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Objectives: To find simple imaging-based features on cardiac magnetic resonance (CMR) that are associated with major adverse cardiovascular events (MACE) in takotsubo syndrome (TTS)., Methods: Patients with TTS referred for CMR between 2007 and 2021 were retrospectively evaluated. Besides standard CMR analysis, commonly known complications of TTS based on expert knowledge were assessed and summarised via a newly developed PE 2 RT score (one point each for pleural effusion, pericardial effusion, right ventricular involvement, and ventricular thrombus). Clinical follow-up data was reviewed up to three years after discharge. The relationship between PE 2 RT features and the occurrence of MACE (cardiovascular death or new hospitalisation due to acute myocardial injury, arrhythmia, or chronic heart failure) was examined using Cox regression analysis and Kaplan-Meier estimator., Results: Seventy-nine patients (mean age, 68 ± 14 years; 72 women) with TTS were included. CMR was performed in a median of 4 days (IQR, 2-6) after symptom onset. Over a median follow-up of 13.3 months (IQR, 0.4-36.0), MACE occurred in 14/79 (18%) patients: re-hospitalisation due to acute symptoms (9/79, 11%) or chronic heart failure symptoms (4/79, 5%), and cardiac death (1/79, 1%). Patients with MACE had a higher PE 2 RT score (median [IQR], 2 [2-3] vs 1 [0-1]; p < 0.001). PE 2 RT score was associated with MACE on Cox regression analysis (hazard ratio per PE 2 RT feature, 2.44; 95%CI: 1.62-3.68; p < 0.001). Two or more PE 2 RT complications were strongly associated with the occurrence of MACE (log-rank p < 0.001)., Conclusions: The introduced PE 2 RT complication score might enable an easy-to-assess outcome evaluation of TTS patients by CMR., Key Points: • Complications like pericardial effusion, pleural effusion, right ventricular involvement, and ventricular thrombus (summarised as PE 2 RT features) are relatively common in takotsubo syndrome. • The proposed PE 2 RT score (one point per complication) was associated with the occurrence of major adverse cardiac events on follow-up. • Complications easily detected by cardiac magnetic resonance imaging can help clinicians derive long-term prognostic information on patients with takotsubo syndrome., (© 2023. The Author(s).)

Aims: The exact role of portal hypertension in cirrhotic cardiomyopathy remains unclear, and it is uncertain whether cardiac abnormalities also occur in non-cirrhotic portal hypertension (NCPH). This magnetic resonance imaging (MRI) study aimed to evaluate the presence of subclinical myocardial dysfunction, oedema, and fibrosis in NCPH., Methods and Results: In this prospective study (2018-2022), participants underwent multiparametric abdominal and cardiac MRI including assessment of cardiac function, myocardial oedema, late gadolinium enhancement (LGE), and abdominal and cardiac mapping [T1 and T2 relaxation times, extracellular volume fraction (ECV)]. A total of 111 participants were included [44 participants with NCPH (48 ± 15 years; 23 women), 47 cirrhotic controls, and 20 healthy controls]. The cirrhotic group was dichotomized (Child A vs. Child B/C). NCPH participants demonstrated a more hyperdynamic circulation compared with healthy controls (cardiac index: 3.7 ± 0.6 vs. 3.2 ± 0.8 L/min/m², P = 0.004; global longitudinal strain: -27.3 ± 4.6 vs. -24.6 ± 3.5%, P = 0.022). The extent of abnormalities indicating myocardial fibrosis and oedema in NCPH was comparable with Child A cirrhosis (e.g. LGE presence: 32 vs. 33 vs. 69%, P = 0.004; combined T1 and T2 elevations: 46 vs. 27 vs. 69%, P = 0.017; NCPH vs. Child A vs. Child B/C). Correlations between splenic T1 and myocardial T1 values were found (r = 0.41; P = 0.007). Splenic T1 values were associated with the presence of LGE (odds ratio, 1.010; 95% CI: 1.002, 1.019; P = 0.013)., Conclusion: MRI parameters of myocardial fibrosis and oedema were altered in participants with NCPH to a similar extent as in compensated cirrhosis and were associated with splenic markers of portal hypertension, indicating specific portal hypertensive cardiomyopathy., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Aim of this study was to assess the impact of virtual monoenergetic images (VMI) in combination and comparison with iterative metal artifact reduction (IMAR) on hip prosthesis-associated artifacts in photon-counting detector CT (PCD-CT). Retrospectively, 33 scans with hip prosthesis-associated artifacts acquired during clinical routine on a PCD-CT between 08/2022 and 09/2022 were analyzed. VMI were reconstructed for 100-190 keV with and without IMAR, and compared to polychromatic images. Qualitatively, artifact extent and assessment of adjacent soft tissue were rated by two radiologists using 5-point Likert items. Quantitative assessment was performed measuring attenuation and standard deviation in most pronounced hypodense and hyperdense artifacts, artifact-impaired bone, muscle, vessels, bladder and artifact-free corresponding tissue. To quantify artifacts, an adjusted attenuation was calculated as the difference between artifact-impaired tissue and corresponding tissue without artifacts. Qualitative assessment improved for all investigated image reconstructions compared to polychromatic images (PI). VMI 100keV in combination with IMAR achieved best results (e.g. diagnostic quality of the bladder: median PI: 1.5 (range 1-4); VMI 100keV+IMAR : 5 (3-5); p < 0.0001). In quantitative assessment VMI 100keV with IMAR provided best artifact reduction with an adjusted attenuation closest to 0 (e.g. bone: PI: 302.78; VMI 100keV+IMAR : 51.18; p < 0.0001). The combination of VMI and IMAR significantly reduces hip prosthesis-associated artifacts in PCD-CT and improves the diagnostic quality of surrounding tissue., (© 2023. The Author(s).)

Purpose: To compare standard breath-hold (BH) cine imaging to a radial pseudo-golden-angle free-breathing (FB) technique in congenital heart disease (CHD)., Methods: In this prospective study, short-axis and 4-chamber BH and FB cardiac MRI sequences of 25 participants with CHD acquired at 1.5 Tesla, were quantitatively compared regarding ventricular volumes, function, interventricular septum thickness (IVSD), apparent signal to noise ratio (aSNR), and estimated contrast to noise ratio (eCNR). For qualitative comparison, three image quality criteria (contrast, endocardial edge definition, and artefacts) were rated on a 5-point Likert scale (5: excellent, 1: non-diagnostic). Paired t-Test was used for group comparisons, Bland-Altman analysis for agreement between techniques. Inter-reader agreement was compared using intraclass correlation coefficient., Results: IVSD (BH 7.4 ± 2.1 mm vs FB 7.4 ± 1.9 mm, p =.71), biventricular ejection fraction (left ventricle [LV]: 56.4 ± 10.8% vs 56.1 ± 9.3%, p =.83; right ventricle [RV]: 49.5 ± 8.6% vs 49.7 ± 10.1%, p =.83), and biventricular end diastolic volume (LV: 176.3 ± 63.9 ml vs 173.9 ± 64.9 ml, p =.90; RV: 185.4 ± 63.8 ml vs 189.6 ± 66.6 ml, p =.34) were comparable. Mean measurement time for FB short-axis sequences was 8.1 ± 1.3 compared to 4.4 ± 1.3 min for BH (p <.001). Subjective image quality between sequences was deemed comparable, (4.6 ± 0.6 vs 4.5 ± 0.6, p =.26, for 4-chamber views) with a significant difference regarding short-axis views (4.9 ± 0.3 vs 4.5 ± 0.6, p =.008). aSNR was similar (BH 25.8 ± 11.2 vs FB 22.2 ± 9.5, p =.24), while eCNR was higher for BH (89.1 ± 36.1 vs 68.5 ± 32.1, p =.03)., Conclusion: FB sequences yielded comparable results to BH regarding image quality, biventricular volumetry, and function, though measurement times were longer. The FB sequence described might be clinically valuable when BHs are insufficiently performed., 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 Elsevier B.V. All rights reserved.)

Background The objective of this study was to investigate cardiac abnormalities in intensive care unit (ICU) survivors of critical illness and to determine whether temporary acute kidney injury (AKI) is associated with more pronounced findings on cardiovascular magnetic resonance. Methods and Results There were 2175 patients treated in the ICU (from 2015 until 2021) due to critical illness who were screened for study eligibility. Post-ICU patients without known cardiac disease were prospectively recruited from March 2021 to May 2022. Participants underwent cardiovascular magnetic resonance including assessment of cardiac function, myocardial edema, late gadolinium enhancement, and mapping including extracellular volume fraction. Student t test, Mann-Whitney U test, and χ 2 tests were used. There were 48 ICU survivors (46±15 years of age, 28 men, 29 with AKI and continuous kidney replacement therapy, and 19 without AKI) and 20 healthy controls who were included. ICU survivors had elevated markers of myocardial fibrosis (T1: 995±31 ms versus 957±21 ms, P <0.001; extracellular volume fraction: 24.9±2.5% versus 22.8±1.2%, P <0.001; late gadolinium enhancement: 1% [0%-3%] versus 0% [0%-0%], P <0.001), more frequent focal late gadolinium enhancement lesions (21% versus 0%, P =0.03), and an impaired left ventricular function (eg, ejection fraction: 57±6% versus 60±5%, P =0.03; systolic longitudinal strain: 20.3±3.7% versus 23.1±3.5%, P =0.004) compared with healthy controls. ICU survivors with AKI had higher myocardial T1 (1002±33 ms versus 983±21 ms; P =0.046) and extracellular volume fraction values (25.6±2.6% versus 23.9±1.9%; P =0.02) compared with participants without AKI. Conclusions ICU survivors of critical illness without previously diagnosed cardiac disease had distinct abnormalities on cardiovascular magnetic resonance including signs of myocardial fibrosis and systolic dysfunction. Findings were more abnormal in participants who experienced AKI with necessity of continuous kidney replacement therapy during their ICU stay. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT05034588.

Purpose: To investigate and compare the physical properties of the new generation Gore VIATORR-Controlled Expansion Endoprosthesis (VCX) to those of the predecessor VIATORR stent in an in vitro experimental setup., Materials and Methods: A total of 12 stents (8 VCX; 4 VIATORR; GORE, USA) were examined. Radial resistive force (RRF) and chronic outward force (COF) were assessed using a radial force testing machine (RX-650, Machine Solutions Inc., USA). To assess the radial forces of the VCX above 8 mm, balloon expansion was performed between cycles., Results: All VCX stents show an abrupt decrease in COF at an external diameter of 8.3 mm; RRF decreases likewise at an external diameter of 8.5 mm. The predecessor VIATORR stent without the "controlled expansion" feature shows linear radial force reduction until full expansion at a diameter of 10 mm. The physical properties of the VCX can be altered by balloon modulation. Point of COF (RRF) reduction shifts to 8.5 mm (8.6 mm), 8.6 mm (8.8 mm) and 9.3 mm (9.6 mm) following modulation with a 8 mm, 9 mm and 10 mm balloon., Conclusions: The VCX shows an abrupt and disproportionate decrease in COF and RRF at an external diameter of 8.3 mm, thus passive expansion to its nominal diameter of 10 mm is not to be expected. By means of balloon dilatation the physical properties of the stent can be altered, enabling customized TIPS creation. The previous VIATORR stent shows continuous COF and RRF until total expansion., (© 2023. The Author(s).)

