Group Title: Journal of Cardiovascular Magnetic Resonance 2009, 11 (Suppl 1): P193
Title: Co-registration of CTA coronary artery/vein maps and MR myocardial viability/scar maps for optimized revascularization or resynchronization therapy planning
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Title: Co-registration of CTA coronary artery/vein maps and MR myocardial viability/scar maps for optimized revascularization or resynchronization therapy planning
Series Title: Journal of Cardiovascular Magnetic Resonance 2009, 11 (Suppl 1): P193
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Creator: O'Donnell TP
Dikici E
Swenson T
Shaffer J
White RD
Publication Date: 1/28/2009
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Journal of Cardiovascular Ce

Magnetic Resonance



Volume II Suppl I, 2009
Meeting abstracts

Abstracts of the 12th Annual SCMR Scientific Sessions 2009

Orlando, FL, USA
29 January-I February 2009

Published: 28 January 2009
These abstracts are available online at http://jcmr-online.com/supplements/I 1/SI


ORAL PRESENTATIONS

01
Contrast enhanced cardiovascular magnetic
resonance imaging prior to prophylactic
implantation of a cardioverter/defibrillator
identifies patients with increased risk for
ventricular arrhythmias
Philipp Boy6, Hassan Abdel-Aty, Udo Zacharzowsky,
Alexander Schirdewan, Rainer Dietz and
Jeanette Schulz-Menger
Franz-Volhard Clinic, Charite Campus Buch, Berlin, Germany
journal of Cardiovascular Magnetic Resonance 2009, 1I (Suppl I):O I
Introduction: Prophylactic implantation of a cardioverter/
defibrillator (ICD) has been shown to reduce mortality in
patients with chronic myocardial infarction (CMI) and an
increased risk for life threatening ventricular arrhythmia (VA).
The use of ICDs in this large patient population is still limited by
high costs and possible adverse events including inappropriate
discharges and progression of heart failure. VA is related to
infarct size and seems to be related to infarct morphology.
Contrast enhanced cardiovascular magnetic resonance imaging
(ceCMR) can detect and quantify myocardial fibrosis in the
setting of CMI and might therefore be a valuable tool for a more
accurate risk stratification in this setting.
Hypothesis: ceCMR can identify the subgroup developing VA
in patients with prophylactic ICD implantation following MADIT
criteria.
Methods: We prospectively enrolled 52 patients (49 males, age
69 10 years) with CMI and clinical indication for ICD therapy
following MADIT criteria. Prior to implantation (36 78 days)
patients were investigated on a 1.5 T clinical scanner (Siemens
Avanto, Germany) to assess left ventricular function (LVEF), LV
end-diastolic volume (LVEDV) and LV mass (sequence para-
meters: GRE SSFP, matrix 256 x 192, short axis stack; full LV
coverage, no gap; slice thickness 6 mm). For quantitative
assessment of infarct morphology late gadolinium enhancement
(LGE) was performed including measurement of total and
relative infarct mass (related to LV mass) and the degree of
transmurality (DT) as defined by the percentage of transmurality
in each scar. (sequence parameters: inversion recovery gradient
echo; matrix 256 x 148, imaging 10 min after 0.2 pg/kg
gadolinium DTPA; slice orientation equal to SSFP). MRI images
were analysed using dedicated software massS, Medis,


Netherlands). LGE was defined as myocardial areas with signal
intensity above the average plus 5 SD of the remote myocardium.
After implantation, patients were followed up including ICD
readout after 3 and than every 6 months for a mean of 945 344
days. ICD data were evaluated by an experienced electrophysiol-
ogist. Primary endpoint was the occurrence of an appropriate
discharge (DC), antitachycard pacing (ATP) or death from cardiac
cause.
Results: The endpoint occurred in 10 patients (3 DC, 6 ATP, I
death). These patients had a higher relative infarct mass (28 7%
vs. 22 1 %, p = 0.03) as well as high degree of transmurality
(64 22% vs. 44 25%, p = 0.05). Their LVEF (29 8% vs.
30 4%, p = 0.75), LV mass (148 29 g vs. 154 42 g,
p = 0.60), LVEDV (270 133 ml vs. 275 83 ml, p = 0.90) or
total infarct mass (43 19 g vs. 37 21 g, p = 0.43) were
however not significant from the group with no events. In a cox
proportional hazards regression model including LVEF, LVEDV, LV
mass, DT and age, only degree of transmurality and relative
infarct mass emerged as independent predictors of the primary
end point (p = 0.009).
Conclusion: In CMI-patients fulfilling MADIT criteria ceCMR
could show that the extent and transmurality of myocardial
scarring are independent predictors for life threatening ventri-
cular arrhythmia or death. This additional information could lead
to more precise risk stratification and might reduce adverse
events and cost of ICD therapy in this patient population. Larger
trials are needed to confirm this finding.

02
Cardiac T2* magnetic resonance for prediction of
cardiac complications in thalassemia major
Paul Kirk', Michael Roughton', John B Porter ,
John M Walker2, Mark A Tanner', Junaid Patel',
Dianne Wu', Jane Taylor', Mark AWestwood',
Lisa Anderson' and Dudley J Pennel'
'Royal Brompton Hospital, London, UK
2University College Hospital London, London, UK
Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):02
Background: Myocardial siderosis is the main cause of
morbidity and mortality in thalassaemia major. In the United
Kingdom approximately 50% of patients die before reaching
35 years. The cardiomyopathy is reversible if chelation is
commenced early but diagnosis is often delayed due to the late
onset of symptoms. T2* CMR can now assess cardiac iron


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directly and this has profound implications for clinical manage-
ment of iron overload and the assessment of chelation regimes.
Left ventricular ejection fraction falls with increasing myocardial
iron (reduced myocardial T2*; normal value >20 ms), and
accordingly iron overloaded patients with symptomatic heart
failure have a low T2*. Although data is available on the level of
T2* in patients developing heart failure there is no published data
on the incidence of heart failure and arrhythmia in patients
during follow-up according to baseline myocardial T2*. The aim
of this study therefore was to establish the risk of cardiac
complications in patients with cardiac siderosis as measured by
T2*.
Methods: A prospective database containing clinical data and
T2* values on 652 thalassaemia major patients (1442 scans) was
maintained over a 6 year period with 1,285 patient years of
prospective follow-up. Of these patients, 3 19 were male and 333
female with a mean age at time of first scan of 27.1 9.6 years.
The mean number of blood units transfused per year per patient
was 32.6 1 1.5.
Results: At I year of follow-up, there were 84 episodes of
heart failure and 100 episodes of arrhythmia. There were
4 deaths, with 3 patients dying from sepsis following bone
marrow transplant and I patient dying following an episode of
ventricular tachycardia.
Heart failure: For the 84 heart failure episodes, 64 presented
in New York Heart Association (NYHA) class two, 16 were
NYHA class three, and 4 were NYHA class four. The mean
ejection fraction of these patients was 43.1 7.2%. In these
heart failure patients, the preceding cardiac T2* was 6.7 1.8
ms, the liver T2* 3.9 3.7 ms and ferritin 2,713 1,686 pg/L. In
comparison with cardiac T2* values >20 ms, there was a
significantly increased risk of heart failure associated with cardiac
T2* values < 10 ms (Relative Risk 159, P < 0.001) and T2*<6
(RR 268, P < 0.001). Serum ferritin using the conventional
threshold was a significant but weaker predictor of heart failure
(ferritin >2500 pg/L, RR 0.56, P = 0.021). Liver T2* < 0.96 ms
(equivalent to the conventional threshold of > 15 mg/g/dw iron)
was not a significant predictor of heart failure (liver T2* < 0.96
ms, RR 1.25, P = 0.76). The Kaplan Meier curve of T2* vs heart
failure is shown in Figure I.
Arrhythmia: For the 100 episodes of arrhythmia, 79 episodes
were atrial fibrillation (AF), 14 episodes were supraventricular
tachycardia (SVT), 6 episodes were ventricular tachycardia (VT),


Figure I (abstract 02)


040-

S030
C
0 0
0,


Figure 1


Figure 2 (abstract 02)


025.

020.
015.



i 005-


Figure 2


0 30 60 90 120 150 180 210 240
Foow up tme (days)


270 300 330 380


and I episode was ventricular fibrillation (VF). The mean cardiac
T2* was 13.5 9 ms, mean liver T2* 6.0 6.4 ms, mean serum
ferritin 2140 1540 pg/L, and the mean ejection fraction was
60.7 9.3%. In comparison with cardiac T2* values >20 ms,
there was a significantly increased risk of arrhythmia associated
with cardiac T2* values <6 ms (RR 8.65, P < 0.001) and T2*<20
(RR 4.6, P < 0.001). There was no significant predictive value
using the conventional thresholds of ferritin (ferritin >2500 pg/L,
RR 0.90, P = 0.66) or liver T2* (T2* < 0.96 ms, RR 0.78,
P = 0.68). (See Figure 2.).
Conclusion: These data provide strong evidence that a
myocardial T2* <10 ms predicts a high risk of developing heart
failure. It is clear that these patients should be aggressively
chelated to reduce their high morbidity and mortality from
cardiac siderosis.


03
Sub-clinical systolic dysfunction with persistent
myocardial edema and inflammation in elite
high-endurance athletes with common colds: a
cardiovascular magnetic resonance study
Myra S Cocker', Oliver Strohm', David J Smith2,
Craig Butler Israel Belenkie3, Willem Meeuwisse4
and Matthias G Friedrich'
'Stephenson CMR Centre at the Libin Cardiovascular Institute,
University of Calgary, Calgary, AB, Canada
2Human Performance Lab, Faculty of Kinesiology,
University of Calgary, Calgary, AB, Canada
3Department of Cardiac Sciences at the Libin Cardiovascular
Institute, University of Calgary, Calgary, AB, Canada
4Sports Medicine Centre, University of Calgary,
Calgary, AB, Canada

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):03
Background: Basic research has demonstrated that myocardial
inflammation may be a feature of systemic viral inflammation,
resulting from agents such as influenza. Physical activity during
exposure to pathogens has been shown to exacerbate the
propensity to develop adverse cardiac events. As such, based
upon empirical findings, current guidelines on athletic training


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


deter athletes from participating in sport during common colds.
Cardio-vascular Magnetic Resonance (CMR) allows for non-
invasive visualization of myocardial inflammation, where it has
emerged as the imaging modality of choice to assess the course
of myocarditis. Thus, using CMR-based tissue characterization,
we hypothesized that colds in elite high-endurance athletes
would lead to depressed cardiac function and myocardial
inflammation.
Methods: 62 (32 male, 31 13 years) elite high-endurance
athletes were prospectively recruited. CMR scans were
performed at baseline, with an acute common cold, and
4 weeks after. Pre-defined symptoms were used to rule in an
acute cold. LV function, edema, and myocardial inflammation
were assessed using standard SSFP, T2-, and T I-weighted imaging,
respectively, on a 1.5 T MRI system.
Standard, previously described approaches for the quantification
of LV function, edema and myocardial inflammation were utilized.
Statistical comparisons were performed with repeated measures
ANOVA, at 2 levels of measurement.
Results: During the I I-month period of recruitment,
21 athletes completed all 3 scans. During an acute cold, we
observed a significant increase in LVESVI, with reduced LVSVI and
LVEF (p < 0.05), while LVEDVI and LVMI did not differ (Table I).
Moreover, there were no statistical differences between LV
volumes at the 4-week follow-up to those at baseline or with an
acute cold.
In terms of tissue characterization, 19% of athletes had evidence
for myocardial edema with an acute cold, and 24% at follow-up


Figure I (abstract 03)


Reduced contractile function in an elite professional swimmer with
a common cold (LVEFcold 47%, LVEFbaeline 54%) (A, B). Visually apparent
increased early enhancement post-contrast in TI-weighted images
(C, D) suggestive of myocardial inflammation, with an early enhancement
ratio of 5.7. Evidence of global myocardial edema (E, ratio 2.6).


Table I (abstract 03) LV volume and CMR markers for edema
and inflammation at baseline, with a common cold and at a
4-week follow-up. Volumetric data are presented as mean
standard deviation

Baseline Visit with 4-week
visit common cold follow-up

LVEDVI (ml/m) I 11.4 20 10.0 22 109.9 21
LVESVI (ml/m) 39.4 11 41.7 I 1* 40.6 9
LVSVI (ml/m) 72.0 12 68.3 13* 69.3 15
LVEF (%) 65.0 4.8 62.5 4.9* 63.0 5.8
LVMI (g/m) 58.8 15 59.1 15 60.1 16
Edema (n) 4 of 21 4 of 21 5 of 21
Inflammation (n) 7 of 21 8 of 21 10 of 21

*p < 0.05 baseline compared to visit with common cold.


(Figure I). 38% had myocardial inflammation during an acute
cold; and this proportion increased to 48% at follow-up.
Conclusion: We provide first evidence of sub-clinical myocar-
dial involvement with common colds in high-endurance athletes.
Colds were associated with a small yet significant decrease of
systolic function, and persisting myocardial inflammation visua-
lized with CMR-derived markers for edema and inflammation.
Further research is required to investigate the implications of
these findings on athletic performance.


04
A T2-mapping method to quantitatively
differentiate edema from normal myocardium
Shivraman S Giri', Yiu-Cho Chung2, Ali Merchant',
Tam Tran', Subha Raman' and Orlando Simonetti'
'The Ohio State University, Columbus, OH, USA
2Siemens Medical Solutions, Columbus, OH, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):04
Introduction: T2-Weighted (T2W) imaging sequences can
detect myocardial edema associated with acute inflammation,
infarction, and the area at risk, but these techniques suffer from
several drawbacks [I]. In this work, we describe a rapid
technique for quantitative myocardial T2 mapping. This method
is expected to quantitatively differentiate edema from normal
tissue, to be insensitive to tissue motion, to easily distinguish
edema from stagnant blood, and to be immune to surface coil
sensitivity variations. The proposed T2-mapping method can be
performed with either a short breath-hold or respiratory
navigator gating.
Purpose: To develop a rapid, quantitative method of myocar-
dial T2-mapping to detect edema in patients with acute coronary
syndrome.
Methods: Sequence: A single-shot T2-prepared SSFP acqui-
sition was used to generate images with three T2-prep times: 0
(i.e., no T2 prep), 24, and 55 ms with parameters listed in
Table I. The technique is relatively motion insensitive due to the
SSFP readout and the non-selective T2-preparation pulse. T2
maps were produced by fitting pixel intensities to a two-
parameter mono-exponential model (Signal = MO exp(-TE/
T2)), and setting any pixel with T2 > 120 ms to zero.
Phantom: A two-compartment phantom was created to approx-
imate the TI and T2 values of normal (TI/T2 = 897/52.3 ms) and


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Table I (abstract 04) Imaging parameters

Parameter T2Prep SSFP DB-TSE

TE (ms) 0, 24, 55 62
TR 2 x RR 2 x RR
Avg. FOV 350 x 400 350 x 400
Image Matrix 128 x 160 144 x 192
Flip angle 40 90


edematous myocardium (TI/T2 = I 19/101.8 ms) [2]. Phantom TI
and T2 values were verified using a standard spin echo sequence.
In-vivo: T2 Maps were acquired in 9 healthy subjects to
determine the normal range of T2 values. Three short-axis and
two long-axis views were imaged during breath hold (duration -5
HB) and in free breathing using navigator gating. In 5 subjects, four
averages were acquired with navigator gating to test the benefits of
increased SNR. Average T2 values were calculated in 16 myocardial
segments using both methods and compared. Measurements were
pooled to obtain global mean and standard deviation to investigate
inter-subject and inter-segment variability.
Signal intensity variability: In six healthy subjects, T2W
images using conventional dark-blood STIR turbo spin echo (DB-
STIR-TSE) were acquired and compared to the T2 maps
generated using the proposed method. Only anterior coil
elements were used to investigate signal variability due to surface
coil intensity variation, as well as motion induced signal loss.
Parameters are listed in Table I. In each subject, average signal
was computed and normalized to the maximum segment. The
standard deviation (SD) of this normalized mean was used as a
measure of variability.
Animal studies: Three pigs underwent 90 minute LAD
occlusion and were imaged with breath-hold within six hours
of reperfusion.
Results: Phantom: T2 values were slightly overestimated
(107.9 ms vs. 101.8 ms, and 60.7 ms vs. 52.3 ms) in the two
phantom compartments.
In-vivo: T2 values did not show significant variation among the
16 segments (p = 0.277, ANOVA) or between breathhold and
free breathing techniques (p = 0.76, paired t-test). The mean T2
and standard deviation were 51.54+3.5 ms (range: 49.6 to
53 ms). Figure I demonstrates the discrimination of static apical
blood from myocardium in the T2 map.
Signal intensity variability: Signal in T2W DB-STIR-TSE
showed high variability (36.7%) while T2 maps showed no such
variation (3%) as seen in Figure 2.


Figure 2 (abstract 04)


T2W image (left) shows a lot of signal variability due to surface coil
sensitivity variations and motion as compared to the corresponding
T2 Map (right). Similar color map used in both images for comparison.


Figure 3 (abstract 04)


Figure I (abstract 04)


T2 Weighted image (DB-STIR-TSE) (I) showing high signal intensity due
to stagnant blood in the apical regions. The corresponding T2 Map clearly
distinguishes myocardium from stagnant blood.


T2 Maps from a pig showing enhanced T2 in anterior segment (arrow). In
this pig, T2 in anterior segment was 83.5 + II ms vs. 58.6 + 4.5 ms in
inferior segment.



Table 2 (abstract 04) Results from pig studies.

Animal # Infarcted segment Remote normal segment

I 83.5,1 1 58.6,4.5
2 80.4,6.8 51.1,5.6
3 83.6,10 58.4,7.2

The values are mean, SD of T2 (ms) in mid ventricular SAX slice.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Animal study: Results from the pig study are shown in Figure 3
and Table 2. In each animal, edematous segment showed a T2 value
> 2 SD of remote segment.
Conclusion: We have demonstrated a rapid method of
T2-mapping for quantitative detection of myocardial edema.
Direct quantification of T2 eliminates many unwanted sources of
signal variation, and removes the subjectivity of observer
interpretation of bright regions. Further studies with patients
are required to assess sensitivity and specificity.
References
I. Arai AE: Circulation 2008, 118(8):795-6.
2. Aletras AH, et al: Magn Reson Med 2008, 59(2):229-35.


05
3T contrast-enhanced whole heart coronary
MRA using 32-channel cardiac coils for
the detection of coronary artery disease
Qi Yang', Kuncheng Li', Xiaoming Bi2, Jing An3,
Renate Jerecic2 and Debiao Li4
'Xuanwu hospital, Beijing, PR China
2Siemens Medical Solutions, Chicago, IL, USA
3Siemens Mindit Magnetic Resonance Ltd, Shenzhen, PR China
Department of Radiology, Northwestern University,
Chicago, IL, USA

Journal of Cardiovascular Magnetic Resonance 2009, 1I (Suppl 1):05
Introduction: In recent years, improved gradient performance
and radiofrequency (RF) receiving coils and advanced data
acquisition techniques including navigator gating and parallel
imaging allowed non-invasive whole-heart coronary imaging.
Previous studies have shown that 3.0 T is a promising platform
for the detection of significant coronary artery stenoses with
contrast-enhanced data acquisition. However, the imaging time
(-10 minutes) and spatial resolution (1.3 x 1.3 x 1.3 mm3)
remain major limitations [I]. Newly developed 32-channel
cardiac coils allow greater acceleration factors and thus reduced
imaging time and higher spatial resolution [2].
Purpose: To evaluate the feasibility and diagnostic accuracy
of 3 T contrast-enhanced whole-heart coronary MRA using
32-channel cardiac coils. The imaging time, image quality score,
and diagnostic accuracy were evaluated in consecutive patients
with suspected coronary artery disease.
Methods: 20 patients with suspected coronary artery disease
who were scheduled for x-ray coronary angiography (mean age
68 14 years, I I males) underwent MRA at 3 T (MAGNETOM
Tim Trio, Siemens) after informed consent was obtained.
Contrast-enhanced coronary MRA was also performed in 5
patients who were scheduled for 64-slice coronary CTA. The
imaging technique was an ECG-triggered, navigator-gated, inver-
sion-recovery, segmented gradient-echo sequence. A 32-channel
matrix coil was used for data acquisition. To reduce imaging time,
parallel acquisition (GRAPPA) was used in the phase-encoding
direction with an acceleration factor of three. Imaging para-
meters included: voxel size 0.55 x 0.55 x 0.65 mm3 (interpo-
lated from I.I x I.I x 1.3 mm3), TR/TE = 3.3/1.5 msec, flip
angle = 200, bandwidth = 700 Hz/pixel. Contrast agent (0.15
mmol/kg body weight, Multihance, Bracco Imaging SpA, Italy) was
intravenously administered at a rate of 0.3 ml/sec. The diagnostic
accuracy of MRA in detecting significant stenoses ( 50%) with
the intention to diagnose method was evaluated on a


Figure I (abstract 05)


3 T Coronary MR image of a 50-year-old patient. Reformatted images (a, b)
and volume rendering image demonstrates normal RCA, LM, LAD. Better
visualization of the entire coronary artery tree after removing the
background of myocardium, long segments of all major coronary arteries
are well depicted and correlate well with X-ray angiography (d, e).

per-segment basis using x-ray angiography as the reference,
non-assessable segments were considered to be false-negative or
false-positive, respectively.
Results: Whole-heart coronary MRA was successfully com-
pleted in 19 of 20 (95%) patients who were scheduled for x-ray
coronary angiography and in 5 patients who were scheduled for
64-slice coronary CTA. The averaged imaging time with
32-channel cardiac coils was 6.2 1.3 min. The sensitivity,
specificity, positive predictive value, and negative predictive value
of coronary MRA for detecting significant stenoses were 81%
(62-94%), 96% (92-98%), 71% (52-86%), 98% (94-99%),
respectively, on a per-segment basis. Figure I.
Conclusion: Combined with dedicated 32-channel cardiac coils,
parallel imaging with higher acceleration factors allows improve-
ments in imaging speed, study success rate, and reduced dose of the
contrast agent when compared with conventional 12-channel coils.
Higher study success rate achieved by 32-channel coils substantially
improved overall accuracy of coronary MRA in detecting coronary
artery disease when using the intention to diagnose method.
References
I. Qi Yang and Li DB, et al: #2917 Proceedings of 16th annual
ISMRM, Toronto 2008.
2. Niendorf T, et al: Magn Reson Med 2006, 56:167-176.


06
Mt Everest trek causes impaired cardiac high
energy phosphate metabolism and diastolic
impairment
Cameorn J Holloway', Andrew Murray ,
Lowri E Cochlin Yaso Emmanuel Denny ZH Levett2
Oliver J Rider', Damian J Tyler', Matthew Robson',
Jane M Francis', Hugh Montgomery2,
Michael PW Grocott2, Stefan Neubauer
and Kieran Clarke'
'University of Oxford, Oxford, UK
2UCL, London, London, UK

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):06
Background: Cardiac function in normal subjects is altered by
exposure to hypobaric hypoxia, yet the cellular mechanisms


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Figure I (abstract 06)


24
2.2
2 I
1.8
ba


12

Trmk Pst-Trek Folbwup Trek Post-Trk Posl-Trk



leading to such changes are unknown. We have examined the
impact of sustained exposure to environmental hypobaric
hypoxia, on cardiac function and energetic.
Methods and results: Healthy normal volunteers (n = 7)
were studied immediately before, and within four days of return
from 17 days exposure to environmental hypobaric hypoxia
whilst trekking to Mount Everest Base Camp (17388 feet,
5300 m) and back. 31P magnetic resonance (MR) spectroscopy
was used to measure cardiac phosphocreatine (PCr)/ATP and
MR imaging and echocardiography were used to assess cardiac
function. All measurements were repeated six months after
return from Everest. Immediately after their return from Everest,
subjects showed a 24% decrease in cardiac PCr/ATP from
2.19 0.09 to 1.67 0.13 (p < 0.01) (see Figure I). Peak left
ventricular filling rates had declined from 832 64 ml/sec to
691 56 ml/sec (p < 0.05) and transmitral E/A was reduced
from 1.56 0.1 I to 1.16 0.08 (p < 0.05). Left and right
ventricular stroke volumes had fallen by 13%. No change on
cardiac mass was observed. Six months later, all measures had
returned to baseline values.
Conclusion: Exposure to prolonged hypobaric hypoxia is
associated with significant, but reversible, energetic and func-
tional abnormalities in the human heart.




07
Multifunctional perfluorooctylbromide alginate
microcapsules for monitoring of mesenchymal
stem cell delivery using CT and MRI
Yingli Fu', Dorota Kedziorek', Ronald Ouwerkerk',
Veronica Crisostomo2, Wesley Gilson ,
Nicole Azene', Aravind Arepally', Christine Lorenz ,
Steven Shea3, Robert Krieg4, Jeff WM Bulte'
and Dara L Kraitchman'
johns Hopkins University, Baltimore, MD, USA
El Centro de Cirugia de Minima Invasi6n Jesus Us6n,
Caceres, Spain
3Siemens Corporate Research, Baltimore, MD, USA
4Siemens Healthcare, Erlangen, Germany

Journal of Cardiovascular Magnetic Resonance 2009, 1I (Suppl I):07
Background and objectives: Many patients with peripheral
arterial disease (PAD) cannot undergo conventional medical or
surgical therapy due to the extent or severity of atherosclerotic
disease. Stem cell therapy has shown promising results as an


angiogenic therapy in PAD patients. However, the poor survival
of transplanted cells due to early immunodestruction and the
inability to noninvasively monitor and track the distribution and
proliferation of transplanted cells hinders stem cell therapeutic
efficacy. We present here a multifunctional mesenchymal stem
cell (MSC) microencapsulation and trafficking method utilizing
perfluorooctylbromide (PFOB) incorporated alginate-poly-L-
lysine-alginate microcapsules (PFOB Caps) for MSC delivery
and noninvasive engraftment tracking using clinical X-ray and MR
imaging equipment.
Methods: Microencapsulation of bone marrow-derived rabbit
or human MSCs (1.5 x 106cells/ml) were performed by extrud-
ing a PFOB-impregnated 2% (w/v) alginate solution from a syringe
pump in conjunction with an electrostatic droplet generator,
followed by cross linking with poly-L-lysine to form X-ray- and
MRI-visible microcapsules. MSCs viability was examined and
compared between unlabeled capsules and PFOB Caps. Using
19F MRI and rotational angiograms reconstructed into CT-like
images, the minimum detectable concentration was determined
in phantoms using standard clinical imaging systems. X-ray
delivery and tracking of intramuscular injections of PFOB
Caps (-5000 capsules/injection) was assessed in a rabbit PAD
model.
Results: The viability of rabbit MSCs encapsulated with PFOB
was 90 3% immediately after encapsulation and remained high
(88 5% at 4 weeks post-encapsulation). PFOB Caps containing
human MSCs had enhanced cell viability relative to unlabeled
capsules (83 3% for PFOB vs. 50 1% for control at 65 days
post-encapsulation, P < 0.001). Viability of human MSCs in PFOB
Caps was maintained up to 100 days, while it decreased sharply
to <10% in unlabeled capsules at 80 days post-encapsulation. In
vitro CT and 19F MRI imaging of PFOB Caps demonstrated the
ability to detect as few as 2 and 25 capsules (Figure I),
respectively. In vivo, PFOB visibility on CT images was demon-
strated relative to unlabeled capsules with persistence of intact
microcapsules up to 5 weeks post delivery in PAD rabbits.
Conclusion: By adding PFOB, a dual contrast agent and oxygen
carrier, to alginate microcapsules, we have demonstrated the
enhanced viability of MSCs within PFOB Caps, and the ability to
deliver and track engraftment of stem cells using multiple
conventional clinical imaging systems in vivo.


Figure I (abstract 07)


In vito DynaCT and 19F MR images of PFOB Caps phantoms. (A, B)
DynaCT images of PFOM Caps phantoms demonstrated the ability to
detect as few as 2 capsules. (C) 19F MRI (3D-TrueFISP, BW = 1500 Hz/
px, TR/TE = 3.0/1.5 ms, 2.0 x 2.0 x 5.0 mm3, 24 partitions, 4 avgs, 62 s
acquisition) of the same phantom as B showed as few as 25 PFOB Caps
were identifiable.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


08
Cardiac magnetic resonance of targeted
annexin-iron oxide labeling detects cardiac cell death
in vivo after doxorubicin and myocardial infarction
Rajesh Dash', Trevor Chan2, Mayumi Yamada2,
Marietta Paningbatan2, Bat-Erdene Myagmar',
Philip Swigart', Paul C Simpsonjr' and Phillip C Yang2
'San Francisco Veterans Affairs Hospital, San Francisco, CA,
USA
2Stanford University, Stanford, CA, USA
Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):08
Background: Heart failure from myocardial infarction (MI) or
doxorubicin (DOX), used in cancer therapy, is preceded by
significant cell apoptosis. Real-time, non-invasive detection of
early cardiac apoptosis might impact patient treatment and
outcomes. Early apoptosis is detected by Annexin V protein
(ANX) binding to externalized membrane phosphatidylserine. To
this end, we previously conjugated ANX to superparamagnetic
iron oxide (ANX-SPIO). This conjugate specifically binds to early
apoptotic cardiac cells in culture and is detectable by in vitro
magnetic resonance imaging (MRI).
Hypothesis: We tested whether ANX-SPIO could detect
cardiac apoptosis, in vivo, via MRI (3 Tesla, GE Excite, WI) after
ischemic or oxidative injury.
Methods: Mice underwent LAD ligation or intraperitoneal,
cardiotoxic DOX (25 mg/kg) injection. After 24-48 hours,
ANX-SPIO was given by tail vein, and mice were imaged by
T2-weighted cardiac MRI (3 Tesla, GE Excite).
Results: After MI and DOX, myocardial T2 MRI signal was
detectable within 30 minutes of ANX-SPIO delivery, exhibiting
either a focal (Ml) or diffuse (DOX) signal distribution (see Figure I).
Peak signal was evident 24 hours after ANX-SPIO delivery, and
decreased over the next 2 weeks.
Conclusion: Cardiac MRI using ANX-SPIO can accurately
detect myocardial apoptosis in vivo. Distinct MRI signal
distributions were noted following ischemic (MI) versus oxidative
(DOX) injury. This molecular imaging strategy may help identify
'at risk' cardiac cell populations.


Figure I (abstract 08)

A) Post-MI B) Post-DOX


ECG- and respiratory-gated T2-weighted cardiac MRI of mice post-MI
(A, 2-chamber view) and post-DOX (B, short axis view), 30 minutes
after tail vein infection of 100 1p ANX-SPIO. Note focal T2 signal void
(white arrows) of ANX-SPIO in antero-apex of post-MI heart, and diffuse
septal, anterior and inferior T2 signal void in post-DOX heart (LA, left
atrium; LV, left ventricle; RV, right ventricle; AW, anterior wall; IW,
inferior wall).


09
Integrated analysis of diastolic, systolic and
pulmonary vascular function using MRI guided
catheterization
Boris Schmitt', Paul Steendjik2, Karsten Lunze',
Stanislav Ovrouski', Jan Falkenberg',
Pedram Rahmanzadeh', Nizar Maarouf', Peter Ewert',
Felix Berger' and Titus Kuehne'
'Unit of Cardiovascular Imaging Congenital Heart Diseases,
Deutsches Herzzentrum Berlin, Berlin, Germany
2Cardiology, Medical University Leiden, The Netherlands,
Leiden, Netherlands

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):09
Indroduction and purpose: An integrated approach for
assessing ventricular pump function, diastolic compliance
(EDPVR), myocontractility and pulmonary vascular resistance
would be of clinical interest. In addition to pump function, MRI
guided catheterization was demonstrated to accurately measure
myocontractility and vascular resistance. We now extended this
method for acquisition of the EDPVR. Subsequently, this
approach was applied in patients with Fontan hemodynamic in
which abnormalities in pulmonary vascular, myocontractile and
diastolic properties are debated.
Methods: The EDPVR was determined by synchronizing invasive
ventricular pressures with cine and real-time MRI derived ventricular
volumes and pulmonary/aortic blood flow measurements.
Validation part: In 7 pigs the MRI and conductance-catheter
method (gold standard) were compared for measuring the
EDPVR at rest and during dobutamine.
Clinical part: Parameters of global function, myocontractility
(ESPVR), vascular resistance and EDPVR were measured with MRI
at rest and under dobutamine in 14 patients with Fontan circulation.
Results: Bland-Altman test showed agreement between the
conductance-catheter and MRI method. In the pigs, there was in
both ventricles during dobutamine a right/bottom shift of the
EDPVR, the stiffness co efficient decreased slightly (p < 0.05 I). In
the patients during dobutamine we noted failure to increase
stroke volumes despite increased contractility and evidenced
diastolic dysfunction. Active relaxation was inconspicuous but
the EDPVR shifted towards the left/top, the stiffness constant
remained unchanged. Pulmonary resistance decreased slightly
(p = 0.058) and thus showed adequate response to augmented
cardiac outputs.
Conclusion: This novel MRI method provides differential
information about diastolic, systolic and vascular function. The
method evidenced that in Fontan patients diastolic dysfunction is
an important pathophysiologic cause of heart failure.


010
Diffusion-prepared dark blood delayed
enhancement imaging for improved
detection of subendocardial infarcts
Michael Salerno, Frederick H Epstein
and Christopher M Kramer
University of Virginia, Charlottesville, VA, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I): 10
Introduction: Delayed enhancement MRI enables detection of
non-viable myocardium with high spatial resolution and has


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 010)


become the gold standard for imaging myocardial infarction.
However, subendocardial infarcts are sometimes difficult to
detect as they may demonstrate similar image intensity as the
ventricular cavity. A double inversion dark-blood pulse sequence
to create black blood delayed enhancement images of myocardial
infarction has been previously described [I, 2, 3]. The sequence
relies on precise timing of non-selective and selective inversion
pulses, and it is sensitive to incomplete exchange of blood and
changes in TI relaxation of the blood and myocardium. The
technique significantly improves blood-infarct contrast at the


expense of some reduction in SNR and infarct-myocardial
contrast. Diffusion preparation-gradients have been used to
create dark-blood vessel wall images [4], but have never been
applied post-contrast for infarct imaging.
Purpose: To develop a dark-blood delayed enhancement pulse
sequence based on diffusion preparation which would not rely on
complete blood exchange and would be relatively insensitive to
changes in relaxation times.
Methods: A diffusion-prepared inversion recovery (IR) pulse
sequence was developed by adding a driven equilibrium module
using a BIR-4 0 degree radiofrequency pulse with motion
sensitization gradients between its components prior to a
segmented FLASH readout. The timing of this preparation was
optimized to minimize the effects of strain-induced signal loss.
The technique was tested in a canine model of chronic infarction
using a 1.5 T MR scanner (Magnetom Avanto, Siemens Medical
Solutions). Images were obtained 5-10 minutes after injection of
0.15 mg/kg of Magnevist. Sequence parameters included field of
view 300 mm, matrix 192 x 114, TE 2.7 ms, spatial resolution
1.6 x 2.3 x 10 mm, lines per segment 12, bandwidth 400 Hz/
pixel, acquisition duration 16 heartbeats, effective b-value 0.25 s/
mm2
Results: Figure I(a) shows a standard bright-blood IR-FLASH
delayed enhancement image. There is an infarct in the inferior
wall which is difficult to distinguish from the blood pool. Figure I
(b) displays an image of the same slice that demonstrates the
utility of the diffusion-prepared IR sequence. Here, the diffusion
preparation causes suppression of the blood pool, improving the
ability to detect the subendocardial region of infarction.
Conclusion: We have developed a new dark-blood delayed
enhancement pulse sequence which attenuates the blood pool
based on motion sensitization. In preliminary studies, this
technique improves delineation of subendocardial infarcts.
References
I. Rehwald WG, et al: J Cardiovasc Magn Reson 2007, 9:101-2.
2. Salerno M, et al: Proc 15th ISMRM 2007.
3. Rehwald WG, et al: Proc 15th2007.
4. Koktzoglou I, et al: J Magn Reson Imaging 2006, 23:699-705.



01i
Phase-sensitive black-blood coronary vessel
wall imaging
Khaled Z Abd-Elmoniem and Matthias Stuber
Department of Radiology, School of Medicine, Johns Hopkins
University, Baltimore, MD, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):O II
Introduction: Black-blood coronary vessel wall imaging is a
powerful non-invasive tool for the quantitative assessment of
positive arterial remodeling [I]. Although dual-inversion-recov-
ery [2] (DIR) is the gold standard for vessel wall imaging, optimal
lumen-vessel wall contrast is sometimes difficult to obtain and
the time-window available for imaging is limited due to the
competing requirements between TI* (blood signal nulling time)
and TD (period of minimal myocardial motion). In addition,
atherosclerosis is a spatially heterogeneous disease and therefore
imaging at multiple anatomical levels of the coronary circulation
is mandatory. However, this requirement of enhanced volu-
metric coverage typically comes at the expense of increased


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


scanning time. Phase-sensitive IR [3, 4, 5] (PS-IR) has shown to
be valuable for enhancing tissue-tissue contrast and for
making IR imaging less sensitive to TI*. This work extends
PS-IR to PS-DIR and combined with spiral-imaging, multi-slice
black-blood coronary vessel wall imaging is enabled in a single
breath-hold.
Purpose: To develop, and test a phase-sensitive DIR (PS-DIR)
single-breath-hold multi-slice spiral black-blood coronary vessel
wall imaging method.
Methods: Concept: After DIR (Fig. I), the inversion time TI*
allows for signal-nulling of the in-flowing blood-pool at the
anatomical level of interest. Blood-tissue contrast therefore
depends on the accurate determination of TI*. Although the MR
signal is complex (magnitude and phase), DIR images only show
the magnitude of the signal with a suboptimal blood-tissue
contrast if TI does not equal TI*. However, by additionally using
the MR signal phase, a signed (positive/negative) black-blood
image can be acquired at TI less than TI* and reconstructed with
a blood-tissue contrast higher than that obtained at TI*.
Simultaneously, competing constraints related to TI* and TD
are avoided (Fig. I). Consequently, single-breath-hold multi-
slice black-blood coronary vessel wall imaging is enabled using
PS-DIR.
Reconstruction: A local region-growing reconstruction algo-
rithm was developed and is summarized in Fig. 2. Pixels with high


Figure I (abstract O I)


Slice-Sel. Imaging
ECG re-inversion
1 slice
2n since, Ns slices

S tissue


blood


Fig.l.: DIR pulse sequence. TI* is the time when
blood magnetization is nulled. In PS-DIR, imaging
starts at TI slices can be acquired with CNR 2 CNR of DIR.


DIR pulse sequence. TI* is the time when blood magnetization is nulled.
In PS-DIR, imaging starts at TI < TI*. Multiple PS-DIR black-blood slices
can be acquired with CNR > CNR of DIR.

signal near the cross-sectional coronary artery are selected as
seed points. The phase values of these points are used to
estimate the local signal phase inhomogeneity which is needed
for local signed-magnitude image reconstruction [4].


Figure 2 (abstract O 1)


Magnitude Image
M


Region-Growi rig
Seed Pool


Final Image
M cus P14)1


Phase Map Image

P


Phase Region-
Growirg
-of pointZswithSNA
In the top 90%dle


Phase 01-linear
Interpolation


Cropping- Vesel-
wall Local Phase
Inhornogeinelty P


Summary of the PS-DIR Coronary wall signed-image reconstruction algorithm. A ring-shaped region-of-interest is selected around the coronary wall (a).
Phase points with high magnitude SNR are selected for region-growing (b). Map of local phase inhomogeneity is created using bi-linear interpolation (c).
Inhomogeneity is removed from the phase image (d) and a final signed image is calculated (e).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


DIR magnitudee"


PS-DIR


subjects (slice-thickness = 8 mm, FOV = 190 x 190 mm,
matrix = 320 x 320, interleaves = 20, acq.window = 18 ms/
interleaf). CNR was calculated on the signed-magnitude images
reconstructed with the above algorithm. Mean vessel wall
thickness was measured manually on the images obtained with
incremental TI and was compared to that from TI*. Finally, a dual-
slice rather than a multi-phase version of the sequence (Fig. I)
was tested in four subjects.
Results: Using TI less than TI*, Fig. 3 shows that PS-DIR
enables delineation of the coronary artery vessel wall and
supports an increased wall-lumen contrast when compared with

Figure 5 (abstract O I)


Phase


DIR "magnitude"


PS-DIR


PS-DIR Coronary vessel wall imaging at different TI < TI* in two separate
subjects.


