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To develop a free-breathing myocardialFree-running (free-breathing, retrospective cardiac gating) IR radial FLASH is used for data acquisition at 3T. First, to reduce the waiting time between inversions, an analytical formula is derived that takes the incompleteIn comparison to an IR spin-echo reference, phantom results confirm goodMotion-resolved myocardial

Background: Correction of tetralogy of Fallot (cTOF) often results in pulmonary valve pathology and right ventricular (RV) dysfunction. Reduced exercise capacity in cTOF patients cannot be explained by these findings alone. We aimed to explore why cTOF patients exhibit impaired exercise capacity with the aid of a comprehensive cardiopulmonary exercise testing (CPET) and real-time cardiovascular magnetic resonance exercise testing (CMR-ET) protocol. Methods: Thirty three cTOF patients and 35 matched healthy controls underwent CPET and CMR-ET in a prospective case-control study. Real-time steady-state free precession cine and phase-contrast sequences were obtained during incremental supine in-scanner cycling at 50, 70, and 90 W. RV and left ventricle (LV) volumes and pulmonary blood flow (Qp) were calculated. Differences of CPET and CMR-ET between cTOF versus controls and correlations between CPET and CMR-ET parameters in cTOF were evaluated statistically for all CMR exercise levels using Mann-Whitney U and Spearman rank-order correlation tests. Results: CPET capacity was significantly lower in cTOF than in controls. cTOF patients exhibited not only significantly reduced Qp and RV function but also lower LV function on CMR-ET. Higher CPET values in cTOF correlated with higher Qp (Qp 90 W versus carbon dioxide ventilatory equivalent %: R =−0.519, P R =0.452, P r =−0.463, P r =0.66, P r =0.52, P Conclusions: Impaired exercise capacity in cTOF resulted from a reduction in not only RV, but also LV function. cTOF with good exercise capacity on CPET demonstrated higher LV reserve and pulmonary blood flow during incremental CMR-ET. Apart from RV parameters, CMR-ET–derived LV function could be a valuable tool to stratify cTOF patients for pulmonary valve replacement.

Purpose: To develop a free-breathing myocardial T1 mapping technique using inversion-recovery (IR) radial fast low-angle shot (FLASH) and calibrationless motion-resolved model-based reconstruction. Methods: Free-running (free-breathing, retrospective cardiac gating) IR radial FLASH is used for data acquisition at 3T. First, to reduce the waiting time between inversions, an analytical formula is derived that takes the incomplete T1 recovery into account for an accurate T1 calculation. Second, the respiratory motion signal is estimated from the k-space center of the contrast varying acquisition using an adapted singular spectrum analysis (SSA-FARY) technique. Third, a motion-resolved model-based reconstruction is used to estimate both parameter and coil sensitivity maps directly from the sorted k-space data. Thus, spatiotemporal total variation, in addition to the spatial sparsity constraints, can be directly applied to the parameter maps. Validations are performed on an experimental phantom, eleven human subjects, and a young landrace pig with myocardial infarction. Results: In comparison to an IR spin-echo reference, phantom results confirm good T1 accuracy when reducing the waiting time from five seconds to one second using the new correction. The motion-resolved model-based reconstruction further improves precision compared to the spatial regularization-only reconstruction. Aside from showing that a reliable respiratory motion signal can be estimated using modified SSA-FARY, in vivo studies demonstrate that dynamic myocardial T1 maps can be obtained within two minutes with good precision and repeatability. Conclusion: Motion-resolved myocardial T1 mapping during free-breathing with good accuracy, precision and repeatability can be achieved by combining inversion-recovery radial FLASH, self-gating and a calibrationless motion-resolved model-based reconstruction., Comment: Part of this work has been presented at the ISMRM Annual Conference 2021 (Virtual), accepted by Magnetic Resonance in Medicine

Magnetic resonance imaging (MRI) is regarded as a non-harming and non-invasive imaging modality with high tissue contrast and almost no side effects. Compared to other cross-sectional imaging modalities, MRI does not use ionising radiation. Recently, however, strong magnetic fields as applied in clinical MRI scanners have been suspected to induce DNA double-strand breaks in human lymphocytes. In this study we investigated the impact of 3-T cardiac MRI examinations on the induction of DNA double-strand breaks in peripheral mononuclear cells by γH2AX staining and flow cytometry analysis. The study cohort consisted of 73 healthy non-smoking volunteers with 36 volunteers undergoing CMRI and 37 controls without intervention. Differences between the two cohorts were analysed by a mixed linear model with repeated measures. Both cohorts showed a significant increase in the γH2AX signal from baseline to post-procedure of 6.7 % (SD 7.18 %) and 7.8 % (SD 6.61 %), respectively. However, the difference between the two groups was not significant. Based on our study, γH2AX flow cytometry shows no evidence that 3-T MRI examinations as used in cardiac scans impair DNA integrity in peripheral mononuclear cells. • No evidence for DNA double-strand breaks after cardiac MRI. • Prospective study underlines safe use of MRI with regard to DNA damage. • Controlled trial involving both genders investigating DNA DSBs after 3-T MRI.