Background: Complication rates in percutaneous transhepatic biliary drainage (PTBD) are non-uniform and vary considerably. In addition, the impact of peri-procedural risk factors is under-investigated., Purpose: To compare success and complication rates of PTBD in patients with and without accompanying technical risk factors., Material and Methods: A single-center retrospective study was conducted from January 2004 to December 2016. Patients receiving PTBD due to biliary obstruction or biliary leakage were included. Technical risk factors (non-distended bile ducts, ascites, obesity, anasarca, non-compliance) were assessed. Complications were classified according to the Society of Interventional Radiology., Results: In total, 372 patients were included (57.3% men, 42.7% women; mean age = 66 years). Overall, 466 PTBDs were performed. Of the patients, 70.1% presented with malignancy and biliary obstruction; 26.8% had benign biliary obstruction; 3.1% had biliary leakage. Technical risk factors were reported in 57 (15.3%) patients. Overall technical success of initial PTBD was 98.7%, primary technical success was 97.9%. In patients with non-dilatated bile ducts, primary technical success was 68.2%. Overall complication rate was 15.0% (8.1% major complications, 6.9% minor complications). Neither major nor minor complications were more frequent in patients with technical risk factors ( P > 0.05). In left-sided PTBD, hemorrhage was more frequent ( P  = 0.015). Patients with malignancy were significantly more affected by drainage-related complications ( P  = 0.004; odds ratio = 2.03). The mortality rate was 0.5% (n = 2)., Conclusion: PTBD is a safe and effective method for the treatment of biliary obstruction and biliary leaks. Complication rates are low, even in procedures with risk factors.

Background: We aimed to comprehensively assess tricuspid valve anatomy and to determine factors associated with the more advanced stages beyond severe TR (i.e., massive to torrential)., Methods: We retrospectively analyzed the pre-procedural cardiac CT images in patients with ≥severe TR using 3mensio software. The tricuspid valve annulus size, right-atrial and right-ventricular dimensions, tenting height, and leaflet angles were measured., Results: A total of 103 patients were analyzed. The mean effective regurgitant orifice area was 61.7 ​± ​31.5 ​mm 2 , vena contracta was 13.1 ​± ​4.6 ​mm, and massive/torrential TR was observed in 62 patients. Compared to patients with severe TR, patients with massive/torrential TR had a larger tricuspid annulus area (18.6 ​± ​3.4 ​cm 2 vs. 20.6 ​± ​5.3 ​cm 2 , p ​= ​0.037), right atrial short-axis diameter (66.1 ​± ​9.1 ​mm vs. 70.6 ​± ​9.9 ​mm, p ​= ​0.022), increased tenting height (8.8 ​± ​3.6 ​mm vs. 10.7 ​± ​3.7 ​mm, p ​= ​0.014), and greater leaflet angles (anterior leaflet: 22 ​± ​9° vs. 32 ​± ​13°, p ​< ​0.001; posterior leaflet: 22 ​± ​11° vs. 30 ​± ​11°, p ​= ​0.003). In the multivariable logistic regression model, the angle of anterior leaflet (OR 1.08, 95%CI 1.03-1.14, p ​= ​0.004) and posterior leaflet (OR 1.07, 95%CI 1.02-1.13, p ​= ​0.007) were associated with massive/torrential TR. Additionally, patients with massive/torrential TR more often had TR jets from non-central/non-anteroseptal commissure (34% vs. 76%, p ​< ​0.001). In the multivariable model, a greater angle of the leaflets and a more elliptical annulus were associated with non-central/non-anteroseptal TR jets., Conclusions: Anterior and posterior leaflet angles are significant factors associated with massive/torrential TR. Furthermore, leaflet angles and ellipticity of the tricuspid valve are associated with the location of TR jets., Competing Interests: Declaration of competing interest Atsushi Sugiura has received honoraria for lectures from Edwards Lifesciences. Tetsu Tanaka has been financially supported in part by a Fellowship from the Japanese College of Cardiology. Marcel Weber has received lecture or proctoring fees from Abbott and Edwards. Georg Nickenig has received research funding from the Deutsche Forschungsgemeinschaft, the German Federal Ministry of Education and Research, the EU, Abbott, Edwards Lifesciences, Medtronic, and St. Jude Medical and has received honoraria for lectures or advisory boards from Abbott, Edwards Lifesciences, Medtronic, and St. Jude Medical. The other authors have no conflicts of interest., (Copyright © 2023 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to compare a new compressed sensing (CS) method for T2-weighted propeller acquisitions (T2 CS ) with conventional T2-weighted propeller sequences (T2 conv ) in terms of achieving a higher image quality, while reducing the acquisition time., Materials and Methods: Male participants with a clinical suspicion of prostate cancer were prospectively enrolled and underwent prostate magnetic resonance imaging at 3 T. Axial and sagittal images of the T2 conv sequence and the T2 CS sequence were acquired. Sequences were qualitatively assessed by 2 blinded radiologists concerning artifacts, image-sharpness, lesion conspicuity, capsule delineation, and overall image quality using 5-point Likert items ranging from 1 (nondiagnostic) to 5 (excellent). The apparent signal-to-noise ratio and apparent contrast-to-noise ratio were evaluated. PI-RADS scores were assessed for both sequences. Statistical analysis was performed by using Wilcoxon signed rank test and paired samples t test. Intrarater and interrater reliability of qualitative image evaluation was assessed using intraclass correlation coefficient (ICC) estimates., Results: A total of 29 male participants were included (mean age, 66 ± 8 years). The acquisition time of the T2 CS sequence was respectively 26% (axial plane) and 24% (sagittal plane) shorter compared with the T2 conv sequence (eg, axial: 171 vs 232 seconds; P < 0.001). In the axial plane, the T2 CS sequence had fewer artifacts (4 [4-4.5] vs 4 [3-4]; P < 0.001), better image-sharpness (4 [4-4.5] vs 3 [3-3.5]; P < 0.001), better capsule delineation (4 [3-4] vs 3 [3-3.5]; P < 0.001), and better overall image quality (4 [4-4] vs 4 [3-4]; P < 0.001) compared with the T2 conv sequence. The ratings of lesion conspicuity were similar (4 [4-4] vs 4 [3-4]; P = 0.166). In the sagittal plane, the T2 CS sequence outperformed the T2 conv sequence in the categories artifacts (4 [4-4] vs 3 [3-4]; P < 0.001), image sharpness (4 [4-5] vs 4 [3-4]; P < 0.001), lesion conspicuity (4 [4-4] vs 4 [3-4]; P = 0.002), and overall image quality (4 [4-4] vs 4 [3-4]; P = 0.002). Capsule delineation was similar between both sequences (3 [3-4] vs 3 [3-3]; P = 0.07). Intraobserver and interobserver reliability for qualitative scoring were good (ICC intra: 0.92; ICC inter: 0.86). Quantitative analysis revealed a higher apparent signal-to-noise ratio (eg, axial: 52.2 ± 9.7 vs 22.8 ± 3.6; P < 0.001) and a higher apparent contrast-to-noise ratio (eg, axial: 44.0 ± 9.6 vs 18.6 ± 3.7; P ≤ 0.001) of the T2 CS sequence. PI-RADS scores were the same for both sequences in all participants., Conclusions: CS-accelerated T2-weighted propeller acquisition had a superior image quality compared with conventional T2-weighted propeller sequences while significantly reducing the acquisition time., Competing Interests: Conflicts of interest and sources of funding: J.A.L. received payments for lectures from Philips Healthcare and for activities related to the scientific advisory board for Bayer HealthCare. For the remaining authors none were declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Outcome assessment in stroke patients is essential for evidence-based stroke care planning. Computed tomography (CT) is the mainstay of diagnosis in acute stroke. This study aimed to investigate whether CT-derived cervical fat-free muscle fraction (FFMF) as a biomarker of muscle quality is associated with outcome parameters after acute ischemic stroke., Methods: In this retrospective study, 66 patients (mean age: 76 ± 13 years, 30 female) with acute ischemic stroke in the anterior circulation who underwent CT, including CT-angiography, and endovascular mechanical thrombectomy of the middle cerebral artery between August 2016 and January 2020 were identified. Based on densitometric thresholds, cervical paraspinal muscles covered on CT-angiography were separated into areas of fatty and lean muscle and FFMF was calculated. The study cohort was binarized based on median FFMF (cutoff value: < 71.6%) to compare clinical variables and outcome data between two groups. Unpaired t test and Mann-Whitney U test were used for statistical analysis., Results: National Institute of Health Stroke Scale (NIHSS) (12.2 ± 4.4 vs. 13.6 ± 4.5, P = 0.297) and modified Rankin scale (mRS) (4.3 ± 0.9 vs. 4.4 ± 0.9, P = 0.475) at admission, and pre-stroke mRS (1 ± 1.3 vs. 0.9 ± 1.4, P = 0.489) were similar between groups with high and low FFMF. NIHSS and mRS at discharge were significantly better in patients with high FFMF compared to patients with low FFMF (NIHSS: 4.5 ± 4.4 vs. 9.5 ± 6.7; P = 0.004 and mRS: 2.9 ± 2.1 vs.3.9 ± 1.8; P = 0.049). 90-day mRS was significantly better in patients with high FFMF compared to patients with low FFMF (3.3 ± 2.2 vs. 4.3 ± 1.9, P = 0.045)., Conclusion: Cervical FFMF obtained from routine clinical CT might be a new imaging-based muscle quality biomarker for outcome prediction in stroke patients., (© 2023. The Author(s).)

Purpose: To apply Doppler US (DUS)-gated fetal cardiac cine MRI in clinical routine and investigate diagnostic performance in complex congenital heart disease (CHD) compared with that of fetal echocardiography., Materials and Methods: In this prospective study (May 2021 to March 2022), women with fetuses with CHD underwent fetal echocardiography and DUS-gated fetal cardiac MRI on the same day. For MRI, balanced steady-state free precession cine images were acquired in the axial and optional sagittal and/or coronal orientations. Overall image quality was assessed on a four-point Likert scale (from 1 = nondiagnostic to 4 = good image quality). The presence of abnormalities in 20 fetal cardiovascular features was independently assessed by using both modalities. The reference standard was postnatal examination results. Differences in sensitivities and specificities were determined by using a random-effects model., Results: The study included 23 participants (mean age, 32 years ± 5 [SD]; mean gestational age, 36 weeks ± 1). Fetal cardiac MRI was completed in all participants. The median overall image quality of DUS-gated cine images was 3 (IQR, 2.5-4). In 21 of 23 participants (91%), underlying CHD was correctly assessed by using fetal cardiac MRI. In one case, the correct diagnosis was made by using MRI only (situs inversus and congenitally corrected transposition of the great arteries). Sensitivities (91.8% [95% CI: 85.7, 95.1] vs 93.6% [95% CI: 88.8, 96.2]; P = .53) and specificities (99.9% [95% CI: 99.2, 100] vs 99.9% [95% CI: 99.5, 100]; P > .99) for the detection of abnormal cardiovascular features were comparable between MRI and echocardiography, respectively., Conclusion: Using DUS-gated fetal cine cardiac MRI resulted in performance comparable with that of using fetal echocardiography for diagnosing complex fetal CHD. Keywords: Pediatrics, MR-Fetal (Fetal MRI), Cardiac, Heart, Congenital, Fetal Imaging, Cardiac MRI, Prenatal, Congenital Heart DiseaseClinical trial registration no. NCT05066399 Supplemental material is available for this article. © RSNA, 2023See also the commentary by Biko and Fogel in this issue., Competing Interests: Disclosures of conflicts of interest: T.M.V. No relevant relationships. C.H. No relevant relationships. S.Z. Salary from Philips. C.K. Employee of Philips, the manufacturer of the MRI system used in this study. A.I. Grant to author’s university from BONFOR and DFG. C.C.P. Educational grant from Guerbet to author’s institution; advisory board consulting fees from Guerbet to author; payment for speakers bureaus from Guerbet and Julius Zorn to author; support from Guerbet and Julius Zorn for attending meetings and/or travel. D.K. No relevant relationships. B.F. No relevant relationships. B.S. No relevant relationships. U.A. Consulting fees from Bayer Healthcare; payment from Siemens Healthineers for speakers bureau; support from Siemens Healthineers for attending meetings and/or travel. F.K. No relevant relationships. U.H. Leadership or fiduciary role in German Society of Pediatric Cardiology. A.G. No relevant relationships. J.A.L. Received payments for lectures from Philips Healthcare and for activities related to the scientific advisory board for Bayer Healthcare., (© 2023 by the Radiological Society of North America, Inc.)

