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

The Society for Cardiovascular Magnetic Resonance (SCMR) held its 2007 meeting from February 2 to February 4 in Rome, Italy. As has been traditional when it is held in Europe, the meeting was held jointly with the Working Group for Cardiovascular Magnetic Resonance (CMR) of the European Society of

The objective of this magnetic resonance imaging (MRI) study was to (1) test the validity of the ellipsoid formula for estimating kidney volume using ex vivo and in vivo models and (2) establish a normal range of values for kidney length and volume in patients with no known history of renal disease. The volumes of five excised porcine kidneys were measured by (1) disc-summation method, (2) ellipsoid formula, and (3) water displacement method. In a retrospective, consecutive group of clinically referred patients (n = 150; 300 kidneys), individual kidney volume and length were calculated by the disc-summation method and by multiplanar reformation of MRI data, respectively. For comparison, kidney volumes also were calculated using the ellipsoid formula in all patients. Renal volume that was obtained by MRI using the disc-summation method was within 5% of the volume that was determined by the water displacement method, independent of the spatial resolution of the MRI technique used. Data from both the in vivo and the ex vivo models revealed that the ellipsoid formula that commonly is used in ultrasonography underestimates renal volume by 17 to 29% compared with the disc-summation method (P < 0.05). As measured by MRI (mean +/- SD), kidney lengths were 12.4 +/- 0.9 cm for men and 11.6 +/- 1.1 cm for women, and kidney volumes were 202 +/- 36 ml for men and 154 +/- 33 ml for women. The results from the ex vivo MRI study show that the kidney volume that was obtained using the disc-summation method is within 5% of the true kidney volume as measured by the water displacement method. The ellipsoid formula consistently and significantly underestimates the true kidney volume. The length and the volume of kidneys that are obtained by MRI in patients with no known history of intrinsic renal disease are greater than the commonly quoted reference values that are obtained by ultrasonography.

Of the different kinds of coronary anomalies observed in adults, anomalous origin of a coronary artery from the opposite sinus of Valsalva with an “interarterial” course (ACAOS) entails a high risk of clinical consequences related to the intramural course of the ectopic coronary artery. We review current imaging modalities for differentiating this condition from generally benign coronary anomalies and for quantifying the severity of individual cases. For identifying ACAOS, noninvasive modalities (echocardiography, computed tomographic angiography, and coronary magnetic resonance angiography) are preferred: the favored modalities are transthoracic echocardiography in children and multidetector computed tomography in adults. For evaluating the pathophysiologic mechanisms of ischemia in ACAOS and subclassifying the severity of individual forms, coronary intravascular ultrasonography provides enhanced temporal and spatial resolution. The critical quantifiable features of the coronary anatomy in ACAOS seem to be hypoplasia, lateral compression at the level of the intramural course, and possibly exercise-related further narrowing of the proximal ectopic segment. Definitive guidelines are being developed for the optimal workup and treatment of ACAOS. © 2007 Wiley-Liss, Inc.

Purpose: To determine the most efficacious dose of gadodiamide for three-dimensional (3D) contrast-enhanced (CE) magnetic resonance angiography (MRA) of the renal arteries on a patient level based on the sensitivity in detecting the main hemodynamically relevant (≥50% or occlusion) renal artery stenosis (RAS) using intra-arterial digital subtraction angiography (IA DSA) as the gold standard. Materials and Methods: This prospective, randomized, double-blind, parallel-group, multicenter study included 273 patients referred to IA DSA for suspected RAS. Patients underwent 3D CE MRA after injection of 0.01, 0.05, 0.1, or 0.2 mmol/kg of body weight gadodiamide (0.5 mmol/ml). The images were assessed for location and degree of RAS by independent blinded readers (MRA: three readers, IA DSA: one reader). Hypothesis testing for a significant trend in sensitivity across dose groups was based on the one-sided Cochran-Armitage style trend test for each independent MRA reader. Results: The lowest dose group (0.01 mmol/kg) proved non-efficacious in detecting hemodynamically relevant (i.e., ≥50% or occlusion) RAS. A statistically significant dose trend (p < 0.001) was shown for each of the three independent readers. Depending on reader, the sensitivity obtained with 0.05, 0.1, and 0.2 mmol/kg was 63.9–86.1%, 75.8–91.4% and 80.6–90.6%, the specificity was 66.7–73.9%, 59.3–75.0%, and 59.3–75.0% and accuracy was 67.8–78.9%, 75.4–77.4%, and 76.3–81.0%, for the three dose groups, respectively. There were eight non-severe adverse events (AEs). Three serious AEs occurring in one patient were judged not related to gadodiamide by the on-site investigator. Conclusion: A significant dose trend between the four doses examined was observed. The lowest dose (0.01 mmol/kg) differed significantly from those of the other three doses. Based on the analysis of the primary and secondary endpoints, 0.1 mmol/kg gadodiamide appears to be the most suitable dose in diagnosing hemodynamically relevant RAS. The present study also demonstrated gadodiamide to be safe and well tolerated. © 2007 Elsevier Ireland Ltd. All rights reserved.