Left atrial (LA) enlargement and dysfunction are markers of chronic diastolic dysfunction and an important predictor of adverse cardiovascular and cerebrovascular outcomes. Accordingly, accurate quantification of left atrial volume (LAV) and function is needed. In routine clinical cardiovascular magnetic resonance (CMR) imaging the biplane area-length method (Bi-ALM) is frequently applied due to time-saving image acquisition and analysis. However, given the varying anatomy of the LA we hypothesized that the diagnostic accuracy of the Bi-ALM is not sufficient and that results would be different from a precise volumetric assessment of transversal multi-slice cine images using Simpson's method. Thirty one patients of the FIND-AFRANDOMISED-study with status post acute cerebral ischemia (mean age 70.5 ± 6.2 years) received CMR imaging at 3T. The study protocol included cine SSFP sequences in standard 2- and 4 CV and a stack of contiguous slices in transversal orientation. Total, passive and active LA emptying fractions were calculated from LA maximal volume, minimal volume and volume prior to atrial contraction. Intra- and inter-observer variability was assessed in ten patients. Significant differences were found for LA volume and phasic function. The Bi-ALM significantly underestimated LA volume and overestimated LA function in comparison to Simpson's method (Bi-ALM vs. Simpson's method: LAVmax: 80.18 vs. 98.80 ml; LAVpre-ac: 61.09 vs. 80.41 ml; LAVmin: 36.85 vs. 52.66 ml; LAEFTotal: 55.17 vs. 47.85%; LAEFPassive: 23.96 vs. 19.15%; LAEFBooster: 40.87 vs. 35.64%). LA volumetric and functional parameters were reproducible on an intra- and inter-observer levels for both methods. Intra-observer agreement for LA function was better for Simpson's method (Bi-ALM vs. Simpson's method; ICC LAEFTotal: 0.84 vs. 0.96; ICC LAEFPassive: 0.74 vs. 0.92; ICC LAEFBooster: 0.86 vs. 0.89). The Bi-ALM is based on geometric assumptions that do not reflect the complex individual LA geometry. The assessment of transversal slices covering the left atrium with Simpson's method is feasible and might be more suitable for an accurate quantification of LA volume and phasic function.

The purpose of our study was to evaluate magnetic resonance (MR) artifacts related to breast tissue markers in breast imaging procedures.In this bicentric prospective ex vivo study 10 different commercially available markers were measured in self-made breast phantoms. Breast tissue markers varying in marker size, composition, and shape were evaluated. MR imaging (MRI) scans were performed on 1.5 Tesla (T) and 3 T scanners from 2 different vendors, using dedicated breast coils. Three different sequences (T1-weighted images with and without fat saturation, T2-weighted images) were acquired in axial and coronal view. Three blinded readers electronically measured the artifact length.All markers caused artifacts in MRI. The largest median artifact length was 10.4 mm, interquartile range (IQR 9.4-11.0 mm), the smallest 4.8 mm (IQR 4.5-5.2 mm). Relative artifact length (quotient artifact length in mm/real physical length of the marker) ranged between 0.9 (IQR 0.9-1.2) and 3.0 (IQR 2.8-3.4). Mean artifact length was higher for metallic markers (10.2 mm; IQR 8.7-11.5 mm) compared to metallic markers with nonmetallic coating (7.7 mm; IQR 6.3-10.2 mm) and nonmetallic marker (7.6 mm; IQR 5.9-10.0 mm); all p0.0001. Artifact size was higher in coronal in comparison to axial view; p0.05. The results were comparable between the different field strengths, the sites and sequences; p0.05. Interobserver agreement was excellent (ntraclass correlation coefficient = 0.83).Artifacts are necessary in the detection and localization of breast tissue markers, but could also limit the interpretation of MRI due to the possibility of masking the residual tumor after biopsy. This artifact size varies among the different clips evaluated. It depends on marker composition and scan direction but is not influenced by image sequence, field strength or scanner type.

