58 MACE events (5 cardiovascular deaths, 5 PCI, 24 CABG and 24 had myocardial infarction). 47 MACE events occurred in ACAOS with IAC and 11 in those without (p

Background Global longitudinal strain and mitral annular plane systolic excursion (MAPSE) have been validated as an echocardiographic measure of longitudinal function in patients with aortic stenosis (AS). Cardiac magnetic resonance imaging (CMR) offers a simple and easy measure of MAPSE and been validated in various patient groups. Longitudinal function in aortic stenosis is usually reduced before a reduction in ejection fraction is seen. We sought to investigate the impact of TAVI upon longitudinal function and global ejection fraction in patients treated for symptomatic severe AS.

Methods Twenty patients underwent CMR at 3T (Achieva TX system, Philips Healthcare, Best, The Netherlands) within 3 days following reperfused ST-elevation MI. Black blood, cine, T2w, T2-mapping, T2*-mapping and LGE imaging (0.1mmol/kg gadolinium DTPA) were performed in identical short axis locations using the ‘3 of 5’ approach. Data were evaluated offline using commercial software (cvi42 v4.1.5, Circle Cardiovascular Imaging Inc., Calgary, Canada). On the LGE images showing the largest infarct volume, infarct size was determined by using a semi-automated histogram-based thresholding method. This slice was evaluated for visual presence of IMH by the three methods. Signal intensity (SI) and respective standard deviation of SI (SD) were measured for the infarcted myocardium, remote myocardium and any IMH (if present). SNR was computed for each using the formula=0.655((SI)/(SD)). CNR was determined comparing contrast-to-noise of infarcted myocardium to IMH (SNRi-SNRIMH). Results Of the twenty patients, 55% (n=11) had IMH on T2wimaging. The mean (±standard deviation) SNR and CNR values are listed in Table 1. The visual assessment of T2w imaging correlated strongly to T2-maps (r=0.69; p=0.001) and to the T2*-maps (r=0.60; p=0.005). The SNR for IMH and infarct zone were significantly different for only T2w imaging (Figure 1). Quantitative CNR for T2w imaging correlated strongly to visual assessment of all three imaging modalities (T2wr=0.650; p=0.002, T2-mapr=0.454; p=0.04, T2*-mapr=0.603;p=0.005). The CNR for T2-maps and T2*-maps did not show similar correlation to the visual assessment.