Background: To evaluate the great vessels in young children with complex congenital heart disease (CHD) using non-contrast cardiovascular magnetic resonance angiography (CMRA) based on three-dimensional relaxation-enhanced angiography without contrast (REACT) in comparison to contrast-enhanced steady-state CMRA., Methods: In this retrospective study from April to July 2021, respiratory- and electrocardiogram-gated native REACT CMRA was compared to contrast-enhanced single-phase steady-state CMRA in children with CHD who underwent CMRA at 3T under deep sedation. Vascular assessment included image quality (1 = non-diagnostic, 5 = excellent), vessel diameter, and diagnostic findings. For statistical analysis, paired t-test, Pearson correlation, Bland-Altman analysis, Wilcoxon test, and intraclass correlation coefficients (ICC) were applied., Results: Thirty-six young children with complex CHD (median 4 years, interquartile range, 2-5; 20 males) were included. Native REACT CMRA was obtained successfully in all patients (mean scan time: 4:22 ± 1:44 min). For all vessels assessed, diameters correlated strongly between both methods (Pearson r = 0.99; bias = 0.04 ± 0.61 mm) with high interobserver reproducibility (ICC: 0.99 for both CMRAs). Native REACT CMRA demonstrated comparable overall image quality to contrast-enhanced CMRA (3.9 ± 1.0 vs. 3.8 ± 0.9, P = 0.018). With REACT CMRA, better image quality was obtained at the ascending aorta (4.8 ± 0.5 vs. 4.3 ± 0.8, P &lt; 0.001), coronary roots (e.g., left: 4.1 ± 1.0 vs. 3.3 ± 1.1, P = 0.001), and inferior vena cava (4.6 ± 0.5 vs. 3.2 ± 0.8, P &lt; 0.001). In all patients, additional vascular findings were assessed equally with native REACT CMRA and the contrast-enhanced reference standard (n = 6)., Conclusion: In young children with complex CHD, REACT CMRA can provide gadolinium-free high image quality, accurate vascular measurements, and equivalent diagnostic quality compared to standard contrast-enhanced CMRA., (© 2022. The Author(s).)

Background: Mass COVID-19 vaccination campaigns have helped impede the COVID-19 pandemic. In rare cases, some vaccines have led to vaccine associated myocarditis in a specific subset of the population, usually young males. Cardiac magnetic resonance (CMR) can reliably diagnose vaccine associated myocarditis, but follow-up data of CMR proven acute myocarditis is scarce., Materials and Methods: Nine patients with acute vaccine associated myocarditis underwent baseline and follow-up CMR examinations and were compared to baseline parameters at initial presentation and to a group of 20 healthy controls. CMR protocol included functional assessment, T1 and T2 mapping, T2 signal intensity ratio, strain feature tracking, and late gadolinium enhancement (LGE)., Results: Myocarditis patients ( n = 9, aged 24 ± 6 years, 8 males) underwent CMR follow-up after an average of 5.8 ± 4.3 months. All patients showed a complete resolution of visual myocardial edema while also demonstrating a reduction in overall LGE extent from baseline to follow-up (4.2 ± 2.1 vs. 0.9 ± 0.8%, p < 0.001), although visual LGE was still noted in all patients. Left ventricular ejection fraction was normal at baseline and at follow-up (58 ± 6 vs. 62 ± 4%, p = 0.10) as well as compared to a healthy control group (60 ± 4%, p = 0.24). T1 (1024 ± 77 vs. 971 ± 34 ms, p = 0.05) and T2 relaxations times (57 ± 6 vs. 51 ± 3 ms, p = 0.03) normalized at follow-up. Most patients reported a resolution of clinical symptoms, while two (22%) reported new onset of exertional dyspnea., Conclusion: Patients with COVID-19 vaccine associated acute myocarditis showed a complete, uncomplicated resolution of myocardial inflammation on follow-up CMR, which was associated with a near complete resolution of symptoms. Minor, residual myocardial scarring was present on follow-up LGE imaging. The long-term implications of the remaining myocardial scar-tissue after vaccine associated myocarditis remain unknown warranting further studies., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Kravchenko, Isaak, Mesropyan, Bischoff, Pieper, Attenberger, Kuetting, Zimmer, Hart and Luetkens.)

Purpose: To evaluate cardiac MRI characteristics in patients with suspected hypersensitivity myocarditis following mRNA COVID-19 vaccination., Materials and Methods: Patients clinically suspected of acute myocarditis after COVID-19 vaccination were retrospectively analyzed and compared against a healthy control group. Cardiac MRI protocol included parameters such as T1 and T2 relaxation times, extracellular volume (ECV), T2 signal intensity ratio, and late gadolinium enhancement (LGE). Lymph node size was assessed in the patient group on the injection side. Student t-test, analyses of variance (ANOVA) with Tukey post-hoc test, and χ 2 test were used for statistical analysis., Results: 20 patients with clinically suspected post-vaccine myocarditis (28 ± 12 years; 12 men) and 40 controls (31 ± 11 years; 25 men) were evaluated. According to the 2018 Lake Louise criteria (LLC), patients with clinically suspected myocarditis were further subdivided into an LLC-positive group (n = 9) and an LLC-negative group (n = 11). The mean time of symptom onset after vaccination was 1.1 ± 1.2 days (LLC-positive) and 6.5 ± 9.2 days (LLC-negative). Group differences in inflammatory variables between myocarditis patients and control subjects were more pronounced in the LLC-positive group (e. g., T1 relaxation time: 1041 ± 61 ms [LLC positive] vs. 1008 ± 79 ms [LLC-negative] vs. 970 ± 25 ms [control]; p <.001; or T2 signal intensity ratio 2.0 ± 0.3 vs. 1.6 ± 0.3 [LLC-negative] and vs. 1.6 ± 0.3 [control], p = .012). LLC-positive patients were significantly faster in receiving an MRI after initial symptom onset (8.8 ± 6.1 days vs. 52.7 ± 33.4 days; p = .001) and had higher troponin T levels (3938 ± 5850 ng/l vs. 9 ± 11 ng/l; p <.001). LGE lesions were predominantly located at the subepicardium of the lateral wall. Axillary lymphadenopathy was more frequent in the LLC-positive group compared to the LLC-negative group (8/9 [89 %] vs. 0/11 [0 %], p < 0.001)., Conclusion: Vaccine-induced myocarditis should be considered in patients with acute symptom onset after mRNA vaccination, especially if elevated serum troponin T is observed. Imaging findings of vaccine-induced myocarditis are similar to virus-induced myocarditis, allowing for the use of the Lake Louise Criteria for diagnostic purposes., Key Points: · Vaccine-induced hypersensitivity myocarditis can be confirmed with cardiac MRI. · Especially patients with sudden onset of symptoms and elevated serum troponin T had positive cardiac MRI findings. · Cardiac MRI characteristics of vaccine-induced myocarditis are similar to those in virus-induced myocarditis., Citation Format: · Kravchenko D, Isaak A, Mesropyan N et al. Cardiac MRI in Suspected Acute Myocarditis After COVID-19 mRNA Vaccination. Fortschr Röntgenstr 2022; 194: 1003 - 1011., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Purpose: To evaluate technical feasibility and safety of common endovascular visceral interventions using a vascular robotic platform through preclinical study., Material and Methods: The CorPath GRX Robotic System (Corindus Inc, Waltham, Massachusetts) was tested in an anesthetized pig for its ability to navigate various commercially available devices in the abdominal vasculature and to perform routine endovascular visceral procedures. After manually placing a guiding catheter in the celiac trunk, several visceral branches were probed with microcatheters and -wires under robotic assistance, and embolization with liquids (lipiodol), detachable coils and plugs were performed. Furthermore, the origin of the celiac trunk was stented before accessing the left hypogastric artery for pelvic embolization., Results: All procedures were performed with technical success and without any complications. Navigating the catheters and wires via the steering console proved intuitive. Coil, plug and stent deployment were exclusively controlled by remote with remarkable precision and stability., Conclusion: Robotic-assisted visceral embolization and stenting as well as pelvic embolization using the CorPath GRX System is feasible and safe. Application of the platform in the abdominal vasculature is demonstrated for the first time. Considering the precision and the potential for reducing the operator's radiation exposure, further research in this area is highly encouraged to enable translation into clinical practice., (© 2022. The Author(s).)

To explore the image quality and radiation dose of dual source high-pitch cardiac computed tomography with tailored contrast injection protocols for pediatric congenital heart disease patients (CHD). In total, 27 infants with CHD (median age 109 days [IQR 6-199]) were retrospectively analyzed regarding dose length product (DLP) and effective dose (ED) after undergoing cardiothoracic CT imaging. Scan parameters were adjusted on a dual source/detector CT (DSCT) to minimize radiation dose while maintaining adequate quality. Image acquisition was performed at 70% of the R-R interval. Dose reducing measures included prospective electrocardiogram gating, utilizing slow injection velocities and foregoing bolus tracking during contrast injection. Image quality was assessed for artefacts, vessel definition, and noise on a 5-point scale (1 non-diagnostic, 5 excellent). Series were scored on a 0-to-3-point scale regarding answered clinical questions (0 non-diagnostic, 3 all clinical questions could be answered). The median DLP was 5.2 mGy*cm (IQR 3.5-7.8) leading to a median ED of 0.20 mSv (IQR 0.14-0.30). On average the acquired images scored 13.3 ± 2.1 (SD) out of a maximum 15 points with an intraclass correlation coefficient (ICC) of 0.94. All acquired series were able to fully answer all clinical questions scoring maximum points (ICC 1.0). Dual source high pitch CT protocols combined with custom contrast agent injection protocols in pediatric patients with CHD delivered sufficiently high diagnostic imaging quality combined with low submilisievert radiation doses. Prospective high pitch imaging is a reliable method for depiction of cardiac anatomy even in very young pediatric CHD patients with elevated heart rates., (© 2022. The Author(s).)

Purpose: To evaluate the diagnostic performance of layer-specific cardiac MRI feature-tracking (FT) strain analysis in patients with acute myocarditis., Materials and Methods: Seventy patients (mean age, 43 years ± 19 [SD]; 46 men) with clinically defined acute myocarditis and 42 healthy controls who underwent cardiac MRI from March 2014 to November 2018 were retrospectively analyzed. FT-based left ventricular peak systolic global longitudinal strain (GLS) and global circumferential strain (GCS) were assessed at subendocardial, midmyocardial, and subepicardial layers. The 2018 Lake Louise criteria (LLC) were assessed. Patients with myocarditis were dichotomized into two groups: those with preserved and those with reduced ejection fraction. For statistical analysis, unpaired t test, one-way analysis of variance, Pearson correlation, and receiver operating characteristic analysis were used., Results: GLS and GCS values of all layers (eg, midmyocardial GCS: -21.3% ± 5.5 vs -28.0% ± 4.3; P < .001) were impaired in patients with myocarditis compared with controls. Only subepicardial GLS (-20.0% ± 3.3 vs -17.5% ± 3.3; P < .001) and midmyocardial GCS values (-28.0% ± 4.3 vs -23.1% ± 4.3; P < .001) could differentiate between controls and patients with preserved ejection fraction. Midmyocardial GCS correlated with inflammatory myocardial parameters (eg, late gadolinium enhancement percentage, r = 0.48, P < .001). Midmyocardial GCS (area under the receiver operating characteristic curve [AUC], 0.82) and subepicardial GLS (AUC, 0.77) had the highest diagnostic performance for acute myocarditis diagnosis ( P < .05 against all other strain parameters). The diagnostic performance of the 2018 LLC was significantly improved by inclusion of these two strain parameters (AUC, 0.92 vs 0.97; P = .04)., Conclusion: Diagnostic performance of cardiac MRI FT strain was different between myocardial layers in acute myocarditis, with midmyocardial GCS and subepicardial GLS providing the highest diagnostic performance. Keywords: MRI, Cardiac, Heart, Left Ventricle, Inflammation, Tissue Characterization, MR-Functional Imaging, Feature-Tracking Strain, Acute Myocarditis Supplemental material is available for this article. © RSNA, 2022., Competing Interests: Disclosures of conflicts of interest: A.I. Funded by BONFOR-Forschungskommission der Medizinischen Fakultät Bonn and by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) under Germany’s Excellence Strategy, EXC2151–390873048; funders had no influence on study conceptualization and design, collection and analysis of the data, manuscript preparation, or the decision to publish. D. Kravenchko No relevant relationships. N.M. No relevant relationships. C.E. No relevant relationships. L.M.B. No relevant relationships. T.V. No relevant relationships. D.T. No relevant relationships. D.D. No relevant relationships. S.Z. No relevant relationships. U.A. No relevant relationships. D. Kuetting No relevant relationships. J.A.L. Received payments for lectures from Philips Healthcare and for activities related to the scientific advisory board for Bayer HealthCare., (© 2022 by the Radiological Society of North America, Inc.)