Purpose: The aim of this study was to assess the incidence of cardiac and significant extra-cardiac findings in clinical computed tomography of the heart in patients with atrial fibrillation before pulmonary vein isolation (PVI). Materials and Methods: 224 patients (64 ± 10 years; male 63 %) with atrial fibrillation were examined by cardiac 64-slice multidetector CT before PVI. Extra-cardiac findings were classified as “significant” if they were recommended to additional diagnostics or therapy, and otherwise as “non-significant”. Additionally, cardiac findings were documented in detail. Results: A total of 724 cardiac findings were identified in 203 patients (91 % of patients). Additionally, a total of 619 extra-cardiac findings were identified in 179 patients (80 % of patients). Among these extra-cardiac findings 196 (32 %) were “significant”, and 423 (68 %) were “non-significant”. In 2 patients (1 %) a previously unknown malignancy was detected (esophageal cancer and lung cancer, local stage, no metastasis). 203 additional imaging diagnostics followed to clarify the “significant” findings (124 additional CT, costs 38 314.69 US dollars). Overall, there were 3.2 cardiac and 2.8 extra-cardiac findings per patient. Extra-cardiac findings appear significantly more frequently in patients over 60 years old, in smokers and in patients with a history of cardiac findings (p Conclusion: Cardiac CT scans before PVI should be screened for extracardiac incidental findings that could have important clinical implications for each patient. Key points: • Cardiac and extra-cardiac findings are common in patients with an indication for pulmonary vein isolation on previous CT scans. • Malignancies can be detected in 1 % of all patients. • 32 % of all extra-cardiac findings can be of significant relevance with consequences for patients. • Altogether, there are 3.2 cardiac and 2.8 extra-cardiac findings in patients with indication for pulmonary vein isolation and CT. • Extra-cardiac findings appear significantly more frequently in patients over 60 years old, in smokers and in patients with a history of cardiac findings (p Citation Format: • Sohns JM, Menke J, Staab W et al. Current Role of Cardiac and Extra-Cardiac Pathologies in Clinically Indicated Cardiac Computed Tomography with Emphasis on Status Before Pulmonary Vein Isolation. Fortschr Rontgenstr 2014; 186: 860 – 867

Purpose To assess the incidence of extracardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart, and to determine the influence of those findings on patient management. Materials and Methods During 40 months, 854 CMRI were performed at 1.5 T. Extracardiac findings were classified as significant (group A), if recommended for additional diagnostics or therapeutic interventions, and as nonsignificant (group B). Results The most frequent indication for CMRI was evaluation of cardiac stress ischemia. In all, 631 CMRI (74% of 854) showed no extracardiac pathologies. In the remaining 223 CMRI (26% of 854), a total of 286 extracardiac findings were detected. Among these findings, 49 were considered significant (group A) and 237 nonsignificant (group B). In group A, the most common findings were suspicious pulmonary nodules or masses. In group B, the most frequent findings were hepatic cysts or hemangiomas. Eight malignancies were observed with certainty at CMRI. Seven of them had been incidentally diagnosed on CMRI for the first time, and subsequently changed the patients' management. Conclusion Extracardiac findings in clinically indicated CMRI are common (about 26%). Radiologists and cardiologists should be aware of relevant extracardiac findings that might require additional diagnostics or treatment. J. Magn. Reson. Imaging 2014;39:68–76. © 2013 Wiley Periodicals, Inc.

Rationale and Objectives The purpose of this ex vivo study was to investigate artifacts in a cone-beam breast computed tomography (CBBCT) caused by breast tissue markers. Materials and Methods Breast phantoms with self-made tissue pork mincemeat were created. Twenty-nine different, commercially available markers with varying marker size, composition, and shape were evaluated. A dedicated CBBCT evaluation of all phantoms was performed with 49 kVp, 50 and 100 mA, and marker orientation parallel and orthogonal to the scan direction. The resultant images were evaluated in sagittal, axial, and coronal view with a slice thickness of 0.5 mm. Additionally, measurements of all markers in the same directions were done with full-field digital mammography. Results All markers were visible in full-field digital mammography without any artifacts. However, all markers caused artifacts on a CBBCT. Artifacts were measured as the length of the resulting streakings. Median length of artifacts was 7.2 mm with a wide range from 0 to 48.3 mm (interquartile range 4.3–11.4 mm) dependent on composition, size, shape, weight, and orientation of the markers. The largest artifacts occurred in axial view with a median size of 12.6 mm, with a range from 0 to 48.3 mm, resulting in a relative artifact length (quotient artifact in mm/real physical length of the marker itself) of 4.1 (interquartile range 2.3–6.1, range 0–8.7). Conclusions Artifacts caused by markers can significantly influence image quality in a CBBCT, thus limiting primary diagnostics and follow-up in breast cancer. The size of the artifacts depends on the marker characteristics, orientation, and the image plane of reconstruction.

The combined therapeutic impact of atrial overdrive pacing (AOP) and cardiac resynchronization therapy (CRT) on central sleep apnoea (CSA) in chronic heart failure (CHF) so far has not been investigated. We aimed to evaluate the effect of CRT alone and CRT þ AOP on CSA in CHF patients and to compare the influence of CRT on CHF between CSA positive and CSA negative patients. Methods Thirty patients with CRT indication underwent full night polysomnography, echocardiography, exercise testing, and neurohumoral evaluation before and 3 months after CRT implantation. In CSA positive patients (60%), two additional sleep studies were conducted after 3 months of CRT, with CRT alone or CRT þ AOP, in random order. Cardiac resynchronization therapy resulted in significant improvements of NYHA class, left ventricular ejection fraction, N-terminal pro-brain natriuretic peptide, VO2max, and quality of life irrespective of the presence of CSA. Cardiac resynchronization therapy also reduced the central apnoea-hypopnoea index (AHI) (33.6+ 14.3 vs. 23.8+ 16.9 h 21 ; P , 0.01) and central apnoea index (17.3+ 14.1 vs. 10.9+ 13.9 h 21 ; P , 0.01) without altering sleep stages. Cardiac resynchronization therapy with atrial overdrive pacing resulted in a small but significant additional decrease of the central AHI (23.8+ 16.9 vs. 21.5+ 16.9 h 21 ; P , 0.01). Conclusion In this study, CRT significantly improved CSA without altering sleep stages. Cardiac resynchronization therapy with atrial overdrive pacing resulted in a significant but minor additional improvement of CSA. Positive effects of CRT were irrespective of the presence of CSA.