Arrhythmogenic right ventricular dysplasia is a rare disorder that is familial in 30% to 50% of cases. It is characterized by structural and functional abnormalities of the right ventricle and a propensity for ventricular arrhythmias and sudden death. We report the case of a 59-year-old woman who had idiopathic, severe, right-sided heart failure and nonsustained ventricular tachycardia. She was diagnosed with arrhythmogenic right ventricular dysplasia by means of cardiac magnetic resonance imaging. We discuss the clinical features, diagnostic criteria, and role of cardiac magnetic resonance imaging in the diagnosis of arrhythmogenic right ventricular dysplasia.

Purpose To determine whether contrast between acutely infarcted and normal myocardia in T1-rho-weighted cine TFE (T1ρ-TFE) and delayed-enhancement (DE) images (measured using a metric percent enhancement (PE)) varied with the dose or time of imaging after contrast administration. Materials and Methods Eighteen patients with acute myocardial infarction (AMI) were randomly divided into three groups according to the dose of gadoversetamide (0.1, 0.2, or 0.3 mmol/kg) administered. After contrast administration, T1ρ-TFE images were acquired at five and 40 minutes, and DE images were acquired at 10 and 30 minutes. Results For T1ρ-TFE imaging the PE values at 40 minutes were 70 ± 14, 98 ± 14, and 105 ± 41 at 0.1, 0.2, and 0.3 mmol/kg dose levels, which were significantly greater than the corresponding PEs at five minutes after contrast administration (44 ± 12, 71 ±14, and 36 ± 13). For DE and T1ρ-TFE imaging the dose of contrast agent did not significantly affect the PE. However, with DE the PE tended to increase with the dose. At all dose levels, irreversible injury was more conspicuous in T1ρ-TFE images acquired at 40 minutes than at five minutes after contrast. Conclusion In T1ρ-TFE, acute infarction was more conspicuous in images acquired at a later time point, and the PE did not vary with the contrast dose. J. Magn. Reson. Imaging 2006. © 2006 Wiley-Liss, Inc.

In Takotsubo cardiomyopathy, or transient left ventricular (LV) apical ballooning syndrome, normalization of wall motion can occur after as long as 3 months. We report 1 of the largest series to date outside Japan and emphasize the utility of cardiac magnetic resonance imaging (CMR) to show a lack of irreversible damage in the acute setting, thereby reliably predicting recovery. During the previous 6 years, we saw 22 patients who met the following criteria: (1) a suspected myocardial infarction based on symptoms, an abnormal electrocardiogram, and/or elevated serum cardiac markers; (2) an anteroapical wall motion abnormality; and (3) no significant occlusive epicardial coronary artery disease or observed vasospasm. Ten patients underwent delayed enhancement CMR to assess myocardial viability during the index presentation. All 10 patients had an absence of irreversible damage, as evidenced by lack of gadolinium "hyperenhancement"; later, their LV function returned to normal. Eight other patients, available for outpatient follow-up evaluation, also had normalization of LV function. Takotsubo cardiomyopathy is increasingly being recognized outside Japan and must be distinguished from acute myocardial infarction. In conclusion, CMR is useful to document segmental LV dysfunction and lack of irreversible damage and to predict functional recovery.