Implementation: A single breathhold DIR sequence was
implemented (Fig. I) on a clinical 3 T Philips-Achieva MRI-
system. Data were acquired using a segmented k-space spiral
acquisition with spectral spatial excitation [6]. Image processing
was performed off-line on a personal computer.
Experiments: Anatomical slices perpendicular to the proximal
part of the right coronary artery (RCA) at end-systole were
planned similar to a previously published methodology [7]. First,
serial single-slice multi-phase PS-DIR images were acquired with
incremental TI ranging from 50 ms-500 ms in 15 healthy adult


wE
Lln




Dual-slice single breath-hold PS-DIR Coronary vessel wall black-blook
imaging


Figure 4 (abstract OI l)


- PS-Dl0 mnan CIR
- 01R mein CNR at T1


* I .!
E
E '




.C us
a110


-- PFDIB Mean at di lrent Ti
- -DIR NM.n Stdev TI
- IR MN n at T'


s 1 I SO 200 2
n [m&I


300 350 4


100 1 200
T imsl


00 B 400


Left: CNR (mean stdev) at different TI values in PS-DIR signed images (red) and in DIR magnitude images at TI* (green). Right: Wall thickness at
different TI using PS-DIR images (red) and using DIR images at TI*. Note the agreement with the measurements using TI*.


Page 10 of 316
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Figure 3 (abstract OI I)


Phase


E
X8 '

8= ^si


r,~


Zi)


http://jcmr-online.com/supplements/11/S1


u


I


- -r -







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


the conventional DIR in which TI was too short for adequate
blood signal-nulling. Consistent with the visual findings, Fig. 4
shows that the CNR significantly increased in PS-DIR over a
broad range of TI (150 ms-300 ms). Wall thickness measure-
ments using PS-DIR at different TI values were consistent with
those from DIR at TI*. Since the PS-DIR method permits image
data collection over a broad range of TI (Fig. 4), multiple slices
rather than multiple phases can be obtained at no extra cost in
scanning time (Fig 5).
Discussion: PS-DIR provides a TI-insensitive higher CNR
alternative to conventional DIR for coronary vessel wall imaging.
TI-insensitivity can be traded for enhanced volumetric coverage
at no extra-cost in imaging time.
References
I. Kim WY, et al: Circulation 2002, 106(3):296-9.
2. Edelman RR, et al: Radiology 199 1, 181(3):655-60.
3. Borrello JA, et al: Magn Reson Med 1990, 14(1):56-67.
4. Xiang QS: J Magn Reson Imaging 1996, 6(5):775-82.
5. Kellman P, et al: Magn Reson Med 2002, 47(2):372-383.
6. Meyer CH, et al: Magn Reson Med 1990, 15(2):287-304.
7. Botnar RM, et al: Circulation 2000, 102(102)21:2582-7.





012
Imaging the vessel wall in major peripheral
arteries using susceptibility weighted imaging:
visualizing calcifications
Qi Yang', Kuncheng Li', Jiangtao Liu', S Barnes2, Z Wu3,
J Neelavalli2, J Hu2 and EM Haacke2
'Xuanwu Hospital, Beijing, PR China
Wayne State University, Detroit, MI, USA
3McMaster University, Hamilton, ON, Canada

journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):O 12
Introduction: Magnetic resonance imaging (MRI) has been
used for many years to study atherosclerosis [I]. Black blood
techniques are the most ubiquitous and are used to suppress the
signal from flowing blood, making the vessel wall more
conspicuous. The purpose of this study was to demonstrate a
novel approach to imaging the vessel wall and vessel wall
calcification using susceptibility weighted imaging [2] (SWI) with
no need to suppress the signal from the blood.
Methods: Optimizing the imaging parameters: The SWI
sequence parameters were optimized to allow for the best
visualization of the femoral artery lumen in the magnitude images
and the arterial wall in the phase images. Parameters such as
resolution (for time considerations), flip angle (for contrast in the
magnitude images) and echo time (for phase contrast) were
considered.
Vessel wall magnitude and phase measurements: ROIs
from the top to the bottom of the visible portions of the femoral
artery were taken. The lumen SNR and muscle SNR were
calculated on both magnitude and phase images. The contrast-to-
noise ratio of vessel wall/lumen and vessel wall/muscle was also
calculated.
Patients study: A series of 18 subjects were imaged with
multi-detector computed tomography (MDCT) and high resolu-
tion susceptibility weighted imaging (SWI) at 3 T


Figure I (abstract 012)


(a) CT scan showing calcification at the edge of the popliteal artery just
behind the knee. (b) Magniture gradient echo image showing the signal
loss from the calcification of the same area. (c) Phase image showing the
diamagnetic effect from the calcification. Note the simliar shape and
extent of the calcification in both the CT and MR results. Inserts are
zoomed images of the cross-section of the vessels in reformatted
transverse images.



Calcification Measurements: The area of calcification was
manually measured on CT images and MR images (both
magnitude and phase images) by an experienced radiologist.
SPIN software (Detroit, MI) was used to interpolate the images
by a factor of 4 and measure the calcifications. The correlation of
calcification area (CA) between CT and MR images was
performed and a Pearson correlation coefficient calculated. The
agreement of CA measurements by MR and CTwas assessed by
using the Bland and Altman plot.
Results: The optimal choice of imaging parameters was found
to be: TE = 15.6 ms (in-phase for fat); TR = 25 ms, FA = 10,
BW = 80 Hz/pixel, resolution = 0.5 mm x 0.5 mm in-plane and
1.0 mm through-plane, with an acquisition matrix of
512 x 384 x 64 (for read, phase and slice-select direction) and
a total scan time of 8 minutes. The magnitude contrast-to-noise
ratio (CNR) between artery and vessel wall was 12:1. The phase
CNR between the arterial wall and the lumen was 7:1. A total of
19 calcifications in the femoral vessel wall were identified with
SWI in 8 subjects. The mean area of calcification measured on
CT, magnitude and phase images was 0.37 0.17 cm2
0.29 0.13 cm2, 0.38 0.18 cm2 respectively. The Pearson
correlation coefficient of the measured lesion area between CT
and magnitude image is 0.85 (p < 0.001); between CTand phase
image is 0.92 (p < 0.001). A typical case having popliteal artery
calcification is shown in Figure I. Both magnitude and phase
images show the calcifications clearly in the popliteal artery wall
and correlate well with the CT image.
Conclusion: SWI offers a means to image a large field-of-view
over which the arterial wall can be clearly seen in both
magnitude and SWI filtered phase images. These lesions were
seen in CTand SWI and correlated well in both size and position
with both methods. We anticipate that SWI will play a
complementary role to the current multi-contrast approach in
studying atherosclerosis.
References
I. Yuan C and Kerwin WS: JMRI 2004, 19:710-719.
2. Haacke EM, Xu Y, Cheng YC and Reichenbach JR: MRM
2004, 52:612-618.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


013
European cardiovascular magnetic resonance
(EUROCMR) registry preliminary results
of the German pilot phase
Oliver Bruder', Steffen Schneider2, Detlev Nothnagel3,
Thorsten Dill4, Eike Nagels, Massimo Lombardi6,
Albert C van Rossum7, Anja Wagner8, Juerg Schwitter9,
Jochen Senges2, GeorV Sabin', Udo Sechtemlo
and Heiko Mahrholdt
'Department of Cardiology and Angiology, Elisabeth Hospital,
Essen, Germany
21nstitut fir Herzinfarktforschung, Ludwigshafen, Germany
3Department of Cardiology, Klinikum Ludwigsburg,
Ludwigsburg, Germany
4Department of Cardiology, Kerkhoff-Klinik, Bad Nauheim,
Germany
SDivision of Imaging Sciences, King's College, London, UK
6Clinical Physiology Institute, CNR National Research Council,
Pisa, Italy
7Department of Cardiology, VU Medical Center, Amsterdam,
Netherlands
8Duke Cardiovascular Magnetic Resonance Center, Duke
University Medical Center, Durham, NC, USA
9Clinic of Cardiology and Cardiac MR Center, University of
Zurich, Zurich, Switzerland
'oDepartment of Cardiology, Robert Bosch Medical Center,
Stuttgart, Germany

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):O 13
Background: Cardiovascular magnetic resonance (CMR) has a
broad range of clinical applications and is increasingly used in
daily clinical practice in many European countries.
During its German pilot phase the EUROCMR Registry sought to
evaluate indications, image quality, safety and impact on patient
management of CMR imaging in clinical routine in a large number
of cases.
Methods: Multicenter registry with consecutive enrolment of
patients scanned in 29 German CMR centers using web based
online case record forms.
Results: 6530 consecutive patients were enrolled from April
2007 to September 2008 (66% male, median age 61 years
quartiless 49-70]). Ninety-three percent of patients received a
gadolinium based contrast agent. Twenty percent of patients
underwent adenosine perfusion, and 13% high-dose dobutamine
stress CMR. The indications for CMR can be viewed in Figure I.
Case reading and reporting was mostly done by cardiologists
(70%), or a team of cardiologists and radiologists (26%). Image
quality was found to be good or excellent in 91%, moderate in
8%, and inadequate in 1% of cases.
Severe complications occurred in a minority of patients (0.07%) and
were all associated with stress testing. We reported NSVT (n = I),
VF (n = I) during dobutamine infusion, as well as overt heart failure
(n = 2) and unstable angina (n = I) related to adenosine stress
CMR. No patient died during or due to the CMR procedure.
In nearly half the patients included (48%), CMR findings resulted
in a change of patient management. Importantly, in 16% of cases
the final diagnosis based on CMR was different to the diagnosis
before CMR, leading to a complete change in patient manage-
ment. In more than 70% of cases CMR was capable of satisfying
all imaging needs so that no further imaging procedure was
required after completion of CMR.


Figure I (abstract 013)


Oth'
wnw h@W~sen
Sahwh
soft dahr~ssa
cnbardw kwmr
oarwmwy wws..
ma~ry mwries

Work up of howtMum
nyocwdftl
esrdamVopefty


Ohom 18%


u Suspect


Work


failure 31%


Initial indications for CMR (n = 6530).

Conclusion: CMR is a frequently performed in German clinical
practice. The most important indications are risk stratification in
suspected CAD/Ischemia, workup of heart failure, and assess-
ment of myocardial viability. CMR imaging is a safe procedure, has
diagnostic image quality in 99% of cases, and its results have
strong impact on patient management.

014
Sudden cardiac death with normal coronaries:
cardiac MRI in the differential diagnosis of
underlying disease in survivors
Peter Hunold', Thomas Schlosser2, Kai Nassenstein2
Oliver Bruder Holger Eggebrecht4, Peter W Radkei
and J6rg Barkhausen
'University Hospital Schleswig-Holstein, Campus Lubeck,
Libeck, Germany
2University Hospital Essen, University of Duisburg-Essen,
Essen, Germany
3Elisabeth Hospital, Essen, Germany
4West German Heart Center, University of Duisburg-Essen,
Essen, Germany

Journal of Cardiovascular Magnetic Resonance 2009, I1 (SuppI 1):014
Introduction: Sudden cardiac death (SCD) is most commonly
caused by acute myocardial infarction as a correlate of coronary
artery disease. Therefore, survivors of SCD undergo cardiac
catheter to treat or rule out CAD. However, in cases with
normal coronary arteries SCD often remains unexplained.
Diagnostic work-up in this collective is important to adjust and
optimize therapy.
Purpose: Aim of this study was to evaluate the use of contrast-
enhanced cardiac MRI (CMR) in defining the underlying
pathology of survived SCD in patients without coronary artery
occlusion.
Methods: More than 6.000 contrast-enhanced CMR studies
from 3 different hospitals were reviewed for cases of survived
SCD with angiographic rule out of obstructive coronary artery
disease. The CMR protocol (1.5 T) consisted of a functional left
ventricular study using a segmented SSFP sequence (TrueFISP,
balancedFFE) in long and short axes. Data sets for late gadolinium
enhancement detection were acquired 8-15 min after 0.2 mmol/
kg BW of Gd-based contrast material using a segmented
inversion-recovery TurboFLASH/FGRE sequence (TI, 200-260 ms;


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


slice thickness, 8 mm, 2D or 3D). All cases of non-coronary
SCD were reviewed and the different underlying pathologies as
defined by MRI were collected.
Results: In total, 18 cases of unclear SCD were identified. In
14 patients thereof, MRI could state the diagnosis based on the
typical imaging features of myocardial disease: Primary cardio-
myopathy was found in 7 patients (arrhythmogenic right
ventricular cardiomyopathy, 2; dilated cardiomyopathy, 3; hyper-
trophic cardiomyopathy, I; isolated left ventricular non-compac-
tion, I). Acute myocarditis and acute cardiac sarcoidosis were
found in 3 patients each. Chronic aneurysm of the anterior wall
most probably due to cardiac contusion was found in I patient. In
4 patients, CMR could clarify the etiology of SCD.
Conclusion: Contrast-enhanced CMR has unique features in
detecting and differentiating myocardial disease with possibly
fatal outcome. It has proven to be an utmost valuable tool for
the diagnostic work-up of survivors of unclear SCD. This
underlines the role of CMR as the first-line technique in
myocardial disease.



015
Predictors of subclinical diastolic dysfunction
measured by MRI: multi-ethnic study of
atherosclerosis (MESA)
Sadia Qadir', Wendy S Post2, Gregory W Hundley3,
Gregory DN Pearson4, Shantanu Sinha5, Joao Lima2
and David A Bluemke6
'Massachusetts General Hospital, Boston, MA, USA
Johns Hopkins Hospital, Baltimore, MD, USA
Wake Forest University School of Medicine, Winston-Salem,
NC, USA
4Columbia University, New York, NY, USA
sUCLA School of Medicine, Los Angeles, CA, USA
6National Institute of Health, Bethesda, MD, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):0 15
Introduction: Diastolic dysfunction, often preclinical with no
recognized CHF diagnosis, is associated with marked increases in
all-cause mortality. Current data on diastolic dysfunction have
limitations due to retrospective study designs and/or exclusive
reliance on echocardiography.


Figure I (abstract 015)


0D Females a Males


500

P 450

S400

Eg350

S300

S 250

200


1st 2nd 3rd 4th 5th


Quintiles of EDV (ml)





Purpose: The purpose of this study was to analyze the
predictors of diastolic dysfunction in the MESA population
using cardiac MRI.
Methods: We studied peak filling rate (PFR ml/s) and time to
peak filling (TPFR msec) in a subclinical population (n = 4465,
males 47%, mean age 62 10 years). Mean (SD), correlation
coefficients and multivariable regression coefficients were
determined.
Results: Table I illustrates associations between risk factors
with diastolic LV function. End diastolic volume (EDV) modified
the relationship of gender and PFR. Mean PFR was therefore
analyzed across quintiles of EDV and was found to be higher in
females 386.35, [95%CI 382.53 to 390.17] compared to males
359.1 I ml/s [95%CI 355.05 to 363.17] (Fig I). Comapred to non-
smokers smokers had lower peak filling rates. Compared to
Whites, Hispanics were at a higher risk for diastolic dysfunction,
Chinese ethnicity showed a relative protective effect after
adjusting for all other risk factors.


Table I (abstract 015) Multivariable regressions analysis of predictors of diastolic LV dysfunction

Independent Predictors Peak Filling Rate (ml/s) Time to Peak Filling (msec)

Regression 95% CI P-Value Regression 95% CI P-Value
Coefficient Coefficient

Age (years) -1.70 -1.20 to -1.40 <0.001 1.94 1.53 to 2.36 <0.001
DBP (mmHg) -0.42 -0.78 to -0.05 0.02 0.48 0.14 to 0.82 0.005
HTN meds -5.92 -11.18 to -0.62 0.03 8.86 3.01 to 14.71 0.003
BMI (kg/m2) -0.67 -1.32 to -0.05 0.04 1.37 0.62 to 2. 1 <0.001
Former Smokers -6.52 -12.30 to 0.65 0.03 1.00 -4.56 60 6.58 NS
Impaired Fasting Glucose 2.63 -2.74 to 8.01 NS 9.06 3.21 to 17.38 0.03
Chinese 8.14 -0.25 to 16.53 NS -8.19 -14.27 to -1.87 0.01
Hispanics 8.33 1.88 to 14.88 0.006 4.67 -1.76 to I1.1 NS


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Conclusion: Impaired LV relaxation is associated with increas-
ing age, male gender, obesity, diastolic hypertension, smoking,
and varied by ethnicity.




016
Correlation of pericardial and mediastinal
fat with coronary artery disease, metabolic
syndrome, and cardiac risk factors
Onn Chenn', Ijaz Ahmad', Betty Hua',
Joshua A Sockolow', Igor Klem Terrence Sacchi'
and John F Heitner'
'New York Methodist Hospital, Brooklyn, NY, USA
2Duke University Medical Center, Durham, NC, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):O 16
Background: Obesity and abdominal fat have been shown to
correlate with coronary artery disease (CAD) and may play a
role in development of metabolic syndrome (MS). The signifi-
cance of pericardial adipose tissue (PAT) and mediastinal adipose
tissue (MAT) is less clearly defined.
Objective: To study the association between PAT and MAT
measured by cardiac magnetic resonance with: I) severity of
CAD, 2) MS and 3) cardiac risk factors (CRF) for CAD.
Methods: We enrolled 100 consecutive patients, 63 male, who
underwent CMR for cardiac evaluation and had coronary
angiogram performed within 12 months. The baseline character-
istics of these patients were as follows: Eighty had hypertension
(HTN), 42 had diabetes mellitus (DM), 37 had hyperlipidemia and
4 were smoker. We measured PAT and MAT on 4-chamber cine
view. The surface area of fat was measured by computer analysis
from free-hand region of interest (ROI) curves. The presence and
the extent of CAD were measured using Duke jeopardy Score.
MS was considered positive if the patient had 3 or more of the
5 criteria. The CRF included HTN, DM, hyperlipidemia, smoking,
peripheral vascular disease (PVD) and a family history of
premature CAD (FH).
Results: PAT had significant correlation with MS and HTN, but
not with CAD. MAT did not have a significant correlation with
either CAD or MS, but did correlate with DM, hyperlipidemia,
smoking and FH. The combination of PAT and MAT correlated
with MS and all the risk factors, except PVD, but did not
correlate with CAD. (Data in Table I.).


Conclusion: The combination of MAT and PAT correlates
with MS and a number of CRFs but does not correlate with
CAD.





017
Prognostic significance of magnetic resonance
imaging parameters in patients with idiopathic
dilated cardiomyopathy
Nico Merkle, Jan Torzewski, Georg Grossmann,
Volker Rasche, Matthias Kochs, Jochen Woehrle
and Vinzenz Hombach
University Ulm, Ulm, Germany

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):O 17
Background: Patients with idiopathic dilated cardiomyopathy
(IDC) have a limited prognosis. Aim of this study was to evaluate
the prognostic significance of novel magnetic resonance imaging
(CMR) parameters in IDC patients.
Methods and results: 161 patients with IDC were studied by
CMR for hemodynamic and late enhancement (LE) analysis and
followed for a mean of 933,8 529,2 days. QRS and QTc
intervals were measured from 12-lead ECGs. LV and RV
enddiastolic and endsystolic volume indexes were increased
and ejection fractions (EF) decreased (LV-EF 33 14%, RV-EF
50 16%). LE was seen in 43 patients (27%). Interventricular
dyssynchrony (50.9 67.2 ms) was present in 68 patients (42%).
Primary endpoint was cardiac death, sudden death (SCD) and
rehospitalization for pump failure, secondary endpoint cardiac
death and SCD. 3 patients died from non-cardiac, I0 patients from
cardiac death, 2 patients from SCD and additional 3 patients had
ICD shock for ventricular flutter/fibrillation, and 35 patients were
rehospitalized. Multivariate analysis revealed depressed left
ventricular EF(<25%) right ventricular EF (<30%), as well as the
presence of LE as independent prognostic parameters. Kaplan-
Meier survival analysis displayed low LV (<25%) and RV (<30%)
ejection fraction and the presence of LE as significant parameters
for a worse outcome.
Conclusion: In addition to impaired left ventricular ejection
fraction (<25-30%) a depressed right ventricular function
(EF <30%) and the presence of late enhancement derived from
CMR are novel prognostic parameters in patients with IDCM.


Table I (abstract 016)

Pericardial Fat (cm2) Mediastinal Fat (cm2) Total Fat (cm2)

CAD 8.3 {p-value = 0.317} 19.5 {p-value = 0.16} 27.7 {p-value = 0.03}
Metabolic Syndrome 9.3 {p-value = 0.0005} 18.9 {p-value = 0.19} 26.8 {p-value = 0.02}
Cardica Risk Factors
HTN 9.5 {p. value = 0.008} 19.6 {p-value = 0.08} 29.1 {p-value = 0.03}
DM 9.9 {p-value = 0.08} 21.2 {p-value = 0.05} 31.2 {p-value = 0.03}
Hyperlipidemia 9.0 {p-value = 0.56} 20.4 {p-value = 0.01} 29.4 {p-value = 0.02
Smoking 9.2 {p-value = 0.86} 13.1 {p-value = 0.05} 22.2 {p-value = 0.27}
PVD 11.9 {p-value = 0.008} 19.5 {p-value = 0.79} 32.3 {p-value = 0.05}
FH 9.0 {p-value = 0.74} 23.2 {p-value = 0.02} 31.2 {p-value = 0.58}


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


018
Complementary prognostic values of stress
myocardial perfusion and late gadolinium
enhancement imaging by cardiac magnetic
resonance in patients with suspected
myocardial ischemia
Kevin Steel', Ryan Broderick2, Vijay Gandla2,
Eric Larose Frederick Resnic2
Michael Jerosch-Herold2, Kenneth Brown4
and Raymond Y Kwong2
'Wilford Hall Medical Center, San Antonio, TX, USA
2Brigham and Women's Hospital, Boston, MA, USA
3Quebec Heart Institute, Quebec City, QC, Canada
4University of Vermont College of Medicine,
Burlington, VT USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):O 18

Background: Recent studies have demonstrated the prognos-
tic implication of CMR myocardial perfusion imaging (CMRMPI)
in a clinical setting. Apart from detecting reversible perfusion
defect from flow-limiting coronary stenosis, CMR late enhance-
ment imaging (LGE) is currently the most sensitive method in
detecting clinically unrecognized subendocardial infarction (UMI)
from prior ischemic injury. We therefore tested the hypothesis
that, characterization of these 2 processes from coronary artery
disease (CAD) by CMR can provide complementary patient
prognostic values.
Methods and Results: We performed CMR on 254 patients
referred with symptoms suspicious of myocardial ischemia. Rest


Figure 2 (abstract 018)


Annu ve MACE Cardiac Death
Rates (%) Ratle (%)

50 so 50
40 1 40
30 I 28
20 20

R,.PO UMI B"o RevPO UMI Bolh
R.vPD RwvPD
And And
UMI UMI


I I|'i>,


SPresent


Annual event rates of MACE and cardiac death by RevPD, UMI, and both
RevPD and UMI.




and vasodilator (adenosine or dipyridamole) stress first-pass
CMRMPI images were obtained and followed by LGE imaging. All
CMRMPI images were interpreted for reversible perfusion
defects (RevPD) using the 16-segment nomenclature and graded
segmental LGE in a separate session. The readers were blinded
to any clinical outcome in either session. At a median follow up
of 15 months, 13 cardiac deaths and 26 nonfatal events occurred.
RevPD was the strongest multivariable predictor to MACE,
demonstrating a > 8-fold hazard increase to MACE (P < 0.0001)


Figure I (abstract 018)


too



LUMI Abs&t



UMI Prumnt



0',


Foftw~q Tkne "mri


4


075



E

I


\\


S P-00001


AIWPO Piemem.
Puea 0.93 11111 M m


RaPM PiOMI.
M WPiMt


FollowP rl-e byasl


Kaplan-Meier curves illustrating. A) the prognostic implications of UMI alone and B) the complementary prediction of MACE by RevPD and UMI,
in patients without any history of MI.


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RUMD AbEtLrk
I I UEJ'CbbrI


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4


4 5







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


and a > 4-fold increase to cardiac death (P = 0.02). Adjusted to
the effects of RevPD, LGE maintained a > 2-fold adjusted hazards
with MACE (adjusted HR 2.38, P = 0.03). In 198 patients without
any history of MI, presence of RevPD and UMI by LGE provided
complementary prognostic information after adjusting to each
other's effects. Figures I and 2.
Conclusion: Reversible myocardial perfusion and evidence of
MI, assessed by CMRMPI and LGE, respectively, provide
incremental long-term patient prognostic information.





019
Initiation of station therapy halts progression of
atherosclerotic plaque burden in peripheral
arterial disease
Amy M West, Justin D Anderson, Craig D Meyer,
Frederick H Epstein, Klaus D Hagspiel,
Stuart S Berr, Nancy L Harthun,
Joseph M DiMaria, Jennifer R Hunter,
John M Christopher, Gabriel B Winberry
and Christopher M Kramer
University of Virginia, Charlottesville, VA, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):0 19
Introduction: Studies suggest lipid lowering therapy improves
symptoms and exercise performance in patients with peripheral
arterial disease (PAD); however, the mechanism of action is
unclear.
Purpose: We sought to use CMR to study the relationship
between LDL reduction and superficial femoral artery (SFA)
plaque burden in patients with PAD treated with lipid lowering
therapy over the course of I year.
Methods: 63 patients with mild-to-moderate symptomatic
PAD (mean age 63 10 years, mean ankle brachial index (ABI)
0.69 0.15) had their most symptomatic leg studied with MRI to
assess atherosclerotic plaque burden before and I year after
being started on lipid lowering therapy. At study entry, statin-
naive patients were randomized to either simvastatin 40 mg or
simvastatin 40 mg plus ezetimibe 10 mg (R group, n = 3 1) while
patients already on a station were given open-label ezetimibe
10 mg (Z group, n = 32). Lipid measurements were obtained as
part of the VAP test. CMR was performed using fat-suppressed
multi-slice turbo-spin-echo pulse sequence on a Siemens Avanto
1.5 T scanner. A custom-built flexible, linear four-element
(10 cm x 10 cm square element) surface coil array was placed
over the SFA to image 15-20 cm along the vessel beginning



Table I (abstract O19) Changes in plaque and vessel wall volume
over time

Baseline One Year % Change

Plaque volume (cm3) R 8.64 4.72 8.50 4.70 -2 8%*
Plaque volume (cm3) Z 9.16 4.94 9.53 4.82 +3 1 I 1%
TW (cm3) R 13.61 7.99 13.34 7.93 -2 8%
TW (cm3) Z 14.27 6.88 14.64 6.83 +1 8%

*p < 0.04 vs. Z group.


Figure I (abstract 019)


Left Representative black blood image of SFA from R group patient at
baseline. Right same location imaged one year later. Notice plaque
regression in the SFA.



below the bifurcation of the common femoral. Blood was
suppressed through the multislice data set using spatial
presaturation, with periodic excitation of upstream slices.
Imaging parameters included: repetition time 100 ms, echo
time 7.6 ms, echo spacing 7.5 ms, turbo factor (9), voxel size
0.5 x 0.5 x 3 mm, 4 signal averages, with interleaved image sets.
Plaque volume (PV) defined as total vessel volume (TVV) minus
lumen volume (LV) was measured with VesselMass software.
Changes in all parameters between groups from baseline to
year one were compared by unpaired t-test. Changes in LDL
were compared with changes in plaque parameters by linear
regression.
Results: LDL at baseline was higher in the R group (120 37)
than the Z group (100 27) mg/dl, p = 0.02. The decrease in
LDL at one year was significantly greater in R (-41 37) than Z
(-21 30) mg/dl, p < 0.03, such that final LDL was similar
between groups (79 36 in the R group and 79 33 in the
Z group, mg/dl). The total cholesterol at baseline was higher in
the R group (195 42) than the Z group (171 39) mg/dl,
p < 0.03. There was a trend towards a greater fall in total
cholesterol in R (48 42) compared to Z (27 42) mg/dl,
p = 0.07. The final total cholesterol was similar between
groups. No between group changes in HDL or triglycerides
were seen. See Table I for changes in vessel wall parameters in
the 2 groups. Plaque volume regressed in R while it
progressed in Z and total vessel volume followed the same
trend (p =0.1 1). No between group differences in lumen
volume or change in lumen volume over time was noted. No
correlation was found between change in LDL and plaque
volume in the SFA. Figure I.
Conclusion: Statin-naive patients with PAD who were
begun on either simvastatin or simvastatin plus ezetimibe for
one year had a halting of progression of atherosclerotic plaque
volume in the superficial femoral artery when compared to
those already treated with station given ezetimibe. Reverse vessel
wall remodeling was noted among PAD patients newly treated
with stations compared to those with ezetimibe added to pre-
existing station therapy. Thus the degree and/or mechanism of
LDL lowering rather than the final LDL achieved may be
important in halting atherosclerotic plaque progression. In


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


addition, this study demonstrates that CMR can show differences
in plaque progression in PAD with small numbers per patient
group.


020
Characterization of tissue heterogeneity
by contrast-enhanced cardiovascular
magnetic resonance imaging is a powerful
predictor of ventricular tachyarrhythmias on
ambulatory holter ECG in hypertrophic
cardiomyopathy
Caitlin J Harrigan A Selcuk Adabag2,
Evan Appelbaum3, Kevin S Heffernan',
John R Lesser2, James E Udelson', Warren J Manning4,
Barry J Maron2 and Martin S MaronI
'Tufts Medical Center, Boston, MA, USA
2Minneapolis Heart Institute Foundation,
Minneapolis, MN, USA
3Perfuse Core Lab, Boston, MA, USA
4Beth Isreal Deaconess Medical Center,
Boston, MA, USA
journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):020
Background: Cardiovascular magnetic resonance with late
gadolinium enhancement (LGE-CMR) identifies areas of myocar-
dial scarring in patients with hypertrophic cardiomypathy (HCM).
The presence of LGE identifies HCM patients at risk for
ventricular tachyarrhythmias, which is an independent predictor
of sudden death in this disease. In this study, we sought to
determine whether regions of abnormal tissue at the confluence
of both viable myocardium and fibrosis ("border zone") (BZ) are
more predictive of ventricular tachyarrhythmias than areas of
myocardial scarring alone.
Methods: Cine CMR and LGE-CMR were performed in 145
HCM patients (42 15 years; 74% male) from two HCM referral
centers using standard techniques (0.2 mmol/kg gadolinium-
DTPA). LGE was determined by a blinded, independent reader
using grayscale thresholds of both 4 and 6 standard deviations
(SD) above the mean of normal, remote myocardium. BZ was
determined as the difference between the 4 SD and 6 SD
thresholds. All subjects underwent 24-h ambulatory Holter
electrocardiogram (ECG) within 7.8 8.3 weeks of the CMR
Results: The amount of myocardial scarring (6 SD) alone was
5.5 7.2% of the LV myocardium, while the amount of BZ was
6.5 4.6% of the LV myocardium. Runs of non-sustained
ventricular tachycardias (NSVT) were present in 23 patients
(I 6%), ventricular couplets were present 39 patients (27%), while
premature ventricular couplets (PVCs) were present in 119
patients (82%). There was no significant association with the
extent of myocardial scarring and the occurrence of NSVTs,
couplets, and PVCs (overall p = 0.05). However the extent of BZ
was significantly associated with the occurrence of NSVTs,
couplets and PVCs (overall p < 0.001).
Conclusion: These data demonstrate that in HCM patients, the
extent of BZ may be a superior predictor of ventricular
tachyarrhythmias than myocardial scarring alone (using a
grayscale thresholding technique of 6 SD above normal
myocardium). This study indicates the need for follow-up studies
evaluating the independent prognostic value of BZ in risk
stratification strategies in HCM patients.


021
Late enhancement in 39 cardiac transplant
patients: prevalence, pattern, and extent
Craig RL Butler', Andreas Kumar2, Mustafa Toma',
Richard Thompson', Matthias Friedrich3
and David lan Paterson'
'University of Alberta, Edmonton, AB, Canada
2University of Calgary, Calgary, AB, Canada
3Stephenson Cardiovascular MR Center, Calgary, AB, Canada
Journal of Cardiovascular Magnetic Resonance 2009, I1 (Suppl I):021
Aim: To better characterize delayed enhancement patterns in
the cardiac transplant population.
Background: Cardiac transplant patients experience significant
morbidity related to transplant vasculopathy and acute transplant
rejection, both of which can cause scarring of the myocardium.
Contrast enhanced cardiovascular magnetic resonance (CMR)
has the unique ability to visualize and quantify myocardial
scarring. It is well understood that myocardial infarctions
resulting from transplant vasculopathy adversely affect prognosis
and modify therapy. There is a growing body of evidence from
non-transplant disease states, that the presence of non-infarct
myocardial scar is also correlated to poor prognosis. Currently
there is very little data on the scarring patterns present in the
cardiac transplant population and it is our goal to better describe
this pathology.
Methods: Thirty-nine transplant patients underwent contrast
enhancement imaging at the time of routine myocardial biopsy at
two hospital centers in Alberta, Canada. Standard phase sensitive
inversion recovery sequences were used on commercially
available scanners (Siemens Avanto and Sonata, Siemens,
Erlangen, Germany). Delayed enhancement (DE) was evaluated
visually using CMR42 (Circle Canada Inc, Calgary, Canada)
software analysis package by two independent readers. DE had
to be cross-referenced in two orthogonal views. Disagreements
were settled by consensus. The extent of DE was assessed semi-
quantitatively by scoring each of the 17 myocardial segments
according to the proportion of DE in each segment (I = 75%).
The scores of the 17 individual myocardial segments were added
together to give an aggregate DE burden.
Results: Three (8%) out of 39 patients scanned had to be
excluded due to poor image quality. There were seven women
(18%) and thirty two men (82%). Fifteen (45%) patients had grade
I R cellular rejection rejection, and two (6%) had grade 2R


Figure I (abstract 021)


Transmural lateral wall infarction (a) and Inferoapical infarction (b).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 2 (abstract 021)


Example of non-ischemic fibrosis. Subepicardial delayed enhance-
ment of the anteroseptal and anterior walls (a) and inferior wall (b).


rejection. Mean time since transplant was 37 months (standard
deviation = 55 months). Eighteen (50%) of 36 patients had DE.
Among patients with DE, four patients (22%) had a subendo-
cardial or transmural pattern consistent with myocardial
infarction (Figure I), and 14 (78%) had a midwall or subepicardial
pattern (Figure 2) consistent with non-ischemic injury. Overall,
patients with DE had scores ranging from I to 19, with a mean of
5.4 (standard deviation = 4.8). Non-ischemic DE was most
commonly seen in the anterolateral and inferior walls (Figure 3).
There was no significant association between the presence of DE
and time since transplant or current biopsy result.
Conclusion: DE is a common feature in the transplant
population. Most DE observed is in a non-ischemic pattern;


Figure 3 (abstract 021)


Frequency of any delayed enhancement by myocardial segment.


however a significant proportion had DE patterns consistent with
infarction. The relationship between DE and cumulative episodes
of rejection, hospitalization, and long term prognosis needs to be
explored in more detail.



022
Comparison of a rapid visual algorithm for
quantification of infarct size with direct planimetry
of infarct size by delayed enhancement-CMR
Omar M Cheema, Ankit A Patel and Dipan J Shah
Methodist DeBakey Heart & Vascular Center,
Houston, TX, USA

Journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):022
Introduction: Direct planimetry of myocardial infarct size by
delayed enhancement CMR (DE-CMR) has been well validated as
a technique for quantification of infarct size with both a high
degree of accuracy and reproducibility. Direct planimetry
however requires extensive post processing and is time
consuming and therefore not ideal for performance in a routine
clinical service. We propose a visual algorithm to quantify total
infarct size that would be rapid and easily incorporated into
routine clinical practice. In this study we sought to: I) compare
the level of agreement between our visual scoring algorithm and
direct planimetry of infarct size; 2) compare the time required
for each method of quantifying infarct size.
Methods: We enrolled 101 consecutive patients with known
chronic myocardial infarction (MI) who underwent CMR viability
assessment. Direct planimetry was performed by segmentation
of hyperenhanced (HE) regions (signal intensity > 2 standard
deviations above remote myocardium) in all short axis DE-CMR
slices. The total volume of the HE zone was then divided by the
total volume of myocardium within the left ventricle (calculated
by planimetry of endocardial and epicardial borders on all DE-
CMR images so as to include both HE and non-HE myocardium).
Visual scoring of all studies was performed using a 17 segment
model with scores assigned based on the visual extent of HE
myocardium in each segment (i.e. 0 = no HE, I = 1-25% HE,
2 = 26-50% HE, 3 = 51-75% HE, and 4 = 76-100% HE). Visual
infarct size was then calculated by averaging the midpoint of the
% HE within each of the 17 segments (i.e. score of 0 = 0%,
I = 13%, 2 = 38%, 3 = 63%, 4 = 88%). Agreement between the
visual algorithm and planimetry was compared using Bland-
Altman analysis.
Results: The study population consisted of 101 patients with
chronic MI infarctt age 5.3 6.5 years) of which 70 (69%) were
men, age 63.7 2.3 years, left ventricular (LV) ejection fraction
52.4 15.5%, and LV mass 154.7 51.3 g. Of the 101 patients,
30 (30%) had a history of congestive heart failure, 29 (29%) had
diabetes mellitus, 86 (85%) had hypertension, and 94 (93%) had
hyperlipidemia. The total infarct size was not statistically different
between the visual algorithm (I 1.4 10.4%) and directly
planimetry (9.3 8.5%, p = NS). The range of infarct sizes was
0-40% by direct planimetry. Bland Altman analysis revealed a
nonsignificant bias of 2. 1% of LV (p = NS) with 95% confidence
interval between the visual algorithm and planimetry of +1 1.3%
to -7.1 %, see figure. The visual algorithm required less time than
direct planimetry (5.5 1.6 minutes vs. 22.4 4.5 minutes
respectively; p < 0.001).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Conclusion: The visual algorithm provides a rapid method to
quantify total infarct size with good agreement to direct
planimetry. This is a useful time-efficient alternative for
quantifying chronic infarct size in a routine clinical setting.


023
The utility of cardiovascular magnetic resonance
imaging in Takotsubo Cardiomyopathy (apical
ballooning) for differential diagnosis,
pathophysiological insights and additional findings
Ingo Eitel, Florian Behrendt, Mahdi Sareban,
Gerhard Schuler, Matthias Gutberlet and Holger Thiele
Heart Center Leipzig, Leipzig, Germany

journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):023
Introduction: Takotsubo cardiomyopathy (TTC) is an increas-
ingly recognized acute cardiac syndrome (ACS), which underlying
pathophysiological mechanisms are still controversially discussed.
Cardiovascular magnetic resonance imaging (CMR) contributes
to an understanding and differential diagnosis of this new entity
by demonstrating the absence of irreversible injury (delayed
enhancement) but oedema formation on T2-weighted images.
However, clinical experience with CMR in this entity is still
limited and is based mainly on relatively small case series.
Purpose: The aim of this study was therefore to evaluate CMR
criteria for the diagnosis/differential diagnosis of TTC and the
assessment of potential pathophysiological mechanisms as well as
additional findings by using a comprehensive CMR approach.
Methods: Between January 2005 and October 2008 81
consecutive patients, showing a left ventricular dysfunction
with apical ballooning not explainable by the coronary artery
status and initially admitted with ACS underwent CMR using a
1.5 T MRI scanner. Left ventricular function, T2-weighted spin
echo sequence for oedema and delayed enhancement (DE)
images after administration of Gadobutrol were assessed.
Additionally, in the last 20 patients T2-weighted triple-inver-
sion-recovery imaging to calculate the edema ratio (ER) and T I-
weighted imaging before and after contrast agent administration
to calculate the myocardial global relative enhancement (gRE)
were performed for detection of inflammation.
Results: CMR revealed diagnosis of myocardial infarction in 18
(22.2%) patients and diagnosis of myocarditis in 9 (10.8%)
patients with typical patterns of DE. In all other 54 (67.0%)
patients (51 female, age 71 10 years) no DE was detected,
consistent with the diagnosis of TTC. Of these 20 patients (37%)
showed focal oedema, 17 (3 1%) initial right ventricular involve-
ment and 19 patients a pericardial effusion (PE) (35%). Of the last
20 TTC patients 9 showed elevation of both inflammatory
markers (ER and gRE) with concomitant PE indicating acute
inflammation. Follow-up CMR after three months showed
complete normalization of left ventricular function and inflam-
matory parameters in the absence of DE, oedema and PE.
Conclusion: CMR has incremental value for differential
diagnosis, pathophysiological insights and detection of additional
findings in TTC. Therefore CMR should be performed in all
patients with suspected TTC for further differential diagnosis and
guidance of medical therapy. Moreover, our results support the
probable underlying cause of inflammation in TTC. If inflamma-
tion is the primary cause or secondary phenomena due to
sympathetic overdrive needs further research.