Background Left atrial (LA) performance quantification using Cardiovascular Magnetic Resonance (CMR) is of growing interest. There is evidence that declined left atrial function is associated with a poorer outcome following pulmonary vein isolation (PVI) in atrial fibrillation (AF). Furthermore, the influence of PVI on left atrial performance has not yet been investigated comprehensively. This study was designed to investigate the feasibility of CMR using comprehensive myocardial feature tracking (CMR-FT) and volumetric analyses for serial investigation of atrial performance before and after PVI.

Background Magnetic Resonance Imaging (MRI) is regarded as a non harming and non invasive imaging modality with superb tissue contrast and almost no side effects. Compared to other cross-sectional imaging modalities MRI does not use ionizing radiation. Recently however, strong magnetic fields as applied in clinical MRI scanners have been suspected to induce DNA double strand breaks in human lymphocytes.

Aim To compare estimated pressure gradients from routine follow-up cardiovascular phase-contrast magnetic resonance (PC-MR) with those from Doppler echocardiography and invasive catheterization in patients with congenital heart disease (CHD) and pulmonary outflow tract obstruction. Methods In 75 patients with pulmonary outflow tract obstruction maximal and mean PC-MR gradients were compared to maximal and mean Doppler gradients. Additionally, in a subgroup of 31 patients maximal and mean PC-MR and Doppler pressure gradients were compared to catheter peak-to-peak pressure gradients (PPG). Results Maximal and mean PC-MR gradients underestimated pulmonary outflow tract obstruction as compared to Doppler (max gradient: bias = + 8.4 mm Hg (+ 47.6%), r = 0.89, p

Ebstein's anomaly (EA) involves a displaced and dysplastic tricuspid valve resulting in an atrialized portion of the right ven- tricle and an enlargement of the functional right ventricle and right atrium. Biomarkers targeting heart failure such as brain natriuretic peptide (BNP) or haematological parameters (haemoglobin (Hb) and haematocrit (Hct)) are upregulated in states of pulmonary hypoperfusion. We hypothesized that decreased pulmonary perfusion dependent on the stage of right heart failure is a possible mechanism in EA, and that it can be correlated with cardiac magnetic resonance (CMR) parameters. The aim of this study was to investigate the relationship between BNP and haematological parameters with functional parameters from CMR and exercise testing in patients with EA. Methods and results Twenty-five patients with non-corrected EA were studied prospectively (mean age 26+ 14 years). BNP level was increased (74+ 127 ng/L), and in 16% markedly above the heart failure cut-off level of 100 ng/L. Hb and Hct were increased above normal levels in 20 and 24% of patients, respectively. BNP and Hct/Hb correlated with CMR (total right/left (R/L)-Volume-Index, right atrium-end-diastolic volume index (EDVi), functional right ventricle (fRV)-EDVi, fRV-ejection fraction (EF), tricuspid regurgitation, pulmonary artery flow, and left ventricular EF) and exercise testing (workload/kg, oxygen uptake (VO2), ventilatory response to carbon dioxide production (VE/VCO2), oxygen (O2) pulse, and heart rate reserve). The higher BNP and haematological parameters, the higher was the disease severity and the more limited was the physical exercise capacity. Conclusion In this EA cohort, BNP levels and haematological parameters correlated well with functional data from CMR and exercise testing. The total R/L-Volume-Index and BNP, and to some extent hematological parameters, may be useful as prognostic markers in patients with EA.

Background Cardiovascular Magnetic Resonance myocardial feature tracking (CMR-FT) is a quantitative technique tracking tissue voxel motion on standard steady-state free precession (SSFP) cine images to assess ventricular myocardial deformation. The importance of left atrial (LA) deformation assessment is increasingly recognized and can be assessed with echocardiographic speckle tracking. However atrial deformation quantification has never previously been demonstrated with CMR. We sought to determine the feasibility and reproducibility of CMR-FT for quantitative LA strain and strain rate (SR) analysis.

Background Arrhythmogenic right ventricular cardiomyopathy (ARVC) is associated with increased risk of sudden cardiac death. It is a progressive disease that can already manifest itself during childhood and adolescence. Since little is known about the early stage in pediatric patients, this study sought to determine the influence of right and left ventricular findings from cardiac magnetic resonance imaging (CMR) in pediatric patients ≤ 18 years with suspected ARVC in conjunction with positive genetic testing.