We present an automated left ventricular (LV) myocardial boundary extraction method. Automatic localization of the LV is achieved using a motion map and an expectation maximization algorithm. The myocardial region is then segmented using an intensity-based fuzzy affinity map and the myocardial contours are extracted by cost minimization through a dynamic programming approach. The results from the automated algorithm compared against the experienced radiologists using Bland and Altman analysis were found to have consistent mean bias of 7% and limits of agreement comparable to the inter-observer variability inherent in the manual method.

The purpose of this study was to assess the relative merits of reducing the scanning time of navigator-guided (NAV) coronary MR angiography by including, both independently and in combination, two time-saving strategies: k-space weighted motion-adapted gating (k-MAG) and sensitivity encoding (SENSE, factor = 2).Coronary arteries of 21 healthy subjects were imaged with four NAV MR angiography sequences: conventional NAV sequence, NAV with the addition of SENSE, NAV with the addition of k-MAG, and NAV with a combination of SENSE and k-MAG. All imaging parameters including the magnetization preparation schemes, prescribed spatial resolution, and acquisition duration per R-R interval were identical for all techniques. The total scanning time, navigator efficiency, visible length of the coronary artery, and subjective image quality were used as metrics for evaluating the performance of the techniques.The results show that the addition of k-MAG to NAV coronary MR angiography (with or without SENSE) improved scan efficiency and decreased scanning time by an average of 17% without compromising the length of coronary artery visible or the image quality. The addition of SENSE to the NAV technique (with or without k-MAG) reduces the scanning time by an average of 50%.While the average image quality of coronary arteries was unaffected by the addition of k-MAG to navigator techniques, there was a slight reduction in image quality scores for the navigator sequence with SENSE. Identification of the proximal coronary arteries was not hampered by the addition of k-MAG, SENSE, or both to the NAV coronary MR angiography sequence.

Purpose To evaluate the technical feasibility of two approaches—dual-contrast (DC) cluster analysis, and scout geometry (SG)—for automatic identification of the left ventricular (LV) cavity in short-axis (SA) cine-MR images. Materials and Methods The DC algorithm uses Fuzzy C-Means (FCM) cluster analysis of SA images from a black-blood double-inversion recovery turbo spin-echo (dual IR TSE) sequence, and bright-blood images from a steady-state free precession (SSFP) sequence. The SG algorithm employs geometric information from scout views (i.e., vertical long-axis (VLA) and four-chamber (4CH) views). Both algorithms incorporate additional geometric continuity constraints along with LV region segmentation to identify the LV. The performance of both algorithms was compared on images of eight healthy volunteers, and the SG algorithm was further evaluated on images of 13 clinical patients. Results The DC algorithm identified the LV in 89% (72/75 at end-diastole (ED) and 47/59 at end-systole (ES)) of the images from healthy volunteers, compared to 98% (74/75 at ED and 57/59 at ES) by the SG algorithm. Both methods are robust against interslice signal variations and misalignment. The DC method suffers from misregistration between the dual IR TSE and SSFP images near the apex at ES. The SG method identified the LV in 91% (112/122 at ED and 91/102 at ES) of the images from clinical patients. Conclusion The SG method requires no additional scan, is robust and accurate, and performs better than the DC method for automatic identification of the LV. J. Magn. Reson. Imaging 2006. © 2006 Wiley-Liss, Inc.

Quantitative left ventricular (LV) function was assessed with magnetic resonance imaging in 20 patients by using standard multisection multiphase steady-state free precession (SSFP) imaging and sensitivity encoding (SENSE)-accelerated cine SSFP imaging with identical spatial, contrast, and temporal resolution. The local institutional review board approved the protocol, and all patients gave signed informed consent prior to imaging. The study complied with the Health Insurance Portability and Accountability Act. Results of Bland-Altman analysis showed that both techniques produced similar estimates of LV ejection fraction, LV mass, and blood-to-muscle contrast and demonstrated minimal interobserver variability. The authors showed that it is possible, by combining SENSE with cine SSFP imaging, to reduce acquisition time by 50% without compromising spatial resolution, temporal resolution, or blood-to-muscle contrast-to-noise ratio compared with those achieved by using SSFP imaging without SENSE for quantitative LV function assessment.