We aimed to investigate the diagnostic utility of MRI extracellular volume fraction (ECV) for the assessment of liver cirrhosis severity as defined by Child-Pugh class. In this retrospective study, 90 patients (68 cirrhotic patients and 22 controls), who underwent multiparametric liver MRI, were identified. Hepatic T1 relaxation times and ECV were assessed. Clinical scores of liver disease severity were calculated. One-way analysis of variance (ANOVA) followed by Tukey's multiple comparison test, Spearman's correlation coefficient, and receiver operating characteristic (ROC) analysis were used for statistical analysis. In cirrhotic patients, hepatic native T1 increased depending on Child-Pugh class (620.5 ± 78.9 ms (Child A) vs. 666.6 ± 73.4 ms (Child B) vs. 828.4 ± 91.2 ms (Child C), P < 0.001). ECV was higher in cirrhotic patients compared to the controls (40.1 ± 11.9% vs. 25.9 ± 4.5%, P < 0.001) and increased depending of Child-Pugh class (33.3 ± 6.0% (Child A) vs. 39.6 ± 4.9% (Child B) vs. 52.8 ± 1.2% (Child C), P < 0.001). ECV correlated with Child-Pugh score (r = 0.64, P < 0.001). ECV allowed differentiating between Child-Pugh classes A and B, and B and C with an AUC of 0.785 and 0.944 (P < 0.001, respectively). The diagnostic performance of ECV for differentiating between Child-Pugh classes A and B, and B and C was higher compared to hepatic native T1 (AUC: 0.651 and 0.910) and MELD score (AUC: 0.740 and 0.795) (P < 0.05, respectively). MRI-derived ECV correlated with Child-Pugh score and had a high diagnostic performance for the discrimination of different Child-Pugh classes. ECV might become a valuable non-invasive biomarker for the assessment of liver cirrhosis severity., (© 2022. The Author(s).)

To evaluate the embolic properties of different acrylic adhesive/iodized oil mixtures for lymphatic interventions. Polymerization of histoacryl (HA) (Bayer Healthcare) and glubran 2 (GL) (GEM) mixed with iodized oil (ratios 1:0-1:7) were investigated in lymphatic fluids with low and high triglyceride (low TG & high TG) contents. Static polymerization time and dynamic polymerization experiments with different volumes of glucose flush (1, 2 and 5 mL) were performed to simulate thoracic duct embolization. For both glues, static polymerization times were longer when the iodized oil content was increased and when performed in high TG lymphatic fluid. In the dynamic experiments, the prolongation of polymerization due to the oil content and TG levels was less pronounced for both glue types. Increased lymphatic flow rates decreased embolization times for low glue/oil ratios while preventing embolization for high glue/oil ratios. Higher glucose flush volumes increased occlusion times. Polymerization times of acrylic glue in a lymphatic fluid are prolonged by increasing the iodized oil concentration and triglyceride concentration as well as by using larger volumes of glucose flush. Increased lymphatic flow rates decrease embolization times for low glue/oil ratios and may prevent embolization for high glue/oil ratios.

This study aimed to evaluate the diagnostic and prognostic value of cardiac magnetic resonance in acute peripartum cardiomyopathy (PPCM). A total of 17 patients with PPCM in the acute stage and 15 healthy controls were retrospectively analyzed regarding myocardial function, edema, late gadolinium enhancement (LGE), and T1 and T2 mappings (T1, T2). Echocardiographic follow-ups were performed. Functional recovery was defined as a left ventricular ejection fraction (LVEF) of ≥50%. Patients with PPCM displayed biventricular dysfunction with reduced myocardial strain parameters and left ventricular and atrial dilatation, as well as diffuse myocardial edema (T2 signal intensity ratio: 2.10 ± 0.34 vs. 1.58 ± 0.21, p < 0.001; T1: 1070 ± 51 ms vs. 980 ± 28 ms, p = 0.001; T2: 63 ± 5 ms vs. 53 ± 2 ms, p < 0.001). Visual myocardial edema was present in 10 patients (59%). LGE was positive in 2 patients (12%). A total of 13 patients (76%) showed full LVEF recovery. The absence of visual myocardial edema and impairment of strain parameters were associated with delayed LVEF recovery. Multivariable Cox regression analysis revealed global longitudinal strain as an independent prognostic factor for LVEF recovery. In conclusion, biventricular systolic dysfunction with diffuse myocardial edema seems to be present in acute PPCM. Myocardial edema and strain may have prognostic value for LVEF recovery.

Objectives: To analyse the diagnostic impact of dual energy computed tomography (DECT) in acute gout flares and acute calcium pyrophosphate (CPP) crystal arthritis when compared to the gold standard of arthrocentesis with compensated polarised light microscopy. Microscopy results were also compared to musculoskeletal ultrasound (MUS), conventional radiographs, and the suspected clinical diagnosis (SCD)., Methods: Thirty-six patients with a suspected gout flare (n = 24) or acute CPP crystal arthritis (n = 11, n = 1 suffered from neither) who received a DECT and underwent arthrocentesis were included. Two independent readers assessed DECT images for signs of monosodium urate crystals or calcium pyrophosphate deposition., Results: Sensitivity of DECT for gout was 63% (95% CI 0.41-0.81) with a specificity of 92% (0.41-0.81) while sensitivity and specificity for acute CPP arthritis were 55% (0.23-0.83) and 92% (0.74-0.99), respectively. MUS had the highest sensitivity of all imaging modalities with 92% (0.73-0.99) and a specificity of 83% (0.52-0.98) for gout, while sensitivity and specificity for acute CPP crystal arthritis were 91% (0.59-1.00) and 92% (0.74-0.99), respectively., Conclusion: DECT is an adequate non-invasive diagnostic tool for acute gout flares but might have a lower sensitivity than described by previous studies. Both MUS and SCD had higher sensitivities than DECT for acute gout flares and acute CPP crystal arthritis., (© 2021. The Author(s).)

To evaluate the safety and impact of biopsy tract plugging with gelatin sponge slurry in percutaneous liver biopsy. 300 consecutive patients (158 females, 142 males; median age, 63 years) who underwent computed tomography-guided core biopsy of the liver in coaxial technique (16/18 Gauge) with and without biopsy tract plugging were retrospectively reviewed (January 2013 to May 2018). Complications were rated according to the common criteria for adverse events (NCI-CTCAE). The study cohort was dichotomized into a plugged (71%; n = 214) and an unplugged (29%; n = 86) biopsy tract group. Biopsy tract plugging with gelatin sponge slurry was technically successful in all cases. Major bleeding events were only observed in the unplugged group (0.7%; n = 2), whereas minor bleedings (4.3%) were observed in both groups (plugged, 3.6%, n = 11; unplugged, 0.7%, n = 2). Analysis of biopsies and adverse events showed a significant association between number of needle-passes and overall (P = 0.038; odds ratio: 1.395) as well as minor bleeding events (P = 0.020; odds ratio: 1.501). No complications associated with gelatin sponge slurry were observed. Biopsy tract plugging with gelatin sponge slurry is a technically easy and safe procedure that can prevent major bleeding events following liver biopsy., (© 2021. The Author(s).)

Previous studies suggest an impact of body composition on outcome in melanoma patients. We aimed to determine the prognostic value of CT-based body composition assessment in patients receiving immune checkpoint inhibitor therapy for treatment of metastatic disease using a deep learning approach. One hundred seven patients with staging CT examinations prior to initiation of checkpoint inhibition between January 2013 and August 2019 were retrospectively evaluated. Using an automated deep learning-based body composition analysis pipeline, parameters for estimation of skeletal muscle mass (skeletal muscle index, SMI) and adipose tissue compartments (visceral adipose tissue index, VAI; subcutaneous adipose tissue index, SAI) were derived from staging CT. The cohort was binarized according to gender-specific median cut-off values. Patients below the median were defined as having low SMI, VAI, or SAI, respectively. The impact on outcome was assessed using the Kaplan-Meier method with log-rank tests. A multivariable logistic regression model was built to test the impact of body composition parameters on 3-year mortality. Patients with low SMI displayed significantly increased 1-year (25% versus 9%, p = 0.035), 2-year (32% versus 13%, p = 0.017), and 3-year mortality (38% versus 19%, p = 0.016). No significant differences with regard to adipose tissue compartments were observed (3-year mortality: VAI, p = 0.448; SAI, p = 0.731). On multivariable analysis, low SMI (hazard ratio (HR), 2.245; 95% confidence interval (CI), 1.005-5.017; p = 0.049), neutrophil-to-lymphocyte ratio (HR, 1.170; 95% CI, 1.076-1.273; p < 0.001), and Karnofsky index (HR, 0.965; 95% CI, 0.945-0.985; p = 0.001) remained as significant predictors of 3-year mortality. Lowered skeletal muscle index as an indicator of sarcopenia was associated with worse outcome in patients with metastatic melanoma receiving immune checkpoint inhibitor therapy.

Background Immune checkpoint inhibitors (ICIs) for cancer treatment are associated with a spectrum of immune-related adverse events, including ICI-induced myocarditis; however, the extent of subclinical acute cardiac effects related to ICI treatment is unclear. Purpose To explore the extent of cardiac injury and inflammation related to ICI therapy that can be detected with use of cardiac MRI. Materials and Methods In this prospective study from November 2019 to April 2021, oncologic participants, without known underlying structural heart disease or cardiac symptoms, underwent multiparametric cardiac MRI before planned ICI therapy (baseline) and 3 months after starting ICI therapy (follow-up). The cardiac MRI protocol incorporated assessment of cardiac function, including systolic myocardial strain, myocardial edema, late gadolinium enhancement (LGE), T1 and T2 relaxation times, and extracellular volume fraction. The paired t test, Wilcoxon signed-rank test, and McNemar test were used for intraindividual comparisons. Results Twenty-two participants (mean age ± standard deviation, 65 years ± 14; 13 men) were evaluated, receiving a median of four infusions of ICI therapy (interquartile range, four to six infusions). Compared with baseline MRI, participants displayed increased markers of diffuse myocardial edema at follow-up (T1 relaxation time, 972 msec ± 26 vs 1006 msec ± 36 [ P < .001]; T2 relaxation time, 54 msec ± 3 vs 58 msec ± 4 [ P < .001]; T2 signal intensity ratio, 1.5 ± 0.3 vs 1.7 ± 0.3 [ P = .03]). Left ventricular average systolic longitudinal strain had decreased at follow-up MRI (-23.4% ± 4.8 vs -19.6% ± 5.1, respectively; P = .005). New nonischemic LGE lesions were prevalent in two of 22 participants (9%). Compared with baseline, small pericardial effusions were more evident at follow-up (one of 22 participants [5%] vs 10 of 22 [45%]; P = .004). Conclusion In participants who received immune checkpoint inhibitor therapy for cancer treatment, follow-up cardiac MRI scans showed signs of systolic dysfunction and increased parameters of myocardial edema and inflammation. © RSNA, 2021 Online supplemental material is available for this article.