New EGM Morphology Discrimination for ICDs. Introduction: Wide-spread adoption of ICD therapy has focused efforts on improving the quality of life for patients by reducing "inappropriate" shock therapies. To this end, distinguishing supraventricular tachycardia from ventricular tachycardia remains a major challenge for ICDs. More sophisticated discrimination algorithms based on ventricular electrogram morphology have been made practicable by the increased computational ability of modern ICDs. Methods and Results: We report results from a large prospective study (1,122 pts) of a new ventricular electrogram morphology tachycardia discrimination algorithm (Wavelet™ Dynamic Discrimination, Medtronic, Minneapolis, MN, USA) operating at minimal algorithm setting (RV coil-can electrogram, match threshold of 70%). This is a nonrandomized cohort study of ICD patients using the morphology discrimination of the Wavelet algorithm to distinguish SVT and VT/VF. The Wavelet criterion was required ON in all patients and all other supraventricular tachycardia discriminators were required to be OFF. Spontaneous episodes (N = 2,235) eligible for ICD therapy were adjudicated for detection algorithm performance. The generalized estimating equations method was used to remove bias introduced when an individual patient contributes multiple episodes. Inappropriate therapies for supraventricular tachycardia were reduced by 78% (90% CI: 72.8-82.9%) for episodes within the range of rates where Wavelet was programmed to discriminate. Sensitivity for sustained ventricular tachycardia was 98.6% (90% CI: 97-99.3%) without the use of high-rate time out. Conclusions: Results from this prospective study of the Wavelet electrogram morphology discrimination algorithm operating as the sole discriminator in the ON mode demonstrate that inappropriate therapy for supraventricular tachycardia in a single-chamber ICD can be dramatically reduced compared to rate detection alone.

Background Neointimal proliferation resulting in luminal renarrowing is the major cause of restenosis limiting the long-term success of coronary angioplasty in 20 to 30% of patients. Local transfection of the DNA encoding for VEGF has been shown to enhance re-endothelialization and reduce neointimal proliferation in an experimental model. We tested the hypothesis that transfection of the DNA for the receptor of vascular endothelial growth factor VEGF, KDR-flk-1, reduces neointimal proliferation after angioplasty. Methods In a minipig model, we performed coronary stent implantation, followed by injection of either KDR/flk-1 DNA (200 μg of linearized DNA in a CMV-promotor) or LacZ control in two coronary artery segments per animal in a randomized, blinded protocol ( n = 22 animals). Expression of KDR/flk-1 was analyzed using in situ hybridization after 4, 7, and 14 days. Results In KDR-transfected coronary segments, expression of KDR/flk-1 occurred earlier and to much stronger extent compared to LacZ-transfected segments. After 4 weeks ( n = 10) neointimal proliferation and luminal narrowing was significantly reduced in KDR/flk-1 transfected animals. No expression of locally transfected DNA was detected in other organs. Conclusion The hypothesis is supported, that expression of the VEGF-receptor KDR/flk-1 can be rate-limiting for endothelial regeneration and that its transient overexpression at the time angioplasty can prevent excessive neointimal proliferation resulting in restenosis.

Atrial overdrive pacing markedly improved sleep-disordered breathing in a recent study.Using a single-blind, randomized, crossover design, we aimed to reproduce these findings and investigate the possible underlying mechanisms.Twenty ambulatory patients with an implanted pacemaker or cardioverter defibrillator were studied by polysomnography on 3 consecutive nights in a randomized, single-blind, crossover study in which devices were programmed for nonpacing or for overdrive pacing at 7 or 15 beats/minute faster than the mean nocturnal heart rate. Ventilation and biomarkers (urinary norepinephrine excretion, amino-terminal portion of the precursor of brain natriuretic peptide, or NT-proBNP, were also evaluated.Neither the primary endpoint apnea-hypopnea index, nor the apnea index, oxygen desaturation, ventilation, or biomarkers were affected by the nocturnal atrial overdrive pacing. A small, clinically insignificant, rate-dependent reduction in the hypopnea index was evoked by pacing (nonpacing, 13.4 +/- 1.4; pacing 7, 12.9 +/- 1.4; pacing 15, 10.9 +/- 1.0; p0.01, analysis of variance).The lack of effect on the apnea-hypopnea index means that atrial overdrive pacing is inappropriate for treating sleep-disordered breathing.