Rapid progress has been made in cardiac MRI (CMRI) over the past decade, which has firmly established it as a reliable and clinically important technique for assessment of cardiac structure, function, perfusion, and myocardial viability. Its versatility and accuracy is unmatched by any other individual imaging modality. CMRI is non-invasive and has high spatial resolution and avoids use of potentially nephrotoxic contrast agent or radiation. It has been extensively studied against other established non-invasive imaging modalities and has been shown to be superior in many scenarios, particularly with respect to assessment of cardiac and great vessel morphology and left ventricular function. Furthermore, its clinical use continues to expand with increasing experience and proliferation of CMRI centres. As worldwide prevalence of cardiovascular disease continues to rise, CMRI provides opportunity for improved and cost-effective non-invasive assessment. Continued progress in CMRI technology promises to further widen its clinical application in coronary imaging, myocardial perfusion, comprehensive assessment of valves, and plaque characterisation.

Crisscross heart, or superoinferior ventricles, is a complex and often confusing congenital anomaly. We report a heretofore unreported presentation of “isolated” crisscross heart, in situs inversus levocardia, which allows us to more clearly define the typical features of crisscross ventricles. The case of this 41-year-old woman, who had a peculiar coronary anatomy, underscores the concept that coronary artery anatomy is strictly related to the myocardial mass served. In complex congenital heart defects, development of an anterior descending artery is possible (as a primary artery, along with the circumflex and right coronary arteries) only if the ventricular septum develops properly and is aligned with the semilunar valves. We use the present case of crisscross heart to illustrate the spectrum of anomalies that can occur during formation of the cardiac apex; this spectrum ranges from a normal apex, to a diverted apex (as in dextroversion in situs solitus), to a crisscross anomaly. (Tex Heart Inst J 2003;30:208–13)

The treatment of patients who have cardiac tumors can be challenging, because these tumors occur infrequently and in variable locations, and surgical resection is often technically difficult. We report the cases of 2 patients, each of whom underwent successful surgical excision of large melanomas that had metastasized to the right cardiac ventricle. Although the presence of widespread disease and a limited life expectancy usually prevent surgical therapy for patients who have metastatic cardiac tumors, removal of such masses greatly facilitated subsequent medical management of these 2 patients and improved their quality of life. (Tex Heart Inst J 2003;30:218–20)

The routinely used clinical practice of manual tracing of the blood pool from short axis cine MR images to compute ejection fraction (EF) is cumbersome, time consuming, and operator dependent. In this paper we present an algorithm that automatically segments the left ventricle (LV) using the a priori knowledge of the intensity responses of the tissue in different MR modalities, along with the LV morphology. Our method for the automatic computation of the EF is based on segmenting the left ventricle by combining the fuzzy connectedness and the physics-based deformable model frameworks. We have validated our method against manual delineation performed by experienced radiologists on the data from nine asymptomatic volunteers with very encouraging results.

Myocardial fibrosis can occur in patients who have hypertrophic cardiomyopathy in the absence of epicardial coronary disease. In such patients, myocardial fibrosis has been linked to a poorer prognosis than in those without fibrosis. Gadolinium-DTPA delayed-enhancement magnetic resonance imaging (de-MRI) accurately identifies regions of myocardial fibrosis. We used de-MRI to screen for myocardial fibrosis in 8 patients with nonobstructive hypertrophic cardiomyopathy that had been diagnosed by 2-dimensional echocardiography. After localization of the heart and acquisition of electrocardiographically gated cine images, gadolinium-DTPA (0.2 mmol/kg) was administered to the patient. Fifteen minutes later, de-MRI images were obtained using a T1-weighted, inversion-recovery fast, low-angle shot sequence. Images were gated to end-diastole and obtained during a single breath-hold. The inversion time was modified iteratively to obtain maximal nulling of the signal from the ventricular myocardium. Regions of myocardium with abnormally high signals (300% of remote normal myocardium) were designated as fibrotic. Eight patients with hypertrophic cardiomyopathy underwent de-MRI. The mean age was 52 years, the mean left ventricular mass was 201 grams, and the mean ejection fraction was 0.68. In the 6 patients with recent clinical deterioration, de-MRI showed clearly delineated areas of myocardial fibrosis; no such areas were seen in the 2 asymptomatic patients. We conclude that patients with symptomatic hypertrophic cardiomyopathy display regions of abnormal signal intensity on de-MRI that likely represent fibrosis. This technique may provide useful information in the evaluation of such patients and warrants further study.