024
Potential of multidetector computed tomography
and magnetic resonance imaging in quantifying left
ventricular function, perfusion and viability of
chronic microinfarction
Marcus Carlsson', David Saloner2, Alastair Martin2
Loi Do2 and Maythem Saeed2
'Clinical Physiology, Lund University Hospital, Lund, Sweden
2Dep of Radiology and Biomedical Imaging, San Francisco, CA,
USA

Journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):024
Introduction: Microinfarction is common following coronary
interventions (PCI and CABG) and acute coronary syndromes.
Magnetic resonance imaging (MRI) has become the reference
method for non-invasive quantification of: I) left ventricular (LV)
function using cine imaging and 2) myocardial perfusion deficits
using first pass perfusion and 3) acute and chronic myocardial
contiguous infarction using delayed contrast enhancement (DE)
technique. Modern multidetector computed tomography
(MDCT) has also been recently used in assessing the above
parameters in contiguous infarction. To our knowledge both
modalities have not been tested in the assessment of micro-
infarction caused by microembolic agents.
Purpose: This study aimed to examine the potential of 64-slice
MDCT and MRI in assessing LV function, regional perfusion and
viability in microinfarction.
Methods: An XMR-suite was used to catheterize the LAD
coronary artery under X-ray and to define the LAD-territory
using first-pass MRI during intracoronary injection of 10% Gd-
DOTA. The perfusion territory was selectively microembolized
in six pigs using a microembolic agent (40-120 pm, 250,000



Figure I (abstract 024)


MDC"






MR






TTC


Multi-slice MDCT (top), MR delayed enhancement images (middle) and
TTC slices (bottom) from a representative animal show good
correspondence between modalities in defining patchy microinfarction
embedded in viable myocardium (indicated by arrows).


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count). LV function cinee imaging), perfusion (first-pass imaging)
and viability (DE imaging) were determined 7-8 weeks after
microembolization using MRI followed by MDCT (5 days later).
Histochemical staining (TTC) was used as golden standard for
quantification of microinfarction. Figure I.
Results: The LAD-territory was 32.4 3.8% of the LV mass.
There was no significant difference between MR and MDCT
measurements of systolic wall thickening. Global LV function did
not differ between MRI (end diastolic volume: 92 8 ml, end-
systolic volume 48 5 ml and ejection fraction: 47 3%) and
MDCT (96 8 ml, 49 3 ml, 49 2%, respectively). Both MRI
and MDCT showed a decrease in function in the microembolized
territory and an increased contractility in remote myocardium.
There was no difference in the quantification of systolic wall
thickening (radial strain) between the methods (P = ns for all
segments, bias 0.3 21.9%). MRI, but not MDCT, detected a
perfusion deficit in the microembolized territory (significant
decrease in max upslope and maximum signal intensity).
Microinfarction size did not differ between MDCT (6.3 0.8%
LV), MRI (6.6 0.5%LV) or TTC (7.0 0.6%LV). Bias (Bland-
Altman test) for quantifying microinfarction on MDCT was -
0.6 1.9%LV compared to TTC and for MRI -0.4 1.3%LV
compared to TTC.
Conclusion: Modern MDCT and MRI techniques have the
sensitivity to: I) visualize and quantify chronic microinfarction
and 2) demonstrate regional LV dysfunction. MRI, but not MDCT,
has the sensitivity for detecting small changes in regional
perfusion of chronic microinfarction. Close agreements were
found between MDCT and MRI in measuring regional and global
LV function. The results of this study suggest that MDCTand MRI
can be used for detecting the consequences of microinfarction
following coronary interventions and evaluating the efficacy of
new therapies and devices designed to prevent microemboliza-
tion.
Acknowledgements
This study was supported by grant RO I HL07295 from NIH.


025
Co-localization of areas of delayed mechanical
activation and areas of myocardial scar
Jana G Delfino', Brandon K Fornwalt', Calvin R Kurz2
Jack A Talsma' and John N Oshinski3
'Emory University, Atlanta, GA, USA
2Georgia Institute of Technology, Atlanta, GA, USA
3Emory University/Georgia Institute of Technology, Atlanta,
GA, USA
journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):025
Objective: To determine the overlap between the regions of
delayed mechanical activation and regions of myocardial scar
tissue.
Introduction: The greatest benefit from Cardiac Resynchro-
nization Therapy (CRT) is likely achieved when the LV pacing lead
is placed in the area with the greatest mechanical activation delay
[I]. However, in patients with ischemic heart failure, the region
with the greatest mechanical activation delay may correspond to
an area of myocardial scar. Placing the pacing leads in areas of
scar tissue will result in nonresponse to CRT[2]. The co-
localization of areas of delayed mechanical activation and
myocardial scar in patients with previous MI is not known.


Methods: 16 patients with a prior history of myocardial
infarction (MI) were studied six-months post infarct. Cine SSFP
images were obtained in the 2-chamber, 4-chamber, and short
axis orientations. Following a double-dose injection (0.2 mmol/
kg) of Gd-DPTA, delayed contrast enhancement (DCE) images
were obtained at the same locations as the cine SSFP images.
Mechanical activation delays were calculated from the cine SSFP
images. Radial displacement curves showing movement of the
endocardial border toward the LV center of mass were
calculated for 360 chords around each short axis slice.
Displacement curves were averaged throughout the entire
myocardium to generate a global displacement curve. Cross
correlation analysis between the global curve and the curve for
each chord was done to determine the mechanical activation
delay. A cross correlation delay of 31 msec was used as the
threshold to determine mechanical activation delay[3]. Mechan-
ical activation delay information for the entire myocardium was
mapped onto the standardized AHA Bullseye model.
Endocardial and epicardial borders were traced on the short axis
DCE images. A separate region of interest was drawn around the
area of infarct. Each slice of the myocardium was resampled at
360 chords around the heart, and each chord was assigned a
value between 0 and I depending on the scar burden at that

Figure I (abstract 025)


1 >50% scar tissue

mechanical activation delay

area of overlap


An example patient showing regions of >50% scar tissue, regional
mechanical activation delay, and regions of overlap. In this example, 32%
of the region of delayed mechanical activation was also a region of >50%
scar tissue.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


location (I = transmural infarct, 0 = no infarct). The analysis was
repeated for each short axis slice. DCE information for the
entire myocardium was displayed on the standardized AHA
Bullseye model of the myocardium.
Areas of overlap between mechanical activation greater than 3 I
msec and scar burden >50% transmurality were examined.
Results: A scar burden of >50% was seen in 8.6 +/- 6.7% of the
LV; mechanical activation delay greater than 3 1 msec was seen in
8.0 +/- 4.0% of the LV. On average, only 14.6 +/- 14.7% of the
region of greatest mechanical activation delay was also an area of
>50% scar tissue. However, this value varied greatly between
patients and ranged from 0 to 40%. In the two patients where
there was no overlap, scar burden was <5% of the myocardium.
See Figure I.
Conclusion: The region of greatest mechanical activation delay
does not necessarily correspond to the region of myocardial scar
tissue.
References
I. Becker, et al: Am J Cardiol 2007, 100:1671-6.
2. Bleeker, et al: Circulation 2006, 113:969-76.
3. Fornwalt, et al: J Am Soc Echocardiogr 2007, 20:1330-7.


026
Papillary muscle involvement in acute and chronic
myocardial infarction: an MRI study using
multi-contrast delayed enhancement pulse sequence
Yuesong Yang, Kim Connelly, Jay Detsky, Gideon Paul,
Graham A Wright and Alexander J Dick
Sunnybrook Health Sciences Centre, Toronto, ON, Canada

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):026
Introduction: The papillary muscle (PM) is an integral
component of the mitral valve apparatus. Acute or chronic
myocardial infarction (MI) with PM ischemia is a primary factor
leading to the occurrence of mitral regurgitation, with associated
substantial morbidity and mortality [I, 2]. PM-MI is also a source
of ventricular arrhythmia in these patients [3]. Although DE-MRI
using IR-FGRE can detect PM-MI, its accuracy is primarily limited
by poor contrast between left ventricular (LV) blood pool and
infarcted myocardium.
Hypothesis: We hypothesize that multi-contrast delayed
enhancement (MCDE) imaging will improve the identification of


PM-MI in patients with acute and chronic MI, compared to
conventional IR-FGRE imaging.
Methods: Cardiac DE-MRI studies using both MCDE and IR-
FGRE in patients with MI were reviewed. Twenty-three patients
(2 I males, 2 females, average age of 62 10 years old; 5 acute MI
within 7 days, 18 chronic MI > 4 weeks) met the diagnostic
criteria of PM-MI, as outlined below. All studies were performed
on a 1.5 T GE Signa HDx system (GE Healthcare, Milwaukee,
WI), which included a short-axis oblique (SAO) and two or four
chamber SSFP studies. Both IR-FGRE and MCDE covering the
whole LV in SAO were performed 10-20 minutes after double-
dose bolus injection of Gd-DTPA. For IR-FGRE, the TI varied
from 200 to 300 ms, depending on the null point of healthy
myocardium. For MCDE, a segmented SSFP readout is used
following an inversion pulse, providing 20 cardiac-phase-resolved
images at varying effective TIs [4]. The in-plane resolution was
1.5 x 1.5 mm for both techniques.
PM-MI was considered if the following criteria were satisfied in
the IR-FGRE or MCDE images: (I) the increased signal intensity
of PM was similar to that of adjacent hyper-enhanced infarct
segments; (2) the hyper-enhanced PM region was limited to the
PM area defined by pre-contrast SSFP The contrast between
blood pool and hyper-enhanced LV infarct was rated as excellent
(3), good (2) or fair (I) based on their differentiation.
Results: Based on the standard AHA 17-segment model [5], all
patients with PM-MI demonstrated wall motion abnormalities
and DHE involving multiple coronary artery territories. Of these
23 patients, 13 studies demonstrated primarily involvement of
the territories of the RCA (8 patients) and/or LCX (5 patients)
and 10 involved the territories of LAD with some LCX
involvement. Although IR-FGRE and MCDE determined the
presence and extent of LV MI equally well, better contrast scores
were achieved in MCDE (2.9 0.3) compared to IR-FGRE
(1.6 0.8, P < 0.001). MCDE clearly demonstrated PM-MI in all
cases (100%, 23/23). However, only 39% (9/23) could be
visualized in the corresponding IR-FGRE images (Figure I),
which displayed poor contrast between blood pool and infarcted
myocardium. The multi-contrast capability of MCDE facilitates an
improved differentiation between blood pool and infarct. This is
especially important for the detection of PM-MI since a large of
portion of PM extends within the LV blood pool and does not
attach to the solid LV wall [6]. Moreover, the MCDE sequence
provided cine images that also facilitated the simultaneous


Figure I (abstract 026)


PM involvement in a subject with RCA territorial infarction. Pre-contrast SSFP image (A) depicted the morphology of PM. IR-FGRE image (B) did not
show the PM-MI, while MCDE (C and D) clearly demonstrated the infarcted PM (arrows).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


appreciation of wall motion abnormalities in the region of MI.
Mitral valve regurgitation with mild or moderate degree was
noted on four- and/or two-chamber SSFP scans in 52% (12/23) of
patients.
Conclusion: MCDE imaging provides better contrast between
blood pool and infarcted myocardium, thus improving the
determination of PM-MI that may help identify patients in
whom the significant mitral regurgitation may affect morbidity
and mortality.
References
I. DePasquale NP: Annu Rev Med 1971, 22:327.
2. Han Y, et al: JACC Img 2008, 1:294.
3. Bogun F: JACC 2008, 51:1794.
4. Detsky JS, et al: MRM 2007, 58:365.
5. Cerqueira MD: Circulation 2002, 105:539.
6. Axel L: Circulation 2004, 109:3145.


027
Myocardial salvage in acute myocardial infarction
assessed by magnetic resonance
imaging influences by the antioxidative agent
N-acetylcystein
Holger Thiele', Ingo Eitel' 2, Lysann Hildebrand ,
Carmen Schirdewahn Volker Adams', Georg Fuirnau ,
Matthias Gutberlet' and Gerhard Schuler'
'University of Leipzig Heart Center, Leipzig, Germany
2Internal Medicine Cardiology, Leipzig, Germany

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):O27
Introduction: Myocardial salvage can be assessed retrospec-
tively by T2-weighted and delayed enhancement images as shown
in animal studies [I]. Currently there are only limited data in
humans with acquisition of T2-weighted images not covering the
full ventricle [2]. Animal trials showed that the antioxidant effects
of N-Acetylcystein (N-ACC) reduce reperfusion injury and
N-ACC might prevent the occurrence of contrast-induced
nephropathy (CIN) in patients undergoing primary PCI.
Purpose: Aim of this trial was to establish myocardial salvage
imaging by MR as a surrogate endpoint in a randomized single-
blinded trial and to show that high-dose N-ACC reduces
reperfusion injury by its antioxidative properties. Furthermore,
N-ACC might reduce the incidence of contrast-induced
nephropathy (CIN).
Methods: Two hundred-fifty-one patients undergoing primary
PCI were randomized to either high-dose N-ACC (2 x 1200 mg/
d for 48 hours) or placebo plus optimal hydratation. The two
primary endpoints were: I) occurrence of CIN defined as an
increase in the serum creatinine concentration of >25% from the
baseline value within 72 h; 2) Myocardial salvage measured by
T2-weighted STIR-images (covering the left ventricle from base
to apex) and delayed enhancement MRI at day 2-4 after primary
PCI. Myocardial salvage index was calculated as area at risk-
infarct size/area at risk.
Secondary endpoints were infarct size and microvascular
obstruction, ST-resolution at 90 minutes and occurrence of
MACE at 30 day follow-up.
Results: Due to contraindications MRI could not be performed
in 31 patients. All images were assessable for the calculation of
the myocardial salvage index. The area at risk was 47.3% of the
left ventricular mass (IQR 33.9; 58.8) in the N-ACC group versus


42.7% (IQR 33.7; 53.0; p = 0.39) in the placebo group. The
primary endpoint reperfusion injury measured by myocardial
salvage index was not different between both treatment groups
(57.7; IQR 39.2; 78.0 versus 61.1; IQR 40.6; 77.7; p = 0.32). In
addition, no differences in infarct size (18.3%; IQR 9.3; 26.4
versus 14.9%; IQR 8.0; 26.4; p = 0.48) and microvascular
obstruction (0.7%; IQR 0.2; 1.5 versus 0.6%; IQR 0.0; 1.2;
p = 0.25) as well as in ST-segment resolution were observed. The
median volume of an iso-osmolar contrast agent during PCI was
190 ml (IQR 130, 250 ml) in the N-ACC and 180 (IQR 143; 228
ml) in the placebo group (p = 0.67). The primary endpoint CIN
occurred in 14% in the N-ACC group and in 22% in the placebo
group (p = 0.12).
Conclusion: MRI can reliably measure the area at risk and
infarct size retrospectively and served as a surrogate endpoint in
this randomized clinical trial which showed that high-dose N-
ACC does not provide an additional clinical benefit to placebo
with respect to prevention of myocardial reperfusion injury and
CIN and in patients undergoing primary PCI.
References
I. Aletras AH, Tilak GS and Natanzon A, et al: Retrospective
determination of the area at risk for reperfused
acute myocardial infarction with T2-weighted car-
diac magnetic resonance imaging: Histopathological
and displacement encoding with stimulated echoes
(DENSE) functional validations. Circulation 2006,
1 13:1865-1870.
2. Friedrich MG, Abdel-Aty H, Taylor A, Schulz-Menger J,
Messroghli D and Dietz R: The salvaged area at risk in
reperfused acute myocardial infarction as visualized
by cardiovascular magnetic resonance. J Am Coll Cardiol
2008, 51:1581-1587.

028
Clinical, angiographic, and electrocardiographic
predictors of infarct size and microvascular
obstruction sssessed by MRI
Holger Thiele, Josef Friedenberger, Kathrin Schindler,
Ingo Eitel, Eigk Grebe, Matthias Gutberlet
and Gerhard Schuler
University of Leipzig Heart Center, Leipzig, Germany

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):O28
Introduction: Infarct size (IS) and presence of microvascular
obstruction (MO) assessed by delayed enhancement MRI are
associated with major adverse events in ST-elevation myocardial
infarction (STEMI). The time-to-reperfusion, electrocardio-
graphic and angiographic parameters are also of prognostic
relevance in STEMI patients. Predictors of IS and MO occurrence
have not been assessed so far.
Purpose: To assess predictors of IS and MO in a large
consecutive series of patients with STEMI.
Methods: This study analyzed 358 consecutive STEMI patients
reperfused by primary percutaneous coronary intervention
within 12 hours after symptom onset. IS and MO were assessed
by delayed enhancement MRI as percentage of left ventricular
mass (%LV) 3.1 4.1 days after the index event. Reperfusion
times, 90 min ST-segment resolution, TIMI-flow grades pre and
post PCI, TIMI risk score and multiple clinical parameters such as
cardiovascular risk factors, Killip-class, and infarct location were
assessed.


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Results: In patients with pre PCI TIMI flow 0-1 IS was
significantly higher with 24 14% versus 15 14% in TIMI-
flow 2-3 (p < 0.001). Similarly, the extent of MO occurrence
was affected by the pre PCI TIMI flow. The post PCI TIMI flow
had no significant effect on final IS and MO occurrence. In
patients with TIMI flow <3 IS was 28 1 I% versus 20 12% in
TIMI-flow = 3 (p = 0.05). The ST-segment resolution correlated
inversely with final IS and presence of MO (IS r = -0.34,
p = 0.003; MO r = -0.31, p = 0.004). Anterior MI IS was
25 16% (MO 7.8 9.8%) versus 17 12% (MO 3.8 4.7%)
in inferior MI (p = 0.002 IS; p = 0.003 MO). According to sixtiles
of time-to-reperfusion, there was no interaction between time-
to-reperfusion and IS and extent of MO even when restricted to
patients with pre PCI TIMI flow 0-1. In a multivariable model the
strongest predictors of IS and MO were pre-PCI TIMI-flow,
infarct location, Killip class, and 90 minute ST-segment resolution
(p < 0.05 for all).
Conclusion: The pre-PCI TIMI flow, infarct location, Killip
class and ST-segment resolution are the strongest predictors of IS
and extent of MO. This may explain why these clinical,
angiographic and electrocardiographic measures are associated
with survival. In contrast to other studies the time-to-reperfu-
sion did not affect IS and MO, which might be a selection bias, as
patients with larger infarctions will be treated earlier.

029
Myocardium at risk and myocardial salvage after
acute infarction in humans; quantification by
magnetic resonance imaging
Marcus Carlsson', Joey Ubachs, Einar Heiberg',
Erik Hedstrom', Stefan Jovinge2 and Hakan Arheden'
'Clinical Physiology, Lund University Hospital, Lund, Sweden
2Cardiology, Lund University Hospital, Lund, Sweden

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):029
Introduction: To assess reperfusion therapy, it is necessary to
determine how much myocardium is salvaged by measuring the
final infarct size in relation to the initial myocardium at risk (MaR)
of the left ventricle (LV). T2 weighted MRI has recently been
shown to be able to identify MaR but has not been validated
against an independent method in humans.
Purpose: To validate myocardium at risk by T2 weighted MRI
(T2-STIR) over time, compared to perfusion SPECT in patients
with ST-elevation myocardial infarction (STEMI), and, to assess
the amount of salvaged myocardium after I week
Methods: Sixteen patients with first-time STEMI received
99mTc tetrofosmin prior to primary percutaneous coronary
intervention and SPECTwas performed within 4 hours to identify
MaR. MRI was performed on a 1.5 T Siemens Vision (5 patients)
or Philips Intera. T2-STIR was at I day, I week, 6 weeks and
6 months. Image parameters for T2-STIR were: TE, 43 ms
(Siemens), or 100 ms (Philips); TR, 2 heart beats; NEX, 2; image
resolution, 1.5 x 1.5 mm; slice thickness, 10 mm (Siemens) or 8
mm with a slice gap of 2 mm (Philips). At I week, patients were
injected with a gadolinium-based contrast agent for quantification
of infarct size on delayed contrast enhanced (DE) MRI. T2-STIR
and DE MR images were acquired in the short-axis view, covering
the left ventricle from the base to apex.
Results: MaR at occlusion on SPECTwas 33 10% of the LV.
MaR on T2-STIR did not differ from SPECT, at day I (29 7%,
p = 0.74), or week I (31 + 6%, p = 0.23) but declined at week 6


Figure I (abstract 029)


(10 12%, p = 0.03 vs. I week) and month 6 (4 I 1%, p = 0.02
vs. I week). The difference between SPECT and T2-STIR at
I week was -2.3 5.7%. Both modalities identified MaR in the
same perfusion territory and in concordance with coronary
angiography. Final infarct size was 8 7% and salvage was
75 19% of MaR. Figure I.
Conclusion: This is the first study to validate T2-STIR for
quantification of MaR against an independent method (SPECT) in
patients with acute ST-elevation myocardial infarction after
reperfusion therapy. The results demonstrate that T2-STIR
performed up to one week after reperfusion can accurately
determine myocardium at risk as it was before opening of the
occluded artery. The result of reperfusion therapy can therefore
be assessed clinically by calculating myocardial salvage as the
difference between myocardium at risk and final infarct size using
MR imaging.

030
Impact of myocardial hemorrhage on left
ventricular function and remodeling in patients
with reperfused acute myocardial infarction
Javier Ganame, Giancarlo Messalli, Steven Dymarkowski,
Frank E Rademakers, Walter Desmet, Frans Van de Werf
and Jan Bogaert
University Hospitals Leuven, Leuven, Belgium

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):030
Background: Myocardial hemorrhage is a common complica-
tion following reperfusion of ST-segment-elevation acute myo-
cardial infarction (MI). Although its presence is clearly related to
infarct size, at present it is unknown whether post-reperfusion
hemorrhage affects left ventricular (LV) remodeling. Magnetic
resonance imaging (MRI) can be used to identify myocardial
infarction, myocardial hemorrhage and microvascular obstruc-
tion (MVO), as well as measure LV volumes, function and mass.
Methods and results: Ninety-eight patients (14 females,
84 males, mean age: 57.7 years) with MI reperfused with
percutaneous coronary intervention (PCI) were studied in the
first week and at 4 months after the event. T2-weighted MRI was
used to differentiate between hemorrhagic (i.e., hypo-intense
core) and non-hemorrhagic infarcts (i.e., hyper-intense core).
MVO and infarct size were determined on contrast-enhanced
MRI, while cine MRI was used to quantify LV volumes, mass and
function. Twenty-four patients (25%) presented with a hemor-
rhagic MI. In the acute phase, presence of myocardial hemor-
rhage was related to larger LV end-diastolic and end-systolic
volumes and infarct transmurality, lower LV ejection fraction as


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table I (abstract 030) Results of multiple linear regression of
left ventricular remodeling

Predictors of end point 95% CI R2 F value p value

Hemorrhagic MI 0.15-0.31 0.17 20.19 <0.001
Infarct size at baseline 20.8-27.7 0.16 18.11 0.001
Microvascular obstruction 5.0-9.3 0.12 13.13 0.001
Maximum troponin I 91.9-142.6 0.10 10.75 0.001
Size of area at risk 37.046.5 0.09 9.12 0.003
LV mass at baseline 118.6-131.4 0.02 2.31 0.132
Percent MI transmurality 78.6-87.2 0.03 3.39 0.068
Infarct location 0.37-0.58 <0.01 0.41 0.892
Time to PCI 241.1-305.6 <0.01 0.02 0.874


well as lower systolic wall thickening in the infarcted myocardium
(all p-values < 0.001). Infarct size, size of area at risk and size of
MVO were significantly larger in patients with hermorrhagic MI.
At 4 months, a significant improvement in LV ejection fraction
in patients with non-hemorrhagic MI was seen (baseline:
49.3 7.9% vs. 4 months: 52.9 8.1%; p < 0.01). LV ejection
fraction did, however, not improve in patients with hemorrhagic
MI (baseline: 42.8 6.5% vs. 4 months: 41.9 8.5%; p = 0.68).
Multivariate analysis showed myocardial hemorrhage to be an
independent predictor of adverse LV remodeling at 4 months
(defined as an increase in LV end-systolic volume). This pattern
was independent of initial infarct size (See Table I).
Conclusion: Myocardial hemorrhage, the presence of which
can easily be detected with T2-weighted MRI, is a frequent
complication after successful myocardial reperfusion, and an
independent predictor of adverse LV remodeling regardless of
initial infarct size.



031
Strain-encoded imaging for prediction of
functional recovery in patients after acute
myocardial infarction
Mirja Neizel', Grigorios Korosoglou2, Tim Schaeufele2,
Dirk Lossnitzer2, Harald P Kuehl', Evangelos Giannitsis2
Malte Kelm', Hugo A Katus2, Nael F Osman3
and Henning Steen
'University Hospital Aachen, Aachen, Germany
2University Hospital Heidelberg, Heidelberg, Germany
johns Hopkins University, Baltimore, MD, USA
journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):031
Introduction: Evaluation of reversible dysfunction after acute
myocardial infarction (AMI) has important therapeutic and
prognostic implications. The role of impaired systolic function
for evaluation of functional recovery has been extensively
investigated. However, whether impaired regional diastolic
function after AMI also has predictive implications has not
been investigated so far in humans using magnetic resonance
imaging (MRI). Recently, Strain-Encoded (SENC) Imaging was
introduced as a new MR-technique to evaluate myocardial strain
and strain rate. SENC, compared to MR tagging, is a method that
does not suffer that much from diastolic fading. Therefore, SENC
is an ideal MR-method to determine not only regional systolic but
also regional diastolic function.


Figure I (abstract 031)


Peak cu tnlir train


Y A





Colour coded SENC-image of a patient with transmural myocardial
infarction with corresponding strain-curve.

Purpose: To evaluate the predictive value of regional systolic
and diastolic function for improvement of regional myocardial
function in patients after AMI.
Methods: MRI (1.5 T, Achieva, Philips, the Netherlands) was
performed to 23 consecutive patients (mean age 57 10) 3 I
days after successfully reperfused ST-elevation-myocardial infarc-
tion and at a follow-up of 6 2 month. 10 age-matched
volunteers served as controls. True cine sequences of 3 long-
axis views (2-,3- and 4-chamber) and a short-axis (SA) view
covering the ventricle from apex to basis were acquired using a
Steady State Free Precession (SSFP) sequence. After that, SENC
cine images were acquired on the same long-axis planes to
measure circumferential strains. Finally, using the same plane


Figure 2 (abstract 031)


100 Diastolic strain rate

Ss80

60

S 40 -
C 40
Syak tolic strain
20




0 40 80


100-Specificity

Receiver-operating characteristic (ROC) curve demonstrates that
diastolic strain rate assessed with Strain-Encoded Imaging is more
sensitive than peak systolic strain for prediction of functional recovery
diastolicc strain rate AUC 0.77 (0.67-0.86); peak systolic strain AUC 0.64
(0.53-0.74); p < 0.05).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


orientations, multislice contrast enhanced MRI (CE-MRI) with an
inversion-recovery (IR) sequence covering the whole ventricle
was conducted after injection of 0.2 mmol Magnevist (Bayer,
Germany) and waiting for 10 minutes.
SENC-Data were analysed using a dedicated software (Diagno-
soft, Paolo Alto, CA, USA). Peak systolic circumferential strain
and early diastolic strain rate were measured at each segment in
a modified 17 segment model. Early-diastolic strain rate (ECC/s)
was defined as the slope over the duration from peak-systole to
mid-diastole.
Regional wall motion was evaluated at baseline and at follow-up
semi-quantitatively from the SSFP cine sequences by consensus
reading of two blinded observers as normokinetic, hypokinetic
or akinetic to evaluate functional recovery. CE-MR images were
analyzed to quantify the size and transmurality of the scared
myocardium using a regular workstation (EWS, Philips, the
Netherlands).
Results: 276 segments were analyzed. In 6 segments (2,2%)
image quality did not allow adequate data analysis of SENC-
images. 157 segments showed normal resting function and
I 19 segments showed wall motion abnormalities at baseline.
44 segments showed functional recovery at follow, 75 segments
did not recover.
Peak systolic circumferential strain in healthy volunteers was
-22 3%, early diastolic strain rate was calculated with
122.3 36 Ecc/s.
Peak systolic strain values and early diastolic strain rate (figure I)
were significantly different in segments showing functional
recovery and in segments without functional recovery (peak
systolic strain 10 1% versus 6 1%, p < 0.01; early diastolic
strain rate 75 6 Ecc/s versus 38 5 Ecc/s, p < 0.01).
Diastolic strain rate was more sensitive for prediction of
functional recovery than peak systolic strain (figure 2).
Interestingly, peak systolic strain and diastolic strain rate were
even more impaired in segments showing microvascular
obstruction compared to transmural infarcted segments without
microvascular obstruction (p < 0.05 for both).
Conclusion: SENC allows mechanical characterization of
regional myocardial injury. Diastolic function assessed with
SENC is more precise in predicting functional recovery after
AMI than peak systolic strain.


032
Reperfusion hemorrhage following PCI -
quantification with T2* imaging and impact
on area at risk assessment
Declan P O'Regan', Rizwan Ahmed', Clare Neuwirth',
Yvonne Tan', Giuliana Durighel', Jo V Hajnal',
Imad Nadra2, Simon J Corbett3 and Stuart A Cook'
'Imperial College, London, UK
2Imperial College Healthcare NHS Trust, London, UK
3Southampton University Hospitals NHS Trust,
Southampton, UK

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):032
Introduction: Occlusion of a coronary artery leads to
myocardial tissue edema in the vascular bed downstream of
the vessel. The extent of hyperintense edema on T2-weighted
images allows the area at risk (AAR) from ischemic injury to be
retrospectively determined. However, reperfusion of severely


Figure I (abstract 032)


(A) T2* map acquired 2 days post-PCI. Pixels with a T2* < 20 ms are
shown in red and demonstrate the region of post-reperfusion
hemorrhage (arrow). Susceptibility artifact (arrowhead). (B) The
hemorrhage corresponds to the area of MVO (red contour) shown on
the early enhancement image. (C) Myocardial necrosis (red contour), and
residual MVO (black core), is shown on the late enhancement image.

ischemic myocardium also leads to interstitial hemorrhage and
this may be an important marker for irreversible microvascular
damage.
Purpose: We assessed the feasibility of using T2* mapping to
quantify regions of myocardial hemorrhage following percuta-
neous primary coronary intervention (PPCI) for acute myocar-
dial infarction. We also hypothesized that myocardial
hemorrhage would lead to an underestimate of the AAR on
T2-weighted imaging using conventional signal threshold criteria.
Methods: Fifteen patients who had recently undergone PPCI
within the previous 7 days were imaged. Left ventricular function
was assessed with conventional cine sequences. Myocardial
edema was imaged with a T2-weighted STIR sequence.
Myocardial haemorrhage was imaged with a black-blood
multiecho T2* sequence using navigator respiratory-gating.
Microvascular obstruction (MVO) and late enhancement were
imaged at I minute and 15 minute delays respectively using a
3 dimensional inversion-recovery sequence.
The area of myocardial edema on the T2 STIR images was
measured with a boundary detection tool. This was compared to
a conventional signal intensity threshold method using 2, 3 and
5 standard deviations (sd) above the mean of remote normal
myocardium. A salvage index was calculated as the proportion of
the AAR that did not show late enhancement. T2*-mapping of


Figure 2 (abstract 032)


T2-STIR images in the same patient as in Figure I. Boundary detection
identifies the myocardial edema (green line) which represents the AAR.
The AAR determined at each signal threshold is shown in red. At low
thresholds non-specific signal noise results in bright pixels in non-
ischemic territories causing an overestimation of the AAR. At higher
thresholds the signal from the myocardial edema is masked by the
presence of hemorrhage in the core of the infarct (arrow) and leads to an
underestimation of the AAR.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


the left ventricle was performed using a threshold of 20 ms to
define the presence of hemorrhage.
Results: The mean area of hemorrhage was 5.0% at the level of
the infarct. There was a close correlation between hemorrhage
and the MVO (r2 = 0.75, p < 0.01) and infarct volumes (r2 = 0.76,
p < 0.01) (Figure I). When > 5% hemorrhage is present the AAR
was underestimated by 50% at a 5 standard deviation threshold
compared to a boundary detection tool (21.8% vs 44.0%,
p < 0.05) (Figure 2). Estimation of myocardial salvage at 3 sd
and 5 sd signal thresholds becomes unreliable in hemorrhagic
infarcts as the apparent AAR becomes smaller than the actual
infarct size.
Discussion: Our findings demonstrate the feasibility of using
T2* mapping to quantify myocardial hemorrhage following infarct
reperfusion. Hemorrhage is frequently observed and is asso-
ciated with large infarcts where MVO is present and is an
indicator of poor myocardial salvage. Hemorrhage in the core of
the infarct causes signal loss on T2-weighted imaging and
boundary-detection is required to reliably assess the AAR.
Conclusion: Studies using CMR to determine the AAR and
myocardial salvage should use boundary detection methods for
quantification as arbitrary signal thresholds are unreliable when
hemorrhage is present. Post-reperfusion hemorrhage can be
assessed with T2*-mapping and may provide an imaging marker
of poor myocardial salvage.


033
T2-weighted MRI pulse sequences for imaging
post-infarct edema in mice: comparison of spin
echo and T2 preparation approaches
Ronald J Beyers, Yaqin Xu, Frederick H Epstein
and Brent A French
University of Virginia, Charlottesville, VA, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):033
Introduction: An ongoing diagnostic challenge exists in reliably
differentiating non-salvageable, acutely infarcted myocardium
from surrounding stunned, yet viable, myocardium that defines
the area at risk. T2w cardiac magnetic resonance (CMR) imaging
has previously been used to image the edema characterizing the
area-at-risk region in post myocardial infarcted (MI) canine,
porcine and human hearts. Similar techniques would be valuable
in basic research studies of MI in mice, where they might be used
jointly with gadolinium delayed enhancement (DE) imaging to
non-invasively define infarct size as "% area-at-risk" in transgenic/
knock-out mice. However, the rapid murine heart rate presents
challenges to T2w CMR application in mice. The typical T2w
echo time of 40-60 ms needed for the detection of edema
occupies a significant portion of the murine cardiac cycle (100-
120 ms) with significant periods of blood flow and cardiac
motion.
Purpose: Develop an effective T2w CMR sequence for mice
that exhibits high immunity to flow and tissue motion artifacts
while maintaining sufficient and consistent signal-to-noise (SNR)
and contrast-to-noise (CNR) performance.
Methods: We developed two T2w sequences for murine CMR:
a flow and motion desensitized spin-echo (SE) sequence and a T2
preparation (T2prep) sequence. The SE sequence employed a
slice-selective excitation RF pulse and a thicker slice-selective
refocusing RF pulse, and applied readout and phase encoding


Figure I (abstract 033)


I Gd-OTPA DE Infarct


T2w SE Edema T2w T2nrem Edema I


* a0 a *A DE HlatD T OwSE 0 de Em T2w TipmrtEd








Day Owa2 Day Dy4
08"ysPostMI

Gd-enhanced mid-ventricular image of the mouse heart I day after MI,
showing enhanced infarct region (A) with corresponding thresholded
infarct region (D). Same slice T2w spin echo image (B) with
corresponding thresholded edema (E). Same slice T2w T2prep image
(C) with corresponding thresholded edema (F). Comparison of detected
infarct and edema region areas over Days I through 4 post-MI for each
imaging method.


gradients after the refocusing pulse. The T2prep sequence
employed non-selective MLEV-weighted composite RF pulses
followed by a standard slice-selective gradient-echo readout.
Each sequence was applied on an isoflurane-anesthetized mouse
on Days I through 4 after reperfused MI induced by 60 min
coronary occlusion, as described previously. Parameters for both
sequences included TR = 1500 ms, TE = 40-60 ms, FOV =
25 x 25 mm, slice thickness = I mm, matrix = 128 x 128 and
BW = 520 Hz/pixel. In addition, gadolinium-DTPA DE CMR was
performed each day to define infarct location. All scans of each
sequence were performed consecutively at four identical
contiguous slice positions from mid-ventricular toward the
apex. All scans were performed on a 7 T Bruker/Siemens
ClinScan.
Results: Panels A through C (Fig. I) show example sets of
Gd-DTPA DE, T2w SE and T2w T2prep images (respectively)
from the same LV slice position at Day I post-MI. Panels D
through F show the respective hyperintense regions identified by
threshold analysis performed after manual segmentation of the
left ventricular (LV) myocardium. Threshold analysis for all
images selected any pixels within the segmented myocardium
with >2 standard deviation magnitude than a myocardial image
sample chosen remote from the infarct area. Panel G tracks and
compares the detected infarct and edema region areas over


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Days I through 4 post-MI for each imaging method. Both T2w
sequences detected regions of edema that corresponded to or
surrounded the infarct as determined by DE CMR. The T2w SE
sequence gave a consistently higher SNR of 104 6 (mean
SEM) and CNR of 52 3 over the T2prep SNR of 68 4 and
CNR of 34 2, where CNR was measured between remote and
threshold-selected myocardium. However, the SE sequence had a
higher occurrence of flow and motion artifacts that degraded the
consistency and accuracy of threshold selection.
Conclusion: As shown (panel G), the T2prep yielded a
consistently higher edema area percentage of 48.2 2.5
compared to the infarct area percentage of 41.6 1.8, which
correlates well with previous canine and human studies. Mean-
while, the SE gave a slightly lower mean with higher variance
edema area percentage of 47.0 4.2 that was attributed to flow
and motion artifacts. To our knowledge, this is the first study to
demonstrate the feasibility of performing T2w CMR edema
imaging in mice, which opens a variety of potential basic research
applications investigating the role of individual genes in acute and
chronic settings post-MI.