Background: Inappropriate ICD therapy for supraventricular tachycardia (SVT) remains a significant problem. A morphology-based algorithm (Wavelet™) compares baseline and tachycardia electrograms (EGM). For this analysis different EGM sources can be programmed. This study evaluates the performance of Wavelet using two different EGM configurations (SVC-Can and RV-Can) for the detection of exercise-induced SVT. Methods: Patients with a Medtronic model 7230 single chamber ICD and a dual coil lead were included. For each EGM source (SVC-Can or RV-Can), a baseline EGM template was acquired and the morphology similarity to this template (match percentage) was evaluated for 10–15 beats at different heart rates during exercise testing. The lower VT detection limit was programmed to 600 ms (therapies off). Results: A total of 28 patients (66.9 ± 4.7 years, 93% men) and 5,824 intracardiac QRS complexes were analyzed. With the RV-Can source, a consistently high similarity to the baseline EGM template was observed (≤100 bpm: 90.90 ± 0.56%; >100 bpm: 90.24 ± 0.55%, P > 0.05). In contrast, SVC-Can was associated with a lower match percentage at baseline and a significant decrease at higher heart rates (≤100 bpm: 77.91 ± 2.65%; >100 bpm: 59.05 ± 5.65%, P < 0.005). Accordingly, the specificity for appropriate detection of exercise-induced SVT was higher with RV-Can (21/21 episodes) than with SVC-Can (8/18 episodes, specificity 100% vs 44%; P < 0.0001). Conclusion: The RV-Can configuration appears to be superior to SVC-Can as EGM source for appropriate SVT detection with the Wavelet algorithm.

Transvenous left ventricular (LV) leads are primarily inserted "over-the-wire" (OTW). However, a stylet-driven (SD) approach may be a helpful alternative. A new polyurethane-coated, unipolar LV lead can be placed either by a stylet or a guide wire, which can be inserted into the lead body from both ends. The multicenter OVID study evaluates the clinical performance of this new steroid- and nonsteroid eluting lead. The primary endpoint is the LV lead implant success rate after identification of the coronary sinus (CS). Secondary endpoints include complication rate, short- and long-term lead characteristics, overall procedure and LV lead placement duration, total fluoroscopy time, and lead handling characteristics ratings. To date, 96 patients with heart failure (68 +/- 9 years old, 76% men) are enrolled. The CS was identified in 95 patients and, in 85 (88.5%), the LV lead was successfully implanted. The final lead positioning was lateral in 41%, posterolateral in 35%, anterolateral in 18%, and great cardiac vein in 6% of patients. In 70%, the 85 successful implantations, both stylet-driven and guide-wire techniques were used, a stylet only was used in 22%, and a guide wire only in 8%. Mean overall duration of 85 successful procedures was 112 +/- 40 minutes, total fluoroscopy time 28 +/- 15 minutes, and the duration of LV lead placement was 35 +/- 29 minutes. During a 3-month follow-up, the loss of LV capture occurred in three and phrenic nerve stimulation in six patients. The mean long-term pacing threshold is 0.8 V/0.5 ms and pacing impedance is 550 Omega. The OVID data suggest that these new leads are safe and effective. The choice of both OTW and SD techniques during lead implantation offers greater procedural flexibility.

AIM: To evaluate the potential of real-time phase-contrast flow magnetic resonance imaging (MRI) at 40 ms resolution for the simultaneous determination of blood flow in the ascending aorta (AA) and superior vena cava (SVC) in response to reduced intrathoracic pressure (Mueller manoeuvre). MATERIALS AND METHODS: Through-plane flow was assessed in 20 healthy young subjects using real-time phase-contrast MRI based on highly undersampled radial fast low-angle shot (FLASH) with image reconstruction by regularized non-linear inversion. Haemodynamic alterations (three repetitions per subject = 60 events) were evaluated during normal breathing (10 s), inhalation with nearly closed epiglottis (10 s), and recovery (20 s). RESULTS: Relative to normal breathing and despite interindividual differences, reduced intrathoracic pressure by at least 30 mmHg significantly decreased the initial peak mean velocity (averaged across the lumen) in the AA by -24 +/- 9% and increased the velocity in the SVC by +28 +/- 25% (p < 0.0001, n = 23 successful events). Respective changes in flow volume per heartbeat were -25 +/- 9% in the AA and +49 +/- 44% in the SVC (p < 0.0001, n = 23). Flow parameters returned to baseline during sustained pressure reduction, while the heart rate was elevated by 10% (p < 0.0001) after the start (n = 24) and end (n = 17) of the manoeuvre. CONCLUSIONS: Real-time flow MRI during low intrathoracic pressure non-invasively revealed quantitative haemodynamic adjustments in both the AA and SVC. (C) 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction Persistent left superior vena cava is a rare case with an appearance of 0.3% to 0.5% of individuals in general population. Indication for jugular venous intervention could be different, such as implantable venous catheters for oncological therapy. The present report describes a case of a patient with a persistent left superior vena cava detected after central venous catheter (CVC) installation using computer-assisted tomography (CT). Case description In a control chest X-ray the CVC was not in the right superior vena cava as expected to be. A following blood gas analysis revealed venous concentration. The consultation of additional CT diagnostics yielded a persistent left superior vena cava with an outlet to dilated coronary sinus. Discussion and evaluation The patient was followed over 1 year with the underlying disease of chronic obstructive pulmonary disease. Cardiac insufficiency, sinus aneurysm and arryhtmias could appear with growing age in patients with persistence left superior vena cava, but most of them are asymptomatic. Knowing the venous anatomy is important for correct position and function of e.g. totally implantable venous catheters, central lines or pacemakers. Conclusion The importance of early imaging diagnosis of this anatomical variation could optimize adequate therapy and finally improve living conditions. CT can help adapting correct therapy with correct diagnostics.