Background— This study was designed to define myocardial viability and establish practical cut-off values for differentiating normal myocardial tissue from subendocardial and transmural scar tissue by using electromechanical mapping (EMM). We validated our results by delayed-enhancement cardiac MRI (DE-MRI). Methods and Results— We prospectively studied 15 ambulatory patients with stable coronary disease who were candidates for cardiac catheterization. Within 48 hours of EMM, DE-MRI was performed. Using EMM software, we created a bull’s eye precisely matched to that generated by DE-MRI. Segment by segment, we compared the MRI results to the corresponding unipolar voltage value for that same segment in the EMM bull’s eye. Of 300 total segments, 275 were compared. The segments were divided into normal (n=211), subendocardial scar (n=49), and transmural scar (n=15). We found that subendocardial (6.8±2.9 mV) and transmural (4.6±1.9 mV) scar segments had significantly less unipolar voltage than normal (11.6±4.5 mV) segments ( P Conclusions— Our results demonstrate that normal myocardium can be accurately distinguished from myocardium with subendocardial or transmural infarcts on the basis of unipolar voltage values obtained through EMM. This is the first study to validate these results by using cardiac DE-MRI in humans.

Objective Previous studies have confirmed the poor correlation of symptoms, signs, and levels of acute-phase reactants with disease activity in ∼50% of all patients with Takayasu arteritis (TA). Invasive angiographic studies demonstrate vessel lumen anatomy, but do not provide qualitative information about the vessel wall. Moreover, sequential invasive angiographic studies expose patients to high-dose ionizing radiation and catheter/procedure-related morbidity. The aim of the present study was to determine the utility of new developments in vascular magnetic resonance (MR) technology in patients with TA. Methods Electrocardiogram-gated “edema-weighted” MR was used to evaluate the aorta and its primary branches with regard to the vascular lumen, vessel wall anatomy, and vessel wall edema in 24 TA patients (77 studies). Inclusion criteria were age

AIM: The aim of this study was to investigate the feasibility and accuracy of using symmetrically rotated apical long axis planes for the determination of left ventricular (LV) volumes with real-time three-dimensional echocardiography (3DE). METHODS AND RESULTS: Real-time 3DE was performed in six sheep during 24 haemodynamic conditions with electromagnetic flow measurements (EM), and in 29 patients with magnetic resonance imaging measurements (MRI). LV volumes were calculated by Simpson's rule with five 3DE methods (i.e. apical biplane, four-plane, six-plane, nine-plane (in which the angle between each long axis plane was 90 degrees, 45 degrees, 30 degrees or 20 degrees, respectively) and standard short axis views (SAX)). Real-time 3DE correlated well with EM for LV stroke volumes in animals (r=0.68-0.95) and with MRI for absolute volumes in patients (r-values=0.93-0.98). However, agreement between MRI and apical nine-plane, six-plane, and SAX methods in patients was better than those with apical four-plane and bi-plane methods (mean difference = -15, -18, -13, vs. -31 and -48 ml for end-diastolic volume, respectively, P

Interrupted aortic arch is a rare congenital malformation of the aortic arch that occurs in 3 per million live births. Defined as a loss of luminal continuity between the ascending and descending portions of the aorta, this anomaly entails a very poor prognosis without surgical treatment. To our knowledge, the world medical literature contains only 12 reports of isolated interrupted aortic arch diagnosed in adults. Nine of these patients underwent successful surgical repair, but 1 died during the early postoperative period. We describe a 10th successful surgical repair, which involved a 42-year-old woman who had an asymptomatic type B interrupted aortic arch (characterized by interruption between the left subclavian and left carotid arteries). We performed a single-stage extra-anatomic repair by placing a 16-mm extra-anatomic Dacron graft between the ascending and descending portions of the thoracic aorta and by interposing a 7-mm extra-anatomic Dacron graft between the 16-mm graft and the left subclavian artery. The patient recovered uneventfully and continued to do well 6 months later. (Tex Heart Inst J 2002;29:118–21)