Background Myocardial injury and inflammation at cardiac MRI in patients with COVID-19 have been described in recent publications. Concurrently, a chronic COVID-19 syndrome (CCS) after SARS-CoV-2 infection has been observed and manifests with symptoms such as fatigue and exertional dyspnea. Purpose To explore the relationship between CCS and myocardial injury and inflammation as an underlying cause of the persistent complaints in previously healthy individuals. Materials and Methods In this prospective study from January 2021 to April 2021, study participants without known cardiac or pulmonary diseases prior to SARS-CoV-2 infection who had persistent CCS symptoms such as fatigue or exertional dyspnea after convalescence and healthy control participants underwent cardiac MRI. The cardiac MRI protocol included evaluating the T1 and T2 relaxation times, extracellular volume, T2 signal intensity ratio, and late gadolinium enhancement (LGE). Student t tests, Mann-Whitney U tests, and χ 2 tests were used for statistical analysis. Results Forty-one participants with CCS (mean age, 39 years ± 13 [standard deviation]; 18 men) and 42 control participants (mean age, 39 years ± 16; 26 men) were evaluated. The median time between the initial incidence of mild to moderate COVID-19 not requiring hospitalization and undergoing cardiac MRI was 103 days (interquartile range, 88-158 days). Troponin T levels were normal. Parameters indicating myocardial inflammation and edema were comparable between participants with CCS and control participants (T1 relaxation times: 978 msec ± 23 vs 971 msec ± 25 [ P = .17]; T2 relaxation times: 53 msec ± 2 vs 52 msec ± 2 [ P = .47]; T2 signal intensity ratios: 1.6 ± 0.2 vs 1.6 ± 0.3 [ P = .10]). Visible myocardial edema was present in none of the participants. Three of 41 (7%) participants with CCS demonstrated nonischemic LGE, whereas no participants in the control group demonstrated nonischemic LGE (0 of 42 [0%]; P = .07). None of the participants fulfilled the 2018 Lake Louise criteria for the diagnosis of myocarditis. Conclusion Individuals with chronic COVID-19 syndrome who did not undergo hospitalization for COVID-19 did not demonstrate signs of active myocardial injury or inflammation at cardiac MRI. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lima and Bluemke in this issue.

Background: The diagnostic value of cardiac magnetic resonance imaging (MRI) employing the 2018 Lake Louise criteria in pediatric and adolescent patients with acute myocarditis is undefined., Objective: To evaluate the diagnostic value of the Lake Louise criteria in pediatric and adolescent patients with suspected acute myocarditis and to show the utility of cardiac MRI for follow-up in this patient cohort., Materials and Methods: Forty-three patients (age range: 8-21 years) with suspected acute myocarditis and 13 control patients who underwent cardiac MRI were retrospectively analyzed. T2-weighted and late gadolinium enhancement imaging were performed in all patients. T1 and T2 mapping were available in 26/43 patients (60%). The Lake Louise criteria were assessed. In 27/43 patients (63%), cardiac MRI follow-up was available. Receiver operating characteristic analysis, Pearson's correlation coefficient and paired Student's t-test were used for statistical analysis., Results: In the total cohort, the Lake Louise criteria achieved a sensitivity of 86% (95% confidence interval [CI]: 72-95%) and a specificity of 100% (95% CI: 79-100%) for the diagnosis of acute myocarditis. In the subgroup of patients with available mapping parameters, the diagnostic performance of the Lake Louise criteria was higher when mapping parameters were implemented into the score (area under the receiver operating characteristic curve: 0.944 vs. 0.870; P=0.033). T2 relaxation times were higher in patients with admission to the intermediate care unit and were associated with the length of intermediate care unit stay (r=0.879, P=0.049). Cardiac MRI markers of active inflammation decreased on follow-up examinations (e.g., T1 relaxation times: 1,032±39 ms vs. 975±33 ms, P<0.001; T2 relaxation times: 58±5 ms vs. 54±5 ms, P=0.003)., Conclusion: The Lake Louise criteria have a high diagnostic performance for the diagnosis of acute myocarditis and are a valuable tool for follow-up in pediatric and adolescent patients. The mapping techniques enhance the diagnostic performance of the 2018 Lake Louise criteria., (© 2021. The Author(s).)

Background: Cardiovascular magnetic resonance angiography (CMRA) is a non-invasive imaging modality of choice in pediatric patients with congenital heart disease (CHD). This study was aimed to evaluate the diagnostic utility of a respiratory- and electrocardiogram-gated steady-state CMRA with modified Dixon (mDixon) fat suppression technique and compressed sensing in comparison to standard first-pass CMRA in pediatric patients with CHD at 3 T., Methods: In this retrospective single center study, pediatric CHD patients who underwent CMR with first-pass CMRA followed by mDixon steady-state CMRA at 3 T were analyzed. Image quality using a Likert scale from 5 (excellent) to 1 (non-diagnostic) and quality of fat suppression were assessed in consensus by two readers. Blood-to-tissue contrast and quantitative measurements of the thoracic vasculature were assessed separately by two readers. CMRA images were reevaluated by two readers for additional findings, which could be identified only on either one of the CMRA types. Paired Student t test, Wilcoxon test, and intraclass correlation coefficients (ICCs) were used for statistical analysis., Results: 32 patients with CHD (3.3 ± 1.7 years, 13 female) were included. Overall image quality of steady-state mDixon CMRA was higher compared to first-pass CMRA (4.5 ± 0.5 vs. 3.3 ± 0.5; P < 0.001). Blood-to-tissue contrast ratio of steady-state mDixon CMRA was comparable to first-pass CMRA (7.85 ± 4.75 vs. 6.35 ± 2.23; P = 0.133). Fat suppression of steady-state mDixon CMRA was perfect in 30/32 (94%) cases. Vessel diameters were greater in first-pass CMRA compared to steady-state mDixon CMRA with the greatest differences at the level of pulmonary arteries and veins (e.g., right pulmonary artery for reader 1: 10.4 ± 2.4 vs. 9.9 ± 2.3 mm, P < 0.001). Interobserver agreement was higher for steady-state mDixon CMRA for all measurements compared to first-pass CMRA (ICCs > 0.92). In 9/32 (28%) patients, 10 additional findings were identified on mDixon steady-state CMRA (e.g., partial anomalous venous return, abnormalities of coronary arteries, subclavian artery stenosis), which were not depicted using first-pass CMRA., Conclusions: Steady-state mDixon CMRA offers a robust fat suppression, a high image quality, and diagnostic utility for the assessment of the thoracic vasculature in pediatric CHD patients., (© 2021. The Author(s).)

The pathophysiology of thrombocytopenia after transcatheter aortic valve implantation (TAVI) thrombocytopenia is still poorly understood. We assessed the association of spleen size with acquired thrombocytopenia in patients undergoing TAVI. We included 732 patients who underwent TAVI with new generation transcatheter heart valves (THVs) at our center from February 2016 to July 2019. We measured splenic volume index in consecutive patients derived from multidetector row computed tomographic datasets. Patients were stratified according to post-TAVI thrombocytopenia, which was defined as a decline in platelet count (DPC) ≥50% at nadir, and evaluated regarding baseline characteristics and outcome parameters. After the procedure, platelet counts declined from 212.9 ± 67.4 × 10 9 /L at baseline to 138.8 ± 49.8 × 10 9 /L at nadir after a median of 2 days (interquartile range [IQR] 2 to 3). Of all patients, 10.1% showed a DPC ≥50%. Compared with patients with DPC <50%, patients with DPC ≥50% had significantly lower splenic volume index (95.5 ml/m 2 [IQR 78.0 to 123.7] vs 85.8 ml/m 2 [IQR 71.4 to 102.6], p = 0.008). A multivariable analysis revealed that the splenic volume index was negatively associated with a DPC ≥50% (OR 0.89, 95% CI 0.82 to 0.97, p = 0.005), independent of the type of THV (balloon-expandable THV: OR 2.06, 95% CI 1.13 to 3.76, p = 0.02), major bleeding (OR 13.40, 95% CI 3.58 to 50.40, p <0.001), blood transfusion (OR 3.63, 95% CI 1.54 to 8.56, p = 0.003), or postprocedural paravalvular leakage ≥moderate (OR 5.48, 95% CI 1.23 to 24.40, p = 0.03). Furthermore, DPC ≥50% was independently associated with 1-year mortality (HR 3.36, 95% CI 1.66 to 6.81, p <0.001). In conclusion, acquired thrombocytopenia remains prevalent in modern TAVI patients. Spleen size appears to be associated with the occurrence of thrombocytopenia after TAVI, which is independently correlated with 1-year mortality., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Calculation of extracellular volume fraction (ECV) currently receives increasing interest as a potential biomarker for non-invasive assessment of liver fibrosis. ECV calculation requires hematocrit (Hct) sampling, which might be difficult to obtain in a high-throughput radiology department. The aim of this study was to generate synthetic ECV for hepatic applications without the need for Hct sampling., Methods: In this prospective study participants underwent liver MRI. T1 mapping was performed before and after contrast administration. Blood Hct was obtained prior to MRI. We hypothesized that the relationship between Hct and longitudinal relaxation rate of blood (R1 = 1/T1 blood ) could be calibrated and used to generate the equation for synthetic Htc and ECV calculation. Conventional and synthetic ECV were calculated. Pearson correlation, linear regression and Bland-Altman method were used for statistical analysis., Results: 180 consecutive patients were divided into derivation (n = 90) and validation (n = 90) cohorts. In the derivation cohort, native R1 blood and Hct showed a linear relationship (Hct MOLLI  = 98.04 × (1/T1 blood ) - 33.17, R 2  = 0.75, P < 0.001), which was used to calculate synthetic ECV in the validation and whole study cohorts. Synthetic and conventional ECV showed significant correlations in the derivation, validation and in the whole study cohorts (r = 0.99, 0.97 and 0.99, respectively, P < 0.001, respectively) with minimal bias according to the Bland-Altman analysis., Conclusion: Synthetic ECV seems to offer an alternative method for non-invasive quantification of the hepatic ECV. It may potentially overcome an important barrier to clinical implementation of ECV and thus, enable broader use of hepatic ECV in routine clinical practice., (© 2021. The Author(s).)

Background Cervical spine CT is regularly performed to exclude cervical spine injury during the initial evaluation of trauma patients. Patients with asymmetry of the lateral atlantodental interval (LADI) often undergo subsequent MRI to rule out ligamentous injuries. The clinical relevance of an asymmetric LADI and the benefit of additional MRI remain unclear. Purpose To evaluate the diagnostic benefit of additional MRI in patients with blunt trauma who have asymmetry of the LADI and no other cervical injuries. Materials and Methods Patients who underwent cervical spine CT during initial trauma evaluation between March 2017 and August 2019 were retrospectively evaluated. Those who underwent subsequent MRI because of LADI asymmetry of 1 mm or greater with no other signs of cervical injury were identified and reevaluated by two readers blinded to clinical data and initial study reports regarding possible ligamentous injuries. Results Among 1553 patients, 146 (9%) had LADI asymmetry of 1 mm or greater. Of these, 46 patients (mean age ± standard deviation, 39 years ± 22; 28 men; median LADI asymmetry, 2.4 mm [interquartile range, 1.8-3.1 mm]) underwent supplementary MRI with no other signs of cervical injury at initial CT. Ten of the 46 patients (22%) showed cervical tenderness at clinical examination, and 36 patients (78%) were asymptomatic. In two of the 46 patients (4%), MRI revealed alar ligament injury; both of these patients showed LADI asymmetry greater than 3 mm, along with cervical tenderness at clinical examination, and underwent treatment for ligamentous injury. In 13 of the 46 patients (28%), signal intensity alterations of alar ligaments without signs of rupture were observed. Four of these 13 patients (31%) were subsequently treated for ligamentous injury despite being asymptomatic. Conclusion Subsequent MRI following CT of the cervical spine in trauma patients with lateral atlantodental interval asymmetry may have diagnostic benefit only in symptomatic patients. In asymptomatic patients without proven cervical injuries, subsequent MRI showed no diagnostic benefit and may even lead to overtreatment. © RSNA, 2021 Online supplemental material is available for this article.