034
First-pass myocardial perfusion assessment using
eight-fold accelerated k-t BLAST stress DCE-MRI
with rapid parametric mapping
Aleksandra Radjenovic', Sven Plein Neil Maredia,
Sebastian Kozerke2, John Biglands', John Greenwood'
and John Ridgway'
'University of Leeds, Leeds, UK
2University and ETH, Zurich, Switzerland

journal of Cardiovascular Magnetic Resonance 2009, I (Suppl 1):034
Background: First-pass myocardial perfusion assessment using
dynamic contrast enhanced MRI (DCE-MRI) is still one of the


Table I (abstract 034) DCE-MRI sequence parameters

Saturation recovery pre-pulse delay 150 ms
TFE readout TR/TE/wp = 3.6/1.7/150
k-t acceleration factor 8
Image matrix 192 x 187


most challenging CMR applications. Image quality, spatial and
temporal resolution are limited by the need to acquire multiple
slices as single shot acquisitions within a single heart beat, as
the process of interest is transient and very rapid, especially
under pharmacologically induced stress hyperaemia. This is
why accelerated acquisition methods, such as k-t BLAST [I],
could provide a significant improvement in the assessment of
myocardial perfusion by CMR.
An optimised DCE-MRI sequence with eight-fold k-t BLAST
acceleration was shown to provide a significant improvement in
spatial resolution without loss of image quality[2], making these
datasets very suitable for parametric mapping.
Objective: To investigate the ability of eight-fold k-t BLAST
accelerated stress perfusion DCE-MRI combined with a rapid
parametric mapping algorithm to detect regions of ischaemia in a
pilot cohort of patients with suspected coronary heart disease
(CHD).
Methods: The regional ethics review board's permission was
obtained and ten patients (9 male) were recruited into this study
(age range 46-69, mean 59). First-pass stress myocardial
perfusion DCE-MRI was performed on a whole body 1.5 T MR
scanner (Gyroscan Intera CV, Philips Medical Systems) with
dedicated k-t BLAST acquisition and reconstruction software
(GyroTools Ltd, Switzerland). An optimised DCE-MRI sequence
(Table I) allowed three uniformly prepared slices to be
acquired in every heart beat, for heart rates of up to 100 bpm
[2]. DCE-MRI was acquired under adenosine induced stress with


Figure I (abstract 034)


Representative dynamic frames from ten accelerated DCE-MRI datasets.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table 2 (abstract 034) Median Enhancement Ratios (ER%)

Patient I 2 3 4 5 6 7 8 9 10
Coronary artery X-ray (number of affected territories) I I I I 0 2 I 0 I 3
Median Enhancement Ratio% 61.4 133 64.6 38.3 77.2 33.1 58.0 65.2 40.6 19.1


Figure 2 (abstract 034)


Examples of parametric maps of enhancement ratios in single-vessel
disease (corresponding to images 2, 4 and 7 in Figure I). Dark coloured
voxels belong to the lowest part of the individual study's frequency
distribution.



peripheral venous administration of 0. I mmol/kg Gd-DTPA. The
algorithm for quantitative analysis and parametric mapping
comprised the following steps: I) automated detection of the
target post-contrast frame 2) endocardial border detection in
the target post-contrast frame using automated region-growing
algorithm and a single spline fitting to define epicardial border 3)
automated registration of pre- and post-contrast frames using
incremental rigid translation 4) computation of percentage
enhancement ratios (ER) on voxel-by-voxel basis 5) histogram
analysis of the ER datasets and creation of percentile-based
colour maps.
Results: On coronary X-ray angiography, 8/10 patients had
coronary stenosis 70%, while two had no significant lesions
(Table 2). Representative dynamic frames from all ten DCE-MRI
studies are shown in Figure I. Example parametric maps of ER
are presented in Figure 2. Global enhancement ratios were
computed as a median percentage change over baseline (Table 2).
Motion correction was not required in three datasets, and 1-2
voxel displacement was applied in seven datasets. In patients with
no significant coronary stenoses, the average ratio was 71.2%
(n = 2), in single-vessel disease it was 66.0% (n = 4). In a patient
with two-vessel disease ER was 33.1% and in a patient with three-
vessel disease ER was 19. 1%.
Discussion: The results of this pilot study suggest that the
proposed methods for acquisition and analysis of first-pass
myocardial perfusion are robust and ready for use in clinical
studies, where its diagnostic utility needs to be assessed formally
in a larger patient cohort. The methods allow the assessment of
regional differences in perfusion, as well as global changes in
perfusion. There is scope for further improvement, notably in
increasing resistance to motion artefact and reducing signal
inhomogeneity, which can lead to the appearance of false positive
lesions.
References
I. Tsao, Boesinger and Preussman : Magn Reson Med. 1042,
50:1031-2003.
2. Radjenovic, et al: J Cardiovasc Magn Reson. 2007, 9(2):2 13-
214.


035
k-t SENSE accelerated stress myocardial
perfusion MRI at 3 Tesla
Shingo Kato, Hajime Sakuma, Motonori Nagata,
Nanaka Ishida, Kakuya Kitagawa, Masaki Ishida,
Hiroshi Nakajima, Katsuya Onishi, Masaaki Ito
and Kan Takeda
Mie University Hosiptal, Tsu, Mie, Japan

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):035
Objective: The purpose of this study was to evaluate the
feasibility and diagnostic accuracy of high spatial resolution stress
myocardial perfusion MRI acquired at every heartbeat by using
k-t SENSE and 3 Tesla MR imager.
Background: High spatial and temporal resolutions are
required for the accurate assessment of myocardial ischemia
using stress perfusion MRI.
Methods: Thirty-three patients with suspected coronary artery
disease were studied. High spatial resolution (<2 mm) first-pass
contrast enhanced MR images were obtained at rest and during
stress by using a 3.0 T MR imager (Achieva) and k-t SENSE
acceleration factor of 5. Saturation recovery TFE images were
acquired with TR/TE of 2.9 ms/1.5 ms, FOV = 40 x 30 cm,
matrix = 256 x 192, slice thickness = 8 mm. Three short-axis
sections of the left ventricle were imaged at every heart beat. Two
observers determined the image quality score (I :poor 4:excellent)
and recorded the presence or absence of respiratory artifacts and
endocardial dark rim artifacts using a 16-segment model.
Results: All studies were successfully completed, with the
averaged image quality score of 3.8 0.4. Endocardial dark rim
artifacts were observed in 17 (3.2%) of 528 segments, but there



Figure I (abstract 035)


Rest perfusion MRI acquired with 3 T MR imager, 32 channel cardiac coils
and k-t SENSE in a patient with triple vessel disease. Rest perfusion MRI is
normal and no endocardial banding artifact is observed.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 2 (abstract 035)


Stress perfusion MRI in the same patient with triple vessel disease.
Subendocardial ischemia is clearly demonstrated in the anteroseptal well,
lateral wall and inferior wall on high resolution images.

were no cases in which dark-rim artifacts influenced the
diagnosis. Respiratory artifacts were found in I I (2.1%) of 528
segments. In 14 patients who underwent coronary angiography
within 2 weeks from MR study, stress-rest perfusion MRI
demonstrated the sensitivity, specificity, positive and negative
predictive values and accuracy of were 90.9%(10/1 I), 96.7%(30/
31), 90.9%(10/1 I), 96.7%(30/3 1) and 95.2%(40/42) for detecting
significant coronary artery disease. Figures I and 2.
Conclusion: Perfusion MR images with high spatial resolution
can be acquired at every heart beat by using a 3 T MR imager and
k-t SENSE acceleration. This approach can substantially reduce
endocardial dark rim artifacts and allows for an accurate
detection of myocardial ischemia in patients with flow-limiting
coronary artery disease.


036
Adenosine magnetic resonance imaging versus
dobutamine stress echocardiography in patients
with low probability for coronary artery disease
Stamatios Lerakis, Athanasios V Anadiotis,
Elisa Zaragoza-Macias, Emir Veledar, John Oshinski,
Chris Vaccari, Akbar H Khan, Puneet Sharma,
Irfan Shukrullah, Paolo Raggi and Arthur E Stillman
Emory University, Atlanta, GA, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):036
Introduction: Accurate assessment of patients with chest pain
without electrocardiographic changes or elevation of serum
cardiac enzymes is challenging. There is increased interest in the
role of dobutamine stress echocardiography (DSE) and adenosine
magnetic resonance imaging (AMRI) performed in the chest pain
unit as a diagnostic method to rule out Coronary Artery Disease
(CAD) as the cause of the chest pain in this population.
Purpose: The purpose of this study was to compare DSE and
AMRI in patients with low probability of CAD.
Methods: Inclusion criteria for the study were patients with
normal EKG (no signs of cardiac ischemia) and negative cardiac
enzymes, who were admitted to the Cardiac Decision Unit


Table I (abstract 036)

Characteristics MRI DSE p-value

AGE 52 12 54 13 0.0571
Gender (males) 144 (70.9%) 38 (38%) <0.0001
CAD 16 (16%) 13 (6.4%) 0.0076
HTN 66 (64.7%) 111 (54.7%) 0.0941
DM 30 (29.7%) 36 (17.7%) 0.0171
SMOKING 20 (19.6%) 39 (19.5%) 0.2967
Dyslipidemia 40 (39.2%) 46 (22.8%) 0.0027
Family_history_of_CAD 52 (51%) 74 (54.4%) 0.6029
EF 65.0 10.4 64.2 6.1 0.4235
Coronoary Artery Disease 13 (12.6%) 3 (1.5%) <0.0001
Beta Blocker use 29 (28.4%) 25 (12.4%) 0.0005
Ca_B 19(18.6%) 27 (13.4%) 0.2268
ACEi 21 (20.6%) 21 (10.4%) 0.015
ARBs 14 (13.7%) 20 (9.9%) 0.3178
ASA 27 (26.5%) 21 (10.4%) 0.0003


(CDU) from 2006-2008 at Emory University Hospital. The
diagnostic method used was chosen randomly by physician
preference. T-test was used to assess differences in continuous
variables, and X2 square to test differences in categorical
variables between the two groups. Logistic regression was used
to assess the likelihood of detecting CAD after adjusting for
technique used and baseline characteristics.
Results: A total of 306 patients were included, 103 patients were
evaluated with AMRI and 203 underwent DSE. Mean age was similar
among groups (52 for AMRI vs. 54 for DSE). Patients in AMRI group
were more likely to be males, had more risk factors for CAD, and
used more Beta blockers or aspirin at baseline compared to patients
evaluated by DSE. AMRI identified more patients as having CAD
compared to DSE (13 (12.6%) vs.3 (1.5%), p = < 0.0001). This
difference remained significant even after adjusting for baseline
characteristics and risk factors [OR of CAD by AMRI vs
DSE = 7.01, Cl (1.48-33.16) p = 0.014]. (Data in Table I.)
Conclusion: In this prospective study of patients with low
probability of CAD, AMRI identified more cases of CAD than
DSE even after adjusting for baseline characteristics. Although
selection bias could account for part of these results, a higher
sensitivity for AMRI is suggested.


037
Blood oxygen level-dependent MRI in patients
with coronary artery disease and normal
volunteers: a validation study against PET
Theodoros D Karamitsos', Alejandro Recio-Mayoral2,
I 2 .2
Jayanth R Arnold', Lucia Leccisotti2, Paul Bhamra-Ariza2
Ruairidh K Howells', Nick Searle', Matthew D Robson',
Ornella E Rimoldi2, Paolo G Camici2, Stefan Neubauer'
and Joseph B Selvanayagam'
'University of Oxford Centre for Clinical Magnetic Resonance
Research (OCMR), Oxford, UK
2Medical Research Council (MRC) Clinical Sciences Centre,
Imperial College of Science, Technology and Medicine,
Hammersmith Hospital, London, UK

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):037
Background: Elevated deoxyhaemoglobin seen downstream
in a territory subtended by a stenotic coronary artery can be


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table I (abstract 037) Rest MBF, stress MBF, coronary flow reserve (CFR) and BOLD-signal intensity (SI) change of stenosed, remote
to ischemia and normal segments

CAD patients Normal volunteers

STENOSED N = 59 REMOTE N = 73 NORMAL N = 60 P-value

REST MBF (ml/min/g) 0.95 0.03 (0.90 1.01) 0.94 0.03 (0.88 0.99) t 1.03 0.03 (0.97 1.09) 0.04
REST MBF corrected [ml/min/g/(mmHg.bpm/104)] 1.43 0.05 (1.34 1.52) 1.42 0.04 (1.34 1.51) 1.39 0.04 (1.31 1.46) 0.76
HYPEREMIC MBF (ml/min/g) 2.11 (1.66 2.42) * 2.73 (2.16 3.44)t 3.69 (3.16 -4.61) <0.001
CFR 2.31 (1.70- 2.91) * 3.00 (2.31 -3.98) 3.62 (2.89- 4.93) <0.001

CFR corrected 1.41 (1.06 2.00) * 2.01 (1.55 2.50)t 2.68 (2.32 3.45) <0.001
BOLD SI change (%) 1.25 (-2.38 7.89) * 8.91 (4.95 12.78)t 14.08 (9.23 22.20) <0.001

Data are presented as means standard deviation (95% confidence intervals) or median (interquartile range) as appropriate Rest MBF corrected: rest
MBF corrected for rate-pressure product (RPP), an index of myocardial oxygen consumption: MBF = (MBF/RPP) x 104. Stenosed: myocardial segments
subtended by a >50% stenosed coronary artery. Remote: myocardial segments subtended by arteries with minimal or no CAD. Normal: myocardial
segments in normal volunteers. p < 0.05 for comparison between stenosed and remote segments. t p < 0.05 for comparison between remote to
ischemia and normal segments. p < 0.05 for comparison between stenosed and normal segments.


assessed by blood oxygen level-dependent (BOLD) MRI.
Deoxyhemoglobin is paramagnetic and acts as an intrinsic
contrast agent leading to signal loss in T2- and T2*-weighted
sequences. Previous animal and human BOLD studies at 1.5 Tesla
using T2*-weighted sequences were fundamentally limited by
the relatively small signal differences between normal and
de-oxygenated myocardial regions. A new T2-prepared steady-
state free precession (SSFP) BOLD sequence gave promising
results in animal models at 1.5 Tesla. [I] In theory, implementa-
tion of this sequence at the higher field strength of 3 Tesla would
further improve the detection of BOLD signal intensity (SI)
changes. We sought to apply a T2-prepared SSFP BOLD
sequence at 3 Tesla in patients with coronary artery disease
(CAD) and normal volunteers, and validated it against perfusion
measurements by Positron Emission Tomography (PET).
Methods: Twenty-two patients (age 62 8 yrs, 16 men) with
CAD (at least I stenosis > 50% on quantitative coronary
angiography-QCA) and 10 normal volunteers (age 52 7 yrs,
7 men) underwent 3 T BOLD MRI and PET. For BOLD-CMR, a
single mid-ventricular slice was acquired at mid-diastole using a
T2-prepared SSFP pulse sequence with the following parameters:


T2 preparation weighting 40 ms, matrix 168 x 192, slice
thickness 8 mm, flip angle 44. A set of 6 images was acquired
at rest and at peak adenosine (140 pg/kg/min) stress. Using PET
with oxygen-15 labeled water, myocardial blood flow (MBF) was
measured at baseline and during adenosine hyperemia. The
BOLD short-axis view was divided into 6 segments, according to
the mid-ventricular segments of the I 7-AHA segment model, and
mean signal intensities (SI) were calculated using QMass (Medis)
software. SI values were corrected for differences in TI-
weighting owing to heart rate changes at stress and rest. PET
images were analyzed with home-built software under MATLAB
(MathWorks Inc.) and registered with the BOLD short-axis
image using anatomical landmarks.
Results: Based on the coronary anatomy, 59 myocardial
segments were supplied by significantly stenosed vessels
(stenosed segments) and 73 segments were supplied by vessels
with minimal or no disease (remote to ischemia segments).
A third group of myocardial segments (n = 60) from normal
volunteers were labeled as 'normal' segments. Rest MBF, stress
MBF, coronary flow reserve and BOLD-SI change of stenosed,
remote to ischemia and normal segments are shown in Table I.


Figure I (abstract 037)


. Mr


a .m


V #1I


G






oI

An example of a patient with significant disease in the right coronary artery. A SI drop was noted in the inferior wall (black arrow). All other myocardial
segments showed a rise in SI during stress.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Taking QCA as the gold standard, cut-off values for stress MBF
(< 2.45 ml/min/g AUC 0.83) and BOLD SI change (< 3.74% -
AUC 0.78) were determined to define ischemic segments. BOLD
MRI and PETagreed on the presence or absence of ischemia in 18
of the 22 patients (82%), and in all normal subjects. With regards
to per segment analysis: taking PET as the gold standard and by
applying the cut-off values for stress MBF and BOLD SI, BOLD
MRI had moderate sensitivity (63%) but very good specificity
(88%) for the identification of ischemia. Minor off-resonance
artifacts were found in 9 subjects (7 CAD patients and 2 normal
volunteers). Figure I shows an example of a patient with
significant disease in the right coronary artery.
Conclusion: T2-prepared SSFP 3 T BOLD imaging is feasible in
the clinical setting and has good agreement with PET perfusion
measurements for the detection of myocardial ischemia.
Reference
I. Fieno DS, et al: Circulation 2004, 110:1284-1290.

038
Assessment of stess and rest perfusion in patients
early after first anterior STEMI patients treated
successfully with pPCI
Dorota Piotrowska-Kownacka, Lukasz Kownacki,
Grzegorz Opolski, Leszek Krolicki and Olgierd Rowinski
Medical University of Warsaw, Warsaw, Poland
journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):O38
Introduction: Restoration of normal epicardial coronary flow
in acute ST segment elevation myocardial infarction does not
ensure adequate perfusion at the myocardial tissue level. In the
era of primary PCI, patients with acute myocardial infarction
treated successfully with PCI are discharged mostly within first
week. There are no studies available regarding blood flow at the
tissue level in these patients during effort.
Purpose: Assessment of stess and rest perfusion defects early
after STEMI successfully treated with pPCI.
Methods: 61 patients with first anterior STEMI (57 10 yrs.
52 M) who underwent successful pPCI have been included into
the study. CMR was performed on 1.5 T scanner between 5 and
10 days after pPCI. Myocardial perfusion was assessed at rest and
in stress condition during infusion of adenosine (140 pg/kg b.w./
min., 3 minutes infusion) during first-pass perfusion imaging.
Microvascular obstruction regions (MVO) were assessed on early
enhancement images acquired I-2-minutes after stress perfu-
sion. Delayed enhancement (DE) images were acquired 15
minutes after Gd-DTPA. Transmurality of myocardial perfusion
defects at rest and in stress condition, MVO were evaluated
using 5 point scale in 16 segments. DE was also evaluated in
segment 17. The sum of scores were calculated for each variable.
Scar size and MVO were additionally quantitatively analyzed using


MASS software. The results were given in ml and in % of LV
volume.
Results: Only in 2 patients there was no evidence of at least
subendocardial stress perfusion deficit. Stress perfusion sum of
scores discriminated patients with normal EF (mean 59 1%)
and LV dysfunction (mean EF = 38 9,7). Median stress perfu-
sion sum of scores was 15 points (ranged 0 to 37). Median rest
perfusion scores was significantly lower (3 points; ranged 0-27).
Median MVO and DE sum of scores were 3 points (ranged 0-33)
and 25 (3-42) respectively. DE measured as a % of LV volume has
discriminated patients with severe (mean EF 31,7 8,7) vs
moderate LV dysfunction (mean EF 41,9 9,5; p = 0,001) with a
cut of point 40%. Regression model revealed that only DE and
stress perfusion sum of scores have significantly contributed to
the LV EF model at discharge.
Conclusion: Despite TIMI 3 flow in coronary artery myocar-
dial perfusion defects at the tissue level are very frequent. Only
in patients with preserved LV function pharmacological stress
have not induced or intended perfusion deficits. All patients with
STEMI anterior successfully treated with pPCI, even with mild LV
dysfunction should avoid effort which could induce ischemia. The
pathogenesis remains unknown. Further studies are needed.



039
Evaluation of contrast wash-in and peak
enhancement in adenosine first pass perfusion in
patients post bypass surgery
Christoph Klein', Eike Nagel2, Kristof Graf',
Stephan Dreysse', Bernhard Schnackenburg3
and Eckart Fleck'
'German Heart Institute Berlin, Berlin, Germany
2King's College London, London, UK
3Philips Medical Systems, Hamburg, Germany

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):O39
Introduction: CMR adenosine first pass perfusion yields
excellent results for the detection of significant coronary artery
disease. As in patients after coronary artery bypass grafts
(CABG) myocardial perfusion is more complex and additionally
the kinetic of a first pass bolus may by altered due to different
distances through the bypasses and/or native vessels, this patient
group has been excluded from most published studies.
Parameters like speed of contrast wash-in (upslope, time to
50% or peak enhancement) and peak enhancement are indirectly
used for visual analysis and may be altered post CABG imitating
perfusion defects without significant stenosis. In this case,
adenosine perfusion would be an inadequate diagnostic test.
Purpose: Aim of the study was to evaluate semiquantitative
perfusion parameters in patients after CABG in order to evaluate


Table I (abstract 039) Semiquantitative parameters in native vessels and grafts

Native CABG p (native Correlation p (CABG Correlation
vessel vs. CABG) (native vs. CABG) vs. CABG) (CABG vs. CABG)

Upslope 17.7 7.8 17.3 7.0 >0.05 0.92 >0.05 0.89
Time to 50% 8.2 1.8 8.1 1.8 >0.05 0.94 >0.05 0.90
Time to peak 13.7 3.1 13.7 3.1 >0.05 0.97 >0.05 0.92
Relative peak enhancement 22.9 9.2 22.0 8.7 >0.05 0.91 >0.05 0.86


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 039)


Figure I (abstract 040)


contrast kinetics in areas supplied by native coronaries and
different bypass grafts.
Methods: 32 patients post CABG were included into the study
consisting of adenosine first pass (0.05 mmol/kg Gd-DTPA)
perfusion (3 short axis views/heart beat) and late Gadolinium
enhancement before undergoing invasive coronary angiography.
In invasive angiography, areas perfused by native coronaries and
the different bypasses were identified. In these areas upslope,
time to 50% peak enhancement, time to peak enhancement and
relative peak enhancement were calculated using the ViewForum
(Philips Medical Systems, Best, Netherlands). Only segments
without vessel stenosis and without LGE were used for final
analysis.
Results: Results are displayed in Table I. No significant
differences in any parameter comparing native vessels with
CABG or CABG with CABG were found. Figure I shows
homogenous perfusion enhancement in a patient post CABG
with areas perfused by native RCA, LIMA on LAD and venous
graft on a marginal branch.
Conclusion: Semiquantitaive parameters of first pass adeno-
sine perfusion are similar in areas supplied by native vessels or
by different bypass grafts. These parameters are indirectly used
for visual analysis (speed of contrast wash-in and peak signal
intensity). Therefore the possible different contrast kinetic
through grafts and native vessel does not seem to be a limiting
factor for the accuracy of first pass adenosine perfusion in
patients post CABG.



040
In-room treadmill exercise stress cardiac
magnetic resonance in patients with
suspected ischemic heart disease
Subha V Raman, Mihaela Jekic, Jennifer A Dickerson,
Eric L Foster and Orlando P Simonetti
Ohio State University, Columbus, OH, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):040
Objective: To implement and demonstrate the feasibility of
in-room treadmill exercise stress perfusion and cine CMR in
patients with suspected coronary artery disease (CAD).


p!


4/


Background: Exercise is preferred to pharmacologic stress
because it links physical activity to symptoms and ischemia and
offers important information such as exercise capacity, blood
pressure response, ECG changes, and the presence or absence of
exercise-induced symptoms. The Bruce Treadmill Test is the
most commonly-used protocol for cardiac stress testing in the
US, with proven diagnostic and prognostic value. The lack of
MRI-compatible exercise equipment has made pharmacological
stress the only practical option for CMR stress testing to date.
We implemented treadmill exercise stress cardiac magnetic
resonance imaging (CMR) of both wall motion and perfusion in
patients with suspected ischemic heart disease.
Methods: A treadmill was modified by replacing all ferromag-
netic components except the motor with non-magnetic equiva-
lents. This enabled safe placement of the treadmill in the corner
of the MRI room, approximately 2 m. from the patient table.
Sixteen patients age 56 8 years referred for stress SPECTwere
prospectively enrolled. Tc99m SPECT imaging was performed at
rest; patients were then moved to the MRI suite for stress
testing. Patients were positioned on the MRI table using a vacuum
mattress to enable precise repositioning following treadmill
exercise. Localizer scans followed by resting real-time cine CMR
were performed, and then cine and perfusion scans were queued
for rapid execution immediately following treadmill exercise.
After removing the patient from the magnet, resting ECG was
recorded and treadmill exercise commenced using the Bruce
protocol. 12-lead ECG monitoring was performed throughout
the treadmill test. At peak stress, Tc99m was injected and
patients rapidly returned to their prior position in the magnet for
post-exercise real-time cine followed immediately by multislice
first-pass perfusion imaging with 0.1 mmol/kg IV gadolinium-
based contrast using GRE-EPI TR/TE 5.8/1.2 ms, ETL 4 m matrix
160 x 96 and TSENSE acceleration factor of 2. The patient table
was pulled out of the MRI system and patients remained supine


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i







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


on the patient table for 12-lead ECG monitoring during 5-10 min
of recovery. The table was then returned to magnet bore for
recovery cine and resting perfusion followed by delayed post-
gadolinium imaging. Post-CMR, patients went to the adjacent
SPECT lab for stress nuclear imaging. Five patients underwent
coronary angiography. Images were reviewed blinded to other
results.
Results: All patients completed the examination (Figure I:
ischemia example). Mean time to completion of cine MRI post-
exercise was 73 9 sec, and to completion of perfusion imaging
91 6 sec. Accuracy in the five patients who underwent
coronary angiography was 5/5 for CMR and 3/5 for SPECT.
Follow-up at median of 60 days indicated freedom from
cardiovascular events in 13/13 CMR-negative and 12/13 SPECT-
negative patients.
Conclusion: Exercise stress CMR including wall motion and
perfusion inside the MRI room is feasible in patients with
suspected ischemic heart disease. Preliminary results indicate
favorable accuracy and prognostic value of this new stress
imaging system compared to nuclear perfusion imaging. Further
technical modifications are required to facilitate completion of
cine and perfusion imaging within I minute of peak stress.



041
Adenosine induced pulmonary vasodilation is
blocked by active cigarette smoking, an
evaluation by pulmonary transit time with
first pass perfusion MRI
Jie Jane Cao, Sophie Wang, Marguerite Roth,
William Schapiro, Yi Wang and Nathaniel Reichek
St Francis Hospital, Roslyn, NY, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):04 I
Introduction: Pulmonary transit time (PTT) measures the time
that blood travels through the pulmonary vasculature. PTT
correlates well with pulmonary vascular resistance. It is
prolonged in patients with pulmonary hypertension and con-
gestive heart failure. Similar to systemic and coronary vascu-
lature, the pulmonary arteries dilate in response to purine
nucleoside adenosine which has a direct endothelium indepen-
dent effect on the A2b receptor in vascular smooth muscle.
Despite the detrimental effect of cigarette smoking on endothe-
lium dependent systemic vascular function, little is known of its
effect on endothelium independent function of the pulmonary
vasculature.
Purpose: The objective of this study is to develop a non-
invasive strategy using first pass perfusion MRI to measure PTT
and to test the hypothesis that cigarette smoking inhibits
endothelium independent pulmonary vasodilation.
Methods: The study included 63 prospectively recruited
subjects (65% women) without significant pulmonary disease.
All subjects underwent first pass perfusion cardiac MRI in a 1.5
Tesla Siemens scanner. Three long axis planes were acquired per
heartbeat over 50 heartbeats using a partial Fourier saturation-
recovery steady state free precession sequence during a breath
hold. Dynamic perfusion imaging was first performed during
adenosine infusion at 140 Lg/kg/min with gadolinium concentra-
tion at 0.05 mmol/kg. Following a 20 minute washout period
dynamic imaging was repeated without adenosine using the


same parameters. Images were analyzed in commercial software
(Argus, Siemens, Germany). PTT was measured between the
times when signal intensity reached a peak in main pulmonary
artery and in the left atrium.
Results: The mean age of the study cohort was 55.9 13.1
years. The prevalence of never, past and current smoking was
42.4%, 49.2% and 8.5%, respectively. Compared to rest PTT
(5.98 1.33 s) there was a 25.4% reduction (p < 0.001) in PTT
during adenosine infusion (4.46 0.94 s). When the analysis was
stratified by smoking status significant PTT reduction was seen in
never smokers (25.5%, p < 0.001) and in past smokers (28.5%,
p < 0.001) but not in the current smokers (8.8%, p = 0.433).
However, there was significant correlation between R-R interval
and PTTwith Spearman correlation coefficient 0.640 (p < 0.001)
for rest PTT and 0.55 1, (p < 0.001) for stress PTT In view of a
27.5% heart rate increase (p < 0.001) the analysis was repeated
using PTT values normalized to RR interval. In contrast to
absolute PTT measurements the normalized values demon-
strated minimal change between rest and stress PTT in never
smokers (0.06%, p = 0.989) and in past smokers (-1.55%,
p =0.651). In contrast, there was an 18.7% increase
(p = 0.029) in normalized stress PTTamong current smokers.
Conclusion: Adenosine infusion was associated with significant
PTT shortening in never and past smokers. Shortened PTT likely
represented reduced pulmonary resistance in response to the
endothelium independent vasodilatory effect of adenosine.
However this response appeared to be blocked by active
cigarette smoking. In the absence of active cigarette smoking
PTT normalized to R-R interval remained constant at rest and
during stress, suggesting an intact vasoreactivity to accommodate
increased cardiac output during adenosine infusion. Conversely
this value was significantly prolonged during adenosine infusion
among current smokers, implying impaired vasoreactivity likely
due to the detrimental effect of cigarette smoking, which resulted
in delay of pulmonary blood transit in the presence of increased
blood volume. Our findings suggest that CMR adenosine stress
testing may be an important modality to evaluate pulmonary
arterial function.



042
Coronary artery flow velocity reserve during the
cold pressor test in overweight, healthy women
using spiral imaging at 3 T
Alice Y Chang', Melanie Kotys2, Ivan Dimitrov2,
Andrew Kontak', Hardik Yadav3, Christopher Maroules',
Tommy Tillery' and Ron Peshock'
'UT Southwestern Medical Center at Dallas,
Dallas, TX, USA
2Philips Medical Systems, Cleveland, OH, USA
3University of Texas School of Public Health,
Dallas, TX, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):042
Introduction: Women with chest pain demonstrate coronary
endothelial dysfunction before obstructive disease can be
appreciated by angiography. Invasive measurements of coronary
artery vasoreactivity have been shown to predict future
cardiovascular events. However, there are significant risks
associated with invasive studies. Thus, the ability to non-


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 042)


Cross-sectional images of the RCA at rest in a subject using velocity-
encoded MRI. (A) Phase image and accompanying (B) Magnitude image.




invasively assess coronary vasoreactivity would be especially
useful in the early diagnosis and management of women with
coronary artery disease.
Changes in coronary flow velocity have been successfully
measured by magnetic resonance flow mapping in response to
handgrip stress at 3 T. The challenges for imaging women at risk
for heart disease include the (I) smaller size of their arteries and
(2) the high prevalence of overweight or obesity. In addition, we
tested whether cold pressor stress, another widely used test of
endothelial function that elicits a remarkable central sympathetic
response, could provoke greater changes in coronary flow.
Purpose: We sought to determine the feasibility of coronary
flow velocity measurements in response to the cold pressor test
in overweight women using 3 T MRI.
Methods: Healthy, pre-menopausal women were recruited for
this study and provided informed consent approved by the
institutional review board. Subjects were placed supine in a 3 T
MRI scanner (Achieva, Philips, Best, NL) using a 6 element
cardiac receive coil. Scout scans were performed to determine
the imaging plane orthogonal to the proximal right coronary



Figure 2 (abstract 042)

100 1i


* T

L I


CPTI CPT2 Post min Post 2 nn Post 10 mn
Time Points

Percent changes in peak diastolic flow velocity during cold pressor test.
*p < 0.01 compared to baseline and 10 minutes recovery.


artery (RCA). Baseline coronary velocity measurements were
obtained using a VCG triggered breath-hold (10 to 12 seconds)
velocity-encoded spiral cine sequence perpendicular to the RCA
(FOV 256 x 256 mm2, matrix = 312 x 312, spatial resolution =
0.8 x 0.8 x 7 mm3, TR = 34 ms, TE = 3.5 ms, RF excitation
angle = 200, spiral interleaves = II, VENC = 35 cm/s, temporal
resolution = 69 ms). Heart rate and blood pressure were
measured every 30 seconds during baseline imaging, stress and
into recovery. After baseline imaging, the subject's left hand was
placed in a half-water, half-ice bath for 3 minutes. Two successive
velocity-encoded images of the RCA were acquired during the
CPT After the subject's hand was removed from the water,
images were acquired at I, 2 and 10 minutes into recovery.
Images were analyzed using Q Flow (version 4.1.6, Medis,
Leesburg, Virginia), and peak diastolic coronary velocity was
determined as the maximum velocity during the diastolic rest
period. Coronary flow velocity reserve was calculated as peak
diastolic velocity during stress divided by baseline velocity.
Statistical analysis was performed using a one-way analysis of
variance (ANOVA) with Tukey post-hoc tests of significance
between specific time points.
Results: The mean age of the subjects (n = 7) was 35.1 6.5
(mean SD) and mean body mass index was 25.1 1.8. Rate-
pressure product increased 46.0 23.0% from baseline to peak
effect during CPT Peak diastolic velocity increased significantly
from baseline (13.3 3.9 cm/s) to both CPT time points
(22.7 7.3 cm/s and 21.6 7.5 cm/s) and one minute into
recovery (21.8 8.6 cm/s) (each p < 0.01). Recovery to baseline
was achieved by 10 minutes. The average increase in peak
diastolic flow velocity from baseline to peak cold pressor effect
was 82.7 29.2%. The mean coronary flow velocity reserve was
1.83 0.29. Figures I and 2.
Conclusion: Cold pressor test provokes a significant increase
in coronary flow velocity that is measurable at 3 T in overweight
women. Compared to previous reports of hand-grip stress
during MRI, the CPT stimulated a greater increase in rate-
pressure product (46% CPT v. 25.0% hand-grip) and coronary
flow velocity (82.7% CPT v. 39.6% hand-grip) which persists one
minute after withdrawal of the stress. Future studies will examine
if this greater potential for stress-provoked changes can better
detect more subtle differences in cardiovascular risk factors or
responses to treatments.



043
Association between aortic stiffness
measured by cardiovascular magnetic
resonance and sub-clinical carotid
atherosclerosis in young adults
Ilias Kylintireas, Colin Cunnington, Corinne Trevitt,
Jonathan Diesch, Stefan Neubauer, Matthew Robson
and Paul Leeson
University Of Oxford, Oxford, UK

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):043
Introduction: Increased arterial stiffness is associated with
increased cardiovascular risk in later life. Cardiovascular
magnetic resonance (CMR) allows direct assessment of arterial
stiffness by imaging the elastic properties of the aorta. This
provides measures of both global (pulse wave velocity, PWV) and


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 043)


0.50-


0.4 -


0.40-


0.35 -


0.30-


0.20 -


S


2 3 4 5
PV (m/s)


regional (aortic distensibility) aortic stiffness
combined with precise measurement
burden, a marker of early sub-clinical
investigated whether aortic stiffness in ear
associated with early changes in carotid st
Purpose: To determine whether aortic st
cardiovascular magnetic resonance as pulse
and aortic distensibility (AD) is as
atherosclerosis-related structural changes
Methods: Thirty young healthy volunteer
out history of cardiovascular disease or cl
atherosclerosis) underwent CMR for me
function and carotid wall imaging.
Aortic distensibility was measured from br
steady state free precession (SSFP) imag
calculated as the relative change in area d
pulse pressure. Pulse wave velocity was me
gated, free breathing, spoiled gradient
acquisition. The transit time method was us
of pulse wave velocity (PWV). TI weight
spin echo (TSE) cross-sectional images of
centred at the lowest bifurcation were used
measurements (plaque index represented
wall area/total cross-sectional vascular are
averaged for the common carotid (CPI), t
and the internal carotid artery (IPI).
Results: CMR-derived PWV over the wh
was correlated with carotid plaque index
(Figure I.) particularly of the internal cai
measures of aortic distensibility and pulse
unrelated to carotid atheroma burden.
regression analysis model (including ap
demographics and anthropometric measi
the sole independent predictor of IPI
P < 0.05, R2 = 0.23].
Conclusion: Aortic stiffness assessed b
with early atherosclerosis-related changes
young adults.


044
Relationship between regional wall shear stress
and carotid plaque composition using 3 T MRI and
patient-specific computational fluid dynamics
Raymond Q Migrino', Mark Bowers', Leanne Harmann ,
Robert Prost', Anil Doppalapudi', Tayyab Mohyuddin',
Megan Bright', Jason Jurva', Osama Zaidat'
and John LaDisa2
'Medical College of Wisconsin, Milwaukee, WI, USA
2Marquette University, Milwaukee, WI, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):044
Introduction: Plaque vulnerability arises from the interplay
among factors including plaque composition (PC) and wall shear
stress (WSS). To date, the relationship between spatial WSS and
PC is not established.
6 7 8 Purpose: Our aim is to determine the relationship between
WSS and PC in established carotid atherosclerosis.
Methods: 5 subjects (4 males, 66 8 years), with moderate to
severe carotid plaque underwent 3 T MRI using 4-channel carotid
coil. TI, T2, proton density and time of flight images were
obtained (0.47-0.55 x 0.47-0.55 x 2 mm spatial resolution)
12 mm above and below the bifurcation. Plaque composition
ss. Assessment can be
of. As essment can be (necrotic core and loose matrix) were quantified using Plaque-
Scaroti athero view software (VP Diagnostics). Subject-specific computational
atherosclerosis. We
fluid dynamic models were created from MRI, B-mode ultra-
ly adult life is already sound and blood pressure (BP) data using CVsim software.
ructure. Outlet boundary conditions that replicated flow and BP were
iffness quantified by applied and simulations used a stabilized finite element solver.
wave velocity (PWV) Each carotid slice were divided into 6 circumferential regions
sociated with early where WSS was correlated with PC.
in yng adult life. Results: Please see figure I. WSS correlated significantly with
rs (aged 23-33) (with- necrotic core (R = 0.283, p < 0.001) but not with loose matrix
assical risk factors for
measure t of aort (R = -0.03, p = 0.6). The same relationship was seen in the
common carotid, bifurcation or internal carotid artery. Carotid
plaque regions with necrotic core had higher WSS than those
eath-hold ECG-gated without (34.1 2.6 vs. 17.3 4.6 dyn/cm2, p < 0.001). WSS in
es. Distensibility was regions with and without loose matrix did not differ (25.8 3.6
divided by the central
divided by the central vs. 22.5 3.3, p = 0.7).
measured from an ECG-
eco pase-enoded Conclusion: In established carotid artery disease, regions with
echo phase-encoded
A 4- 1 1 1..; high WSS are associated with increased necrotic core, but not


eu LII LdlLUI ca LIII on
ed black blood turbo
both carotid arteries,
Sfor atheroma burden
cross-sectional vessel
ea). Plaque index was
:he carotid bulb (BPI)

ole length of the aorta
(r = 0.480, P < 0.05)
rotid artery. Regional
e wave velocity were
Applying a multiple
plicable risk factors,
urements) PWV was
[P = 0.02( 0.009),

y CMR is associated
in carotid arteries in


Figure I (abstract 044)


CFD Model and Regional WSS


I UBlood Pool (Red)
Blood Pool (Red)


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0.25







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


loose matrix. This relationship between increased WSS and
necrotic core content in the plaque may play an important role in
plaque vulnerability.

045
A novel, dual-contrast in-vivo MR imaging method
with principal component analysis reliably
quantifies lipid-rich necrotic core and collagen in
human carotid atherosclerotic plaques
Zhen Qian, Sarah Rinehart, Laura J Murrieta,
Gustavo Vasquez, Patrick M Battey and Szilard Voros
Piedmont Heart Institute, Atlanta, GA, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):045
Background: In-vivo multi-spectral imaging of human carotid
plaques using different pulse sequences, with and without
exogenous contrast agents, has been implemented. However,
an in-vivo dual-contrast approach with small paramagnetic iron
oxide (SPIO) and gadolinium at multiple timepoints with principal
component analysis (PCA) has not been previously performed.
Purpose: To develop a novel, PCA-based method for the
detection of lipid-rich necrotic core (LRNC) and collagen in
human carotid plaques utilizing a dual-contrast approach. We
hypothesized that LRNC and collagen can be reliably identified
based on different signal characteristics with different exogenous
contrast agents and multiple different imaging pulse sequences.
Methods: 10 pts scheduled for carotid endarterectomy (CEA)
were imaged at 1.5 Twith a dedicated small surface coil. TI, T2
and inversion recovery delayed hyperenhancement (DHE) images
with magnitude/phase reconstruction were obtained before
contrast, immediately and 24 hours after 0.05 cc/kg of SPIO
(Feridex) and after 30 cc of Gd. Imaging parameters were: TI;
TR: 1500 ms, TE 10 ms, slice 3 mm, matrix 320 x 320, averages
3; T2; TR: 2500 ms, TE 92 ms, slice 3 mm, matrix 320 x 320,
averages 4; DHE; TR: 745 ms, TE 3.5 ms, slice 6 mm, matrix
192 x 192, averages I. Corresponding histological sections from
CEA specimens were stained with Movat's pentachrome for
identification of LRNC and collagen.
For a training dataset, ROI in two pts were normalized to
foreground median intensity and histopathological specimens
were non-rigidly registered to the MR images using anatomical
landmarks and a thin-plate spline-based image morphing
algorithm (Panel C). Plaque composition masks consisting of
6 classes (LRNC [red], calcium [yellow], fibrous collagen [green],
proteoglycans [light blue], elastin [grey], and fibrin [purple]) were
created based on the registered histological images (Panel D). All
4 sequences at all 4 timepoints were independently tested for the
identification of plaque composition. A more comprehensive
PCA analysis utilizing all pulse sequences at all timepoints was
also performed. Signal intensity (SI) statistics are expressed as
mean SD. The performance of composition identification was
measured by comparing the predicted compositions with the
2-class mask, and was evaluated using the two-tailed t-test p
value, and the area under the ROC curve.
Results: See Figure I. SI was significantly higher in LRNC on T2
images immediately after SPIO (Panel A) compared to other
tissues (56.66 18.52 vs. 26.21 12.74, p < 0.0001). PCA
showed significant difference between LRNC and non-LRNC
tissue (p < 0.0001) (Panel E). The percentage of correctly
identified pixels was 80.4%. Predicted total area for LRNC was
71 pixels (22.22 mm2), compared to 66 pixels (20.65 mm2) on


Figure I (abstract 045)


the manually identified mask (Panel F, G). ROC curve analysis
showed that PCA (AUC: 0.96) was significantly better than the
single best approach (T2 immediately post-SPIO; AUC: 0.90)
(p = 0.016) (Panel H).
SI was significantly higher in collagen on the post-Gd DHE
magnitude images (Panel B) (36.56 8.97 vs. 30.21 12.80,
p < 0.0001). PCA showed significant difference between collagen
and non-collagen tissue (p < 0.0001) (Panel I). The percentage of
correctly identified pixels was 65.8%. Predicted total area for
collagen was 104 pixels (32.54 mm2), compared to 98 pixels
(30.67 mm2) on the manually identified mask (Panel J, K). ROC
curve analysis showed that PCA (AUC: 0.68) was similar to the
single best approach (Post-Gd magnitude DHE; AUC: 0.66)
(p = 0.562) (Panel L).
Conclusion: LRNC and collagen can be reliably identified
in-vivo in human carotid atherosclerotic plaques using our novel,
dual-contrast approach; a different pulse sequence with different
exogenous contrast is optimal for the identification of different
tissue components. A more sophisticated PCA analysis is
significantly better than the evaluation of a single pulse sequence
at a single timepoint for the identification of LRNC. Such
sophisticated plaque analysis can now be applied to clinical
outcomes studies and for the evaluation of the effects of
pharmaceutical agents for the modification of atherosclerosis.