Introduction Situs inversus totalis with congenitally corrected transposition of the great arteries represents a relatively rare congenital condition. Case description The current report describes the case of a 56 year old patient with an atrio-ventricular and ventricular-arterial discordance of the heart chambers without surgical correction, incidentally detected during hepatocellular carcinoma evaluation. The systemic venous blood arrived via the right atrium and a mitral valve in the morphologically left but pulmonary arterial ventricle that gave rise to a pulmonary trunk. The pulmonary venous blood passed the left atrium and the tricuspid valve into a morphologically right but systemic ventricle that gave rise to the aorta. Discussion and evaluation The switched anatomy was incidentally detected on echocardiography. The patient was referred to cardiac magnetic resonance imaging (CMR) including flow measurements, volumetry and late enhancement. CMR results showed a mildly impaired function and the switched anatomy. During a follow-up period of 2 years the patient was suffering from only mild heart failure and dyspnea. Conclusions Heart failure symptoms and arrhythmias can appear with increasing age in patients with congenitally corrected transposition. Early CMR allows accurate diagnosis and timely introduction of adequate therapy thereby avoiding disease progression.

Cardiac structure, function and flow are most commonly studied by ultrasound, X-ray and magnetic resonance imaging (MRI) techniques. However, cardiovascular MRI is hitherto limited to electrocardiogram (ECG)-synchronized acquisitions and therefore often results in compromised quality for patients with arrhythmias or inabilities to comply with requested protocols—especially with breath-holding. Recent advances in the development of novel real-time MRI techniques now offer dynamic imaging of the heart and major vessels with high spatial and temporal resolution, so that examinations may be performed without the need for ECG synchronization and during free breathing. This article provides an overview of technical achievements, physiological validations, preliminary patient studies and translational aspects for a future clinical scenario of cardiovascular MRI in real time.

Background Ebstein’s anomaly consists of varying degrees of tricuspid dysplasia and displacement into the right ventricular (RV) cavity, along with changes in ventricular function predominantly affecting the RV. Measuring alterations in contraction pattern and dyssynchrony may provide insights into ventricular performance in this disease. We sought to quantify right and left ventricular (RV and LV) deformation and dyssynchrony in a cohort of patients with Ebstein’s anomaly in comparison with normal controls using cardiovascular magnetic resonance myocardial feature tracking (CMR-FT).

Background Atherosclerosis and its associated diseases are constantly increasing in developed countries. Aortic stiffness is an indicator for atherosclerosis and is associated with mortality and morbidity especially in aortic abdominal aneurysms. For further evaluation of aortic stiffness, we examined n = 13 healthy volunteers using real-time magnetic-resonance imaging (RT-MRI) with highly undersampled radial fast low-angle shot (FLASH) acquisitions, phase-sensitive image reconstructions and regularized nonlinear inversion (NLINV). We hypothesized that RT-MRI is able to determine pulse wave velocity (PWV) and flow data using just one transverse view of the ascending and descending aorta. This method could be superior to complex known MRI methods using velocity projection today. Methods We assessed PWV as surrogate parameter for aortic stiffness by velocity-encoded RT-MRI. Time lag between the ascending and descending aortic pulse wave was calculated and divided by the mean length of the aortic arch for each individual in detail. RT-MRI can determine PWV during normal breathing, physical strain and recovery from strain using the Valsalva (VM) and Mueller maneuvers (MM). During strain/maneuvers volunteers had visual feedback of intra-thoracic pressure via a mouthpiece to ensure adequate strain performance. We calculated PWV in normal breathing, at the end of strain and at the end of the recovery phase. Due to the advantage of a single heart beat-to-beat variability with

Background The aim of this study was to assess the incidence of extra-cardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart including surrounding structures and to determine the influence of those findings on patient’s management. Methods N=854 patient studies (median age 58 ± 12 years, male 63%) were included and examined by 1.5 Tesla (T) MR to primarily analyze the cardiac anatomy and secondly the surrounding structures. Extra-cardiac findings were classified as significant (Group A) if they were recommended to additional diagnostics or therapeutical interventions and as non-significant if there was no influence on patient’s management (Group B). Results 631 patient studies were free of any kind of extra-cardiac pathologies. In the remaining cases, 286 extra-cardiac findings were examined. There were ~0.33 extracardiac findings per patient. 49 were defined as significant (Group A) and 237 as nonsignificant findings (Group B). The most common Group A findings were suspicious pulmonary nodules or masses > 4 mm diameter (n=14) and aortic aneurysms (n=5). In Group B, most of the findings were hepatic cysts or hemangiomas (n=50), followed by renal cysts (n=47). 8 malignancies were certainly observed. The most frequent indication for CMRI was evaluation of cardiac stress ischemia (n=501, 59%). Conclusions Extra-cardiac findings in clinical CMRI are common in patients referred to CMRI (26%). Radiologists and cardiologists have to be aware of relevant extra-cardiac findings which might require additional diagnostics or treatment. There is an importance of paying appropriate attention to structures outside of the heart.