Background: To evaluate a non-contrast respiratory- and electrocardiogram-gated 3D cardiovascular magnetic resonance angiography (CMRA) based on magnetization-prepared Dixon method (relaxation-enhanced angiography without contrast and triggering, REACT) for the assessment of the thoracic vasculature in congenital heart disease (CHD) patients., Methods: 70 patients with CHD (mean 28 years, range: 10-65 years) were retrospectively identified in this single-center study. REACT-CMRA was applied with respiratory- and cardiac-gating. Image quality (IQ) of REACT-CMRA was compared to standard non-gated multi-phase first-pass-CMRA and respiratory- and electrocardiogram-gated steady-state-CMRA. IQ of different vessels of interest (ascending aorta, left pulmonary artery, left superior pulmonary vein, right coronary ostium, coronary sinus) was independently assessed by two readers on a five-point Likert scale. Measurements of vessel diameters were performed in predefined anatomic landmarks (ascending aorta, left pulmonary artery, left superior pulmonary vein). Both readers assessed artifacts and vascular abnormalities. Friedman test, chi-squared test, and Bland-Altman method were used for statistical analysis., Results: Overall IQ score of REACT-CMRA was higher compared to first-pass-CMRA (3.5 ± 0.4 vs. 2.7 ± 0.4, P < 0.001) and did not differ from steady-state-CMRA (3.5 ± 0.4 vs. 3.5 ± 0.6, P = 0.99). Non-diagnostic IQ of the defined vessels of interest was observed less frequently on REACT-CMRA (1.7 %) compared to steady-state- (4.3 %, P = 0.046) or first-pass-CMRA (20.9 %, P < 0.001). Close agreements in vessel diameter measurements were observed between REACT-CMRA and steady-state-CMRA (e.g. ascending aorta, bias: 0.38 ± 1.0 mm, 95 % limits of agreement (LOA): - 1.62-2.38 mm). REACT-CMRA showed high intra- (bias: 0.04 ± 1.0 mm, 95 % LOA: - 1.9-2.0 mm) and interobserver (bias: 0.20 ± 1.1 mm, 95 % LOA: - 2.0-2.4 mm) agreements regarding vessel diameter measurements. Fat-water separation artifacts were observed in 11/70 (16 %) patients on REACT-CMRA but did not limit diagnostic utility. Six vascular abnormalities were detected on REACT-CMRA that were not seen on standard contrast-enhanced CMRA., Conclusions: Non-contrast-enhanced cardiac-gated REACT-CMRA offers a high diagnostic quality for assessment of the thoracic vasculature in CHD patients., (© 2021. The Author(s).)

Purpose:  Compressed sensing (CS) is a method to accelerate MRI acquisition by acquiring less data through undersampling of k-space. In this prospective study we aimed to evaluate whether a three-dimensional (3D) isotropic proton density-weighted fat saturated sequence (PDwFS) with CS can replace conventional multidirectional two-dimensional (2D) sequences at 1.5 Tesla., Materials and Methods:  20 patients (45.2 ± 20.2 years; 10 women) with suspected internal knee damage received a 3D PDwFS with CS acceleration factor 8 (acquisition time: 4:11 min) in addition to standard three-plane 2D PDwFS sequences (acquisition time: 4:05 min + 3:03 min + 4:46 min = 11:54 min) at 1.5 Tesla. Scores for homogeneity of fat saturation, image sharpness, and artifacts were rated by two board-certified radiologists on the basis of 5-point Likert scales. Based on these ratings, an overall image quality score was generated. Additionally, quantitative contrast ratios for the menisci (MEN), the anterior (ACL) and the posterior cruciate ligament (PCL) in comparison with the popliteus muscle were calculated., Results:  The overall image quality was rated superior in 3D PDwFS compared to 2D PDwFS sequences (14.45 ± 0.83 vs. 12.85 ± 0.99; p < 0.01), particularly due to fewer artifacts (4.65 ± 0.67 vs. 3.65 ± 0.49; p < 0.01) and a more homogeneous fat saturation (4.95 ± 0.22 vs. 4.55 ± 0.51; p < 0.01). Scores for image sharpness were comparable (4.80 ± 0.41 vs. 4.65 ± 0.49; p = 0.30). Quantitative contrast ratios for all measured structures were superior in 3D PDwFS (MEN: p < 0.05; ACL: p = 0.06; PCL: p = 0.33). In one case a meniscal tear was only diagnosed using multiplanar reformation of 3D PDwFS, but it would have been missed on standard multiplanar 2D sequences., Conclusion:  An isotropic fat-saturated 3D PD sequence with CS enables fast and high-quality 3D imaging of the knee joint at 1.5 T and may replace conventional multiplanar 2D sequences. Besides faster image acquisition, the 3D sequence provides advantages in small structure imaging by multiplanar reformation., Key Points:   · 3D PDwFS with compressed sensing enables knee imaging that is three times faster compared to multiplanar 2D sequences. · 3D PDwFS with compressed sensing provides high-quality knee imaging at 1.5 T. · Isotropic 3D sequences provide advantages in small structure imaging by using multiplanar reformations., Citation Format: · Endler CH, Faron A, Isaak A et al. Fast 3D Isotropic Proton Density-Weighted Fat-Saturated MRI of the Knee at 1.5 T with Compressed Sensing: Comparison with Conventional Multiplanar 2D Sequences. Fortschr Röntgenstr 2021; 193: 813 - 821., Competing Interests: Julian A. Luetkens has received lecture honoraria from Philips Healthcare., (Thieme. All rights reserved.)

Purpose: Autoimmune hepatitis (AIH) is an immune-mediated chronic liver disease that leads to severe fibrosis and cirrhosis. The aim of this study was to determine the diagnostic value of T1 and T2 mapping as well as extracellular volume fraction (ECV) for non-invasive assessment of liver fibrosis in AIH patients., Methods: In this prospective study, 27 patients (age range: 19-77 years) with AIH underwent liver MRI. T1 and T2 relaxation times as well as ECV were quantified by mapping techniques. The presence of significant fibrosis (≥ F2) was defined as magnetic resonance elastography (MRE)-based liver stiffness ≥ 3.66 kPa. MRE was used as reference standard, against which the diagnostic performance of MRI-derived mapping parameters was tested. Diagnostic performance was compared by utilizing receiver-operating characteristic (ROC) analysis., Results: MRE-based liver stiffness correlated with both, hepatic native T1 (r = 0.69; P < 0.001) as well as ECV (r = 0.80; P < 0.001). For the assessment of significant fibrosis, ECV yielded a sensitivity of 85.7% (95% confidence interval (CI): 60.1-96.0%) and a specificity of 84.6% (CI 60.1-96.0%); hepatic native T1 yielded a sensitivity of 85.7% (CI 60.1-96.0%); and a specificity of 76.9% (CI 49.7-91.8%). Diagnostic performance of hepatic ECV (area under the curve (AUC): 0.885), native hepatic T1 (AUC: 0.846) for assessment of significant fibrosis was similar compared to clinical fibrosis scores (APRI (AUC: 0.852), FIB-4 (AUC: 0.758), and AAR (0.654) (P > 0.05 for each comparison))., Conclusion: Quantitative mapping parameters such as T1 and ECV can identify significant fibrosis in AIH patients. Future studies are needed to explore the value of parametric mapping for the evaluation of different disease stages.

To explore the feasibility of CT-derived myocardial strain measurement in patients with advanced cardiac valve disease and to compare it to strain measurements derived from transthoracic echocardiography (TTE). 43 consecutive patients with advanced cardiac valve disease and clinically indicated retrospectively gated cardiac CTs were retrospectively analyzed. The longitudinal, circumferential as well as radial systolic strain were determined in all patients utilizing a commercially available CT strain software. In 36/43 (84%) patients, CT-derived longitudinal strain was compared to speckle-tracking TTE. Pearson's correlation coefficients as well as Bland-Altman analysis were used to compare the CT-derived strain measurements to TTE. The intra- and inter-reader-reliability of the CT-derived strain measurements were assessed by intra-class correlation coefficients (ICCs). Strain measurements were feasible in all patients. CT-derived global longitudinal strain (GLS) correlated moderately with TTE-derived GLS (r = 0.6, p < 0.001). A moderate correlation between CT-derived GLS and CT-derived left ventricular ejection fraction was found (LVEF, r = - 0.66, p = 0.036). Bland-Altman analysis showed a systematic underestimation of myocardial strain by cardiac CT compared to TTE (mean difference: - 5.8%, 95% limit of agreement between - 13.3 and 1.8%). Strain measurements showed an excellent intra- and inter-reader-reliability with an intra-reader ICC of 1.0 and an inter-reader ICC of 0.99 for GLS measurements. CT-derived myocardial strain measurements are feasible in patients with advanced cardiac valve disease. They are highly reproducible and correlate with established parameters of strain measurements. Our results encourage the implementation of CT-derived strain measurement into clinical routine.

Background: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease, characterized by bile duct inflammation and destruction, leading to biliary fibrosis and cirrhosis. The purpose of this study was to investigate the utility of T1 and T2 mapping parameters, including extracellular volume fraction (ECV) for non-invasive assessment of fibrosis severity in patients with PSC., Methods: In this prospective study, patients with PSC diagnosis were consecutively enrolled from January 2019 to July 2020 and underwent liver MRI. Besides morphological sequences, MR elastography (MRE), and T1 and T2 mapping were performed. ECV was calculated from T1 relaxation times. The presence of significant fibrosis (≥ F2) was defined as MRE-derived liver stiffness ≥ 3.66 kPa and used as the reference standard, against which the diagnostic performance of MRI mapping parameters was tested. Student t test, ROC analysis and Pearson correlation were used for statistical analysis., Results: 32 patients with PSC (age range 19-77 years) were analyzed. Both, hepatic native T1 (r = 0.66; P < 0.001) and ECV (r = 0.69; P < 0.001) correlated with MRE-derived liver stiffness. To diagnose significant fibrosis (≥ F2), ECV revealed a sensitivity of 84.2% (95% confidence interval (CI) 62.4-94.5%) and a specificity of 84.6% (CI 57.8-95.7%); hepatic native T1 revealed a sensitivity of 52.6% (CI 31.7-72.7%) and a specificity of 100.0% (CI 77.2-100.0%). Hepatic ECV (area under the curve (AUC) 0.858) and native T1 (AUC 0.711) had an equal or higher diagnostic performance for the assessment of significant fibrosis compared to serologic fibrosis scores (APRI (AUC 0.787), FIB-4 (AUC 0.588), AAR (0.570))., Conclusions: Hepatic T1 and ECV can diagnose significant fibrosis in patients with PSC. Quantitative mapping has the potential to be a new non-invasive biomarker for liver fibrosis assessment and quantification in PSC patients.