046
In vivo human coronary magnetic resonance
angiography at 7 Tesla
Saskia GC van Elderen', Andrew G Webb',
Maarten Versluis', Jos Westenberg', Joost Doornbos ,
Nadine B Smith', Albert de Roos and Matthias Stuber
'LUMC, Leiden, Netherlands
john Hopkins University, Baltimore, MD, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):046
Introduction: Coronary magnetic resonance angiography
(MRA) is a promising technique for the non-invasive visualization


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 046)


Figure 3 (abstract 046)


of the coronary anatomy. However, due to the small dimensions
and tortuous nature of the coronary arteries, high spatial
resolution and volumetric coverage are mandatory. This
requirement is critically linked with prolonged scanning times.
The use of a high magnetic field strength has several potential
advantages since the higher signal-to-noise ratio (SNR) may
support improved spatial resolution and/or shortened scanning
times. For these reasons we tested the hypotheses that in vivo


Figure 2 (abstract 046)


human coronary MRA technology is feasible and can be
implemented on a commercial 7 Tesla (T) system.
Methods: Eight healthy volunteers (6 men, mean age 34
years 8) were positioned in a 7 T MR system (Philips
Healthcare, Best, NL). A 13-cm diameter anterior surface coil
was designed and constructed and used in transmit/receive
mode. The size was chosen to achieve adequate radio frequency
(RF) penetration. Commercial vector ECG (VECG) technology
was used for R-wave triggering. Volume selective RF power
optimization and swimming were applied for each scan. A


Figure 4 (abstract 046)




r't--4"\t






LAy\^yAy^


(a) ECG outside the magnet; (b) ECG inside the magnet.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Aa -25


Hide I


segmented k-space gradient echo sequence was used for scout
scanning. Multi-slice cine scans were used for coronary artery
localization and for the visual identification of the time period
(Td) of minimal coronary motion. Scan plane localization parallel
to the right coronary artery (RCA) was facilitated using a three-
point planscan tool. Double-oblique free-breathing 3D coronary
MRA (segmented k-space gradient-echo imaging, TR = 4 ms,
TE = 1.5 ms, RF excitation angle = 15, field-of-view = 320 x
291 mm2, scan matrix = 392 x 373, 15 slices, slice thickness =
2 mm, acquisition window -100 ms, scan time -5 min) was
performed using prospective navigator gating with the 2D
selective navigator localized at the heart-lung interface. Image
data were collected in mid-diastole at the predetermined Td. An
adiabatic spectrally selective inversion recovery pre-pulse
(TI = 200 ms) was used for fat suppression and enhanced
contrast between the coronary blood-pool and epicardial fat.
Coronary MRAs were reformatted and length measurements
were performed using the "Soapbubble" software tool.
Results: Right coronary MRAs were successfully obtained in all
8 healthy adult human subjects. Figures I and 2 show scout
images in the coronal and axial plane, respectively, illustrating
that the RF penetration and signal uniformity is sufficient for
RCA imaging. Figure 3 shows a long contiguous segment of
the RCA with high contrast between the blood-pool and the
epicardial fat. The average measured contiguous length of the
RCA was 77 35 mm. One potential concern is that, at
the higher field strength, the magneto-hydrodynamic effect is
amplified with an artificial augmentation of the T-wave of the


Figure 5 (abstract 046)


Page 38 of 316
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7TCoro2mm


!am 1

+25


I Nviptr fisliy


Save


ECG (Figure 4a and 4b). Nevertheless, the VECG algorithm
allowed reliable R-wave triggering. In Figure 5 the navigator signal
from the heart-lung interface received by the surface coil can be
seen.
Discussion: To our knowledge, this is the first report of human
coronary MRA at 7 T. With suitable adaptations of the scanning
protocol (e.g. navigator localization and use of a spectrally
selective adiabatic inversion recovery for fat saturation) and the
use of a custom-built transmit-receive surface coil, coronary
MRA technology has been successfully implemented at 7 T and
long contiguous segments of the RCA can be obtained in vivo
and in humans. Conventional T2-weighted preparation cannot
currently be used for contrast generation because of conserva-
tive specific absorption rate (SAR) constraints. Future work will
focus on optimizing contrast enhancement between the blood-
pool and the myocardium within the SAR and BI homogeneity
constraints. In order to improve volumetric coverage, the
development of larger surface coils or coil arrays will be
required. The latter will be most important in the trade-off
between the expected SNR benefit vs. shorter scanning times.
In conclusion, navigator gated free-breathing 3D coronary MRA
has successfully been implemented in vivo and in humans on a
commercial 7 T system.



047
Whole-heart contrast-enhanced coronary
magnetic resonance angiography in less than
5 minutes using gradient echo interleaved EPI
Himanshu Bhat', Sven Zuehlsdorff2, Xiaoming Bi2,
Xin Liu', Renate Jerecic2 and Debiao Li'
'Northwestern University, Chicago, IL, USA
2Siemens Medical Solutions, Chicago, IL, USA
Journal of Cardiovascular Magnetic Resonance 2009, I(Suppl I):047
Introduction: Whole-heart coronary MRA is challenging
due to the relatively long data acquisition time on the order of
10-15 minutes [I]. Interleaved EPI [2] is a method which can be
exploited to provide significant speed gain for whole-heart
coronary MRA and has previously been reported for volume-
targeted imaging at 1.5 T [3, 4]. The purpose of this work was
to optimize an interleaved EPI acquisition scheme for reducing
the imaging time of whole-heart contrast-enhanced coronary
MRA.
Methods: Sequence design considerations: A schematic
of the EPI-FLASH sequence is shown in Fig. Ia. Segmentation and
interleaving were applied along the phase-encoding direction,
eliminating discrete signal variations in the partition-encoding
direction. The reordering scheme used in the phase-encoding
direction is shown in Fig. Ib. The asymmetric k-space was
divided into 6 regions corresponding to the echo train length,
using the second region as central k-space region. The
interleaved acquisition within a heartbeat initially samples the
lower portion of each region (dashed line) and subsequently
sequentially acquires the central k-space line and top of each
region (dotted line). The signal varies within each heartbeat due
to non steady-state conditions. In combination with the
described reordering scheme, this results in amplitude modula-
tions in k-space, leading to image ghosts [2]. These modulations
were minimized by appropriate selection of the inversion time


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 047)


Figure 2 (abstract 047)


Inversion time TI

4 -------------.-


(a) schematic of the pulse sequence; (b) reordering scheme.



and flip angle, using simulations of the Bloch equations and
phantom studies.
Volunteer imaging: 7 volunteers were scanned on a 1.5 T
Espree scanner (Siemens Medical Solutions). Scan parameters
were: TR = 11.3, TE = 4.27, flip angle = 25, 66 lines per
heartbeat in a window of 124 ms, acquired k-space lines = 132,
readout bandwidth = 977 Hz/pixel, TI = 300 ms, matrix:
256 x 189 x 60, interpolated voxel size: 0.5 x 0.55 x I mm3.
0.2 mmol/kg body weight of Gd-DTPA was injected at 0.5 cc/sec
[5]. The total imaging time for the whole-heart scan was


Coronary artery images using the EPI-FLASH and TrueFISP sequences
with identical imaging times.


Figure 3 (abstract 047)


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6


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o -- - - --- --


3
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.....................................

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Table I (abstract 047) Comparison between EPI-FLASH and TrueFISP with identical resolution and imaging time

Sequence Imaging time Navigator efficiency Image quality score RCA length LAD length

EPI-FLASH 4.7 0.7 44.7 6.2 3 0.3 10.8 2.1 11.5 3.2
TrueFISP 4.9 0.9 45.5 7.9 2.2 0.3 9.1 1.72 1.0 4.1
p value (n = 7) 0.5 0.8 0.001* 0.01* 0.4


Page 39 of 316
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Coronary artery images using the EPI-FLASH sequence and a TrueFISP
sequence with longer imaging time.



2 minutes (for a heart-rate of 60 without navigator gating). For
comparison, a 3D TrueFISP whole-heart scan was acquired using
matched data acquisition time and spatial resolution. The image
quality scores (I, poor; 2, fair; 3, good; 4, excellent) and lengths
of the coronary arteries visualized by the 2 techniques were
compared. In addition, for a qualitative comparison, a whole-
heart TrueFISP protocol [5] with longer scan time, representing
the state of the art for coronary MRA at 1.5 Twas performed on
2 of the volunteers.
Results: The average imaging time for contrast-enhanced
whole-heart imaging was 4.7 0.7 minutes with an average
navigator efficiency of 44.7 6.2%. Fig. 2 shows coronary artery
images from 2 volunteers using the EPI-FLASH acquisition and
the TrueFISP acquisition with identical imaging time. The EPI-
FLASH acquisition shows excellent depiction of all the coronary
arteries. In comparison, the TrueFISP acquisition is very noise
due to the high acceleration factor used. Quantitative compar-


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k -0







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


ison between the two sequences is shown in Table I. Fig. 3
shows coronary artery images from a volunteer using the
EPI-FLASH acquisition (imaging time = 5.6 minutes, navigator
efficiency = 45%) and a TrueFISP acquisition (imaging time =
13.2 minutes, navigator efficiency = 38%). Both the sequences
show similar depiction of the coronary arteries, but the imaging
time for the EPI-FLASH technique is reduced by more than a
factor of 2.
Conclusion: An EPI-FLASH sequence was optimized for
contrast-enhanced whole-heart coronary MRA at 1.5 T. In
volunteers, all the major coronary arteries were clearly depicted
in a scan time under 5 minutes. Clinical utility of the technique
needs to be tested on a patient population.
References
I. Magn Reson Med. 50:1223-1228.
2. Magn Reson Med. 30:609-61 6.
3. JMRI 13:676-681.
4. JMRI 10:821-825.
5. Magn Reson Med. 58:1-7.



048
Right ventricular ejection fraction, measured
during inter-stage cardiac magnetic resonance
imaging, predicts outcome for patients with
hypoplastic left heart syndrome
Marina L Hughes', Katherine Brown', Vivek Muthurangu2,
Victor Tsang and Andrew Taylor2
'Great Ormond Street Hospital for Children, London, UK
institute of Child Health and Great Ormond Street Hospital
for Children, London, UK

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):048
Background: Since 2003 our unit has adopted an imaging
protocol for all infants with hypoplastic left heart syndrome
(HLHS), which includes CMR imaging for inter-stage assessment
prior to the formation of a bidirectional cavo-pulmonary shunt.
The aim of this study was to assess whether the CMR data
acquired during this protocolised follow-up could help to stratify
the risk for these patients.
Methods: We assessed all locally followed patients, who had
undergone the Norwood procedure for HLHS between January
2003 and May 2008, and who had undergone CMR imaging
according to unit protocol.
Imaging was performed under general anaesthetic, using a 1.5 T
MR scanner, and a combination of cine sequences, phase
contrast flow sequences and gadolinium-enhanced MR angiogra-
phy. From short axis cine images, manual segmentation of the
ventricles was completed, giving ventricular volumes, ejection
fraction and cardiac output (CO). Arterial measurements were
made from the isotropic angiographic data using 3D analysis
software. The pulmonary artery (PA) measurements were made
at the proximal native vessel and distally, just prior to the Ist
lobar branch. Aortic measurements were made at the narrowest
point of the proximal descending aorta (CoA) and at the
diaphragmatic-level descending aorta. At each site the shortest
and orthogonal cross-sectional diameters were averaged, to
correspond with conventional 2D measurement methods.
Additionally, the exact cross-sectional area of the vessel at
each point was measured using manual planimetry. The


Figure I (abstract 048)


Kaplan-Meier Survival Estimates by RVEF



7T_


RVEF 50%
RVEF61%-56%
RVEF 56%


O 2 4 6

Analysis time (months)


Kaplan-Meier survival estimates by RVEF



coarctation (CoA) index was defined as the (CoA measure-
ment/diaphragmatic aorta measurement), for vessel diameter and
planimetered area respectively.
The primary outcome measure was survival to analysis date (Ist
October 2008). Secondary, functional outcome measures were
RV ejection fraction (RVEF), and CO.
Results: A total of 30 patients comprised the cohort of
survivors of the first stage Norwood procedure, undergoing
protocolised CMR. Of these 30 patients, 15 had a Sano-type, and
15 a conventional Norwood. The median age and weight at CMR
scan was 9 1 (33 291) days, and 5 (3.2 I I) kg respectively. The
planimetered area index of vessels was smaller than averaged
orthogonal diameter index. The mean ratio of the CoA diameter
index to the CoA area index was 1.4 (95% Cl 1.25 1.55),
indicating that diameter measurements may underestimate true
narrowing. The PA size and indices of proximal stenosis did not
correlate with outcome. The median CoA area index for all
patients was 0.52 (0.22 1.0). Twenty-one (70%) patients had a
CoA area index < 0.7, with no difference between the Sano-type
and conventional Norwood surgery. There was a significant
correlation between the CoA diameter index and cardiac output
-1.09 (95%CI -2.17 -0.02) (p = 0.04), but the CoA size indices
were not correlated with RVEF. The median RVEF for this cohort
was 53% (30 81%). Eight patients had RVEF < 50%. There were
7 deaths in this cohort, during a total follow-up time of 67 person
years. The RVEF was strongly predictive of death, with a hazard
ratio 0.92 (95% Cl 0.86 -0.99) (p = 0.02). Figure I demonstrates
a Kaplan Meier survival curve with patients stratified by RVEF
Other factors, such as the age at time of MRI, the type of
Norwood, the CO, the CoA and the PA indices did not predict
death.
Conclusion: This study shows that death is a more likely
outcome in HLHS patients with a lower RV ejection fraction at
inter-stage CMR. Other CMR-measured factors such as CoA
and PA size indices did not predict outcome. Measures to
preserve RV systolic function, and CMR assessment of this,
should be paramount in the complex management of these
patients.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


049
Teleradiologic network for central management
and analysis of MR images: a three-years
experience of the competence network for
congenital heart disease
Samir Sarikouch', Philipp Beerbaum2, Stefan Mueller3,
Ulrich Sax3 and Titus Kuehne4
'Department for Heart-, Thoracic-, Transplantation- and
Vascular Surgery, Hannover Medical School, Germany
2Division of Imaging Sciences, King's College,
Guy's & St Thomas' Hospital, London, UK
3Department for Medical Informatics, University of Goettingen,
Goettingen, Germany
4Unit of Cardiovascular Imaging Congenital Heart Diseases,
German Heart Center, Berlin, Germany

journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):049
Background: Analysis of cardiovascular MRI requires increas-
ingly high standards and produces costs for specially trained
personal and technical equipment. At the same time clinical
decision making relies, particular in congenital heart diseases
(CHD), more and more on MRI derived data. In the German
Competence Network for CHD, a science-association was
founded in which MRI data were acquired in peripheral institutes
and than send by teleradiologic means to a core-labaratory for
central data analysis and archiving. The first three years of
operation of this network were evaluated regarding its technical
course of activity, accuracy of MRI data analysis and costs.
Methods: 16 cardiovascular institutes form part of the net-
work MR images are acquired in these institutes (Philips,
Siemens, GE scanners) using a standardized protocol. Images
are send by teleradiologic means (pseudonomyzed via internet)
to a central core-laboratory. There, images are analysed for
parameters of cardiac function using custom-made software.
Variability of the measured parameters is continuously deter-
mined (quality assessment). Thereafter, analysed data and original
MR images are archived and are accessible to the participating
institutes by a remote-data-entry-system (RDE). Economic
evaluation of the network was done by cost-analysis and ex
post-contemplation under consideration of investments, labor-
and consumption-costs.
Results: Data transmission speed was approximately 300 kbit/s
upstream. MR images arrive at the core-laboratory as pseudo-
nymized DICOM-data. After the pilot phase, no errors in image
transmission (e.g. incomplete data sets) were observed. There-
fore, all MRI scans that were acquired using standardized
protocols could be analysed in the core-labaratory, so far more
than 1000 scans. Interobserver variability of quantitative function
parameters was significantly lower when analysis was done in the
core-labaratory, compared to individual analysis in the peripheral
institutes. MR images were ubiquitously accessible in the RDE-
system and via the internet at any time. Ex-post evaluation
showed an expenditure of 155 EUR per MRI data set when
552 sets per year are enrolled under scientific (non economic)
conditions to the core-labaratory.
Conclusion: A teleradiologic network was successfully estab-
lished in a science-association for congenital heart disease and
optimized for primary health care and scientific purposes. The
first three-year experiences showed that this network/core-lab is
attractive by reducing labor-, investment- and consumption costs
and at the same time improves quality of data. Finally, the data


archives of the core-labs are a very large and invaluable source of
data for current and future scientific studies.

050
Location, patterns, and quantification of
myocardial fibrosis identified by cardiac
magnetic resonance delayed enhancement
late after fontan operation
Rahul H Rathod, Ashwin Prakash, Andrew J Powell
and Tal Geva
Children's Hospital Boston, Boston, MA, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):050
Objective: The objective of this study was to investigate the
frequency, location, patterns, and quantification of myocardial
fibrosis as identified by the CMR myocardial delayed enhance-
ment (MDE) technique and describe its association with
functional single ventricular ejection fraction (EF) and regional
wall motion abnormalities (WMA) in patients late after the
Fontan operation.
Background: MDE has been associated with adverse ventri-
cular mechanics late after tetralogy of Fallot repair and in patients
with systemic right ventricles. No studies have reported the
frequency, patterns, or associations of MDE in patients late after
the Fontan operation.
Methods: All patients at our center following a Fontan
operation who had a CMR study with MDE from January 2002
to July 2008 were retrospectively identified. MDE was character-
ized by: I) spatial location; 2) pattern; and 3) MDE quantification
expressed as the MDE percent of ventricular mass (MDE %).
MDE % was calculated using the histologically verified, full-width
at half-maximum (FWHM) technique (Amado et al. JACC 2004;
44: 2383). Patterns of MDE were categorized as transmural,
subepicardial/intramural, subendocardial, circumferential endo-
cardial fibroelastosis (EFE), and speckled (Figure I). Multivariate
linear regression analysis with forward stepwise selection was
used to investigate independent associations of functional single
ventricular EF. Covariables included demographic data, cardiac
diagnosis, ventricular morphology, Fontan type, surgical history,
MDE locations, MDE patterns, and MDE %.
Results: Of the 85 subjects included (65% male; median age at
Fontan 4.5 [2.0, I 1.2] years; mean age at CMR 23.1 I1.2 years), 2 1
(25%) had positive MDE in the ventricular myocardium. MDE was
seen in the following locations: dominant ventricle free wall (n = 13,
62%), secondary ventricle free wall (n = 9, 43%), septal insertion
(n = 5, 24%), ventricular septum (n = 3, 14%), apex (n = 2, 10%),
previous surgical sites (n = 2, 10%), and papillary muscle (n = 2,
10%). MDE was seen in the following patterns: transmural lesion


Figure I (abstract 050)


Arrows identify patterns of MDE. a) transmural; b) subendocardial;
c) EFE; d) subepicardial/intramural.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table I (abstract 050) Univariate analysis of MDE location and pattern

MDE location in the dominant ventricle free wall Transmural MDE pattern

MDE Pos (n = 13) MDE Neg (n = 72) p value MDE Pos (n = 9) MDE Neg (n = 76) p value

EF (%) 41 13 56 I 0.0001' 39 11 55 12 0.0001'
EDVi (ml/m2) 112 [93, 196] 84 [65, 101] 0.0042 144 [93, 196] 83 [65, 101] 0.0062
ESVi (ml/m2) 70 [50, 129] 35 [26, 46] 0.00012 77 [50, 132] 35 [27, 48] 0.0012
MASSi (g/m2) 72 [59, 93] 47 [40, 59] 0.0012 63 [49, 80] 49 [40, 64] 0.052
Regional WMA 10(77%) 18(25%) 0.0013 9 (100%) 19 (25%) 0.00013
Dyskinesis 6 (46%) 3 (4%) 0.00014 6 (67%) 3 (4%) 0.00014

Values are mean SD, median [25%, 75%], or n (%); 'Student t test, 2Mann-Whitney U test, 3Fisher exact test, 4Chi-squared test of independence.


(n = 9, 43%), subepicardial/intramural (n = 5, 24%), subendocardial
(n = 5, 24%), circumferential endocardial fibroelastosis (n = 4, 19%),
and speckled (n = 2, 10%). Results of univariate analysis comparing
patients with and without MDE, stratified by location and pattern are
summarized in Table I. Multivariate linear regression analysis
demonstrated that higher MDE % (slope: -1.7, Cl: -2.5 to -1.0,
p < 0.0001) and age at CMR(slope: -0.6, CI: 1.0to -0.3, p = 0.002)
were independently and inversely associated with EF (R2 = 0.59).
Conclusion: In patients late after the Fontan operation,
myocardial fibrosis was common and was associated with
lower EF, higher ventricular volumes, WMA, and dyskinesis.
Further studies are warranted to examine the mechanisms of
myocardial fibrosis and their impact on ventricular performance.


051
Left ventricular T2 distribution in Duchenne
Muscular Dystrophy
Janaka Wansapura', Robert Fleck', Kan N Hor',
Wojciech Mazur2, Woodrow Benson'
and William M Gottliebson'
'Cincinnati Children's Hospital, Cincinnati, OH, USA
2Christ Hospital, Cincinnati, OH, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):05 I
Background: The transverse relaxation time (T2) of water
molecules differ between tissues. Because the molecular motion
of water is significantly affected by macro molecules, tissue
containing fibrous polymers such as collagen has shorter T2
values. Patients with Duchenne Muscular Dystrophy (DMD)
develop myocardial fibrosis in the late stage of the disease. The
goal of this study was to determine the association of myocardial
T2 distribution to the severity of DMD.
Methods: Twenty six DMD patients and eight normal subjects
were studied. T2 maps of the left ventricle were generated using
a black blood dual spin echo method. (TE, = 6 ms, TE2 = 34 ms)
DMD patients were grouped according to the ejection fraction
(EF) and the circumferential strain (Ecc) as: A: EF 56%, Ecc >
12%, mean age = 10.5 yrs, B: EF 56%, Ecc 12%, mean
age = 17.5 yrs, C: EF 56%, mean age = 17.5 yrs. T2 values
were plotted for each subject as a histogram. The normalized
mean histograms from each group were compared by the Full
Width of Half Maximum (FWHM).
Results: The FWHM of the T2 histogram was significantly
higher in group B and C compared to that of group A and the
normal group, indicating significantly high heterogeneity in T2
in Group B and C. FWHM/T2mean is significantly (p < .0001)


Figure I (abstract 051)


The T2 maps of a normal (a) and a DMD subject (b) showing the left
ventricle in the short axis view.


Figure 2 (abstract 051)


0.8


S0.6


0.4


0.2


u.


6 8 10 12
I Ecc | (%)


14 16 18


Association between FWHM/T2mean and ec in group A and B. Pearson
correlation coefficient r = .51.


Page 42 of 316
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FfW7if/T2=- 02S|Ecc- 0 83
95% Prediction bounds


x
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X
x xx
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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


higher in group B (0.42 0.06) compared to Group A
(0.54 0.08). Regression analysis show moderate association
between FWHM/T2mean and IEccl in group A and B. (Pearson
correlation coefficient r = .51).
Conclusion: The distribution of T2 in the LV of the DMD
subjects were remarkably heterogeneous compared to that of
normal subjects. These characteristics may suggest early signs of
diffused collagen accumulation in the LV in DMD.

052
4D flow for accurate assessment of differential
pulmonary arterial flow in patients with
tetralogy of Fallot
Alison K Meadows, Michael D Hope, David Saloner
and Charles B Higgins
University of California San Francisco, San Francisco, CA, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):052

Objective: To demonstrate that 4D flow, in a single acquisition,
can provide efficient, accurate, and complete data sets to
determine differential pulmonary blood flow in patients with
Tetralogy of Fallot (TOF).
Background: Patients with tetralogy of Fallot (TOF) often
have branch pulmonary artery (PA) stenoses and abnormalities


Figure 2 (abstract 052)


n-


AsA

\ -x MPA
SRPA


\LPA







Semen orf ucI Cyut


Healthy subject pulmonary flow.


in flow distribution. Such abnormalities can be addressed and
have an impact on clinical management. Distorted anatomy,
turbulent flow jets, and/or metallic stents often make the choice


Figure I (abstract 052)


4D wam 2D fl


I0






G0


50



so

30


20


10


is Blm


4D versus 2D flow.


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1



9





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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 3 (abstract 052)


Figure 5 (abstract 052)


SAAo -- MPA

\ RPA LPA


/






Samw of dCodi cylt


Flow profile.


of 2D phase contrast flow planes difficult, time consuming, and
labor intensive. As a result, studies may be completed without
collection of the data necessary to determine flow distribution.
4D flow techniques permit the collection of temporally-resolved
3D data sets of the central systemic and pulmonary vasculature
in a single acquisition. Complete data acquisition is guaranteed
and appropriate planes for flow quantification can be chosen
during post processing.
Methods: Employed was a temporally-resolved, 3D phase
contrast technique (4D flow), optimized for blood flow analysis
in the thoracic vasculature. Data was acquired using an RF-
spoiled 3D gradient echo pulse sequence with velocity encoding
in 3 spatial directions. All measurements were performed on a
1.5 T clinical scanner (Signa CV/I, GE, Milwaukee, WI) using an
8-channel cardiac coil. Scan parameters were as follows:
VENC = 160-200 cm/s; fractional FOV = 300 x 270 mm2, slab
thickness = 78 mm, and matrix = 256 x 192 x 30 yielding a
spatial resolution of 1.17 x 1.56 x 2.60 mm3. Within each


Figure 4 (abstract 052)


cardiac cycle, the in-plane phase encode value was held constant
while 4 slice-encoding phase encodes are acquired to encode all
flow directions. Parallel imaging (GRAPPA) with an acceleration
factor of 2 was used. Scan times ranged from 12-16 minutes
depending on heart rate. Retrospective EKG gating was used to
resolve 20 time frames through the cardiac cycle yielding a
temporal resolution of 50-80 msec. Respiratory compensation
was employed. The raw data was reconfigured for EnSight
visualization (CEI Inc., Apex, NC). Navigation within the 3D data
set allows retrospective placement of planes perpendicular to
the vessel of interest. 10 subjects with TOF were prospectively
enrolled. For each subject, a 4D flow data set was obtained and
an attempt was made to obtain 2D flow in 4 locations; the
ascending aorta (AsAo), main pulmonary artery (MPA), and
branch PA's (RPA and LPA).
Results: Of a total of 40 data points, there were 16 missing
2D data points and 7 missing 4D data points. Missing 2D data
were secondary to aliasing and inappropriate prescription of
2D flow planes. Missing 4D data were secondary to aliasing.
There were 20 total paired data points (Figure I). There was
good correlation between the two techniques (Spearman's rho
value of 0.91, p < 0.0001). The 4D flow data were internally
consistent: AsAo flow equaled left ventricular stroke volume,
MPA flow equaled right ventricular stroke volume, and the
sum of the branch PA flows equaled MPA flows, all to within 10%.
This internal consistency is demonstrated in Figures 2 and 3,
which display flows in the AsAo, MPA, RPA, and LPA over the
cardiac cycle in a normal subject and a patient with TOF
respectively. Figure 4 and 5 present streamlines in the pulmonary
arteries at peak systole in the axial and sagittal planes
respectively.
Conclusion: 4D flow provides complete and accurate
assessment of differential pulmonary blood flow in patients
with Tetralogy of Fallot (TOF) in a single acquisition.
Good correlation between 4D and 2D techniques for blood
flow quantification in the central systemic and pulmonary
vasculature is demonstrated. Navigation within 4D flow
data sets allows placement of planes at will without being
hindered by the prospective prescription of traditional 2D flow
techniques.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


053
Effect of flow angle and flow profile on phase
contrast flow measurements: overestimation at
extreme angles and skewed profiles
Kevin K Whitehead, Ravi Doddasomayajula,
Matthew A Harris, Matthew J Gillespie and Mark A Fogel
Children's Hospital of Philadelphia, Philadlephia, PA, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):053
Introduction: Flow measurements derived from phase con-
trast velocity mapping (PC-MRI) have become an important part
of pediatric cardiology, allowing accurate quantification of shunts,
valve regurgitation, and cardiac output. Clinicians generally try to
align the imaging plane orthogonal to flow. However, while flow
velocities decrease by the cosine of the angle from orthogonal,
the area should ideally increase by the same rate. There are
situations in which it may be desirable to quantify flow in a vessel
on an image that was not intended during the acquisition. In
addition, in some flow regimes with highly skewed flow it is
sometimes difficult to align the imaging plane with flow.
Understanding the settings in which PC-MRI is accurate is
important to the evaluation of congenital heart disease.
Purpose: The purpose of this in vitro investigation is to assess
the accuracy of PC-MRI flow measurements as a function of
the angle of the imaging plane to the direction of flow. We
hypothesize that the imaging angle does not have a significant
effect on flow measurements.
Methods: Both steady and pulsatile flows (0.7-10 L/min) were
driven through an in vitro flow phantom consisting of tube
diameters ranging from 10 mm to 19 mm both in a straight tube
configuration and just distal to a 90 degree bend to simulate
skewed flow. Through-plane PC-MRI velocity maps were
obtained at each flow rate (1.5 T Siemens Avanto) with the
imaging plane oriented from 0 to 75 degrees (15 degree
increments). Actual flows were measured for each condition
using an MRI-compatible calibrated ultrasound flowmeter
(Transonics) interfaced to a PC. Flow was measured using off-
line analysis (Argus, Siemens). Normalized flows (measured flow/
actual flow) were compared to the angle from orthogonal to flow




Figure I (abstract 053)

1.6
*I 1.5
S. y=0.0021x + 0.9663
1.4 r=0.322
1.3 p < 0.025





0.8^
0.7
0.6
0 10 20 30 40 so 60 70 s8
Angle (in degrees from orthogonal to flow)

Normalized flow vs imaging angle.


for all flow conditions. Variances in flow measurements between
angles were compared using an F-test.
Results: Normalized flow demonstrated weak but significant
correlation with flow angle for both steady and pulsatile flow
conditions (p < 0.05). For pulsatile flow, mean normalized values
ranged from 0.97 for 0 degrees to 1.12 for 75 degrees, and
overestimation was as high as I 1% for 0 degrees to as high as
56% for 75 degrees. Variability also tended to increase as angle
increased, and the variance for 75 degrees was significantly
greater than 0, 15, and 30 degrees. The flow estimation was not
significantly different for skewed flow (distal to elbow) compared
to flow in straight tubes. Figure I.
Conclusion: While PC-MRI is fairly robust with respect to
flow angle, overestimation of flow increases significantly as a
function of flow angle, to as high as a mean of 12% for the
75 degree angle. This is counterintuitive, and suggests that in
general the measured velocity is not decreasing to the same
degree that area is increasing. In addition, the variability of the
measurements increases with increasing flow angle, especially at
larger flow angles. The etiology of the error is likely related to
partial volume effects. Care should be taken to be as orthogonal
to flow as possible during PC-MRI to avoid overestimating flow.


054
CMR assessment of right ventricular function in
patients with combined pulmonary stenosis and
insufficiency after correction of tetralogy of Fallot
Maureen Kohi, Karen G Ordovas and Charles B Higgins
University of California, San Francisco, San Francisco, CA, USA

journal of Cardiovascular Magnetic Resonance 2009, I (Suppl 1):054
Introduction: Tetralogy of Fallot is the most common form of
cyanotic congenital heart disease. Following surgical correction,
most patients present with pulmonary insufficiency (PI) which
plays a pivotal role in right ventricular (RV) dysfunction. Multiple
prior studies have demonstrated the accuracy of CMR for
assessment of RV volumes, ejection fraction and pulmonary
regurgitant fraction, especially in the setting of an enlarged right
ventricle. The deleterious effect of chronic pulmonary regurgita-
tion on RV function is well known and pulmonary valve
replacement has been shown to improve ventricular function in
these patients. However, the effects of residual pulmonary
stenosis on RV function are not well understood. Using CMR
and conductance catheter techniques, a study performed in
a growing pig model demonstrated that chronic pulmonary
stenosis and insufficiency (PSPI) results in improved RV
myocardial contractility when compared to a group with isolated
PI, indicating a possible protective effect. The combined effect of
PSPI on RV function has never been reported in a human model.
Purpose: The purpose of this study was to compare CMR
parameters for assessment of RV volumes and function between
patients with combined PSPI and isolated PI following surgical
repair of Tetralogy of Fallot.
Methods: A retrospective review of patients with corrected
Tetralogy of Fallot who had undergone CMR and echocardiogram
was performed. A total of 46 patients were included: 9 patients
with PSPI and 37 patients with isolated PI. Cine MRI images in the
short-axis plane were used to calculate the following parameters:
pulmonary regurgitant fraction (PRF), RV end-diastolic volume
(RVEDV), RV end-systolic volume (RVESV), RV stroke volume


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


(RVSV) and RV ejection fraction (RVEF). RV end-diastolic volume
and end-systolic volume indexes (RVEDVi, RVESVi) were
calculated based on the body surface area. Peak pressure
gradient across the pulmonary valve was obtained from
echocardiogram performed within 3 months of the CMR.
Means and standard deviations of the CMR parameters were
compared between the combined PSPI and isolated PI groups
using Student's t-test. A p < 0.05 was considered statistically
significant.
Results: RVEF was significantly higher in combined PSPI
patients (47 9%) than in isolated PI patients (40 10%)
(p = 0.042). RVESVi was significantly lower in combined PSPI
patients (67.3 19 ml/m2) than in patients with isolated PI
(92.1 43 ml/m2) (p = 0.026). There was no significant
difference between RVEDVi (p = 0.44) and PRF (P = 0.38) in
the two groups.
Conclusion: RV function as assessed by RVEF and RVESVi was
improved in patients with combined PSPI when compared to
patients with isolated PI following surgical correction of Tetralogy
of Fallot with similar degree of pulmonary regurgitation.


055
Chemotherapy induced abnormal aortic function
assessed by magnetic resonance imaging
Narumol Chaosuwannakit, Ralph D'AgostinoJr,
Craig A Hamilton, Julia Lawrence, Frank M Torti,
William C Little and W Gregory Hundley
Wake Forest University School of Medicine, Winston-salem,
NC, USA
journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):055
Introduction: Abnormally increased cardiovascular stiffness is
an independent predictor of cardiovascular events. Compared to
age and gender matched healthy individuals, cancer survivors
previously exposed to chemotherapy experience an elevated risk
of cardiac events. We hypothesized that the administration of

Figure I (abstract 055)


2.5


2



1 1.
q.5
E
r E



0.5


0*


P<0.0001

-i P





Ii i


Control


/ C
Chemotherapy


Figure 2 (abstract 055)


16

14

12

10
E
E 8

6

4

2


0Cont


Control


Chemotherapy

Chemotherapy


chemotherapy may increase arterial stiffness above that observed
in age and gender matched controls.
Purpose: To determine if chemotherapy increases arterial
stiffness within the thoracic aorta.
Methods: We performed a prospective, case-control study of
23 participants that received chemotherapy (cases) with 13 that
did not (controls). For a variety of malignant neoplasms, 22
participants received anthracyclines and/or other therapies
including trastuzumab or Herceptin (n = 5), paclitaxel (n = 7)
or cyclophosphamide (n = II). Each participant underwent
phase-contrast cardiovascular magnetic resonance imaging (PC-
CMR) at baseline (before chemotherapy administration in cases)
and 3 to 4 months later. During CMR, thoracic aortic
distensibility and pulse wave velocity (PWV) were determined
according to the following formula:
Aortic distensibility (103 mmHg) = [maximal aortic area -
minimal aortic area]/[pulse pressure x minimal aortic area]
PWV (m/s) = Distance between ascending and descending
thoracic aorta/Transit time of the flow wave
PC-CMR parameters included an 8 mm thick slice with a
192 x 108 matrix, a 36 cm FOV, a 15 flip angle, a 76.5 ms TR, a
3.14 ms TE and a through-plane velocity encoding of 150 cm/sec.
A nonferromagnetic brachial blood pressure cuff was applied to
record heart rate and blood pressure noninvasively during the
phase-contrast acquisition. To compare groups at their follow-up
visit, four one-way analysis of covariance models (ANCOVA)
were fit where factors known to influence aortic stiffness were
included as covariates in the model.
Results: At 3 months, arterial stiffness (distensibility and PWV)
remained similar in the control participants. However, in the
participants receiving chemotherapy, aortic stiffness markedly
increased as evidenced by a decrease in distensibility and an
increase in PWV. When we compared the participants receiving
chemotherapy with controls directly using an ANCOVA model


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


that adjusted for baseline aortic stiffness, age, gender, body mass
index, systolic blood pressure, heart rate, pulse pressure,
medication use, and the presence of hypertension, diabetes and
hyperlipidemia, distensibility and PWV were significantly different
between controls and chemotherapy recipients (p < 0.0001;
Figures I and 2).
Conclusion: Patients receiving relatively short courses of
chemotherapy (3 months) experience a significant increase in
vascular stiffness (manifest as both reduced aortic distensibility
and increased PWV) compared to healthy controls. These results
indicate that previously regarded cardiotoxic chemotherapy
adversely increases cardiovascular stiffness, a known indepen-
dent predictor of cardiovascular events.



056
Marfan's cardiomyopathy is associated with aortic
annular and root dilatation in the absence of
significant valvular regurgitation
Joyce Wong, Francisco Alpendurada, Elizabeth Burman
and Raad Mohiaddin
Royal Brompton Hospital, London, UK

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):056
Introduction: Marfan syndrome is the commonest inherited
disorder of connective tissue affecting multiple organ systems,
caused by heterozygous mutations in the gene (FBNI) that
encodes the extracellular matrix protein fibrillin-1. Limited
evidence is available that Marfan syndrome is associated with a
primary cardiomyopathy. Cardiovascular Magnetic Resonance
(CMR) plays an important role in the identification and evaluation
of cardiovascular disease in this population, the major source of
morbidity and mortality. CMR was used to assess the prevalence
and predictors of primary cardiomyopathy, in a Marfan popula-
tion without evidence of significant valvular regurgitation or
aortic disease.
Methods: 120 Marfan patients were consecutively referred to
our centre for cardiovascular assessment with CMR between
January 2003 and June 2007 (diagnosis based on Ghent criteria).
Our study population consisted of 66 of these patients who had
no significant valvular regurgitation, and no previous aortic or
cardiac disease warranting surgery. This included 38 males
(57.8%) and 28 females (42. 1%), with a mean age of 33,2 years.
Thoracic aortic dimensions were evaluated. Left ventricular (LV)
volumes, ejection fraction, and mass were evaluated using semi-
automated analysis software (CMRtools, Cardiovascular Imaging
Solutions, London, UK). The volumes and mass were then
indexed to the body surface area. Aortic (AV) and mitral valves
(MV) anatomy and function were assessed, and thoracic
musculoskeletal deformities identified. The final values were
compared with previously published normal values with values
being considered abnormal if they were outside the 95%
confidence interval. We similarly compared our population to
an age and sex matched cohort of normal individuals when
assessing aortic dimensions.
Results: A significant proportion of this population demon-
strated reductions in LV ejection fraction (27%). LV indexed
volumes were also significantly different. Annular and aortic root
dimensions were increased in the population with reduced LV
ejection fraction when compared with population with normal


ejection fraction (r of 0.33 and 0.26 respectively, p < 0.05 for
both values, Pearson's coefficient). There was no significant
difference in global aortopathy indices or incidence of muscu-
loskeletal deformities between the two groups.
Conclusion: We confirm that Marfan syndrome is associated
with a primary cardiomyopathy in a population without
significant valvular disease. Moreover, annular and root dimen-
sions are increased in patients with LV dysfunction when
compared with patients with preserved LV systolic function,
suggesting that aortopathy and cardiomyopathy could be related
in this multi-systemic disorder. Recent advances in the molecular
pathogenesis of Marfan syndrome suggest that modulation of
abnormal fibrillin-l-TGF beta signalling by angiotensin-ll receptor
blockade in Marfan patients may reverse aortopathy. It remains to
be determined whether angiotensin-ll receptor blockade may
reverse aortopathy and associated cardiomyopathy.



