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Background It is a class I indication to place AICDs in patients with ischemic or nonischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) ≤ 35%. Most commonly, the need is determined by LVEF measurements on 2-D echo. This practice was utilized prior to cardiac MRI (CMR) establishment as the LVEF “gold standard” modality. Transthoracic echocardiography is still widely employed because of its wide availability and perceived cost savings. This study was designed to compare LVEF by both 2-D and CMR prior to AICD, along with analysis of comparative Medicare reimbursement.

Background: Of patients with acute chest pain(CP), only 10% have acute coronary syndrome. About 20% of these CP patients have an obvious non-cardiac etiology, while the remaining 70% undergo diagnostic testing to exclude coronary atherosclerosis(CAD). Myocardial perfusion imaging(MPI) is commonly used to assess these patients. A normal MPI effectively excludes CAD and the patient is labeled as having “non-cardiac” CP. Late gadolinium enhancement(LGE) by Cardiac MRI(CMR) offers detection of pericardial disease. This study was undertaken to assess the role of CMR in CP patients with a normal MPI. Methods: An institutional cardiac imaging database was queried for all patients with new onset CP. The study was composed of those CP patients who did not have ACS or an obvious non-cardiac etiology. The cohort was divided into 2 groups. Group A patients underwent MPI as their initial test and were negative for ischemia, but had continued CP. Group B had CMR as their initial test and were negative for ischemia. The detection of pericarditis in these 2 patient groups was assessed using LGE of the pericardium. Results: 3,525 patients who presented with chest pain and no evidence of ACS underwent nuclear MPI. 347(9.8%) of these 3,525 patients had a normal nuclear MPI, but subsequently underwent a CMR for persistent chest pain and constituted Group A. 63 of 347(18.1%) Group A patients with a normal MPI had evidence of pericarditis on LGE. Group B had 505 patients with chest pain who underwent a CMR stress study, noting 461(82.4%) were normal, while 89(17.6%) had evidence of CAD. Of the 461 patients with a normal CMR stress, 80(19.2%) had evidence of pericarditis on LGE. Conclusions: About 10% of patients with CP and normal MPI may continue to complain of discomfort. These patients are usually labeled as “non-cardiac”, and often undergo gastrointestinal and musculoskeletal evaluation. Evaluation of this group of patients with CMR shows that 18-19% have pericarditis by LGE and are incorrectly labeled as “non-cardiac”. Newer treatments for pericarditis with colchicine/non-steroid anti-inflammatory drugs have high success rates, while undiagnosed/untreated pericarditis is likely a precursor to constrictive disease, making the need for a correct initial diagnosis imperative.

Background Progressive pressure overload to the left ventricle, which occurs with aortic stenosis(AS), is a known stimulus to left ventricular hypertrophy (LVH). However, assessment of LV wall thickness with 2-D echo has failed to show a useful correlation with severity of AS. The absence of a relationship may be due to inherent limitations in 2-D echo assessment of LV wall thickness and aortic valve area. This study was designed to determine if cardiac magnetic resonance imaging (CMR) may be a more useful diagnostic tool.

Background Left ventricular cavity dimensions and volumes are useful parameters to diagnose and monitor cardiac pathologies which lead to LV volume overload. 2-D echo/ Doppler is the most commonly used imaging modality to assess LV volume overload in patients with valvular regurgitant disease. However, 2-D echo suffers from inherent limitations related to adequacy of the intercostal echo window, anatomic positioning for cavity dimensions and volumes and incomplete visualization of the entire left ventricular cavity. This study was designed to compare assessment of LV cavity dimensions and volumes by 2-D echo and cardiac magnetic resonance (CMR) techniques in patients with LV volume overload due to valvular regurgitation

Background Cardiac diagnostic testing is responsible for a significant portion of non-therapeutic radiation exposure in the United States. The major source of cardiac-related radiation exposure is nuclear based myocardial perfusion imaging (MPI). Furthermore, a higher radio-isotope dose is necessary for MPI in obese patients, a growing segment of the population. As of January 1, 2014, the American Society of Nuclear Cardiology (ASNC) recommended that measures be taken to ensure a mean dose of ≤9.0 mSv per MPI study, a goal which has been difficult for many institutions to achieve. This study was designed to assess the role of cardiac MRI (CMR) stress imaging in reducing radiation exposure in a “real-world” setting, particularly the growing subset of obese patients.

Chest pain in young patients may be a diagnostic challenge. “Non-coronary” etiologies are often considered. Criteria for pericarditis include chest pain, EKG changes, pericardial effusion and a friction rub. These findings can be absent or transient. Cardiac MRI(CMR) T2 STIR and late gadolinium

Background False positive nuclear stress myocardial perfusion imaging(MPI) findings are known to occur in obese patients and women with large breasts due to attenuation artifact. A false positive MPI study may lead to unnecessary coronary arteriography(Cath). CMR stress perfusion imaging is not affected by obesity and has better spatial resolution than MPI, without radiation exposure. The CE-MARC study showed superiority of CMR stress compared to MPI, but did not include patients > 120 kg (mean BMI = 29.2 kg/m2) due to magnet bore size limitations. This study was designed to assess the cost benefit of CMR stress as an alternative to MPI for obese patients with chest pain. Methods Concordance of MPI and Cath procedures were retrospectively assessed from data in an institutional cardiac imaging database. MPI procedures were classified as Positive (at least 1r egion ofischemia or infarction) or Negative (no ischemia or infarction). Cath procedures were classified as Positive (at least 1 stenosis > 70%) or Negative (no lesion > 70%). Concordance of MPI and CMR stress was assessed from a cohort of patients with both a CMR stress and a MPI within a 6 month time frame. There was no patient weight limit for either procedure since a wide bore magnet was available for obese patients. Concordance for both patient cohorts were also analyzed by body mass index (BMI) 35 kg/m2.. From these data, using Medicare and private payor reimbursement data, analysis was carried out to compare the cost of the MPI versus cMRI stress perfusion strategies for obese patients with BMI > 35 kg/m2. Cost of Cath for false positive MPI and cMRI was included to assess the true cost of each strategy. Cost was computed assuming a patient population of 60% Medicare and 40% private insurance. Results The concordance rate of MPI and Cath for patients with a BMI > 35 kg/m2 was only 26%, indicating that 74% of patients with a BMI > 35 kg/m2 had a MPI which resulted in a Cath which may have not been necessary. The concordance of MPI and cMRI stress was similarly low, at only 21%(14% true positive). 84% of the discordant MPI-CMR patients had a false positive MPI, yielding a Cath rate of 30%. Using an MPI strategy, the cost per 100 patients was $418,237(or $4,182 per patient). Using a cMRI stress strategy, the cost per 100 patients was $193,617(or $1,936 per patient). Conclusions

Background Evaluation of chest pain(CP) patients with cardiac MRI (CMR) provides a comprehensive exam including myocardial structure, function, perfusion and viability in 30-35 min without radiation or iodinated contrast. Patients who present with CP, but no ECG changes and normal biomarker levels are candidates for CMR evaluation. This study was designed to assess the diagnostic value of T2 weighted imaging, incorporated into a standard CMR chest pain protocol.