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

Manual tracing of the blood pool from short axis cine MR images is routinely used to compute ejection fraction (EF) in clinical practice. The manual segmentation process is cumbersome, time consuming, and operator dependent. In this paper, we present an algorithm for the automatic computation of the EF that is based on segmenting the left ventricle by combining the fuzzy connectedness and deformable model frameworks. Our contributions are the following: 1) we automatically estimate a seed point and sample region for the fuzzy connectedness estimates, 2) we extend the fuzzy connectedness method to use adaptive weights for the homogeneity and the gradient energy functions that are computed dynamically, and 3) we extend the hybrid segmentation framework to allow forces from dual contrast and fuzzy connectedness data integrated, with shape constraints. Finally, we compare our method against manual delineation performed by experienced radiologists on the data from nine asymptomatic volunteers with very encouraging results.

Cardiac magnetic resonance (CMR) identifies important prognostic variables in ischemic cardiomyopathy (ICM) patients such as left ventricular (LV) volumes, LV ejection fraction (LVEF), peri-infarct zone, and myocardial scar burden (MSB). It is unknown whether Doppler-based diastolic dysfunction (DDF) retains its prognostic value in ICM patients, in the context of current imaging, medical, and device therapies. Methods: Diastolic function was evaluated in ICM patients (LVEF ≤40% and ≥70% stenosis in ≥1 coronary artery) who underwent transthoracic echocardiogram and delayed hyperenhancement CMR studies within 7 days. The association of DDF with the combined end point was assessed after risk-adjustment using Cox proportional hazards models. Results: A total of 360 patients with severe LV dysfunction (LVEF = 24±9%) and extensive MSB (31±17%) were evaluated; DDF was present in all patients (stage 1%-44%, stage 2%-25%, stage 3%-31%). There were 130 events (124 deaths and 6 heart transplants) over a median follow-up of 5.8 years (IQR, 3.7-7.4 years). On multivariable analysis, DDF > stage 1 (HR, 1.37; P = .007) was associated with the combined end-point, independent of clinical risk score (HR, 2.40; P < .0001), implantable cardioverter defibrillator implantation (HR, 0.60; P = .009), incomplete revascularization (HR, 1.32; P = .003), mitral regurgitation (HR, 3.37; P = .01), peri-infarct zone area (HR, 1.04; P = 0.02), and MSB (HR, 1.02; P = .01). DDF had incremental prognostic value for the combined end-point (model χ 2 increased from 89 to 95, P = .02). Conclusion: DDF is a powerful predictor of mortality in ICM patients with significant LV dysfunction, independent of clinical and CMR data. DDF assessment provides incremental value, improving risk stratification. © 2014 Mosby, Inc. All rights reserved.

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

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

Background. In patients with atrioventricular and arterioventricular discordance congenitally corrected transposition, the morphologically right ventricle may progressively deteriorate while functioning in the systemic circuit. The double switch operation has been proposed to limit this functional deterioration. Methods. From October 1993 to August 1998, the records of 27 patients with congenitally corrected transposition were reviewed. Age at operation ranged from 3 months to 55 years. Associated defects included ventricular septal defects in 18, pulmonary atresia in 7, and pulmonary stenosis in 11 patients. Twenty-two patients had double switch operations (10 arterial switch plus Senning procedures and 12 Rastelli plus Senning procedures). Five patients were not candidates for the double switch. Before the double switch, 6 patients required pulmonary artery banding and 10 had functioning systemic to pulmonary artery or cavopulmonary shunts. Results. There was no early or late mortality. Two patients required pacemaker implantation, both later regained normal sinus rhythm. Tricuspid valve function improved in all patients except one. Moderate left ventricular dysfunction developed 5 months postoperatively in 1 patient. Conclusions. The double switch operation can be performed in selected patients with minimal early morbidity and mortality. Longer follow-up is necessary to determine whether this complex approach is indeed warranted.