057
Prevalence and imaging features of nephrogenic
systemic fibrosis at two large medical centers
Martin R Prince', Honglei Zhang', Michael F Morris2
Jennifer L MacGregor2, Yang Zhang', Marc E Grossman2
Jeffrey Silberzweij Robert L DeLapaz2, Henry J Lee ,
Cynthia M Magro Anthony M Valeri David N Silvers
and Joan C Prowda2
'Weill Medical College of Cornell University,
New York, NY USA
2Columbia University, New York, NY USA

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):057
Introduction: Nephrogenic Systemic Fibrosis (NSF) is a rare
disease, seen in patients with severe renal impairment, that has
garnered increased interest among radiologists due to reports of
its association with gadolinium based contrast agents (GBCA).
Purpose: To determine the prevalence and illustrate the
spectrum of imaging findings with photographic and histopatho-
logic correlation of nephrogenic systemic fibrosis (NSF) in
patients undergoing gadolinium based contrast agent (GBCA)
enhanced MRI and associated risk factors.
Methods: With Institutional Review Board approval (informed
consent not required) medical records from two hospitals were
retrospectively reviewed to identify all cases of biopsy-confirmed
NSF and all patients receiving GBCA administration from I/I/
1997 to 6/30/2007. Prevalence of NSF was calculated for patients
receiving standard dose GBCA, high dose GBCA as well as in
subgroups of patients with renal impairment. Imaging studies of
these patients were reviewed to correlate with photographic and
histopathologic findings.
Results: Fifteen patients had NSF following GBCA enhanced
MR. All had an estimated glomerular filtration rate (eGFR) < 30
m L/min and I I had acute renal failure or acute deterioration of
chronic renal failure. NSF prevalence following GBCA without
screening for renal function was 0/74124 for standard dose and
15/8997 (0.17%) for high dose (p < 0.001). The high dose
prevalence increased to 0.4% for chronic hemodialysis patients
and 8.8% for patients with eGFR < 15 mL/min but not on dialysis
(p < 0.001). NSF prevalence in patients with acute renal failure
given high dose GBCA during rising serum creatinine was 19%
(I 1/58) when dialysis was delayed by > 2 days. More NSF patients


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


had pro-inflammatory events, lower pH, younger age, lower
eGFR, elevated serum phosphate and increased delay between
GBCA injection and dialysis compared to patients without NSF
NSF has a variable appearance on routine imaging studies. Plain
radiographs can demonstrate joint contractures, skin thickening
and possibly cutaneous calcinosis; ultrasound may show thicken-
ing and edema of the cutis, particularly in the breast; CT may
show skin thickening and infiltration of subcutaneous tissues;
MRI may show increased signal on fluid sensitive sequences in the
skin, subcutaneous tissues, and extremity musculature; bone
scintigraphy may show diffuse soft tissue uptake in the
extremities.
Conclusion: For patients with eGFR < 15 mL/min, hemodia-
lysis is protective. For patients with eGFR < 30 mL/min receiving
high dose GBCA, acute renal failure, delay in dialysis after GBCA
injection, pro-inflammatory events and hyperphosphatemia were
associated with increased NSF risk. Features of NSF may be
evident on the patient's skin as well as on routine imaging studies
although these imaging findings are nonspecific and more likely to
occur with other diseases.



058
The role of peri-aortic fat in aortic atherosclerosis
Ilias Kylintireas, Ikhlef Bechar, Cheerag Shirodaria,
Alistair Lindsay, Justin Lee, Matthew Robson,
Stefan Neubauer and Robin Choudhury
University Of Oxford, Oxford, UK

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):058

Introduction: Recent data suggest that perivascular fat is
metabolically active and may play a role in the initiation and
progression of atherosclerosis mediated by the paracrine action
of the adipokines it produces. MRI offers the unique capability for
clear depiction and accurate quantification of adipose tissue
alongside an effective non invasive and radiation free assessment
of both early and advanced atherosclerotic effects on the
vasculature.
Purpose: We investigated the relationship between perivascu-
lar adipose tissue and atherosclerosis-related structural and
functional changes of the vasculature in an elderly population at
high cardiovascular risk.
Methods: Fifty elderly subjects [mean age = 65 ( 8), 16/
50 = 32% women] with at least one major cardiovascular risk
factor (smoking, diabetes, hypertension, hyperlipidemia) under-
went MRI (1.5 T Siemens Sonata) for abdominal and peri-aortic
adipose tissue quantification and aortic atherosclerosis asses-


Figure I (abstract 058)


Figure 2 (abstract 058)


036-





0.341-



9.26-

0.24-

0.22


C
* S




* t


.I 21
1-6 LX 21e


ment. A Water Suppression (WS) TI weighted (TIW) Turbo
Spin Echo (TSE) multi-slice sequence was used for visceral
adipose tissue (VAT) and abdominal subcutaneous adipose tissue
(SCAT) measurement.
A modified version of the same sequence was used to produce
WS cross-sectional images covering the descending thoracic
aorta (figure la). On these images peri-vascular adipose tissue
(PVAT) area was measured within a radius equal to three times
the radius of the vessel cross-section. PVAT index (PVATI) was
defined as the PVAT area divided by the cross-sectional area of
the vessel (in order to normalise to the vessel size) and averaged
for all the images along the aorta to produce a PVATI value per
patient. Inter-scan and intra-observer variability of this method
was very satisfactory (coefficient of variance was 0.06 and 0.03
respectively).
Proton density weighted fat saturation black blood turbo spin
echo (TSE) cross-sectional images covering the descending
thoracic aorta (figure la) were used for atheroma burden



Figure 3 (abstract 058)


Wa s -


.4eS -

tent -

045 -


t.w -

Wstl -


S

9


S ~ .

rr
w-


I I I L I
16 t0e 2r


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I0. 1.0 1.2 1.4
PVATI


I I I I
IJS le 1*2 I.-
PIAII


http://jcmr-online.com/supplements/11/S1








Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


measurements (expressed as plaque index (PI) = cross-sectional
vessel wall area/total cross-sectional vascular area).
Aortic distensibility was assessed from breath-hold ECG-gated,
steady state free precession (SSFP) images through the thoracic
descending aorta. Distensibility was calculated as the relative
change in area divided by peripheral pulse pressure.
Results: Aortic PVATI correlated with aortic atheroma burden
(r = 0.44, P < 0.005) (figure 2) and inversely correlated with
descending thoracic aortic distensibility (r = -0.45, P < 0.005)
(figure 3). VAT and SCAT measurements did not correlate with
thoracic aortic PI or descending thoracic aortic distensibility.
Applying corresponding multiple regression analysis models
(including classical risk factors, demographics and anthropo-
metric measurements) PVATI emerged as an independent
predictor of both aortic atheroma burden [b = 0.06 ( 0.02),
P < 0.05, R2 = 0.35] and descending thoracic aortic distensibility
[b = -0.00014 ( 0.00005), P < 0.01, R2 = 0.42].
Conclusion: These results suggest a pathophysiological link
between peri-vascular adiposity and the atherosclerotic process
in the underlying vessel. MRI is an effective tool in depicting and
quantifying PVAT Further, interventional and analytical studies
are required to elucidate this relationship.




059
MRI evaluation of right and left ventricular
remodeling and surrogate markers of
PH following acute pulmonary embolism
Frederikus A Klok, Soha AH Romeih, Jos JM Westenberg,
Lucia JM Kroft, Menno V Huisman and Albert de Roos
LUMC, Leiden, Netherlands

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):059
Introduction: It is difficult to identify patients at risk for
chronic-thromboembolic pulmonary hypertension (CTEPH) in
the clinical course of pulmonary embolism (PE). We evaluated
ventricular remodeling and markers of pulmonary hypertension
(PH) using cardiac MRI in PE patients after 6 months treatment.
Methods: Fifteen PE-patients and 10 controls, in whom PE was
suspected but ruled out, were studied. A baseline CT scan was
performed to diagnose PE and to assess dynamic right and left
ventricular (RV; LV) function. After 200 days, a MRI scan was
performed to assess bilateral ventricular function and several
surrogate markers of PH.
Results: Baseline characteristics of both controls and PE-
patients were comparable. In the control cohort, end-systolic
(ESV) and end-diastolic volume (EDV) in both ventricles did not
change in time. PE patients with normal RV function at baseline
had a significant improvement in RVEF (+5.4 3.1%) due to a
relative decrease in ESV (-17 7.9%). Patients with abnormal RV
function at baseline had a significant improvement in RVEF
(+14 15%) due to relative decrease in both ESV (-36 23%)
and EDV (-22 16%). Furthermore, LVEDV increased signifi-
cantly (15 1I%).
Pulmonary distensibility index (0.033 0.0058) was significant
decreased in patients with persistent RV dysfunction compared
to patients with restored RV function (0.22 0.18) and controls
(0.28 0.25). In addition, decreased stroke volume (71 21 ml
versus 103 40 ml and 94 19 ml respectively) and PH specific


alterations in the pulmonary flow curves were found in these
patients compared to both other groups.
Conclusion: RV remodelling after PE is dependent on the
degree of baseline RV dysfunction. RVEF improves due to
decrease in RVESV and in lesser extent to RVEDV. Compared to
controls and PE patients with normalized RV function, patients
with persistent RV dysfunction have PH specific pulmonary
flow alterations and a stiffened pulmonary artery. It remains to
be studied whether these patients are at risk for developing
CTEPH.

060
Effect of age on stress induced changes in
aortic distensibility
Haroon L Chughtai, William G Hundley, Tim Morgan
and Craig Hamilton
Wake Forest University Health Sciences, Winston Salem,
NC, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):060
Introduction: Aging increases aortic stiffness. We describe a
novel method for assessing aortic distensibility throughout stress
with dobutamine.
Purpose: Previous studies have shown aortic stiffness to be a
predictor of adverse cardiovascular outcomes and mortality.
Aging is one of the most significant factors associated with aortic
stiffness. Aortic stiffness can be assessed by measuring aortic
distensibility non-invasively with cardiac magnetic resonance. We
undertook this study to assess and understand the changes in
aortic distensibility with stress (induced by dobutamine) and find
an association of these changes with advancing age.
Methods: We studied 128 patients (48% women) aged 55-85
years in which aortic distensibility was determined during
intravenous dobutamine infused to achieve 85% of predicted

Figure I (abstract 060)


0
0
o 0
OD
80- 0 0
0 0
00
0 0 0
o 0
S o00

o oo



o o ooo o
o o o o
S O 0 0 0
o- 00
S70- 00000 0 0




000
0 0 0 0
o 0 0 0 0
0o o
0 0 0 0
0 0 0
0 0 0 0
00 0

2.00 400 8.00 8.00

Lowdose Ascending Aortic
Distensibility (10-3 mmhg-1)


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 2 (abstract 060)


8D- 0 0
0 0 0
0 0


o oo oo o
0 o
<3D 00
0 0 0

0o o

So
0 O000 0




00 00
0 0
0 00 0



00
0 0 00


-5.00 -2.50 0.00 2.50

Change in Ascending Aortic Distensibility (10-3 mmhg-l)
From Low Dose to Peak Dose



heart rate response for age. Image acquisition was accomplished with
phase-contrast gradient echo cardiovascular magnetic resonance.
Images were acquired perpendicular to the course of ascending aorta
at the middle level of the left atrium. Aortic distensibility was
determined by measuring cardiac cycle dependent changes in aortic
area/{brachial pulse pressure x the end-diastolic area of the aorta}.
Changes between different stages of stress were calculated and
correlated with age using linear regression.
Results: Resting baseline ascending aortic distentesibility was
2.0 x 103 mmhg After infusion of low dose dobutamine
(7.5 pg/kg/min), mean ascending aortic distensibility was
1.9 x 103 mmhg At peak stress, mean ascending aortic
distensibility was 1.8 x 103 mmhg On Pearson correlation, all
the individual distensibilities (baseline, low dose and peak dose)
correlated negatively with age (baseline and low dose significant
at p of .00). In the second step, differences between each of
baseline to low dose and low dose to high dose distensibilities
were calculated. From baseline to low dose, mean difference was
0.178 x 103 mmhgl which correlated with age at an r of -0.24
(significant at a p value of .00). The mean difference between low
dose to peak dose was -0.308 x 103 mmhg' which correlated
with age at an r of -0.22 (significant at a p value of .01). A partial
correlation was also done after adjustment for gender,
hypertension and diabetes, which showed persistence of negative
correlation of baseline, low dose and peak dose ascending aortic
distensibilities with age (baseline and low dose were statistically
significant). The adjusted analysis also showed the independent
negative correlation of age with change in ascending aortic
distensibility from low dose to peak dose (r of -0.25 at a p value
of .01). Figures I and 2.
Conclusion: Our study indicates that advanced age is an
independent predictor of impaired ascending aortic distensibility
and inability to adequately change distensibility during stress.
These data imply that advanced aging may alter the relationship
between aortic stiffness and left ventricular emptying during
pharmacologic stress.


061
Does lipid lowering therapy improve calf muscle
perfusion and cellular metabolism in
peripheral arterial disease?
Amy M West, Justin D Anderson, Frederick H Epstein,
Craig H Meyer, Klaus D Hagspiel, Stuart S Berr,
Nancy L Harthun, Arthur L Weltman, Joseph M DiMaria,
Jennifer R Hunter, John M Christopher
and Christopher M Kramer
University of Virginia, Charlottesville, VA, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):061

Introduction: Previous studies suggest that lipid lowering
therapy improves symptoms and walking performance in patients
with peripheral arterial disease (PAD). We studied the relation-
ship between LDL reduction and both tissue perfusion and
cellular metabolism in PAD using magnetic resonance imaging
(MRI) and spectroscopy (MRS).
Methods: 61 patients with mild-to-moderate symptomatic
PAD (mean age 63 10 years, ankle brachial index
0.69 0.15) were studied before and I year after starting one
of 3 lipid lowering therapies. Statin-naive patients were
randomized to simvastatin 40 mg or simvastatin 40 mg plus
ezetimibe 10 mg (n = 31) and patients already on a station were
given open-label ezetimbibe 10 mg (n = 30). Lipid measurements
were obtained as part of the VAP test. Patients with interval
stenting of the leg studied (n = 4) or bypass surgery (n = I) were
excluded from analysis. All 56 remaining patients had calf muscle
phosphocreatine recovery time constant (PCr) measured using
31phosphorus (P) MRS immediately after symptom-limited calf
muscle exercise using a MR compatible ergometer on a Siemens
Sonata 1.5 T scanner. Exercise time was recorded. 31P MRS was
obtained using a single-pulse, surface coil localized, 512 ms free
induction decay acquisition with 20 averages centered on the
mid-calf. PCr was then calculated using a monoexponential fit of
phosphocreatine concentration versus time, beginning at cessa-
tion of exercise. Calf muscle tissue perfusion (TP) was measured
in 50 patients using first-pass contrast-enhanced MRI at peak
exercise. The remaining 6 patients were excluded due to
compromised renal function. The patients pushed a MR-
compatible foot pedal ergometer at a steady rate (10-12 bpm)
until limiting symptoms or exhaustion while in a Siemens Avanto
1.5 T scanner and gadolinium (0.1 mM/kg) was infused at peak
exercise. Work expended during exercise was recorded. Time
intensity curves were generated with ARGUS image analysis
software from the region of calf muscle with the greatest
intensity post contrast and the slope of this curve was defined as
TP To assess microvascular blood flow within the calf muscle, TP


Table I (abstract 061) Changes in perfusion,
exercise parameters over time


metabolism, and


Baseline Follow up

Perfusion Work, j 225.6 156.1 250.8 293.9
Tissue perfusion 6.45 3.42 6.32 3.44
Perfusion index 0.57 0.39 0.60 0.42
PCr Exercise, sec 156.6 58.8 173.1 57.9*
PCr, sec 85.9 59.3 85.8 59.8

*p = 0.06 vs. baseline.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


was indexed to macrovascular blood flow into the calf by dividing
it by the slope of the popliteal arterial input curve to obtain a
perfusion index (PI). Changes in all parameters from baseline to
year one were compared by paired t-test and between group
differences by unpaired t-test.
Results: LDL at baseline was I 10 34 and was lower at one
year (79 34 mg/dl, p < 0.0001). The total cholesterol at
baseline was 183 42 and decreased significantly at one year
to 146 42 mg/dl, p < 0.0001 as did triglycerides (165 119
to 145 81 mg/dl, p = 0.05). There was no change in HDL from
baseline to follow-up (44 14 to 43 14 mg/dl, p = NS). See
Table I for changes in TP PI, PCr, exercise time and work
expended between baseline and year one. A trend was noted
towards an increase in exercise time for 31P MRS. There were no
between group differences in any MR or exercise outcome
parameter in patients treated with different lipid lowering
regimens.
Conclusion: Lipid lowering therapy over the course of one
year in PAD did not improve tissue perfusion as measured by first
pass contrast-enhanced MRI or cellular metabolism as measured
by phosphocreatine recovery kinetics, although exercise time
tended to improve. Thus, the previously demonstrated increase
in exercise capacity with LDL lowering in PAD is unlikely due to
improvements in tissue perfusion or skeletal muscle metabolism,
suggesting that other potential mechanisms of benefit must be at
play.


062
Incremental value of cardiac magnetic resonance
in the characterization of unselected patients
referred to exclude arrhythmogenic right
ventricular cardiomyopathy
Alberto Roghi, Stefano Pedretti, Patrizia Pedrotti
and Santo Dellegrottaglie
Department of Cardiology, Niguarda Ca'Granda Hospital,
Milan, Italy

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):062
Introduction: Cardiac magnetic resonance (CMR) may be
efficiently applied to recognize morphologic and functional
aspects employed in the diagnosis of arrhythmogenic right
ventricular cardiomyopathy (ARVC). However, limited informa-
tion is available regarding the actual impact of CMR findings in
reaching a diagnosis of ARVC in an unselected population of
patients referred to a CMR laboratory.
Purpose: Aim of the study was to evaluate the incremental
value of CMR over preliminary clinical/instrumental data in
characterizing a group of consecutive patients referred for
suspected ARVC.
Methods: From January 2006 to April 2008, a total of
91 consecutive patients (60% males; mean age, 35 18 years,
range 8-72 years) underwent CMR (1.5 T, Magnetom Avanto,
Siemens) to exclude ARVC. In each patient, CMR imaging
protocol applied at the ventricular level included the acquisition
of images for the identification of: (I) regional and/or global
systolic dysfunction and chamber dilation (steady-state free
precession sequences); (2) myocardial areas of fatty infiltration
(TI-weighted fast spin-echo sequences with and without fat-
saturation); myocardial areas of edema/flogosis (T2-weighted
short-tau inversion recovery sequences); myocardial areas of


delayed post-contrast enhancement (gradient-echo inversion
recovery sequences). All patients had been previously evaluated
by resting electrocardiogram, exercise stress test, 24-h Holter
electrocardiogram monitoring and transthoracic echocardiogra-
phy. Major and minor criteria for ARVC diagnosis were defined
according to the standard Task Force criteria.
Results: The studied patients were referred for the CMR study
mainly based on frequent premature ventricular contractions
(52%) or morphologic/functional alterations of the right ventricle
(29%). By considering pre-CMR clinical/instrumental data only,
diagnosis of ARVC was already reached in 3 (3%) patients, while
the majority of patients (n = 62, 68%) presented with a low pre-
test probability of disease. Inclusion of CMR data allowed to
reach a diagnosis for ARVC in 4 (4%) patients. In none of the
patients in the subgroup at low pre-test probability, CMR
information led to a diagnosis for ARVC. With the CMR protocol
employed in this study, diagnosis other than ARVC were obtained
in 17 patients (19%), including: acute or chronic myocarditis
(n = 5); chronic myocardial infarction (n = 2); partial anomalous
pulmonary venous return (n = 2); other diagnoses (n = 8).
Conclusion: In an unselected population of patients with
suspected ARVC, the proportion of cases with a confirmed
diagnosis of ARVC is not significantly impacted by CMR
information over preliminary clinical/instrumental data. In 19%
of patients referred to exclude ARVC, CMR allows the
identification of previously unrecognized conditions other than
ARVC.


063
Delayed hyper-enhancement cardiac magnetic
resonance imaging is more accurate than
other noninvasive parameters in diagnosis
of patients with endomyocardial biopsy positive
cardiac amyloidosis
Bethany A Austin, Scott D Flamm, E Rene Rodriguez,
Carmela Tan, Randall C Starling and Milind Y Desai
Cleveland Clinic, Cleveland, OH, USA

journal of Cardiovascular Magnetic Resonance 2009, II(Suppl 1):063
Introduction: In patients with nonischemic cardiomyopathy
and suspected cardiac amyloidosis (CA), endomyocardial biopsy
(EMB) provides a definitive diagnosis. A multitude of noninvasive
parameters, including electrocardiography (ECG) and transthor-
acic echocardiography (TTE) have been utilized as potential
markers of CA. Recently, it has been demonstrated that, in
patients with CA, delayed hyper-enhancement cardiac magnetic
resonance (DHE-CMR) reveals a characteristic diffuse enhance-
ment of the entire subendocardium (arrows) with extension into
the neighboring myocardium (Figure I).
Purpose: We sought to determine the diagnostic accuracy of
DHE-CMR, as compared to standard noninvasive parameters, in
patients with suspected CA that underwent EMB.
Methods: A total of 38 patients (mean age 62 14 years, 71%
men, 57% with New York Heart Association class > 2) with
suspected CA underwent electrocardiography (ECG), TTE
(including tissue Doppler), DHE-CMR (Siemens 1.5 T scanner,
Erlangen, Germany) and EMB between 1/05 and 4/08. Low
voltage on ECG was defined as sum of S wave in lead VI + R wave
in lead V5 or V6 < 15 mm. Measured TTE parameters included
left atrial size, interventricular septal thickness, speckled


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 063)


appearance, E/A ratio, E/E' ratio, stage of diastology, deceleration
time (msec) and myocardial performance index [(isovolumic
contraction time + isovolumic relaxation time)/ejection time].
DHE-MR images were obtained in standard long and short axis
orientations (covering the entire LV), after injection of
Gadolinium dimenglumine using an inversion recovery spoiled
gradient echo sequence: TE 4 msec, TR 8 msec, flip angle 30,
bandwidth 140 Hz/pixel, 23 k-space lines acquired every other
RR-interval, field of view (varied from 228-330 in the x-direction
and 260-330 in the y-direction) and matrix size (varied from
140-180 in the x-direction and 256 in the y-direction). CMR was
considered positive in the presence of DHE of entire sub-
endocardium with extension into the neighboring myocardium.


Results: There were 17 each with EMB-positive CA and CMR-
suspected CA. Using EMB as gold-standard, there was 2 false-
positive and 2 false-negative CMR. Sensitivity, specificity, positive
predictive value (PV) and negative PV of DHE-CMR in the
diagnosis of CA were 88%, 90%, 88% and 90% respectively.
Logistic regression analysis demonstrating the association
between EMB-positive CA and various noninvasive parameters
is shown in Table I.
Conclusion: DHE-CMR is highly accurate in noninvasive
diagnosis of EMB-positive CA as compared to standard ECG
and TTE criteria. Incremental prognostic value of DHE-CMR in
CA for clinical outcomes needs to be determined.



064
Influence of late gadolinium enhancement
on left ventricular morphology and function in
patients with sarcoidosis
Amit R Patel, Nadera J Sweiss, Sonal Chandra,
Lissa Sugeng, Kirk T Spencer, Jeanne M DeCara,
Martin C Burke, Timothy B Niewold, Douglas K Hogarth,
Stephen L Archer and John F Beshai
University of Chicago, Chicago, IL, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):064
Background: Cardiac involvement in sarcoidosis patients is
associated with an increased risk of sudden death. However,
conduction block and cardiomyopathy are late and therefore
potentially insensitive markers of cardiac sarcoidosis. Prior
publications have suggested that the detection of late gadolinium
enhancement (LGE) by cardiac magnetic resonance (CMR) may
be a more sensitive parameter for diagnosing cardiac sarcoidosis.
Using CMR, in patients with known sarcoidosis, we sought I) to
further define the incidence of cardiac involvement and 2) to
determine the correlation between LGE and structural cardiac
pathology.
Methods: We retrospectively evaluated 55 consecutive
patients with known sarcoidosis who were referred for CMR.
Imaging was performed on a 1.5 Tesla MRI scanner with a flexible
surface coil. Retrospectively gated cines of the left ventricular


Table I (abstract 063) Logistic univariate regression analysis testing the association between endomyocardial biopsy proven cardiac
amyloidosis and various noninvasive imaging parameters

Univariate Multivariate

Noninvasive imaging parameters Wald XZ Statistic p-value Wald XZ Statistic p-value

Carroll' Criteria on ECG 2.23 0.13
Rahman's Criteria on ECG 0.60 0.40
Dilated left atrium (> 20 cm2) 0.98 0.33
Interventricular septal thickness 8.6 0.003 1.7 0.19
Left ventricular ejection fraction 0.04 0.83
Speckled appearance on surface echocardiography 0.0 0.9
Pseudonormal or restrictive physiology on Doppler echocardiography 2.1 0.15
E/A ratio 1.9 0.17
E/E' ratio > 15 1.06 0.30
Abnormal deceleration time (< 150 msec) 0.002 0.97
Myocardial performance index 1.7 0.20
Positive delayed hyper-enhancement cardiac magnetic resonance 16 < 0.001 9.6 0.002


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 064)


Figure 2 (abstract 064)


E150



10ao


P-0.59







P-0.66







LGE


P-0.16















0


70 I
-70


,60
I

00i


IVEDV LVESV LVEF
(ml) (ml) M%)


(LV) 2-, 3-, and 4-chambers, and a short-axis stack were obtained
using steady state free precession imaging (TR 2.9 ms, TE 1.5 ms,
flip angle 600, temporal resolution 25-40 ms). LGE images of the
same views were obtained 10-20 minutes after infusion of Gd-
DTPA (0.15-0.2 mmol/kg) using a TI-weighted inversion
recovery GRE pulse sequence (TI based on optimal myocardial
nulling, TR 3.9 ms, TE 1.7 ms, flip angle = 15-30). The cines of
the short-axis stack were used to determine LV and right
ventricular end-diastolic volume (LVEDV and RVEDV), end-
systolic volume (LVESV and RVESV), ejection fraction (LVEF and
RVEF), and LV mass. The presence or absence of LGE was
determined for each of the 17 segments of the American Heart
Association left ventricular model. Continuous variables were
reported as mean standard deviation, groups (based on the
presence or absence of LGE) were compared using a t-test, and
linear regression analysis was used to investigate the correlation
between LGE and LV size and function. A p value < 0.05 was
considered statistically significant.
Results: The patients were 48 13 years old and the majority
were women (73%). Twenty-two percent of the patients had LGE
involving on average 14 12% of the LV. In patients with or
without LGE, there was no difference in LVEDV (147 35 ml vs.
150 35 ml, p = 0.59), LVESV (64 16 ml vs. 57 16 ml,
p = 0.66), LVEF (58 8% vs. 62 + 7%, p = 0.16), LV mass
(I 16 46 g vs. 99 24 g, p = 0.47), RVEDV (172 35 ml vs.
171 46 ml, p = 0.91), RVESV (85 26 ml vs. 82 27 ml,
p = 0.78) and RVEF (52 6% vs. 53 7%, p = 0.70). See figure I.
Moreover, based on linear regression analysis, in the patients
with LGE, the extent of enhancement did not influence LVEDV
(r2 = 0.14, p = 0.29) and LV mass (r2 = 0.03, p = 0.65). However,
there was a trend that the extent of LGE correlated with both
LVESV (r2 = 0.27, p = 0.13) and LVEF (r2 = 0.29, p = 0.1 I) (See
figure 2). All of the above relationships persisted even after
accounting for body surface area.


rz-0.27
p-0.13
OJ 01d d2 03
% WE


P.'O. 11
-0 01 O d3
%LGE


Conclusion: In patients with known sarcoidosis, nearly a
quarter had evidence of cardiac involvement, as defined by the
presence of LGE, despite the lack of any difference in traditional
measures of cardiac structure and function. These preliminary
findings suggest that volumetric and functional assessments alone
are inadequate for the detection of cardiac sarcoidosis and that
tissue characterization using LGE is essential. Further studies are
needed to determine the long-term prognostic value of LGE and
to further clarify the relationship between the extent of LGE and
left ventricular morphology and physiology in patients with
cardiac sarcoidosis.



065
Delayed hyper-enhancement cardiac magnetic
resonance provides incremental prognostic value
in patients with cardiac amyloidosis
Bethany A Austin, Scott Flamm, E Rene Rodriguez,
Carmela Tan, WH Wilson Tang, David O Taylor,
Randall C Starling and Milind Y Desai
Cleveland Clinic, Cleveland, OH, USA

journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):065
Introduction: Patients with cardiac amyloidosis (CA) have an
unfavorable, albeit a variable prognosis. In patients with
documented cardiac amyloidosis (CA), delayed hyper-enhance-
ment-cardiac magnetic resonance (DHE-CMR) has been demon-
strated to have a high diagnostic accuracy. However, its
prognostic utility in CA has not been determined.
Purpose: We sought to determine the incremental prognostic
value of DHE-CMR in CA.
Methods: We studied 47 consecutive patients with suspected
CA (mean age 63 13 years, 70% men, 55% with NYHA class > 2)
that underwent electrocardiography (ECG), transthoracic echo-
cardiography (TTE), DHE-CMR (Siemens 1.5 T scanner,
Erlangen, Germany) and biopsy (38 endomyocardial, 9 extra-
cardiac) between 1/05 and 7/08. Low voltage on ECG was
defined as sum of S wave in lead VI + R wave in lead V5 or
V6 < 15 mm. Measured TTE parameters included left atrial size,
interventricular septal thickness, speckled appearance, E/A ratio,
E/E' ratio, stage of diastology, deceleration time (msec) and
myocardial performance index [(isovolumic contraction time +
isovolumic relaxation time)/ejection time]. DHE-CMR images
were obtained in standard long and short axis orientations


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table I (abstract 065) Cox proportional hazard analysis of various clinical and noninvasive imaging predictors of long-term mortality
in patients with biopsy proven cardiac amyloidosis

Univariate Analysis Multivariate Analysis

Variable XZ p value p value

Age 3.8 0.05 0.10
Gender 0.15 0.69
New York Heart Association Class 3.3 0.07 0.16
Low voltage on electrocardiogram 0.67 0.41
Left atrial size > 20 cm2 0.76 0.39
Left ventricular ejection fraction 2.21 0.14
Interventricular septal thickness 1.7 0.19
E/E' > 15 on Doppler echocardiography 1.12 0.29
Deceleration time on Doppler echocardiography < 150 msec 1.41 0.23
Myocardial performance index 2.10 0.15
Diastology grade 0.35 0.55
Delayed hyperenhancement on cardiac magnetic resonance 4.91 0.03 0.02

Chi-square for multivariate model = 12.27, p-value = 0.007.


(covering the entire LV), after injection of Gadolinium
dimenglumine using an inversion recovery spoiled gradient
echo sequence: TE 4 msec, TR 8 msec, flip angle 30, bandwidth
140 Hz/pixel, 23 k-space lines acquired every other RR-interval,
field of view (varied from 228-330 in the x-direction and 260-
330 in the y-direction) and matrix size (varied from 140-180 in
the x-direction and 256 in the y-direction). CMR was
considered positive in the presence of DHE of entire
subendocardium with extension into the neighboring myocar-
dium. All-cause mortality was ascertained.
Results: At baseline, 59% patients had low voltage on ECG,
while 67% had deceleration time < 150 msec and 53% had E/E' >
15 (both on Doppler echocardiography). Mean MPI, left
ventricular ejection fraction and interventricular septal thickness
were 0.51 0.3, 51% 13 and 1.5 cm 0.5, respectively. At up
to I-year after biopsy, there were 9 (19%) deaths. Results of Cox
Proportional Hazard survival analysis are shown in Table I. On
univariate Kaplan-Meier survival analysis, presence of DHE on



Figure I (abstract 065)


-DHE-CMR positive
- DHE-CMR negative













Log-rank statistic p-value = 0.03


0 50 100 150 200 250 300 350 400
Time (in days)


CMR was associated with worse I-year survival (log rank statistic
p-value = 0.03, Figure I).
Conclusion: Presence of DHE on CMR is associated with
worse I-year survival in CA. Along with a high diagnostic
accuracy; DHE-CMR adds incremental prognostic value in CA,
independent of other variables.



066
Delayed-enhanced magnetic resonance
imaging for identifying the ventricular
arrhythmia substrate in non-ischemic
cardiomyopathy
Benoit Desjardins', Fred Morady2 and Frank Bogun2
'University of Pennsylvania, Philadelphia, PA, USA
2University of Michigan, Ann Arbor, MI, USA

Journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):066
Introduction: Scar tissue is often noted in the myocardium of
patients with non-ischemic cardiomyopathy. Delayed-enhanced
magnetic resonance imaging (DE-MRI) can precisely define the
extension and distribution of this scar tissue. Such scar tissue can
act as arrhythmogenic substrate and lead to ventricular
arrhythmia. Patients with non-ischemic cardiomyopathy who
present with ventricular arrhythmia can undergo ablation therapy
to eliminate these arrhythmia.
Purpose: The purpose of the study is to determine if DE-MRI is
useful to guide mapping of ventricular arrhythmias in patients
with non-ischemic cardiomyopathy.
Methods: DE-MRI was performed in 28 consecutive patients
(mean age 50 15 years) with non-ischemic cardiomyopathy
(mean ejection fraction 38 9%) referred for catheter ablation
of ventricular tachycardia (VT) or premature ventricular
complexes (PVCs). If scar tissue was found on the DE-MRI, the
myocardial contours and scar distribution was semi-automatically
extracted, in order to generate 3-D maps of scar distribution.
These maps were then integrated into the electroanatomic map
using the CARTO Merge function (Figure I). This integration
involved initial matching of fiducial markers (LV apex, center of
mitral valve, aortic outflow tract) in both modalities, and then a


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- -







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 066)


Fused DE-MRI and endocardial maps. The endocardial map is projected
on the endocardial surface as determined by MRI. Areas with low
voltages are illustrated in red, and areas of normal voltages are in purple.
The 3-D distribution of DE on MRI (including both surface and
transmural extent) are represented in gray. There is excellent correlation
between the distribution of scar as represented by DE on MRI, and the
areas of low voltage on the endocardial map.



surface based optimized registration within the CARTO Merge
software. Mapping data were correlated with respect to the
localization of scar tissue (right ventricular vs left ventricular and
endocardial vs epicardial vs intramural).
Results: Scar tissue was identified by DE-MRI in 13 out of
28 patients. Characteristics of these 13 patients were as follow.
Patients had either sarcoidosis (n = 3) or dilated cardiomyopathy
(n = 10). They either had a single focus on DE-MRI (n = 5) or
multifocal disease (n = 8). The ventricular arrhythmia were VT
(n = 9) or PVC (n = 4). The distribution was predominantly
endocardial (n = 5), midmyocardial (n = 4), epicardial (n = 2)
and transmural (n = 2). On the electroanatomic map, there was
always low voltage present and matching the endocardial or
epicardial surface displaying DE on MRI. The size of the
endocardial scar on DE-MRI correlated well with the size of
the endocardial scar defined by voltage mapping (45+-14 cm2,
R = 0.94, p < 0.0001 with cutoff of 1.5 mV). All patients with
inducible VTor sustained VT had evidence of DE on MRI. In all
patients with DE on MRI where a critical site for the arrhythmia
could be identified, this critical site was confined to the scar
tissue.
Conclusion: DEMRI in patients without prior infarctions can
help to identify the arrhythmogenic substrate; furthermore it
helps to plan an appropriate mapping and treatment strategy.


067
Quantification of myocardial fibrosis by
delayed-enhanced MRI in patients with severe
aortic valve disease: correlation with quantified
histopathology
Carlos E Rochitte, Clerio F Azevedo, Marcelo Nigri,
Flavio Tarasoutchi, Pablo M Pommerantzeff,
Roney O Sampaio, Max Grinberg and Maria L Higuchi
Heart Institute InCor University of Sao Paulo Medical
School, Sao Paulo, Brazil

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):067
Introduction: Chronic aortic valve disease is characterized
by progressive accumulation of interstitial myocardial fibrosis
(MF) and impairment of myocyte ultrastructure. The amount of
interstitial MF may play an important role in the transition from
well-compensated hypertrophy to overt heart failure in the
setting of chronic LV mechanical overload. However, assessment
of interstitial MF and myocyte degeneration has only been
possible through histological analyses of myocardial fragments
from endomyocardial biopsies. Recently, delayed-enhancement
magnetic resonance imaging (deMRI) has been shown to
provide an accurate assessment of myocardial necrosis and
fibrosis.
Purpose: We employed a semi-automatic algorithm for the
quantification of MF using deMRI technique in patients with
severe aortic valve disease. We sought to determine whether the
amount of MF by deMRI demonstrated good correlation when
compared with the gold-standard histopathological analyses. In
addition, we investigated the relationship between the amount of
MF and resting LV function before aortic valve replacement
(AVR) surgery.
Methods: Fifty-four patients scheduled to undergo AVR
surgery were examined by cine and deMRI in a 1.5 T scanner.
From the deMRI dataset, the regions of MF were automatically
determined as the sum of pixels with signal intensity (SI) above a
pre-determined threshold. The definition of this threshold was
based on the mean SI of total myocardium, plus the SI variability
we would expect from a non-diseased myocardium (free of focal
regions of MF), and also taking into consideration the variability
introduced by image noise. More specifically, the threshold was
calculated as: mean SI of total myocardium + 2 standard
deviations (SD) of mean SI of a remote area + 2 SD of mean SI
of air. The remote area was manually delineated in a myocardial
region free of hyper-enhancement. In addition, interstitial MF was
quantified by histological analysis of myocardial samples obtained
during AVR surgery and stained with picrosirius red. Eight
subjects with no previous history and who died of noncardiac
causes served as controls for the quantitative histopathology.
Results: The amount of interstitial MF determined by histo-
pathology was higher in patients with aortic valve disease than in
controls (24.6 9.8% versus 6.0 1.8%, P < 0.0001). For each
patient, the amount of interstitial MF was considered abnormally
increased when it was higher than mean+2 SD of control
interstitial MF, i.e., higher than 9.6% (6.0% + 3.6%). The amount
of MF measured by deMRI was 3.72 2.17% for all patients,
4.35 2.32% in aortic regurgitation and 3.15 1.87% in aortic
stenosis subgroup (p = 0.04 between subgroups). Quantification
of MF by de-MRI showed good correlation with measurements
obtained by histopathology (y = 3.10x + 13.0; r = 0.69,
P < 0.0001). Correlation was also good if considered only the


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


subgroup of patients with aortic regurgitation (y = 3.09x + 12.3;
r = 0.70, P < 0.0001) or aortic stenosis (y = 3.34x + 12.9;
r = 0.67, P = 0.0001). Considering histopathology as the method
of reference, ROC analysis revealed a good accuracy of deMRI in
identifying patients with increased degrees of MF accumulation
(area under the curve = 0.92; 95% Cl 0.81 to 1.00). In addition,
the amount of MF by deMRI showed an inverse correlation with
LV EF (r = -0.67; p < 0.0001) and direct correlations with LV
EDV (r = 0.46; p = 0.0005), LV ESV (r = 0.62; p < 0.0001) and
LV mass (r = 0.46; p = 0.0005) before AVR surgery.
Conclusion: Delayed-enhanced MRI allows for the non-
invasive quantification of MF with good accuracy when compared
with histopathology in patients with severe aortic valve disease.
In addition, the amount of MF by deMRI is associated with worse
LV morphological and functional parameters before AVR surgery
in this population.