Objectives: In patients with advanced liver disease, portal hypertension is an important risk factor, leading to complications such as esophageal variceal bleeding, ascites, and hepatic encephalopathy. This study aimed to determine the diagnostic value of T1 and T2 mapping and extracellular volume fraction (ECV) for the non-invasive assessment of portal hypertension., Methods: In this prospective study, 50 participants (33 patients with indication for trans-jugular intrahepatic portosystemic shunt (TIPS) and 17 healthy volunteers) underwent MRI. The derivation and validation cohorts included 40 and 10 participants, respectively. T1 and T2 relaxation times and ECV of the liver and the spleen were assessed using quantitative mapping techniques. Direct hepatic venous pressure gradient (HVPG) and portal pressure measurements were performed during TIPS procedure. ROC analysis was performed to compare diagnostic performance., Results: Splenic ECV correlated with portal pressure (r = 0.72; p < 0.001) and direct HVPG (r = 0.50; p = 0.003). No significant correlations were found between native splenic T1 and T2 relaxation times with portal pressure measurements (p > 0.05, respectively). In the derivation cohort, splenic ECV revealed a perfect diagnostic performance with an AUC of 1.000 for the identification of clinically significant portal hypertension (direct HVPG ≥ 10 mmHg) and outperformed other parameters: hepatic T2 (AUC, 0.731), splenic T2 (AUC, 0.736), and splenic native T1 (AUC, 0.806) (p < 0.05, respectively). The diagnostic performance of mapping parameters was comparable in the validation cohort., Conclusion: Splenic ECV was associated with portal pressure measurements in patients with advanced liver disease. Future studies should explore the diagnostic value of parametric mapping accross a broader range of pressure values., Key Points: • Non-invasive assessment and monitoring of portal hypertension is an area of unmet interest. • Splenic extracellular volume fraction is strongly associated with portal pressure in patients with end-stage liver disease. • Quantitative splenic and hepatic MRI-derived parameters have a potential to become a new non-invasive diagnostic parameter to assess and monitor portal pressure.

Purpose:  To investigate if T1 and T2 mapping is able to differentiate between diseased and healthy myocardium in patients with systemic sarcoidosis, and to compare the standard mapping measurement (measurement within the whole myocardium of the midventricular short axis slice, SAX) to a more standardized method measuring relaxation times within the midventricular septum (ConSept)., Materials and Methods:  24 patients with biopsy-proven extracardiac sarcoidosis and 17 healthy control subjects were prospectively enrolled in this study and underwent CMR imaging at 1.5 T including native T1 and T2 mapping. Patients were divided into patients with (LGE+) and without (LGE-) cardiac sarcoidosis. T1 and T2 relaxation times were compared between patients and controls. Furthermore, the SAX and the ConSept approach were compared regarding differentiation between healthy and diseased myocardium., Results:  T1 and T2 relaxation times were significantly longer in all patients compared with controls using both the SAX and the ConSept approach (p < 0.05). However, LGE+ and LGE- patients showed no significant differences in T1 and T2 relaxation times regardless of the measurement approach used (ConSept/SAX) (p > 0.05). Direct comparison of ConSept and SAX T1 mapping showed high conformity in the discrimination between healthy and diseased myocardium (Kappa = 0.844)., Conclusion:  T1 and T2 mapping may not only enable noninvasive recognition of cardiac involvement in patients with systemic sarcoidosis but may also serve as a marker for early cardiac involvement of the disease allowing for timely treatment. ConSept T1 mapping represents an equivalent method for tissue characterization in this population compared to the SAX approach. Further studies including follow-up examinations are necessary to confirm these preliminary results., Key Points:   · Mapping may enable noninvasive recognition of cardiac involvement in patients with systemic sarcoidosis. · Mapping may serve as a marker for early cardiac involvement in patients with systemic sarcoidosis. · The ConSept approach can be used as an alternative measuring method in sarcoidosis patients., Citation Format: · Dabir D, Luetkens J, Kuetting D et al. Myocardial Mapping in Systemic Sarcoidosis: A Comparison of Two Measurement Approaches. Fortschr Röntgenstr 2021; 193: 68 - 76., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Impaired skeletal muscle quality is a major risk factor for adverse outcomes in acute respiratory failure. However, conventional methods for skeletal muscle assessment are inapplicable in the critical care setting. This study aimed to determine the prognostic value of computed tomography (CT) fatty muscle fraction (FMF) as a biomarker of muscle quality in patients undergoing extracorporeal membrane oxygenation (ECMO). To calculate FMF, paraspinal skeletal muscle area was obtained from clinical CT and separated into areas of fatty and lean muscle based on densitometric thresholds. The cohort was binarized according to median FMF. Patients with high FMF displayed significantly increased 1-year mortality (72.7% versus 55.8%, P = 0.036) on Kaplan-Meier analysis. A multivariable logistic regression model was built to test the impact of FMF on outcome. FMF was identified as a significant predictor of 1-year mortality (hazard ratio per percent FMF, 1.017 [95% confidence interval, 1.002-1.033]; P = 0.031), independent of anthropometric characteristics, Charlson Comorbidity Index, Simplified Acute Physiology Score, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction Score, and duration of ECMO support. To conclude, FMF predicted 1-year mortality independently of established clinical prognosticators in ECMO patients and may have the potential to become a new muscle quality imaging biomarker, which is available from clinical CT.

Background Cardiac involvement in liver cirrhosis in the absence of underlying cardiac disease is termed cirrhotic cardiomyopathy . The pathophysiology of this condition is still poorly understood. Purpose To investigate the extent of subclinical imaging changes in terms of fibrosis and inflammation and to explore the relationship between the severity of liver disease and the degree of myocardial involvement. Materials and Methods In this prospective study from November 2018 to December 2019, participants with liver cirrhosis and healthy control participants underwent hepatic and cardiac MRI. The multiparametric scan protocol assessed hepatic (T1 and T2 relaxation times, extracellular volume [ECV], and MR elastography-based liver stiffness) and cardiac (T1 and T2 relaxation times, ECV, myocardial edema, late gadolinium enhancement [LGE], and myocardial strain) parameters. Student t tests, one-way analysis of variance, Pearson correlation, and multivariable binary regression analysis were used for statistical analyses. Results A total of 42 participants with liver cirrhosis (mean age ± standard deviation, 57 years ± 11; 23 men) and 18 control participants (mean age, 54 years ± 19; 11 men) were evaluated. Compared with control participants, the participants with liver cirrhosis displayed reduced longitudinal strain and elevated markers of myocardial disease (T1 and T2 relaxation times, ECV, and qualitative and quantitative LGE). Myocardial T1 (978 msec ± 23 vs 1006 msec ± 29 vs 1044 msec ± 14; P < .001) and T2 relaxation times (56 msec ± 4 vs 59 msec ± 3 vs 62 msec ± 8; P = .04) and ECV (30% ± 5 vs 33% ± 5 vs 38% ± 7; P = .009) were higher depending on Child-Pugh class (A vs B vs C). Positive LGE lesions (three of 11 [27%] vs 10 of 19 [53%] vs nine of 11 [82%]; P = .04) were more prevalent in advanced Child-Pugh classes. MR elastography-based liver stiffness was an independent predictor for LGE (odds ratio, 1.6; 95% confidence interval: 1.2%, 2.1%; P = .004) and correlated with quantitative LGE ( r = 0.67; P < .001), myocardial T1 relaxation times ( r = 0.55; P < .001), and ECV ( r = 0.39; P = .01). Conclusion In participants with liver cirrhosis, systolic dysfunction and elevated parameters of myocardial edema and fibrosis were observed at MRI, which were more abnormal with greater severity of liver disease. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by de Roos and Lamb in this issue.

Background: Myocardial native T1 and T2 relaxation time mapping are sensitive to pathological increase of myocardial water content (e.g. myocardial edema). However, the influence of physiological hydration changes as a possible confounder of relaxation time assessment has not been studied. The purpose of this study was to evaluate, whether changes in myocardial water content due to dehydration and hydration might alter myocardial relaxation times in healthy subjects., Methods: A total of 36 cardiovascular magnetic resonance (CMR) scans were performed in 12 healthy subjects (5 men, 25.8 ± 3.2 years). Subjects underwent three successive CMR scans: (1) baseline scan, (2) dehydration scan after 12 h of fasting (no food or water), (3) hydration scan after hydration. CMR scans were performed for the assessment of myocardial native T1 and T2 relaxation times and cardiac function. For multiple comparisons, repeated measures ANOVA or the Friedman test was used., Results: There was no change in systolic blood pressure or left ventricular ejection fraction between CMR scans (P > 0.05, respectively). T1 relaxation times were significantly reduced with dehydration (987 ± 27 ms [baseline] vs. 968 ± 29 ms [dehydration] vs. 986 ± 28 ms [hydration]; P = 0.006). Similar results were observed for T2 relaxation times (52.9 ± 1.8 ms [baseline] vs. 51.5 ± 2.0 ms [dehydration] vs. 52.2 ± 1.9 ms [hydration]; P = 0.020)., Conclusions: Dehydration may lead to significant alterations in relaxation times and thereby may influence precise, repeatable and comparable assessment of native T1 and T2 relaxation times. Hydration status should be recognized as new potential confounder of native T1 and T2 relaxation time assessment in clinical routine.

Background Diagnosis of chylous effusions normally requires invasive paracentesis. Purpose To assess whether MRI with multipoint Dixon fat quantification allows for noninvasive differentiation of chylous and nonchylous ascites and pleural effusions. Materials and Methods Phantom, ex vivo, and in vivo MRI examinations were performed by using a commercially available multipoint Dixon pulse sequence with a 1.5-T MRI system. Fat fraction values were measured with a region of interest-based approach on reconstructed maps. For phantom evaluation, eight titrated fatty fluid solutions (nonhuman samples) with varying triglyceride content (145-19 000 mg/dL [1.64-214.7 mmol/L]) were examined. For ex vivo evaluation, 15 chylous and five nonchylous study participant fluid samples were examined. In a prospective study performed from June 2016 to February 2018, 29 study participants with known chylous ( n = 17) and nonchylous ( n = 12) effusions were evaluated with MRI. All clinical samples underwent laboratory testing for triglyceride level, total protein level, white blood cells, and red blood cells. Laboratory values were correlated with fat fraction values; the optimal fat fraction threshold was determined to differentiate chylous and nonchylous fluids. Results Phantom analysis showed that fat fraction values correlated with triglyceride content ( r = 0.99, P < .001). In ex vivo studies, multipoint Dixon-derived fat fraction was higher in chylous versus nonchylous fluids (mean, 2.5% ± 1.2 [standard deviation] vs 0.8% ± 0.2; P = .001). Fat fraction was correlated with triglyceride content ( r = 0.96, P < .001). For in vivo studies, fat fraction was greater for chylous versus nonchylous fluids (mean, 6.2% ± 4.3 vs 0.6% ± 0.6; P < .001). In vivo fat fraction was correlated with triglyceride content ( r = 0.96, P < .001). Use of a fat fraction cutoff value greater than 1.8% yielded a sensitivity of 14 of 17 (82% [95% confidence interval (CI): 57%, 97%]) and a specificity of 12 of 12 (100% [95% CI: 74%, 100%]) for differentiation of chylous and nonchylous effusions. Conclusion MRI can help identify chylous versus nonchylous ascites and pleural effusions through use of multipoint Dixon fat quantification. © RSNA, 2020 Online supplemental material is available for this article.