To evaluate right ventricular abnormalities with magnetic resonance (MR) imaging in patients with arrhythmia but without arrhythmogenic dysplasia.In 53 patients being evaluated for right ventricular arrhythmia and 15 control subjects, MR imaging was performed to evaluate fixed thinning, fatty replacement, or reduced systolic wall thickening or motion. A diagnosis of idiopathic right ventricular outflow tract tachycardia or indeterminate was assigned for each patient, and the severity of arrhythmia was categorized.Right ventricular abnormalities were revealed in 32 (60%) of the 53 patients: fixed thinning in 27 (84%), fatty replacement in eight (25%), and reduced wall thickening or motion in 31 (97%). Right ventricular abnormalities were found in 35 (76%) of 46 patients with idiopathic right ventricular outflow tract tachycardia and in seven (39%) of 18 patients with indeterminate diagnoses (P = .022).Mild right ventricular abnormalities are likely sources for arrhythmias, even in the absence of arrhythmogenic right ventricular dysplasia.

Background T1 mapping is increasingly employed for evaluation of diffuse fibrosis within the left ventricular (LV) myocardium. Physiological confounders require correction of raw data prior to analysis. T1 values have been inversely correlated with LV systolic and diastolic function. We sought to evaluate the feasibility of right ventricular (RV) T1 mapping and to assess its relationship with RV function.

To evaluate magnetic resonance (MR) imaging findings of intramural hematoma of the thoracic aorta and their relationship to prognosis.MR images of 22 patients with intramural hematoma of the thoracic aorta were reviewed retrospectively. Site, thickness, degree of mural involvement, and signal intensity on spin-echo (SE) and cine gradient-echo (GRE) images of the hematoma were noted. MR findings of patients who did and those who did not develop complications were compared.Hematoma site was the only MR finding that correlated significantly with patient outcome. Complication frequencies in four (80%) of five patients with hematoma of the ascending aorta (type A) and in two (12%) of 17 patients with hematoma of the descending aorta (type B) were significantly different (P = .009). There were moderately strong correlations between days after symptom onset and signal intensity of the hematoma on SE (r = 0.78) and GRE (r = 0.72) images. MR images of two of three patients who developed early-subacute complications showed signal intensity changes of the hematoma that were consistent with recurrent bleeding.Patients with MR findings consistent with type A intramural hematoma of the thoracic aorta should undergo surgery. In cases of type B intramural hematoma of the thoracic aorta, MR imaging can be useful for detecting complete resolution or impending complications of the hematoma.

The sections in this article are 1 Introduction 2 Imaging Techniques 3 Level of Current Clinical Activity 4 Acquired Heart Disease 5 Congenital Heart Disease 6 The Future 7 Biographical Sketches Related Articles

This editorial refers to “Safety and feasibility of high-dose dobutamine-atropine stress cardiovascular magnetic resonance for diagnosis of myocardial ischaemia: experience in 1000 consecutive cases”1 by A. Wahl et al. on page 1230 Cardiovascular magnetic resonance imaging (CMRI) has had particularly rapid advances in the evaluation of ischaemic heart disease over the last five years. The introduction of steady-state free precession sequences has improved both spatial and temporal resolution in cine imaging for evaluation of global and regional left ventricular function,1 the advent of delayed-enhancement imaging has thrust CMRI into the forefront of myocardial viability assessment,2 and on-going advances on multiple fronts are bringing magnetic resonance angiography of the coronary arteries for stenosis detection closer to clinical reality.3 Nonetheless, it is perhaps in the area of pharmacological stress ischaemia evaluation that CMRI may show the broadest clinical utility and greatest promise. In this edition of the European Heart Journal , Wahl et al.4 report a five-year experience in performing high-dose dobutamine (Dob) stress CMRI examinations for determination of myocardial ischaemia. This group of investigators brings extensive experience to this arena, having been the first to report a large study of Dob-CMRI with a head-to-head comparison with Dob-echocardiography.5 In the current study, Wahl et al. performed 1000 Dob-CMRI studies in 960 patients from a clinically referred pool of 1075 potential patient studies. Patients were not excluded from analysis for lack of imaging as a result of claustrophobia or obesity – well-acknowledged limitations of MRI technology in clinical evaluations. Of the 1000 … *Correspondence to: Scott D. Flamm, M.D., Department of Radiology, MC 2-270, St. Luke's Episcopal Hospital, 6720 Bertner Avenue, Houston, TX 77030, USA. Tel.: +1-832-355-4201; fax: +1-832-355-2591 E-mail address: sflamm{at}sleh.com

Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) enables estimation of scar burden in hypertrophic cardiomyopathy (HCM). However, quantitative methods vary with recent data suggesting that higher semi-automated LGE gray-scale thresholds above the mean signal intensity for

Methods 5 control patients (4M/1F, age 44±21 y) with normal left ventricular (LV) function and no history of heart disease, 5 patients with ICM (3M/2F, 63±2 y), and 16 patients with HCM (10M/6F, age 51±15y) were recruited into an IRB approved protocol. All subjects were imaged at 1.5T (Achieva XR, Philips). T1 mapping was performed using MOLLI and LL at 2 LV short axis levels (basaland midcavity) before and after contrast agent injection (Magnevist; 0.2 mmol/kg). Post gadopentetate dimeglumine (Magnevist; 0.2 mmol/kg) injection time was about 15 min for HCM and ICM patients and was shorter (about 5 min) for the controls due to organizational reasons. For each subject, TI measurements were made in 6 ROIs per level.

Methods We performed CMR in 24 patients with idiopathic nonischemic cardiomyopathy (16 men, mean age 58±11 years) and also in 12 healthy volunteers as control subjects. T1 mapping was performed with post-contrast Look-Locker gradient echo. Baseline echocardiography as well as hemodynamic and metabolic data were collected at the time of CMR. Patients were followed over a median time of 8 months for LVRR which was defined as a left ventricular ejection fraction (LVEF) increase of ≥10 U and a decrease in indexed left ventricular end-diastolic diameter (LVEDD) of ≥10% or indexed LVEDD of < 33 mm/m at 24 months. A multivariable logistic regression analysis was performed to identify associations with LVRR.

We present 2 cases of apical hypertrophic cardiomyopathy (HCM) with similar presentations but different imaging appearances. Case #1 is an 82-year-old female with exertional dyspnea and mildly elevated troponin. Electrocardiogram (ECG) (A, left panel) , echocardiogram (with contrast) ( B, left panel

Unlike Framingham risk score (FRS), Reynolds risk score (RRS) predicts future coronary heart disease (CHD) while incorporating C-reactive protein (CRP) & family history. Coronary calcium scoring (CAC) has shown additive value over FRS but not RRS. We investigated if CAC leads to reclassification of

Background Autologous bone marrow mononuclear cell (ABMMNC) therapy has shown promise in patients with heart failure (HF). Cell function analysis may be important in interpreting trial results. Methods In this prospective study, we evaluated the safety and efficacy of the transendocardial delivery of ABMMNCs in no-option patients with chronic HF. Efficacy was assessed by maximal myocardial oxygen consumption, single photon emission computed tomography, 2-dimensional echocardiography, and quality-of-life assessment (Minnesota Living with Heart Failure and Short Form 36). We also characterized patients' bone marrow cells by flow cytometry, colony-forming unit, and proliferative assays. Results Cell-treated (n = 20) and control patients (n = 10) were similar at baseline. The procedure was safe; adverse events were similar in both groups. Canadian Cardiovascular Society angina score improved significantly ( P = .001) in cell-treated patients, but function was not affected. Quality-of-life scores improved significantly at 6 months ( P = .009 Minnesota Living with Heart Failure and P = .002 physical component of Short Form 36) over baseline in cell-treated but not control patients. Single photon emission computed tomography data suggested a trend toward improved perfusion in cell-treated patients. The proportion of fixed defects significantly increased in control ( P = .02) but not in treated patients ( P = .16). Function of patients' bone marrow mononuclear cells was severely impaired. Stratifying cell results by age showed that younger patients (≤60 years) had significantly more mesenchymal progenitor cells (colony-forming unit fibroblasts) than patients >60 years (20.16 ± 14.6 vs 10.92 ± 7.8, P = .04). Furthermore, cell-treated younger patients had significantly improved maximal myocardial oxygen consumption (15 ± 5.8, 18.6 ± 2.7, and 17 ± 3.7 mL/kg per minute at baseline, 3 months, and 6 months, respectively) compared with similarly aged control patients (14.3 ± 2.5, 13.7 ± 3.7, and 14.6 ± 4.7 mL/kg per minute, P = .04). Conclusions ABMMNC therapy is safe and improves symptoms, quality of life, and possibly perfusion in patients with chronic HF.