068
Myocardial fibrosis is a prevalent finding
in elite high-endurance athletes
Myra S Cocker', Oliver Strohm', David J Smith2
Craig Butler', Israel Belenkie3, Willem Meeuwisse
and Matthias G Friedrich'
'Stephenson CMR Centre at the Libin Cardiovascular Institute,
University of Calgary, Calgary, AB, Canada
2Human Performance Lab, Faculty of Kinesiology, University
of Calgary, Calgary, AB, Canada
3Department of Cardiac Sciences at the Libin Cardiovascular
Institute, University of Calgary, Calgary, AB, Canada
Sports Medicine Centre, University of Calgary, Calgary,
AB, Canada

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):068
Background: Autopsies in athletes have shown that athletes have
diffuse myocardial fibrosis, and epidemiological findings place
athletes at a greater relative risk of sudden death due to
cardiovascular causes. Electrocardiography abnormalities are well
documented in athletes, where it is widely accepted that these are
characteristic of the 'athlete's heart'. Furthermore, biochemical
markers of collagen breakdown and myocardial fibrosis are elevated
in athletes. As such, using CMR late Gadolinium enhancement (LE)
imaging, we hypothesized that fibrosis is a feature of the athlete's
heart and is associated with reduced cardiac function.
Methods: 48 elite athletes (25 male, age 32 13 years), and a
control group of 8 healthy individuals (4 male, 31 9 years)
were prospectively recruited. On a 1.5 T MRI system, standard
protocols for assessment for LV function and TI-weighted LE
were performed.
Two experienced observers assessed LE images visually for the
presence of fibrosis. The extent of fibrosis was assessed
quantitatively, using semi-automated detection where regions
that had signal enhancement above a threshold of 5 standard
deviations from the mean signal of healthy myocardium, were
considered to represent fibrosis. Areas that had a lack of contrast
enhancement were used to define healthy myocardium.
Abbreviations utilized: LVEDVI LV end-diastolic volume indexed-
to-height; LVESVI LVend-systolic volume indexed-to-height; LVSVI -
LV stroke volume indexed-to-height; LVEF LV ejection fraction
Results: 37 of 48 (77%) athletes had non-ischemic diffuse LE,
compared with I of 8 (13%) of controls. The extent of myocardial
fibrosis in athletes who had visual evidence for LE was 10.7 3.3%.


Figure I (abstract 068)


T I-weighted late gadolinium enhancement images. Left panels: Evidence of
subepicardial non-ischemic myocardial fibrosis in athletes I and 2
(arrows), with none in healthy control. Right panels: Quantification of
myocardial fibrosis by manually tracing a region of interest in health
remote myocardium (blue outline). Automated computer thresholding
set at 5 standard deviations above the mean signal intensity of remote
myocardium detects fibrosis (red overlay). The detected extent of fibrosis
for athlete I is 14.12%, I 1.30% for athlete 2 and 0.20% for control.

Athletes with fibrosis had increased LVEDVI (117 19 vs.
98 15 ml/m, p < 0.05), LVESVI (44 II vs. 34 10 ml/m,
p < 0.05), and LVSVI (73 II vs. 64 7 ml/m, p < 0.05), while
LVEF (63 5 vs. 66 6%, p > 0.05) did not differ, when compared
to those who did not have fibrosis. Figure I.
Conclusion: This is the first evidence of myocardial fibrosis
being a prevalent finding in elite athletes, and its relation to
cardiac morphology with depressed cardiac function. Long-term
follow-up is required to assess the impact of fibrosis on outcome
and prognosis in the 'athlete's heart'.


069
Non-rheumatic streptococcal myocarditis
mimicking acute ST-segment elevation
myocardial infarction: characterization
by cardiac magnetic resonance
Rasoul Mokabberi, Jamshid Shirani,
Afsaneh Haftbaradaran Mohammadi
and William Schiavone
Geisinger Medical Center, Danville, PA, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):069
Introduction: Acute myocarditis may mimic acute ST-segment
elevation myocardial infarction (STEMI) and result in unnecessary
invasive coronary angiography. Cardiac magnetic resonance


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table I (abstract 069) Clinical and Imaging Characteristic in 6 Patients

Patient I 2 3 4 5 6

Age (years) 27 35 33 32 29 22
Sex M M M M F M
ECG ST-Elevation Inferolateral Inferolateral Lateral Lateral Inferolateral Inferolateral
Echo RWMA Inferolateral, lateral Inferior, inferoseptal Inferior, inferolateral Inferior Inferior, inferoseptal Inferolateral
Echo WMSI 1.24 1.12 1.24 1.12 1.12 1.12
Echo LVEF (%) 40 45 45 57 52 51
Segments with LGE NA 4 3 3 5 9


(CMR) can differentiate myocarditis from acute ischemic
myocardial injury and provide a basis for adoption of an
appropriate treatment strategy in such patients.
Purpose: The aim of this observation was to determine the
diagnostic value of CMR in assessment of patients with acute
non-rheumatic streptococcal myocarditis.
Methods and results: We evaluated 6 young adults [age 22-
35 (mean 29 5) years, 5 men] with acute non-rheumatic
streptococcal myocardits following recent (mean 4.8 days prior
to presentation) pharyngitis (positive throat culture or rapid
antigen test, elevated antistreptolysin antibody). All patients
presented with non-pleuritic chest pain and focal ST segment
elevation on admission electrocardiogram. Cardiac enzymes
(creatine phosphokinase and troponin T) were elevated and
emergent coronary angiography revealed normal coronary
arteries. Two-dimensional transthoracic echocardiography
showed regional wall motion abnormality (RWMA) with wall
motion score index (WMSI) ranging from 1.12-1.24 and left
ventricular ejection fraction (LVEF) ranging from 40-57%, and
contrast-enhanced CMR demonstrated characteristic subepicar-
dial late gadolinium enhancement (LGE) involving 4.8 2.4
myocardial segments without an early perfusion defect (Table I).
Patients were treated with antibiotics and anti-inflammatory
agents and showed clinical recovery within 3 days.
Conclusion: Acute non-rheumatic streptococcal myocarditis
may mimic STEMI. Clinical history (young individual, preceding
pharyngeal infection), laboratory evidence of acute streptococcal
infection and characteristic CMR findings can distinguish these
patients from those with acute STEMI who benefit from primary
coronary intervention.


070
Screening for hypertrophic cardiomyopathy:
a cost analysis of echocardiography, cardiac
magnetic resonance and genetic testing
Thomas H Hauser, Martin S Maron and Warren J Manning
Beth Israel Deaconess Medical Center, Boston, MA, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):070

Introduction: Hypertrophic cardiomyopathy (HCM) is the
most common heritable cardiomyopathy and is the leading
cause of sudden cardiac death early in life. Screening of first
degree relatives for HCM phenotype is recommended, typically
with serial echocardiography (Echo). Recently, cardiovascular
magnetic resonance (CMR) and genetic testing (GT) have
emerged as additional screening strategies. Up to 5% of patients
with HCM on CMR have normal Echo findings. GT has been
proposed as a method for eliminating unnecessary diagnostic


imaging tests in genotype negative family members in families
identified to have a disease causing mutation, present approxi-
mately 50% of the time. Because large, long-term trials to
compare these methods are not feasible, modeling of costs and
outcomes can provide insight into the potential costs and
benefits of various screening strategies.
Purpose: The objective of this study is to evaluate the costs
and benefits of screening strategies of HCM using Echo, CMR and
GT.
Methods: We developed a Markov model to evaluate 5
screening strategies: Echo, CMR, Echo and GT, CMR and GT,
and Echo, CMR and GT. All screening strategies were designed
based on standard guidelines with first testing at age 13, with
imaging with Echo and/or CMR every 2 years until age 25 and
every 7 years until age 50. GTwas performed once only at the
start of screening. The model was tested using a theoretical
cohort of 1000 probands with an average of 4 first degree
relatives that required testing. The base case assumed an Echo
cost of $650, CMR cost of $800, and GT cost of $3000. The
penetrance of HCM was modeled such that, of those destined to
have HCM, 90% of screened first degree relatives would have
phenotypic HCM by age 25 with the remaining 10% evident by
age 50. Echo was assumed to have a 5% error rate compared to
CMR. The analysis was performed from the societal perspective
using constant 2008 dollars. A 3% discount rate was used.
Results: GT resulted in increased costs with no improvement
in diagnostic accuracy when paired with either Echo or CMR.
Echo was the least expensive strategy with a cost per patient
screened of $3754, but did not identify phenotypic HCM in 6%.



Figure I (abstract 070)


6000
S) 5m,

400D
i 3000
CL
o2000
0
0


m - ,

.' *


0 1000 2000 3000
CostofGT ($)

Cost per patient for HCM screening.


-Echo
CIR
- Echo and GT
CMR and GT




4000


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


CMR cost $4546 per patient screened and did not identify 1% of
patients with phenotypic HCM. The incremental cost for each
additional diagnosis of HCM with CMR was $15,840. The
addition of Echo to CMR increases costs without any increase in
diagnostic accuracy. Sensitivity analysis showed that the cost of
GT had a large influence on the analysis. The break even cost for
GTwas $1243 when used with Echo and $1530 when used with
CMR (figure I).
Conclusion: In this model of screening for HCM, GT increased
costs without improving outcome. Screening with CMR identi-
fied a larger proportion of patients with HCM with an associated
increase in cost.


071
Impaired aortic distensibility determined by
magnetic resonance imaging in patients with
different bicuspid aortic valve phenotypes
Thananya Boonyasirinant, Randolph M Setser,
Milind Y Desai and Scott D Flamm
Cleveland Clinic, Cleveland, OH, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):071
Introduction: Beyond the morphologic and functional
abnormalities of the bicuspid aortic valve (BAV) there is also
intrinsic pathology of the aortic wall, manifested by potentially
lethal complications such as aortic aneurysm or dissection.
Aortic distensibility and compliance are impaired in athero-
sclerotic aortic aneurysms and Marfan syndrome. Similar
abnormalities of compliance are felt to occur in the setting of
BAV, though this has been little studied with velocity-encoded
magnetic resonance imaging (VENC-MRI), and further there is no
data on the influence of BAV morphology on this abnormality.
VENC-MRI is a potent non-invasive technique to determine
aortic distensibility via aortic pulse wave velocity (PWV)
measurements; in addition these measurements do not depend
on knowledge of central arterial pressure or geometrical
assumptions that may limit alternative measurement tools.


Figure I (abstract 071)


Left panel: Through-plane velocity-encoding magentic resonance imaging
ascending (red circle) and proximal descending aorta (blue circle). Middle
panel: Corresponding flow measurement at ascending (red line) and
proximal descending aorta (blue line). Right panel: The measurement of
arrival time at ascending and proximal descending aorta. The pulse wave
velocity was calculated as the aortic path length between these 2 sites
divided by the time delay between the arrival of the foot pulse wave at
these 2 sites.


Figure 2 (abstract 071)


I
Normal


RIuon
R-L fusion


fusion
R-NC fus;ion


The pulse wave velocity (PWV) in normal patients, right and left (R-L)
fusion, and right and non-coronary (R-NC) bicuspid aortic valve patients.
Circal, mean and whiskers. 95% confidence intervals.



Purpose: We sought to assess thoracic aortic distensibility by
PWV measurements from VENC-MRI in patients with bicuspid
aortic valve, and to determine if differences exist between
different BAV phenotypes.
Methods: VENC-MRI was performed in 100 BAV patients and
35 controls (trileaflet aortic valve without dysfunction, and no
aortic aneurysm). The PWV was determined between the mid
ascending and proximal descending aorta. Velocity measurements
were made perpendicular to the long axis of the mid ascending
and proximal descending thoracic aorta. The aortic path length
between the two locations was directly measured from three-
dimensional reconstruction in the oblique sagittal orientation
encompassing the aortic arch. The BAV phenotypes were imaged
using a cine-SSFP or cine-GRE across the face of the aortic valve,
and then classified as: right-left cusp fusion (R-L fusion), right and
non-coronary cusp fusion (R-NC fusion), and left and non-
coronary cusp fusion (L-NC fusion).
Results: BAV phenotypic classification: 76 R-L, 23 R-NC, and
I L-NC fusion were identified. Mean age was not significantly
different among patients with R-L fusion, R-NC fusion, and
controls (49.0, 49.6, and 45.3 years, respectively; p = NS). BAV
patients revealed increased PWV compared to controls (9.8 vs.
3.8 m/s; p < 0.0001). Furthermore, PWV was significantly
different among patients with R-NC fusion, R-L fusion pheno-
types, and controls (14.9, 8.0, and 3.8 m/s, respectively;
p < 0.0001). Figures I and 2.
Conclusion: This study, in the largest cohort of BAV patients
studied with MRI to date, has identified significantly diminished
aortic distensibility (increased PWV from VENC-MRI) compared
to controls. Further, this study is the first to demonstrate greater
impairment of aortic distensibility in the phenotype of R-NC
fusion as compared to R-L fusion. There is a clear association
between impaired aortic distensibility and aortic valve config-
uration; the greater impairment in aortic distensibility in
BAV with R-NC fusion phenotype raises concern for amplifica-


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...... po ...... -----...-- ---....---








-- p0.02 -----



rI


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


tion of aortic pathology. This differentiation based on valvular
phenotype suggests a potentially novel parameter for enhanced
surveillance and potentially altered surgical triage in this high
risk group.



072
A short-term, high fat diet impairs
cardiac high energy phosphate metabolism,
without change in cardiac function
Cameorn J Holloway, Yaso Emmanuel, Lowri E Cochlinl,
Cezary Szmigielski, Lindsay M Edwards, Jane M Francis,
Stefan Neubauer and Kieran Clarke
University of Oxford, Oxford, UK
journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):072
Introduction: Heart failure patients have low cardiac phos-
phocreatine/ATP (PCr/ATP) ratios, which may be related to
elevated circulating free fatty acids (FFAs).
Purpose: We tested whether raising plasma FFAs, using diet,
causes abnormalities in cardiac energetic or function.
Methods: Healthy males (n = 16, age 22 I years), recruited
from the University of Oxford, were randomised to five days of a
high fat diet (HFD) containing 75 1% of calorie intake
through fat consumption, or an isocaloric control diet, providing
23 1% of calorie intake as fat. In a cross-over design, subjects
undertook the alternate diet after a two week wash out period.
Cardiac 31P magnetic resonance (MR) spectroscopy was
performed to assess PCr/ATP before and after the diets. MR
imaging and echocardiography were performed to assess left
ventricular function.
Results: Subjects on the HFD had a two-fold elevation in
plasma FFAs, 12% lower cardiac PCr/ATP with no change in
cardiac systolic or diastolic function. Figure I.
Conclusion: We have shown a short term, high fat diet raised
plasma FFA concentrations, impaired myocardial energetic
without effect on systolic or diastolic function. This suggests
that high plasma FFAs may be detrimental for heart in normal
subjects and shows a potential mechanism of impairment in heart
failure patients.




Figure I (abstract 072)

Free Fatty Acids Cardiac PCrIATP






I"1L

*. L ti

Pre Diet Post Diel Pre Diet Pst Diet
"P C .0; < U.aUI


073
Relationship of ostial pulmonary vein
scar with reduction in pulmonary vein size
after atrial fibrillation ablation
Thomas H Hauser, Dana C Peters, John Wylie,
Catherine Lau, Mark E Josephson and Warren J Manning
Beth Israel Deaconess Medical Center, Boston, MA, USA
journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):073
Introduction: Atrial fibrillation (AF) is the most common
sustained arrhythmia. Ablation procedures to electrically isolate
the pulmonary veins (PV) from the left atrium have become
increasingly popular for the prevention of recurrent AF PV
stenosis is a rare but serious complication of the procedure,
thought to be due to scarring of the PV. Previous studies have
shown that the intensity of ablation is related to the reduction in
PV size after the procedure, but direct assessment of scar in
patients has not been performed.
Purpose: We sought to define the relationship of the change
PV size after AF ablation with ostial PV scar as determined by late
gadolinium enhancement (LGE) cardiovascular magnetic reso-
nance (CMR).
Methods: We performed 3D breath-held contrast-enhanced
CMR angiography of the PV before and after AF ablation using a
1.5 T MR system. The diameter and cross sectional area (CSA)
were determined in the sagittal plane using a previously published
method. LGE CMR of the left atrium and PV was obtained after
AF ablation using a high-resolution, 3D, navigator gated
technique. The scar volume at the ostium of each PV was
measured using a threshold technique. The scar volume was
normalized to the PV CSA. The change in PV diameter and CSA
was expressed as the percentage change compared to the pre-AF
ablation PV measurement. The change in PV size before and after
evaluation was evaluated using a paired T test. The relationship of
the change in PV diameter and CSA to ostial PV scar was
evaluated with standard correlation and linear regression.



Figure I (abstract 073)


0.00 0.02 0.04 0.06 0.08

Scar Volume (ml)/PV CSA (mm2)


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Results: The study cohort was comprised of 23 subjects
(3 women, age 58 13 years). CMR was performed 41 17
days after AF ablation. The left sided PV had a common origin in
5 subjects. Scar could not be assessed in one PV due to artifact.
A total of 85 PV were available for analysis. Mean PV diameter
was 22 7 mm before ablation and declined to 21 6 mm after
(p = 0.001) while mean PV CSA declined from 285 141 mm2
before ablation to 246 1 10 mm2 after (p < 0.001). A significant
correlation was found between ostial PV scar with both the
change in PV diameter (r =-0.21, p = 0.049) and was even
stronger with PV CSA (r = -0.28, p = 0.010, figure I).
Conclusion: PV diameter and CSA significantly decrease after
AF ablation. There is a linear relationship between these changes
and the magnitude of PV scar as measured by LGE MR.


074
Right ventricular dysfunction and injury
following marathon running: correlating
biomarkers with cardiac MRI
Negareh Mousavi', Andrew Czarnecki', Kanwal Kumar',
Nazanin Fallah-Rad', Matthew Lytwyn', Song-Yee Han',
Andrew Francis', lain D Kirkpatrick', Tomas G Neilan2,
Sat Sharma' and Davinder S Jassal'
'St. Boniface General Hospital, University of Manitoba,
Winnipeg, MB, Canada
2Massachusetts General Hospital, Harvard Medical School,
Boston, MA, USA
journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):074
Background: Although previous studies including endurance
athletes following marathon running have demonstrated bio-
chemical evidence of cardiac injury and have correlated these
findings with echocardiographic evidence of cardiac dysfunction,
in particular the right ventricle, a study of marathon athletes
incorporating biomarkers, echocardiography and cardiac MRI
(CMR) has not been performed to date.
Objective: To demonstrate the cardiac changes associated with
participation in a marathon using serial cardiac biomarkers,
echocardiography and CMR.
Results: Fourteen participants (mean age 33 6 years;
8 males) completed the full marathon. Serum myoglobin, creatine
kinase and troponin T were elevated in all athletes post-race.
There was a strong linear correlation between right ventricular
(RV) fractional area change (FAC) as assessed by echocardio-
graphy and RV ejection fraction as assessed by CMR (r = 0.96)
post marathon (Figure I). RV function, using echocardiography,
transiently decreased from pre- to post-race (RV FAC 43 5%
vs. 34 7%, p < 0.05). There were also post-race changes in LV
and RV diastolic filling. While RV systolic changes were transient,
both LV and RV diastolic abnormalities persisted up to one week
post marathon. We did not find evidence of delayed enhance-
ment of the LV myocardium on CMR suggesting that the increase
in cardiac biomarkers post-marathon is not due to myocardial
necrosis.
Conclusion: Right ventricular systolic dysfunction transiently
occurs post marathon, and has been validated for the first time
by CMR. The increase in cardiac troponin following marathon
running is due to cytosolic release of the biomarker, and not due
to true breakdown of the myocyte as confirmed by delayed
enhancement CMR.


Figure I (abstract 074)


40 .. .
as
35

30
27 29 31 33 35 37 39 41 43 45
RV FAC Echo (%)


075
Cardiovascular magnetic resonance imaging
for the assessment of cardiac inflammation and
injury following prolonged exercise
Rory 0' Hanlon Gregory P Whyte2, Gillan Smith',
Francisco Alpendurada, Joyce Wong', Matthew Wilson3,
David Oxborough4, Richard Godfrey5, Keith George6,
Annette Dahl', David Gaze7, Dudley J Pennell'
and Sanjay K Prasad'
'Royal Brompton Hospital, London, UK
2Institute for Sport and Exercise Science, Liverpool, UK
3University of Wolverhampton, Wolverhampton, UK
4University of Leeds, Leeds, UK
SBrunel University, London, UK
6 LiverpoolJohn Moores University, Liverpool, UK
7St George's Hospital, London, UK

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):075
Introduction: Acute bouts of ultra-endurance exercise may be
deleterious for cardiac structure and function as demonstrated
by a reduction in diastolic and systolic function concomitant, and
elevations in humoral markers of cardiac myocyte damage above
acute myocardial infarction cut-off levels most notably reflected
by an elevation in troponin levels. A possible mechanism of
biomarker release may be secondary to acute myocardial
inflammation. CMR is established as the imaging modality of
choice to visualize myocardial inflammation and fibrosis using
STIR (short tau inversion recovery) imaging and early/delayed
enhancement imaging following intravenous contrast administra-
tion. The relationship between ultraendurance exercise, biomar-
ker elevation and CMR imaging for inflammation and fibrosis has
not been studied before.
Aims: We proposed that acute ultra endurance exercise in
moderately trained athletes leading to elevation of cardiac
troponin is associated with CMR detectable myocardial inflam-
mation
Methods: We performed CMR in 18 male athletes of moderate
to high fitness levels 24 hrs pre and 6 hours post a marathon run.
Each scan was performed by the same operator on a 1.5 T
Siemens Avanto scanner using a 4 channel body array coil.
Myocardial structure and function was assessed using breathhold
SSFP cine imaging in long and short axis views. The presence of


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


myocardial inflammation and oedema was assessed using STIR
imaging and a 3-4 minute spin echo sequence immediately post
0.1 mmol intravenous gadolinium-DTPA (Magnavist, Schering,
Germany) given using an automated injector, to assess relative
gadolinium enhancement. Inversion recovery segmented-FLASH
imaging with TI adjusted to null normal myocardium to highlight
regions of fibrosis was used to image delayed enhancement. Each
subject had bloods drawn for Tnl, NT-proBNP, and CRP at
baseline, immediately post and 6 hours after the run. Each CMR
scan was analyzed by a blinded observer for wall thickness per
segment, volumes and function, myocardial oedema using
customized software (CMRTools, London, UK). Delayed
enhancement images were analysed using Medis software
(MASS Medis, Leiden) using a full width half maximum technique.
Results: All 18 subjects completed the study protocol and
none complained of any cardiovascular symptoms. Biventricular
volumes, stroke volume, ejection fraction, and mass were
unchanged pre and 6 hrs post marathon. The majority of
subjects were found to have a rise in BTproBNP levels
immediately and 6 hours after the race as well as elevations in
Tnl above the level of cut off for myocardial infarction
(P = 0.001). There were no focal regions of visual signal increase
on the STIR images in any of the 18 subjects. Global myocardial
oedema was predefined using a cut off ratio of 1.9 comparing SI
of myocardium to skeletal muscle on STIR imaging, and a relative
45% increase in the SI myocardium/skeletal muscle immediately
post intravenous gadolinium on relative gadolinium enhancement
imaging (rGE). No subject reached these cut off values. None had
any visual myocardial fibrosis on late enhancement imaging or
using automated software (MASS, Medis, Leiden).
Conclusion: Serum markers of myocardial cell damage post
ultra endurance exercise are not associated with CMR detectable
levels of myocardial oedema, inflammation or scarring. These
findings suggest lower degrees of myocardial damage than that
normally sustained in patients with acute myocardial infarction or
myocarditis, inspite of similar levels of troponin elevation.

076
Molecular imaging of atherosclerotic plaque
targeted to oxidized LDL receptor LOX-I using
magnetic resonance
Dayuan Li, Amit R Patel, Alexander Klibanov,
Christopher M Kramer, Rene J Roy, Mirta Ruiz,
David K Glover, George A Beller and Craig H Meyer
University of Virginia, Charlottesville, VA, USA
journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):076
Background and objectives: Oxidized low-density lipopro-
tein and its receptor LOX-I play a crucial role in the initiation,
progression, and destabilization of atherosclerotic lesions. A
noninvasive tool to improve the clinical characterization of this
pathological process is needed. The aim of this study was to
assess the feasibility of CMR based molecular imaging targeted to
LOX-I which is highly expressed on atherosclerotic lesions in
mice.
Materials and methods: LDLR-/- mice on an atherogenic
diet for > 16 weeks were used. The imaging probe consisted of
liposomes decorated with anti-LOX-I antibody (or nonspecific
IgG), gadolinium and Dil fluorescence markers. MRI at 7.0 T
(Clinscan, Bruker/Siemens) was performed at baseline and 24 hrs
after intravenous injection of 150 pl of probe containing LOX- I


Figure I (abstract 076)


LOX-1



nlgG


preC MRI posl MRI Fluo. Image








U,.1N/


HAE staining


Mr


m %CNR ta %ER
n n Xs nor 1t
2W6 ptOS In


t40


nigG LOX-1 nigG


;orI


LOX-1


antibody (n = 7) or nonspecific IgG (nlgG) (n = 5) with
0.075 mmol Gd/kg, followed by excision of the aorta for frozen
cross-sections. The fluorescence image used to indicate whether
the probe bound to the plaque was examined under fluorescence
microscopy.
MRI of the ascending aorta was performed with a TI-weighted
black-blood spiral gradient-echo sequence (echo time, 1.2 ms;
flip angle, 90; field of view, 3 x 3 cm; 135 interleaves; readout
window, 4.1 ms; spatial resolution, 67 pm)) with I I contiguous
0.5 mm-thick slices. Four signal averages with cardiac and
respiratory gating were used, for a total imaging time of 2.5
minutes per slice. For the post-injection scan, the slices were
matched to the baseline preinjection scan by using the left main
and LAD coronary artery as anatomic landmarks.
To quantitatively analyze the MRI results, signal intensity (SI) was
measured in 4 regions of interest within the aortic wall as well as
the aortic lumen and muscle on each slice at both time points.
The standard deviation of noise was also recorded for each slice.
These measurements were recorded for all slices at every time
point imaged. The contrast-to-noise ratio (CNR) of aortic wall to
lumen was calculated for each slice. %CNR = (CNRpost-
CNRprecontrast)/CNRprecontrast. The normalized enhance-
ment ratio (NER) was defined as the average post-contrast SI
from 4 regions of interest within the aortic wall divided by the
muscle SI in the same slice and then divided by the pre-contrast
SI. %NER = (NER-I) x 100.
Results: Fluorescence imaging found that the LDLR-/- mice
injected with the LOX-I antibody probe showed significant
uptake in atherosclerotic plaque (Fig. I E, white arrows). There
was little fluorescence signal in atherosclerotic plaques in
LDLR-/- mice that received the nlgG probe (Fig. IF). The MR
images consistently showed strong post-contrast signal (red
arrows, C) on atherosclerotic plaques at 24 hours in LDLR-/-
mice injected with LOX- I antibody probe, but not those injected
with nlgG probe (Fig. I D). The % CNR was significantly higher at
24 hours in LDLR-/- mice that received the probe with LOX-I
antibody compared to nlgG (187.4 71.5% vs. 58.4 46.9%,


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


p < 0.05, Fig I, bottom left panel). Accordingly, the %NER was
also significantly higher at 24 hours in LDLR-/- mice that
received the probe with LOX-I antibody compared to nlgG
(121.1 38.9% vs. 18.4 13.9%, p < 0.01, Fig I, bottom right
panel). The atherosclerotic lesions were similar between the 2
groups as determined by H&E staining of aortic cross-sections
(G&H).
Conclusion: MRI with liposomes containing gadolinium and
LOX- I antibody demonstrates specific targeting of atherosclero-
tic plaques with high contrast to noise ratios. Spiral imaging
produced high spatial resolution without motion artifacts and
black blood imaging improved visualization of vessel wall. Further
study on imaging of LOX-I may provide more detailed
characterization of atherosclerotic plaque in vivo. This technique
shows significant promise for molecular MR imaging of athero-
sclerosis.

077
Controlling ventricular preload using an
MRI-compatible lower body negative pressure
chamber: measuring changes in volumes,
mechanical and hemodynamic function
Richard Thompson Ben Esch2, Jessica Scott2,
June Cheng Baron', Kelvin Chow', lan Paterson'
and Mark Haykowskyl
'University of Alberta, Edmonton, AB, Canada
2University of British Columbia, Vancouver, BC, Canada

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):O77
Introduction: Cardiac output is dependent, in part, on the
ability of LV to accept preload at low filling pressure. Systematic
modulation of preload is thus an important capability for the
study of the preload dependence of any given aspect of cardiac
performance in health and disease. Previously, LV (un)loading has
been studied by control of lower body pressure, used to

Table I (abstract 077) Heart rate and volumes and function

HR* EDV(mL)** ESV(mL) SV(mL)** EF(%)*

0 60.6(10.7) 177.6(28.6) 68.7(16.3) 109.0(14.8) 61.6(3.7)
-30 mmHg 63.5(9.7) 153.1(25.6) 65.8(17.1) 87.2(10.6) 57.5(4.4)


modulated central blood volume, primarily in conjunction with
echocardiographic or invasive measures of LV volumes and
systolic function[l, 2, 3]. MRI offers the gold standard measures
of LV volumes and a growing number of functional parameters
based on tissue and blood dynamics, but has not previously been
used in conjunction with lower body pressure control. Using a
low-cost custom-made MRI-compatible lower body pressure
chamber we illustrate controllable preload modulation of LV
volumes and mechanical and hemodynamic functional parameters
(several of which have not previously been measured with
variable preload).
Methods: MRI-Compatible Pressure Chamber: A sealed
and flexible pressure chamber was constructed from a waterbed
mattress using a thin flexible veneer wood frame and a kayak
water skirt for subject entry (Figure I). A compact 20 HP
vacuum was used to pressurize the system with a supine subject
in place (tested for pressures of -50 to 50 mmHg). 10 healthy
male subjects (3 I 9 yrs) were studied at atmospheric and -30
mmHg box pressures (serially); the later is comparable the
unloading provided by standing. A 5 element cardiac receiver was
used in all subjects, who were studied with conventional cines,
phase contrast (LAX and SAX at base) and tissue tagging (5 SAX,
3 LAX slices) to measure a wide range of systolic and diastolic
parameters; EDV, ESV, SV, EF, E and A filling waves (peak filling
velocity (cm/s) and filling rate (mL/s)), intraventricular (IVPG) and
atrial (IAPG) pressure gradients (calculated from LAX phase
contrast data), peak systolic (S') and diastolic (E') annular
velocities (cm/s), peak torsion (deg) and rate of untwisting
(deg/sec), peak diastolic radial velocity (ventricular average cm/
s), and peak diastolic circumferential strain rate (ventricular
average, s ). All studies were breath held with ECG gating
(Siemens Sonata, 1.5 T).
Results: All subjects were comfortable throughout volume
unloading experiments (-20 minutes). Tables I, 2 and 3 summar-
ize the changes in physiologic parameters with volume unloading.
All values are reported as mean (SD). A paired t-test was used to
determine if changes in parameters are significant (* p < 0.05,
** p < 0.001).
Conclusion: We have shown that a simple MRI-compatible
lower body pressure chamber can significantly unload the LVand
that a comprehensive systolic and diastolic function study is
feasible during this unloading (45 minute study duration for both
atmospheric and -30 mmHg unloading). Our changes in EDV and


Table 2 (abstract 077) Hemodynamics

E(cm/s)** A(cm/s)* Evol(mL/s)** Avo,(mL/s)* IVPGpeak(mmHg)** IAPGpeak (mmHg)**

0 61.6(7.7) 34.0(9.4) 567(109) 258(50) 2.9(1.2) 1.9(0.4)
-30 mmHg 46.5(10.4) 25.9(11.6) 371(57) 208(47) 1.8(0.7) 1.3(0.4)



Table 3 (abstract 077) Tissue mechanics

E' S'(cm/s) Peak Peak Radial Circumferential
(cm/s)** Torsion(deg)* Untwisting Velocity (cm/s)** Strain rate (s ')**
Rate (deg/sec)

0 14.7(3.1) 8.3(3.0) 11.1(2.1) 157(28) 4.4(0.9) 1.60(0.24)
-30 mmHg 9.7(2.0) 8.8(2.0) 13.4(2.8) 162(32) 3.5(0.7) 1.37(0.21)


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 077)


Figure I (abstract 078)


Volunteer in the lower body pressure chamber.


SV and standard measures of early filling (E, A and E') are
comparable to previous echocardiography unloading studies[l, 2,
3] and we report significantly larger decreases in pressure
gradients than previous studies[l]. To our knowledge, this is the
first report of the unloading dependence of torsion (which is
shown to increase with unloading), untwisting rate and radial and
circumferential parameters. The superior quantitative functional
imaging capabilities of MRI in combination with variable loading
conditions enabled by the lower body pressure control will allow
detailed physiological studies in controls and any patient group
that can be studied using MRI.
References
I. Popovic ZB, et al: American journal of physiology 2006, 290:
H 1454-1459.
2. Firstenberg MS, et al: journal of the American College of
Cardiology 2000, 36:1664-1669.
3. Levine BD, et al: Circulation 1991, 84:1016-1023.



078
The MR-stethoscope: safe cardiac gating
free of interference with electro-magnetic
fields at 1.5 T, 3.0 Tand 7.0 T
Frauenrath Tobias', Sebastian Kozerke2, Fabian Henzel'
and Thoralf Niendorf'
'RWTH Aachen, Aachen, Germany
institute for Biomedical Engineering, University and ETH
Zurich, Zurich, Switzerland

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):078
Introduction: In clinical CVMR, cardiac motion is commonly
dealt with using ECG-gating. ECG, being an inherently electrical
measurement, is prone to lead and patient burns. Furthermore,
ECG is corrupted by interference with electromagnetic fields
and by magneto-hydrodynamic effects. Consequently, artifacts in
the ECG trace and T-wave elevation might be mis-interpreted as
R waves resulting in erroneous triggering together with motion
corrupted image quality an issue which is pronounced at (ultra)
high fields.


1.5T T 4




7.0 T



Purpose: Overcome the challenges of conventional ECG-
gating by developing an acoustic cardiac gating approach, which
offers (i) no risk of high voltage induction and patient burns, (ii)
immunity to electromagnetic interference, (iii) suitability for all
magnetic field strengths and ease of use for the pursuit of robust
and safe clinical CVMR. For this purpose, this study examines and
demonstrates the suitability, efficacy and robustness of acoustic
cardiac triggering (ACT) in CVMR applications at 1.5 T, 3.0 Tand
7.0 T including prospective gating and retrospective triggering
regimes.
Methods: The acoustic gating device consists of three main
components: (i) an acoustic sensor, (ii) a signal processing unit
and (iii) a coupler unit to the MRI system. An acoustic wave guide
was used for signal transmission while accomplishing galvanic
decoupling. Signal conditioning and conversion were conducted
outside of the scanner room using dedicated electronic circuits.
All scanner and gradient coil noise contributions to the acoustic
signal were cancelled using a 3rd order inverse Chebychev filter.
The final waveform was delivered to the internal physiological
signal controller circuitry of a clinical MR scanner. The current
implementation connects the trigger signal with the MR-scanner's
standard ECG-signal input. Hence, no changes to the MR
system's hardware and software are required. Volunteer studies
(n = 10) were performed on 1.5 T, 3.0 Tand 7.0 Twhole body
MR systems (Achieva, Philips, Best, The Netherlands). The
acoustic sensor was positioned at the anterior left side of the
torso to obtain acoustic cardiograms. For comparison, ECG was
recorded for all subjects. A retrospectively triggered 2D CINE
SSFP technique was used to examine acoustic gating for reliable
tracking of myocardial contractions over entire R-R intervals.
Black blood prepared gradient echo imaging, 3D phase contrast


Figure 2 (abstract 078)

a) free breathing b) breath-hold c) breath-hold d) 3D phase contrast
30 SSFP coronary MRA 20 CINE SSFP 2D double IR-GRE MR angiography


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1 1 I


3.U I


3.u I


/.U I







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


MRA and free breathing 3D coronary MRA were employed to
evaluate acoustic triggering in a prospective gating regime.
Results: The acoustic MR-stethoscope provided cardiograms at
1.5 T, 3.0 Tand 7.0 T free of interference from electromagnetic
fields or magneto-hydraulic effects and hence is suitable for
synchronization (Fig I). In comparison, ECG waveforms were
susceptible to T-wave elevation and other distortions which were
pronounced at (ultra)high fields (Fig I). Acoustically triggered 3D
SSFP coronary MRA imaging produced images free of motion
artifacts (Fig. 2a). Conversely, R-wave mis-registration occurred
in ECG-triggered acquisitions due to T-wave elevation, which
made 3D coronary MRA prone to motion artefacts (Fig. 2a).
Motion artifacts were not present in full R-R interval coverage,
acoustically triggered CINE imaging (Fig. 2b). The merits of
acoustic triggering were further explored in prospectively gated,
blood suppressed anatomic imaging, which provided image
quality competitive or even superior to that obtained from the
ECG-gated approach as indicated by Fig. 2c. Acoustically
triggered 3D PC MRA acquisitions resulted in MR angiographies
of superb quality free of motion artifacts even at (ultra)high
magnetic field strengths, as shown in Fig. 2d.
Discussion and conclusion: The proposed acoustic approach
was found to fully meet the demands of cardiac gated/triggered
MRI. Its superior robustness has been demonstrated by
eliminating the frequently-encountered difficulty of mis-triggering
due to ECG-waveform distortions. ACT-MR substantially reduces
the complexity of patient preparation by obviating the need to
set up ECG-electrodes and position ECG-leads, and hence serves
to streamline clinical CVMR.