Background Patients with corrected Tetralogy of Fallot (cTOF) can develop supraventricular arrhythmias. So far, right atrial (RA) volume in TOF has not been evaluated in the context of arrhythmia. The aim of this study was to evaluate if right atrial (RA) volume in TOF correlates with the occurrence of supraventricular arrhythmias. To identify other risk factors for arrhythmias additional parameters were included in the analysis: anthropomorphic parameters (BMI, age, gender), previous shunt, high right ventricular (RV) volumes and pulmonary regurgitation (PR). Methods Cardiac MRI (CMR) and 24h Holter ECG-monitoring were performed in 69 consecutive patients with cTOF (Table 1). CMR protocol included triplanar HASTE sequences, standard SSFP cine images, flow measurements of the aorta, pulmonary trunk and pulmonary arteries. RA and LA volumes were retrieved from HASTE sequences and SSFP cine images. Results Mean values for RA volume were 49 +-19 ml/m 2 from HASTE sequences. In 23 patients endsystolic and enddiastolic RA-volumes were obtained from cineSSFP and compared to HASTE sequences. Bland-Altman analysis confirmed correlation of RA volumes from both sequences in atrial diastole with minimal overestimation by HASTE sequences. Mean RV volumes were 97 +-27 ml/m 2 ,p ulmonary valve regurgitation fraction 21 +-19 %. Mean heart rate on Holter was 75, ranging from from 52 to 124 bpm. 57 of 69 patients had supraventricular arrhythmias as singular extrasystolies, couplets or short runs. Mean BMI was 25 kg/m 2 with a range from 15.5 to 36 kg/m 2 . Based on multivariate regression analysis RA volume (p

Background A new MRI technology for real-time MRI at high temporal and high spatial resolution was applied to CMR. First clinical applications cover dynamic imaging of wall motion and volume changes during cardiac arrhythmias as well as quantitative flow measurements under physiologic stress maneuvers. Methods A recently introduced real-time MRI method based on undersampled radial FLASH sequences with image reconstruction by regularized nonlinear inversion was applied to CMR. Anatomical imaging in real time was performed at 34 ms temporal resolution (30 fps) using 1.5 mm in-plane resolution and 6 mm slice thickness. Real-time quantitative flow measurements employed two acquisitions at 20 ms resolution, yielding a temporal resolution of 40 ms (25 fps) at 1.3 mm in-plane resolution and 6 mm slice thickness. Healthy volunteers as well as patients with arrhythmia were examined in a clinical 3T MR scanner. The image series were analyzed using a modified standard software capable of dealing with 100 to 900 images per slice position. The ECG signal was co-registered for documentation and ease of image analysis. Results The new high-resolution real-time MRI technique was used to analyze the beat-to-beat variability of patients with arrhythmia and to define ejection fractions in normal and arrhythmic episodes. Quantitative flow measurements were obtained in all major intrathoracic vessels during free breathing. Specific measurements during increased (Valsalva maneouver) and reduced intrathoracic pressure (Mueller maneouver) were obtained in healthy volunteers to document cardiovascular response to physiologic stressors. Regional wall motion, ventricular volumes, myocardial mass and ejection fraction were derived including standard deviations based on temporal variability of the heart cycle. Suitable software strategies for the analysis of the large datasets are indispensible to bring real-time CMR into clinical routine.

To assess the incidence of extracardiac findings in patients undergoing clinical cardiac magnetic resonance imaging (CMRI) of the heart, and to determine the influence of those findings on patient management.During 40 months, 854 CMRI were performed at 1.5 T. Extracardiac findings were classified as significant (group A), if recommended for additional diagnostics or therapeutic interventions, and as nonsignificant (group B).The most frequent indication for CMRI was evaluation of cardiac stress ischemia. In all, 631 CMRI (74% of 854) showed no extracardiac pathologies. In the remaining 223 CMRI (26% of 854), a total of 286 extracardiac findings were detected. Among these findings, 49 were considered significant (group A) and 237 nonsignificant (group B). In group A, the most common findings were suspicious pulmonary nodules or masses. In group B, the most frequent findings were hepatic cysts or hemangiomas. Eight malignancies were observed with certainty at CMRI. Seven of them had been incidentally diagnosed on CMRI for the first time, and subsequently changed the patients' management.Extracardiac findings in clinically indicated CMRI are common (about 26%). Radiologists and cardiologists should be aware of relevant extracardiac findings that might require additional diagnostics or treatment.