Purpose: The use of pharmacomechanical thrombectomy in patients with symptomatic iliofemoral deep venous thrombosis (DVT) not responsive to conservative treatment is under-investigated until now. This prompted us to review and analyze our results (technical/clinical outcome, complications) and compare them to the current literature., Materials and Methods: Between 2013 and 2019, 19 patients (14 women and 5 men; mean age: 41.2 years, SD: 18.2) with iliofemoral DVT and excessive pain not responsive to conservative treatment were treated with pharmacomechanical thrombectomy. Patients were followed up for 12 months. Demographics, technical success and clinical outcome data (pain score/Villalta score) were collected., Results: Thrombectomy ± thrombolysis was successful in all cases (n = 19). No major complications were observed. Eight out of nineteen cases developed hematoma at the sheath insertion site not requiring further treatment. Seven out of nineteen cases required additional continuous lysis for complete iliofemoral clot solution. All patients received balloon angioplasty to treat post-thrombotic strictures. In 16/19 cases, stents were placed to preserve iliofemoral caliber and maintain unrestricted iliac venous outflow. Three patients (16%) required re-intervention due to re-thrombosis or in-stent stenosis after 4, 14 days and 4 months, respectively. Symptoms could be improved temporarily or indefinitely in 19 out of 19 patients. 1 year following thrombectomy mean pain score was reduced by 87%, mean Villalta score was 2.6 (SD: 4), and iliofemoral veins were patent in 15/17 patients., Conclusion: In symptomatic patients with iliofemoral DVT, refractory to conservative treatment, catheter-directed thrombectomy enables rapid and long-lasting pain relief. High patency rates can be achieved in patients receiving PTA and venous stenting post-thrombectomy.

Purpose: Optical flow feature-tracking (FT) strain assessment is increasingly being employed scientifically and clinically. Several software packages, employing different algorithms, enable computation of FT-derived strains. The aim of this study is to investigate the impact of the underlying algorithm on the validity and robustness of FT-derived strain results., Material and Methods: CSPAMM and SSFP cine sequences were acquired in 30 subjects (15 patients with aortic stenosis and associated secondary hypertrophic cardiomyopathy, and 15 controls) in identical midventricular short-axis locations. Global peak systolic circumferential strain (PSCS) was calculated using tagging and feature-tracking software with different algorithms (non-rigid, elastic image registration, and blood myocardial border tracing). Intermodality agreement and intra- as well inter-observer variability were assessed., Results: Intermodality/inter-algorithm comparison for global PSCS using Friedman's test revealed statistically significant differences (tagging vs. blood myocardial border tracing algorithm). Intermodality assessment revealed the highest correlation between tagging and non-rigid, elastic image registration ( r = 0.84), while correlation between tagging and blood myocardial border tracing ( r = 0.36) and between the two feature-tracking software packages ( r = 0.5) were considerably lower., Conclusions: The type of algorithm employed during feature-tracking strain assessment has a significant impact on the results. The non-rigid, elastic image registration algorithm produces more precise and reproducible results than the blood myocardium tracing algorithm., Competing Interests: The authors declare no conflict of interest., (Copyright © Polish Medical Society of Radiology 2020.)

Introduction: A combined assessment of different parameters of cardiovascular (CV) risk and prognosis can be supportive and performed with cardiac magnetic resonance (CMR). Aortic stiffness, epicardial fat volume (EFV), left ventricular (LV) strain and fibrosis were evaluated within a single CMR examination and results were related to the presence of hypertension (HTN) and diabetes mellitus (DM)., Methods: 20 healthy controls (57.2 ± 8.2 years(y); 26.2 ± 3.9 kg/m 2 ), 31 hypertensive patients without DM (59.6 ± 6.7 y; 28.4 ± 4.7 kg/m 2 ) and 12 hypertensive patients with DM (58.8 ± 9.9y; 30.7 ± 6.3 kg/m 2 ) were examined at 1.5Tesla. Aortic stiffness was evaluated by calculation of aortic pulse wave velocity (PWV), EFV by a 3D-Dixon sequence. Longitudinal & circumferential systolic myocardial strain (LS; CS) were analyzed and T1-relaxation times (T1) were determined to detect myocardial fibrosis., Results: EFV was highest in hypertensive patients with diabetes (78.4 ± 28.0 ml/m 2 ) followed by only hypertensive patients (64.2 ± 27.3 ml/m 2 ) and lowest in controls (50.3 ± 22.7 ml/m 2 ; p < 0.05). PWV was higher in hypertensive patients with diabetes (9.8 ± 3.3 m/s) compared to only hypertensive patients (8.6 ± 1.7 m/s; p < 0.05) and to controls (8.1 ± 1.9 m/s; p < 0.05). LS&CS were worse in hypertensive patients with diabetes (LS:-20.9 ± 5.1% and CS: -24.4 ± 5.7%) compared to both only hypertensive patients (LS: -24.7 ± 4.6%; CS: -27.1 ± 5.0%; p < 0.05) and to controls (LS: -25.5 ± 3.8; CS: -28.3 ± 4.1%; p < 0.05). Both hypertensive groups with and without DM had higher T1́s (994.0 ± 43.2 ms; 991.6 ± 35.5 ms) than controls (964.6 ± 40.3 ms; p < 0.05)., Conclusion: CMR revealed increased aortic stiffness and EFV in hypertensive patients, which were even higher in the presence of DM. Also signs of LV myocardial fibrosis and a reduced strain were revealed. These parameters support the assessment of CV risk and prognosis. They can accurately be measured with CMR within a single examination when normally different techniques are needed., (© 2020 The Authors. Published by Elsevier B.V.)

Purpose: To compare the diagnostic performance of the original Lake Louise criteria (LLC) and the 2018 LLC for the diagnosis of acute myocarditis and simultaneously validate previously reported cutoff values for parametric mapping techniques., Materials and Methods: A total of 40 patients with acute myocarditis and 26 control participants underwent cardiac MRI. Cardiac MRI protocol allowed for assessment of T2 signal intensity ratio, early gadolinium enhancement ratio, late gadolinium enhancement, T1 relaxation times, extracellular volume fraction, and T2 relaxation times. The original and the 2018 LLC were assessed, and differences between sensitivities and specificities were calculated with the McNemar test., Results: The 2018 LLC yielded a sensitivity of 87.5% (95% confidence interval [CI]: 73.9%, 94.5%) and a specificity of 96.2% (95% CI: 81.1%, 99.3%). The original LLC had a sensitivity of 72.5% (95% CI: 57.2%, 83.9%) and a specificity of 96.2% (95% CI: 81.1%, 99.3%). Sensitivity of the 2018 LLC was significantly higher compared with the sensitivity of original LLC ( P = .031). No differences in specificity were observed between both scores ( P = .999)., Conclusion: Multiparametric cardiac MRI has a high diagnostic value for the diagnosis of patients clinically suspected of having acute myocarditis. The 2018 LLC further improve the diagnostic performance of cardiac MRI by increasing its sensitivity. An implementation of the new score into routine diagnostic protocols should be considered.© RSNA, 2019See also the commentary by Gutberlet and Lücke in this issue. Supplemental material is available for this article., Competing Interests: Disclosures of Conflicts of Interest: J.A.L. disclosed no relevant relationships. A.F. disclosed no relevant relationships. A.I. disclosed no relevant relationships. D.D. disclosed no relevant relationships. D.K. disclosed no relevant relationships. A.F. disclosed no relevant relationships. F.C.S. disclosed no relevant relationships. A.M.S. disclosed no relevant relationships. D.T. disclosed no relevant relationships., (2019 by the Radiological Society of North America, Inc.)

Purpose:  Percutaneous treatment of biliary leaks is frequently required, yet technically challenging and limited to smaller fistulas. This study sought to evaluate the off-the-shelf use of the ArtVentive EOS device for the occlusion of biliary or cystic stump leaks., Materials and Methods:  ePTFE-covered ArtVentive EOS devices were used to perform biliary leak embolization in 5 explanted porcine livers and in 3 explanted bovine livers. After establishing standard percutaneous transhepatic biliary drainage access, artificially created biliary leaks were occluded using 5 & 8 mm EOS devices. Using the 5 mm device, peripheral (n = 3), central (n = 1) and cystic duct leaks (n = 1) were occluded. Using the 8 mm device, peripheral (n = 1), central (n = 1), main (n = 1) and cystic duct leaks (n = 2) were occluded. Total leak occlusion was controlled by cholangiography., Results:  Selective deployment and occlusion of central biliary leaks (3/3) and cystic stump leaks (3/3) was successful in all cases. Peripheral leaks could not be selectively catheterized in 3 out of 4 cases, making device deployment several millimeters proximal to the leaks necessary., Conclusion:  Selective occlusion of the cystic stump, central biliary, and larger peripheral biliary leaks using the EOS device is technically feasible ex-vivo in a single setting., Key Points:   · Due to the impermeable ePTFE membrane, one EOS suffices to completely occlude biliary leaks.. · The EOS enables selective occlusion of central and larger peripheral biliary leaks.. · Smaller biliary leaks cannot be treated selectively with the EOS.., Citation Format: · Kuetting D, Schild HH, Pieper CC. Ex Vivo Evaluation of the ArtVentive EOS Occlusion Device for the Management of Biliary Leaks. Fortschr Röntgenstr 2019; 191: 553 - 559., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To evaluate polymerization of N-butyl cyanoacrylate (NBCA)/iodized oil mixtures for lymphatic interventions in vitro., Materials and Methods: Polymerization times of different NBCA/iodized oil mixtures (ratios of 1:0-1:7) were investigated in a static and dynamic experimental setup (performed in a lymph flow model in a silicone tube). Eight lymphatic samples with different triglyceride (TG) concentrations (low TGs, < 50 mg/dL; medium TGs, approximately 100-400 mg/dL; high TGs, > 700 mg/dL) were investigated. Morphologic changes during NBCA polymerization were monitored and recorded by video. Statistical analysis was performed with intergroup comparisons (Kruskal-Wallis test) and multiple regression analysis., Results: Static experiments showed increasing polymerization times with increasing concentrations of iodized oil as well as increasing concentrations of TGs. In the low-TG group, polymerization time increased from 14 s at a 1:1 ratio of NBCA to iodized oil to 1,336 s at a 1:7 ratio; times in the medium-TG group increased from 21 s (1:1) to 2,546 s (1:7), and those in the high TG group increased from 168 s (1:1) to 16,530 s (1:7). In dynamic experiments, prolongation of polymerization time was less pronounced. For low- and medium-TG groups, total occlusion of the silicon tube was observed in all cases during the embolization procedure at between 26 seconds (1:1 ratio) and 52 seconds (1:7). In the high-TG group, polymerization took considerably longer (between 43 s [1:1] and 467 s [1:7]) or failed completely., Conclusions: Polymerization time of NBCA/iodized oil in lymph seems to be prolonged by increasing iodized oil and TG concentrations., (Copyright © 2018 SIR. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate AngioJet-assisted transvenous portal vein (PV) thrombectomy for non-cirrhotic patients with total portal vein and mesenteric vein thrombosis (PVMVT)., Material and Methods: From 2015 to 2016 four patients (3 male, mean 43.9 years, range 33-52 years) with acute (3 cases) and acute-on-chronic (1 case) PVMVT underwent transvenous thrombolysis. All patients received initial AngioJet (Boston Scientific, Natick, MA, USA) thrombectomy followed by continuous catheter directed thrombolysis with Urokinase (Medac, Wedel, Germany) for 22-52 hours. Transjugular intrahepatic portosystemic shunts (TIPS), using Viatorr stent grafts (W.L. Gore and Associates, AZ, USA; mean diameter: 10 mm, length: 60-80 mm), were implanted in all patients. Patients were followed clinically and with imaging (mean 646 days, range 392 to 936 days)., Results: Technical success was 100%. Therapeutic success was achieved in 75% of cases. AngioJet-assisted thrombectomy substantially reduced thrombus load in the acute cases, while only slight improvement was achieved in the acute-on-chronic case. Continuous thrombolysis subtotally re-established PV flow in the acute cases, while only minimal improvement was seen in the acute-on-chronic case. Following TIPS implantation complete PV recanalisation could be achieved in all acute cases. In the acute-on-chronic case initial stagnant PV flow was seen; however, PV and TIPS re-occluded 10 days after implantation. During follow-up PV remained patent in acute cases., Conclusions: AngioJet-assisted thrombectomy was technically feasible and uncomplicated in all of our patients. The initial results suggest that AngioJet-assisted thrombectomy facilitates recanalisation in acute and severe cases of PVMVT., Competing Interests: The authors report no conflict of interest.