079
Non-invasive monitoring allograft rejection by
simultaneous cellular and functional cardiac MRI
Yijen L Wu, Qing Ye, Kazuya Sato, Lesley M Foley, T
Kevin Hitchens and Chien Ho
Pittsburgh NMR Center for Biomedical Research, Carnegie
Mellon University, Pittsburgh, PA, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):O79
Inroduction: The current gold standard for diagnosing and
staging rejection after organ transplantation is biopsy, which is
not only invasive, but is also prone to sampling errors. The
regimen for treating acute rejection after heart transplantation
varies among treatment centers, partly due to lack of sensitive
and reliable indices for assessing the status of myocardial
rejection. The goal of this study is to establish sensitive and
reliable indices using cellular and functional MRI for non-invasive
detection of acute cardiac allograft rejection after heart
transplantation. Using a rodent model of cardiac transplantation,
we monitor both immune cell infiltration and cardiac dysfunction
resulting from rejection in the same imaging session. Immune
cells, mainly monocytes and macrophages, are labeled in situ with
dextran-coated ultra-small superparamagnetic iron oxide
(USPIO) nano-particles. T2*-weighted MRI and strain analysis of
tagged MRI are used to correlate immune-cell infiltration and
ventricular function with rejection grades.
Methods: I. Animal model: An abdominal heterotopic
working heart and lung transplantation model with DA to BN
transplantation rat pairs was used. The transplanted hearts
exhibit cardiac outputs and ventricular pressure similar to those


Figure I (abstract 079)


T2*-weighted in vivo MRI for different allografts after USPIO administra-
tion. Areas with UPSIO-labeled macrophage infiltration show signal loss
in both LV and RV.

of native hearts. In this model, mild (Grade IA or B) rejection
develops by post-operation day (POD) 2.5-3.5, Grade 2
rejection develops on POD 4.5-5.5, and moderate to the severe
(Grade 3A) rejection develops after POD 6-7.
2. MRI methods: ECG and respiration gated T2*-weighted
cine imaging on Bruker AVANCE 4.7-T system was used for
in-vivo imaging with an in-plane resolution of 156 pm. Tagged MRI
is achieved with a modified DANTE sequence. Strains were
analyzed by the HARP method with software obtained from
Diagnosoft, Inc.
3. Iron-oxide particle labeling: Immune cells, mostly macro-
phages, are labeled in situ by direct intravenous injection of
USPIO particles I day prior to MRI scans.
Results: Immune cells, mainly monocytes and macrophages,
take-up circulating USPIO particles by endocytosis. Foci of
labeled immune cells in the rejecting graft are observed by
regions of hypointensity in T2*-weighted images (Fig. I). The


Figure 2 (abstract 079)


(A) T2*-weighted MRI for an allograft after USPIO administration. (B)
Pseudo-coloring of different contrast-to-noise ratios (CNR) for easier
visualization. (C, D) Tagged MRI of the same allograft heart at ED (C) and
ES (D). The block arrows point to regions with compromised contractile
functions. (E) Colored Ecc strain map of the allograft. (F) Ecc stran values
of 48 probe-points throughout LV.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 3 (abstract 079)


2345


O






35
34




2


15


B GI Gl GUII


'" --_ -__
co




CL
1
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20-
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(A) Ecc strain values of 48 probe-points throughout LVfor an isograft (triangle) and 2 allografts with Grade II (square) and Grade IV (circle) rejection. (B)
Status of probe-points for 3 allografts with different rejection grades. Compromised probe-points are black, whereas the normal probe-points are left
blank. (C) Degrees of compromised probe-points for different rejection grades.


observed immune-cell infiltration is heterogeneous, thus it is not
surprising to have incidences of false-negative results with biopsy.
Monitoring immune-cell infiltration with MRI is not only non-invasive,
but also provides whole-volume 3D perspective of rejection.
To discern if the heterogeneity of rejection is manifested in cardiac
function, tagged MRI is used to monitor regional ventricular
contractile function. Although global function may appear normal,
the rejected allograft may show local hypokinesis (Fig. 2D). Strain
analysis by HARP was used to quantify the local contractile function.
Regions with compromised strains (Fig. 2E &2F) largely correlate
with the areas of higher macrophage infiltration.
For easier visualization of the regions with compromised strains,
48 probe-points were placed evenly throughout LV, starting at
the anterior intercept of LV and RV (Fig. 2F & Fig. 3A). The
probe-point is considered "compromised" if the strain value of
the particular location deviats from the mean isograft values by
more than I standard deviation; otherwise the probe-point is
scored as "normal" (Fig. 3B). The number of compromised
probe-points is well correlated with rejection grades (Fig. 3C),
which can potentially be useful clinical index for rejection.
Conclusion: In our model, acute allograft rejection after heart
transplantation is spatially heterogeneous, which is manifested in
both immune-cell infiltration and ventricular function. Cardiac
MRI is both non-invasive and provides 3D, whole-heart
perspective of rejection status, which potentially allows more
reliable detection of acute allograft rejection.

080
Fat/water separation imaging shows fatty
deposition in areas of chronic left ventricular
myocardial infarction
James W Goldfarb, Margeurite Roth and Jing Han
St Francis Hospital, Roslyn, NY, USA
journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):080
Introduction: Several studies indicate that fatty replacement of
myocardium occurs after left ventricular myocardial infarction.


Magnetic resonance imaging can readily identify the location and
morphology of both fatty tissue and myocardial infarction and
may have the ability to non-invasively identify fatty replacement
within infarcted regions. Fat deposition may impair global and
regional cardiac function as well as the electrical activation of the
heart.
Methods: Twenty-five patients (patient age: 64 I I yrs, infarct
age: 12 9 yrs) with documented prior myocardial infarctions and
ten normal volunteers (age: 63 10 yrs) underwent MR imaging on
a clinical 1.5 T scanner using precontrast fat-water separated
(Dixon) and late gadolinium-enhanced infarct imaging. Myocardial
infarct location and size were assessed using the full width half
maximum (FWHM) infarct sizing algorithm applied to the late
gadolinium-enhanced images. Fat-water separation was performed
using a three-point Dixon reconstruction from in- and opposed-
phase gradient-echo images (Echo times (TEs) = 4.8, 7.2, 9.6 ms).
Fat segmentation was performed on a slice by slice basis using a
signal intensity threshold set two standard deviations above the
noise level. Volumes of myocardial late gadolinium-enhancement and
fat deposition were compared using a Student's t-test. Precontrast
infarct location and detection was compared with late gadolinium-
enhanced infarct imaging using a seventeen segment model.
Results: Subjects with prior myocardial infarction had a 68%
prevalence of fat deposition (17/25). In subjects without a history
of myocardial infarction, fat deposition and late gadolinium-
enhancement were not detected (0/10). In the patients with fat
deposition, the fat volume was 19.6 19 ml (range: 1.7-62.6 ml)
vs late gadolinium-enhancement volume of 30 15 ml (range:
9.6-59.2 ml). The volumes of late gadolinium-enhancement and fat
deposition were statistically different (p = 0.01). Of the
425 myocardial segments, 156 (37%) had late gadolinium-
enhancement and 76 (18%) had fat deposition. 65 segments
(15%) had both fat deposition and late gadolinium-enhancement,
while 91 segments (21%) had late gadolinium-enhancement and no
fat deposition. I I segments (2.6%) had fat deposition and no late
gadolinium-enhancement, but all II segments had adjacent
myocardial segments with late gadolinium-enhancement. Figure I.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 080)


Results from three patients show fat deposition in areas of late
gadolinium-enhancement (LGE).


Conclusion: Fatty replacement of myocardium after myocar-
dial infarction is common and can be readily identified using fat/
water separation MR imaging. The clinical significance and
biologic mechanism of fatty deposition in infarction remain to
be determined.


081
Shared velocity encoding (SVE): a new method
for real-time velocity measurement
with high temporal resolution
Hung-Yu Lin Yu Ding', YiuCho Chung2
and Orlando Simonetti'
'The Ohio State University, Columbus, OH, USA
2Siemens Healthcare, Inc, Malvern, PA, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):081
Objective: To develop and demonstrate a new method for
rapid, real-time, phase-contrast velocity measurement using
Shared Velocity Encoding (SVE) and gradient-echo planar imaging
(GRE-EPI).
Introduction: Conventional ECG-triggered, segmented phase-
contrast imaging (PC-MRI) is an accurate and clinically proven
technique to characterize blood flow velocity. However, this


method requires reliable cardiac gating, regular cardiac rhythm,
and either signal-averaging, respiratory gating, or breath-holding
to suppress respiratory motion artifacts. Furthermore, the
resulting velocity information is a weighted temporal average of
information acquired over multiple cardiac and respiratory
cycles;short-term hemodynamic variations are lost. Real-time
PC-MRI has been previously proposed using GRE-EPI [I] and
spiral acquisitions [2], but limited performance has precluded
routine clinical application. The aim of the present work is to
design and demonstrate a novel method for rapid real-time
velocity measurement with sufficient temporal resolution to
eliminate the need for ECG synchronization and breath-holding,
and to provide beat-to-beat hemodynamic information.
Methods: Sequence: SVE is a PC-MRI reconstruction tech-
nique designed to improve temporal resolution. Conventional
real time PC-MRI works by alternating the polarity of velocity
encoding gradients from one image frame to the next between
positive (+) and negative (-) velocity encoding (i.e., [+ -], [+ -]).
The velocity map is obtained by subtracting the negative velocity
encoded image from the positive encoded image. The temporal
resolution of the velocity map is therefore half the image frame
rate. In SVE, images are acquired in the same way, but the velocity
map is reconstructed by sliding the pair of images for subtraction
one frame at a time (instead of two), resulting in a factor of
2 improvement in effective temporal resolution. This recon-
struction technique was implemented to improve the temporal
resolution of a GRE-EPI sequence for real-time PC-MRI on a 1.5
T MR scanner (MAGNETOM Avanto, Siemens, Germany).
Imaging: Five healthy volunteers with no history of cardiovas-
cular disease were scanned. Through-plane velocity measure-
ments using segmented, spoiled gradient echo PC-MRI and the
proposed real-time GRE-EPI with echo train length = 15 and SVE
reconstruction were acquired for two slices: (i) cutting the
ascending and proximal aorta and (ii) perpendicular to the distal
descending aorta (2 cm superior to the renal arteries). Common
acquisition parameters were: FOV = 350 x 262 mm, matrix =


Figure I (abstract 081)

a


Magnitude images acquired using (a) conventional segmented, (b) real-
time GRE-EPI SVE PC-MRI, and phase velocity maps from (c)
conventional segmented PC-MRI, and (d) real-time GRE-EPI SVE PC-
MRI sequence in a slice cutting the ascending and descending aorta close
to the aortic arch.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table I (abstract 081) Peak velocities and RMSE) of the real-time SVE technique with respect to conventional PC-MRI

ROI Peak Velocity (Segmented) Peak Velocity (Real-time SVE) RMSE

Proximal Ascending Aorta 83.7 4.23 cm/s 87.4 5.43 cm/s 3.6153 cm/s
Proximal Descending Aorta 24.4 5.61 cm/s 23.7 5.39 cm/s 1.1573 cm/s
Distal Descending Aorta 20.4 4.97 cm/s 20.4 4.77 cm/s 1.0744 cm/s


160 x 120, flip angle = 250, spatial resolution = 2.18 x
2.18 mm2, GRAPPA acceleration rate = 2, and Venc = 150 cm/s.
The TE/TR/temporal resolution of the conventional gradient-echo
and real-time GRE-EPI sequences were 3.5/7.0/42.0 ms and
2.9/14.6/58.4 ms, respectively.
Analysis: Peak velocity measurements were compared, and
Root-Mean-Square Error (RMSE) was calculated between
velocity curves obtained using the real-time SVE and the
conventional sequence. Linear interpolation was used prior to
RMSE calculation to compare curve values at exactly the same
time points.
Results: In vivo images from one volunteer are shown in Figure
I. Magnitude images clearly show vascular anatomy in both the
segmented (Figure la) and real-time sequences (Figure Ib). In
Table I, peak aortic velocity measurements show good agree-
ment between conventional segmented PC-MRI and real-time
PC-MRI with SVE reconstruction (r = 0.93, p < 0.05). Insignificant
RMS errors (Table I) were obtained in all regions-of-interest
showing good agreement between velocity curves generated by
conventional and real-time SVE techniques.
Conclusion: We have demonstrated the new SVE method that
results in a factor of 2 improvement in effective temporal
resolution in PC-MRI without sacrificing spatial resolution. With
SVE reconstruction, real-time velocity measurement becomes
practical with temporal resolution approaching that of conven-
tional segmented PC-MRI.
References
I. Debatin JF, et al: Magn Reson Imaging 1995, 5(6):656-662.
2. Park JB, et al: Magn Reson Med 2003, 49(2):322-328.

082
On the sensitivity of steady-state free precession
myocardial blood-oxygen-level-dependent
MRI at 1.5 T: theory and experiment
Xiangzhi Zhou', Richard Tang2, Rachel Klein ,
Debiao Li' and Rohan Dharmakumar
'Department of Radiology, Northwestern University, Chicago,
IL, USA
2Northwestern University, Chicago, IL, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):082
Introduction: Through theoretical simulations and experi-
mental studies, it has been shown in whole blood and in skeletal
muscle that SSFP-based BOLD contrast is strongly dependent on
repetition time(TR) and flip angle(FA). While these studies
accounted for spin exchange effects between intra-(IV) and
extra-vascular(EV) spaces, they have largely ignored the diffusion
effects, particularly in the EV space. Since most of the blood
present in the microvasculature of the heart is in the capillaries,
we hypothesize that diffusion-mediated effects is an important
mechanism allowing for the detection of oxygenation changes
with SSFP-based myocardial BOLD imaging.


Figure I (abstract 082)


2D late diastole cine SSFP BOLD images of a dog with severe LCX
stenosis and adenosine infusion obtained at different TR and FA:
TR/FA = 3.5 ms, 30 (A); 3.5 ms, 70 (B); 6.0 ms, 30 (C); and 6.0 ms,
70 (D). LCX territories are the shorter arcs subtended by arrows.



Purpose: To investigate the effect of TR and FA on SSFP-based
myocardial BOLD sensitivity through a theoretical model
accounting for diffusion effects and validate it using a controlled
canine model.
Methods: Monte-Carlo simulations(MCS): Approximat-
ing capillaries as an infinite cylinder, the magnetic field variation
(ABz) outside the capillary vessel was computed as BoAX(R/r)2
cos(2(p)sin26/2 (EV) and BoAX(cos26-1/3)/2 (IV), where R is the
vessel radius, r the distance from vessel axis, 0 the angle between
the main magnetic field (Bo) and the vessel axis, and (p the angle
between r and the projection of the main magnetic field onto the
plane orthogonal to the vessel axis. The susceptibility difference
AZ between IV and EV space is: AZ = Hct(I-Y)AX, where
AX = 3.39 ppm is the susceptibility difference between fully
oxygenated and deoxygenated hemoglobin, Hct is hematocrit
(0.4), and Y is oxygen saturation(20% and 80%). Spin diffusion
was modeled as 3D Brownian motion of 5000 spins inside a cubic
box with time steps of 50 ps and diffusion coefficient of


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 2 (abstract 082)


30 50 70 30 50 70
Flip Angle (degrees) Flip Angle (degrees)


SSFP-baseed Myocardial BOLD contrast obtained from MCS and
experimental studies with the same parameters (TR = 3.5 ms, 4.7 ms,
6.0 ms; Flip angle = 30, 500, 700). For a given FA and TR, MCS oxygen
contrasts were computed assuming myocardial oxygenation in the
territory supplied by a stenotic vessel is 20%, while that supplied by a
healthy vessel is 80% under pharmacological stress, assuming myocardial
blood volume fraction of 9%.



1.5 x 10 9m2/s. Other parameters were: R = 6 x 106m, blood
volume fractions = 9%, number pulses to reach steady-state =
2000; TR = 3.5, 4.7, 6.0 ms; and FA= 30, 50, 70.
Experimental studies: An external hydraulic occluder was
placed around the left circumflex coronary(LCX) for the
purpose of inducing reversible stenosis in 4 dogs. Following
recovery(I week), animals were sedated, ventilated and placed in
the scanner (1.5 T Siemens Espree). ECG-gated and multiple
breath-held 2D-Cine SSFP sequences were prescribed under
pharmacological stress with and without LCX stenosis over the
LV. Three short-axis images with centre slice located on mid-LV
were acquired for each study. Scan parameters: in-plane
resolution = 1.2 x 1.2 mm2, slice thickness = 5 mm, TR/
TE = 6.0 ms/3.0 ms, 4.7 ms/2.35 ms, 3.5 ms/1.75 ms, flip
angle = 70, 50, 30, segments/cardiac phase were adjusted to
achieve an optimal temporal resolution(10 ms-20 ms) that
minimize motion/flow artifacts.
Data analysis: Regional SSFP BOLD signal contrast, [ILAD-
ILCX]/ILAD was used to evaluated the SSFP BOLD sensitivity,
where ILAD and ILCX are average SSFP signal intensities measured
within LAD and LCX territories.
Results: Figure I shows a typical set of 2D late diastole short-
axis cardiac images from SSFP cine scans of a dog with severe
stenosis and adenosine infusion for different TR and FA. Note
that the global and regional signal intensities are strongly
dependent on imaging parameters. Figure 2 shows the SSFP
BOLD signal contrast obtained from MCS and experimental
studies. The regional BOLD signal contrast between LAD and
LCX supplying regions match well with the MCS.


Discussion: MCS and experimental studies showed that TR
and FA play a significant role in determining SSFP-based
myocardial BOLD contrast. In particular, both MCS and
experiments showed that increasing the FA or TR gave a
concomitant increase in SSFP-based myocardial BOLD contrast.
We found that a combination of TR/FA = 6.0 ms/700 gave the
highest oxygen contrast among all the parameter sets studied,
although more artifacts were observed in certain cardiac phases
as TR was increased from 3.5 ms. In order to enable the entire
cine image set to provide reliable regional BOLD contrast at
large TRs, robust artifact correction methods need to be
developed.



083
Acute and chronic cardiac radio frequency
ablation lesion visualisation using magnetic
resonance imaging
Benjamin R Knowles Dennis Caulfield',
Michael Cooklin2, Aldo Rinaldi2, Reza Razavi',
Tobias Schaeffter' and Kawal S Rhode'
'King's College London, London, UK
2Guy's and St Thomas' NHS Foundation Trust, London, UK

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):083
Introduction: The use of electro-anatomical mapping
systems (EAMS) for catheter guidance and ablation point
recording is widespread for the treatment of atrial
arrhythmias using radio frequency ablation (RFA). Also, the
evolution of RFA lesions over time may be an important factor in
the reoccurrence of arrhythmias. In this study, we use late
enhancement (LE) magnetic resonance imaging (MRI) as a tool to
measure RFA lesions and present a novel visualisation method to
represent this information in an intuitive way. This allows the
validation of the in-vivo accuracy of EAMS and the examination of
the evolution of RFA lesions from the acute to the chronic
timescales.
Methods: Six patients with either atrial fibrillation (AF, 5 cases)
or flutter (AFL, I case) underwent RFA. Prior to the procedure,
each patient underwent a MRI examination that included
administration of a double dose of Gd-DTPA contrast agent
followed by MR angiography (MRA) and a T2-prepared balanced-
SSFP (bSSFP) sequence. Approximately 20 minutes after contrast
administration, a free-breathing, cardiac triggered, 3D LE scan
was performed. The scan was inversion recovery-prepared with
a resolution of 1.3 x 1.3 x 2 mm3 and TR/TE/i of 6.2 ms/3.0 ms/
30. Signal was acquired using Turbo Field Echo (TFE) with a
100 ms window and a low-high K-space ordering. Inversion time
was determined from a Look-Locker scan. All scans were
performed using a 1.5 T Philips Achieva MR scanner. During the
procedure, ablation points from various EAMS (NavX, CARTO,
XMR-EAMS [I]) were recorded. Post ablation, the patient
returned to the MR scanner for a further examination including
the bSSFP and LE scans. Approximately 6 weeks later, the patient
returned for follow-up MR imaging. Offline, an atrial surface
model was generated from the MRA scan, and was transformed
into the coordinate system of each of the LE images. Integration of
the LE image along the normal vector at each of the surface
vertices was performed. This integral was used to colour code the
surface model. Areas of LE were defined by integral values higher


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 083)


3D representation of LE MR images of acute (A-B) and chronic (C-D)
RFA lesions. Overlaid in blue are the ablation points acquired with NavX.
It can be seen in the chronic image that an area of enhancement is no
longer apparent around the right lower PV




than the mean of the healthy myocardium plus three standard
deviations. EAMS data from NavX and CARTO were exported.
The EAMS-derived and the MR-derived cardiac surfaces were
registered using a landmark-based registration. Using this
registration, the EAMS lesions were transformed onto the MR-
derived cardiac surface and repositioned at the nearest vertex.
Results: Enhancement was present in all acute and chronic LE
images. However, on inspection of the lesion patterns in three
dimensions it could be ascertained that from the five patients
undergoing PV isolation, one had isolation of both the left and
right PVs, three had isolation of the left PVs, and one had
isolation of neither. On comparing with the points acquired from
NavX, on average 50% of the points were found in the MR-
defined area of enhancement. In the patient after AFL ablation, a
line of enhancement between the inferior vena cava and the
tricuspid valve was visible, and 100% of ablation points acquired
from the XMR-EAMS were found in an area of LE. The change in
scarring between acute and chronic lesions was found to be
considerable in all cases. Enhancing areas were either greatly
reduced or non-existent, as shown in figure I.
Conclusion: We have presented a technique based on LE MRI
coupled to a novel visualisation method to measure RFA lesions.
This technique has been applied to six patients undergoing RFA
and used to assess the accuracy of EAMS and to monitor the
evolution of lesions over time. We envisage that such an
approach will have potential benefit in understanding the causes
of arrhythmia reoccurrence and also in the guidance of redo
ablations.
Reference
I. Rhode, et al: IEEE Trans Med Imaging 2005, 24(I I): 1428-40.


084
Towards MR-guided EP interventions using
an RF-safe approach
Sascha Krueger Oliver Lips', Bernd David',
Daniel Wirtz', Steffen Weiss', Steen F Pedersen2
Dennis Caulfield3, Julian Bostock3, Reza Razavi3
and Tobias Schaeffter3
'Philips Research Europe, Hamburg, Germany
2MR Research Centre, University Hospital,
Aarhus, Denmark
3Division of Imaging Sciences, King's College, London, UK

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):084
Introduction: Various cardiac arrhythmias, e.g. atrial fibrilla-
tion and ventricular tachycardia, can be treated by electro-
physiological (EP) interventions [I]. Applying MR for guiding
these interventions offers advantages like 3D visualization of the
cardiac soft tissue in relation to the catheter and absence of
ionizing radiation [2]. In this work, a prototype MR-EP system
and catheter for diagnostic EP-interventions is described, which
integrates concepts for RF-safe MR-tracking [3] and EP
diagnostics [4]. The operation of the system is demonstrated in
MR-guided EP experiments in pigs including mapping and pacing.
RF-safety of the diagnostic MR-EP catheter prototype is shown
and signal quality is compared to conventional EP catheters.
Materials and methods: System setup: All experiments
were performed on a clinical whole-body 1.5 T MR scanner
(Achieva I/T, Philips Healthcare, Netherlands) equipped with an
in-room display and an additional MR-EP-workstation (MR-EP-
WS) including a standard EP-recorder (EP Tracer, CardioTek,
Netherlands). This workstation, located next to the scanner,
combines and displays incoming real-time 2D and 3D images and
real-time tracking positions from the MR scanner as well as real-
time EP-data from the EP-recorder.
A 7F diagnostic EP catheter (Fig. I) with two ring electrodes and
a tracking coil was used. Intracardiac and tracking signals are
transferred via RF-safe high resistance wires [2] and a
transformer-based transmission line [3], respectively.


Figure I (abstract 084)


Diagnostic RF-safe MR-EP catheter.


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Figure 4 (abstract 084)


EP signals acquired in the RV (a) with the MR-EP catheter equipped with
highly resistive wires and (b) with the conventional catheter.


Comparison MR-EP/conventional EP catheter: Conven-
tional diagnostic EP catheters (Supreme Quad, JSN, 5F, St Jude,
MN) and MR-EP catheters were compared under X-ray. Bipolar
intracardiac electrograms (IEGM) were acquired with both
catheters at corresponding locations (RA lateral wall, RV apex,
TV ring, and HIS).
In-vivo proof of RF-safety: Temperature recordings during a
typical real-time bFFE sequence (TR 2.4 ms, flip 650, global SAR
4 W/kg) were performed for the MR-EP and the conventional EP
catheter. The catheters were equipped with fiber optic
temperature probes and were inserted into the RA.
EP-Mapping procedure: The RA and RV were mapped using
the MR-EP system and catheters. 3D bFFE and 3D CE-MRA
datasets were acquired prior to catheterization of the animals.


Top: Roadmap-based real-time 3D-visualization of the catheter position
during recording (red dot) on the MR-EP workstation. The yellow dots in
the 3D rendering of the heart indicate previous mapping positions.
Bottom: In-bore EP recordings at two selected positions showing an atrial
signal (left) and a ventricular signal (right).


Figure 3 (abstract 084)


In-vivo temperature increase (a) with the MR-EP catheter and (b) with the conventional catheter.


Page 70 of 316
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Figure 2 (abstract 084)


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a 1 2 3 4 5 6 7 8 9 10 1
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(a) (b)


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


All MR and EP data can be combined and displayed on the MR-EP-
WS for guidance, including a surface model of the cardiac vessels,
reformatted slices at the catheter position either manually
angulated or using the real-time MR imaging geometry.
Results: Comparison with conventional EP catheter:
IEGMs acquired with the MR-EP catheter were equivalent in quality
to those acquired with the conventional EP catheter (Fig. 2).
In-vivo proof of RF-safety: The MR-EP catheter's maximal
temperature increase after 10 min of RF transmission at 4 W/kg
was 0.7 K (Fig. 3a) almost corresponding to the expected
increase in global body temperature (0.6 K). Hence, device-
related local heating effects are negligible.
In contrast, an increase of up to 7.5 K in only 80 s was observed
at the tip of the conventional catheter (Fig. 3b).
EP recording under MRI: The MR-EP-WS enabled a fast
mapping, e.g. 40 points in RV in 20 min. The in-bore IEGM
recordings were comparable to those under X-ray (Fig. 4).
Furthermore, atrial and ventricular pacing was achieved via the
MR-EP catheters. Successful stimulation was confirmed by a
second MR-EP catheter and was also clearly visible in the surface
ECG.
Conclusion: Recording of intracardiac electrograms is feasible
with the MR-EP catheter. EP data quality is equivalent to
conventional EP catheters. The combined use of highly resistive
wires and a transformer-based transmission line for active tip
tracking effectively suppresses RF-heating even during high SAR
MRI.
The prototype setup of the MR-EP system provided excellent
guidance and an efficient workflow for diagnostic MR-EP
interventions.
References
I. Singer I and (ed): Interv Electrophys Lippincott Williams &
Wilkins; 22001.
2. Lardo AC: Pediatr Cardiol 2000, 21:80-98.
3. Weiss S, et al: Magn Reson Med. 2005, 54:182-189.
4. Wirtz D, et al: ISMRM 2007, 738.


085
Assessment of myocardial perfusion reserve
with blood oxygen level-dependent
cardiovascular magnetic resonance imaging
Jacqueline A Flewitt, Matthias VOhringer2, Jordin Green3
and Matthias Friedrich'
'Stephenson CMR Centre, Calgary, AB, Canada
2Robert-Bosch-Krankenhaus, Stuttgart, Germany
3Seimens Healthcare Canada, Calgary, AB, Canada

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):085
Background: New Blood Oxygen Level-Dependent Cardio-
vascular Magnetic Resonance Imaging (BOLD-CMR) sequences
show a high sensitivity and consistent image quality that allows
for assessing tissue oxygenation. We hypothesized that BOLD-
CMR can quantitatively assess myocardial blood flow changes
using myocardial oxygenation as a biomarker.
Objective: To test whether a BOLD-CMR sequence accurately
estimates myocardial perfusion changes.
Methods: Six anesthetized mongrel dogs were instrumented
with a coronary infusion catheter in the circumflex coronary
artery (LCX), an MR-compatible epivascular flow probe around
the LCX and a catheter in the coronary sinus. Using a clinical


Figure I (abstract 085)


130




120




110




00oo


Y= 98.3+25.4*(l -eOD'7x)


0 200 400 000 a So 1000
LCX flow tellof to bmflue I%)


Blood flow
infusion.


1200 1400


changes and BOLD-SI in canine model under adenosis


1.5 T MRI system (MAGNETOM Avanto, Siemens Healthcare,
Germany), SSFP BOLD-CMR was performed during graded
intracoronary infusion of adenosine in the LCX. Typical scan
parameters were: Field-of view (FOV) 190 x 280 mm; matrix
size 106 x 192; slice thickness 10 mm; TR/TE 5.8/2.9 ms; flip
angle 90; typical breath-hold duration 14 s. Images were
analyzed using clinically validated software (cmr2, Circle
Cardiovascular Imaging Inc., Calgary, Canada) and the BOLD
signal intensity (SI) for each was calculated. Correlations of
coronary flow, oxygen saturation in the coronary sinus and
myocardial BOLD-CMR signal intensity (BOLD-SI) changes were
calculated by regression analysis. The same CMR imaging
protocol was used in II healthy volunteers (6 male, 5 female)
before, during and after intravenous adenosine infusion (140
micro-g/kg). Myocardial perfusion reserve in the human volun-
teers was calculated from flow measurement in the coronary
sinus using velocity-encoded CMR.
Results: In dogs, adenosine-induced blood flow changes in the
LCX agreed very well with changes in coronary venous
saturation (logarithmic scale, r2 = 0.94, p < 0.001). Furthermore,
coronary venous saturation showed a strong yet linear correla-
tion with BOLD-SI changes (r2 = 0.80, p < 0.001). Consequently,
as shown in Figure I, blood flow changes correlated very well
with the BOLD-SI (r2 = 0.84, p < 0.001). The exponential
correlation is described by the equation (y) = 98.3+25.4
*(I-e-0.0017x) (x = flow, y = BOLD-SI). In the volunteers,
adenosine infusion resulted in a significant myocardial perfusion
increase (416 69% of baseline, p < 0.001). BOLD SI increased
significantly by 20.1 9.5% (p < 0.001 as compared to baseline).
The reproducibility of the BOLD-SI in the two baseline
measurements before and after adenosine infusion was excellent
(mean difference 0. I 2.6%, p = 0.97).


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,~







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Conclusion: State-of-the-art BOLD-sensitive MRI sequences
detect changes of myocardial perfusion in an experimental animal
model and in humans in vivo. This technique may allow for an
accurate, non-invasive assessment of myocardial perfusion
reserve in humans.


086
Feasibility of noninvasive 3 T MRI-guided
myocardial ablation with high intensity
focused ultrasound
Aravind Swaminathan', Viola Rieke2, Randy L King2,
John Pauly3, Kim Butts-Pauly2 and Michael McConnell'
'Stanford Hospital &Clinics, Stanford, CA, USA
2Stanford University Department of Radiology,
Stanford, CA, USA
3Stanford University Department of Electrical Engineering,
Stanford, CA, USA

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):086
Objective: This study sought to determine the feasibility of
noninvasive myocardial HIFU ablation using real-time MRI
guidance and thermometry.
Background: Invasive catheter-based myocardial ablation has
become an important treatment of hypertrophic cardiomyopathy
(HCM) and cardiac arrhythmias, but has known complications as
well as the inability to actively visualize and control the extent of
ablated tissue. High-intensity focused ultrasound (HIFU) can
noninvasively create focal ablation lesions and has been



Figure I (abstract 086)


A) Real-time MR-temperature map during HIFU septal ablation (red
zone on image), B) T2 MR image of HIFU lesions, C) Gross pathology of
septal lesions from (B) using multiple 20s pulses, D) Lesions, each
4 mm x 4 mm created with single 20s HIFU pulses along the LV lateral
wall.


Figure 2 (abstract 086)


Lesion rea I mm2l vs. Pulse

Duration ImsI
20

15

10

5



1000 500 300 200 100


Lesion size (mm2) as a function of pulse duration. Pulses were cycled on
and off with a signal generator at I Hz.



developed for multiple non-cardiac clinical applications. MRI, in
addition to imaging of myocardial pathology, can provide image
guidance of HIFU targeting and then perform real-time monitor-
ing of myocardial temperature during ablation. This study
included preliminary feasibility work on ex-vivo MRI-guided
myocardial HIFU with cardiac gating.
Methods: For ex vivo ablation, an existing MRI-guided HIFU
ablation system (Insightec Ltd., Tirat Carmel, Israel) was used on
a 3 T MRI scanner (GE Healthcare, Milwaukee, WI). Ex-vivo
porcine hearts (N = 7) were immersed in water and degassed.
MR scout imaging was performed to identify and guide the
myocardial treatment areas to the septum. Multiple HIFU
ablations lesions were formed using acoustic powers between
60-90 Watts and sonication duration of 20 s at a HIFU frequency
of I.I MHz. MR thermometry was performed during lesion
formation to verify correct ablation location and achievement of
thermal ablation threshold (>55C). T2-weighted imaging was
used to image lesions post-ablation. Lesion location and size was
confirmed by pathology. Additional experiments were performed
to simulate cardiac gating HIFU pulses (acoustic power 150 W,
duration 20 s) were activated once per second (assuming heart
rate of 60 bpm) with a range of pulse durations (100 ms-I s).
Results: Ablation lesions were formed in the ventricular
septum of ex-vivo porcine hearts, with lesion size adjustable
depending on the number of sonications used (each 20 s pulse
created a 4 mm x 4 mm lesion). (Figure la-d). Lesion size
decreased at lower pulse duration. Pulse durations as low as 200
ms with interval cooling durations of 800 ms created HIFU
lesions as small as I mm x I mm with no visible lesion at lower
duration (Figure 2). This cutoff is compatible with ablation during
normal cardiac cycle lengths (600-1000 ms).
Conclusion: This study shows noninvasive MRI-guided HIFU is
feasible on ex-vivo myocardium using a 3 T MRI-guided HIFU
system with MR-based temperature monitoring. Furthermore,
lesions could be created with HIFU pulses under physiologic
cardiac gating intervals. Further work is needed based on
these results to allow animal testing and ultimately clinical
translation.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


087
XMR is a useful modality to guide, map
and quantify the perfusion territories
of coronary arteries
Marcus Carlsson' and Maythem Saeed2
'Clinical Physiology, Lund, Sweden
2Dep of Radiology and Biomedical Imaging, San Francisco,
CA, USA

journal of Cardiovascular Magnetic Resonance 2009, I (Suppl 1):087
Introduction: The effects of locally delivered angiogenic
factors or stem cells are not well defined. Obstacles to effective
angiogenic treatment have been the difficulties in providing clear
delineation of the status and extent of the injury and the
coronary artery perfusion territory.
Purpose: This study aimed to determine the ability of selective
injection of Gadolinium based MR contrast media (MR-CM) to
map and quantify the territories of the major coronary arteries
using first-pass perfusion (FPP) and early contrast enhanced (CE)
MRI.
Methods: Selective coronary catheterization (n = I6 pigs) was
performed under X-ray and MRI fluoroscopy in an XMR-suite.
Catheters were placed in LAD, circumflex or right coronary
artery. The coronary perfusion territories were mapped by
intracoronary injection of 6-10 ml 10% diluted MR-CM using a
saturation-recovery gradient echo sequence for FPP images (TR/
TE/flip = 4.5 ms/2.2 ms/200, slice thickness = 10 mm) and an
inversion recovery gradient echo sequence for early CE MRI (TR/
TE/flip = 5 ms/2 ms/15", shot interval = 2RR-intervals, slice
thickness = 3-4 mm). Cine MRI was used to quantify LV mass.
In 12 animals, the LAD was occluded by embospheres to create
infarction. Infarct size was measured on delayed enhanced (DE)
MRI after intravenous injection of MR-CM. Figure I.
Results: Catheterization of the coronary arteries was success-
ful in all animals under X-ray guidance (n = 13) and MRI guidance
(n = 3) and took 15-20 min for X-ray and 30-45 min for MRI
fluoroscopy. The perfusion territories of the coronary arteries
were defined as hyperenhanced regions on FPP and CE-MRI. The
LAD territory was 33.7 2.2% of LV-mass on FPP and
33.0 2.3% on CE-MRI (P = 0.63). Bland-Altman analysis



Figure I (abstract 087)


Multislice MR images showing the LVon cine (top) and the LAD perfusion
territory on corresponding FPP (middle) and early CE (bottom) MRI as
hyperenhanced regions.


showed close agreement between the two methods (0.7 5%).
The signal intensity of LAD territory after injection of diluted
Gd-based MR contrast media retuned to baseline after 6-8 min
on CE MR imaging, suggesting complete washout of the contrast
medium from normally perfused myocardium and lack of
myocardial damage due to coronary catheterization. DE-MRI
demonstrated the infarcted myocardium as hyperenhanced sub-
regions of the perfusion territory (7.5 1.2% LV mass) which did
not differ from post mortem TTC size (7. I 0.8% LV mass, P =
0.99). Postmortem inspection revealed that there was no
evidence of vascular or valvular injury caused by the endovas-
cular catheter.
Conclusion: In this experimental study, we developed a
method combining X-ray and MR fluoroscopy for selective
mapping of the perfusion territories of the LAD, circumflex and
right coronary arteries and quantifying the LAD perfusion
territory. The extents of the LAD coronary artery perfusion
territory measured on FPP and CE-MRI did not differ and neither
did the infarct size on DE-MRI and TTC staining. This
experimental method can be used prior to and after local
delivery of angiogenic factors or stem cell therapy to determine
their efficacy.
Acknowledgements
This study was supported by a grant from NIH (RO I HL07295).



088
CMR atrial angiography makes redo AF ablations
faster and easier with less x-ray fluoroscopy
Andrew S Flett, Don M Milliken, Syed S Ahsan,
James McReady, Pier D Lambiase and James C Moon
The Heart Hospital, London, UK

journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl 1):088
Objective: To determine if merging CMR atrial angiograms
with the fluoroscopy and ECG mapping during the ablation
procedure make redo AF ablations easier.
Background: AF ablations have a relatively low success rate
(52-74%) and are long, complex procedures. CT merge into
electroanatomic mapping in the catheter lab has been shown to
produce better outcomes than using electroanatomic mapping
alone. However, CT is associated with substantial radiation
exposure. It is unclear whether CMR integration offers similar
benefits. We hypothesised that CMR-derived 3D atrial anatomi-
cal merge would result in faster, easier procedures with less use
of ionising radiation.
Methods: 64 patients (39 male, mean age: 57 +/- 12 years)
underwent repeat radiofrequency catheter ablation of atrial
fibrillation. Twenty-two (34%, the MERGE group) had a CMR
merge, while 42 (66%, NO MERGE) did not. All patients
underwent their procedure using the Ensite NavX system (St
Jude Medical). The CMR atrial angiogram was performed prior to
the procedure (non-gated, 3D atrial angiogram, 0.1 mmol/Kg
contrast, timed for atrial delineation), and was available (non-
subtracted) for importing into the cardiac catheterisation suite.
Results: Compared to the NO MERGE group, the MERGE
group demonstrated a substantial reduction in both total
procedure time (34 minutes, 119 vs. 153 min; p = 0.01) and
fluoroscopy time (19 minutes, 60 vs. 41 min; p = 0.01). In
addition, there was a trend towards a reduction in left atrial


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 088)


Atrial ablation procedem time and
flu oroscopy time


A CMR atrial anglogram with PV isolation
bums overlaid


po001


p0Ial


Nne ~ I


mapping time (27 vs. 33 minutes; p = 0.25) and fewer radio-
frequency lesions being required (204 vs. 250; p = 0.3). Figure I
Conclusion: CMR integration into electroanatomic mapping
results in a reduction in procedure times and x-ray fluoroscopy in
redo AF ablation compared to electroanatomic mapping alone.
This is a potential benefit over CT image integration and
electroanatomic mapping alone.


089
Magnetic resonance imaging for identification
of myocardial injury during ablation for
atrial fibrillation: first experiences with the
Miyabi MRI system
Anil-Martin Sinha', Guido Ritscher', Christian Mahnkopf',
Nathan Burgon2, TroyJ Badger3, Martin Schmidt,
Harald Marschang', Klaus J Gutleben',
Edward VR DiBella4, Nassir F Marrouche3
and Johannes Brachmann
'Klinikum Coburg, Coburg, Germany
2School of Medicine, University Of Utah, Salt Lake City,
UT, USA
3School of Medicine, University of Utah, Salt Lake City, UT USA
4Center of Advanced Imaging Research, University of Utah,
Salt Lake City, UT USA
journal of Cardiovascular Magnetic Resonance 2009, II (Suppl 1):089
Introduction: Pulmonary vein antrum isolation (PVAI) has
become an effective therapy in patients with paroxysmal atrial
fibrillation (AF). Extension and location of ablation lesions often
remain unclear during the procedure.
Purpose: We evaluated a new approach on visualization of
myocardial injury using cardiac magnet resonance imaging (CMR)
during PVAI procedure.
Methods: Patients who underwent PVAI, received CMR before
and at the terminal phase of PVAI using the Miyabi-MRI system
(Siemens, Germany). Delayed enhancement (DE-CMR) free
breathing sequences were applied, and maximum intensity
projections (MIP) obtained. Myocardial injury size was then


measured on manually segmented 3D images by a computer
algorithm using dynamic thresholding.
Results: 30 patients received PVAI from February to July 2008. In
a subset of 14 patients, CMR was performed before and during the
procedure. Using DE-CMR, the increase in average lesion to healthy
myocardium ratio was 10.3 4.1% during PVAI. Figure I shows an
example of MIP of a DE-CMR scan in 2D (A, B) and 3D
segmentation (C, D) in a anterior view pre (A, C), and during PVAI


Figure I (abstract 089)


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I
U '


Nonm AMPl


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


(B, D). Myocardial injury is identifiable as white tissue around PV
single ostia (full arrows) and common trunk (dashed arrows).
Conclusion: Using CMR is feasible in the course of ablation
procedures. In PVAI patients, DE-CMR allowed identification of
location and extension of myocardial injury. Therefore, this new
CMR approach might improve ablation techniques, and thus long-
term success of PVAI.


090
Cine DENSE MRI for circumferential and
radial dyssynchrony in patients referred for
cardiac resynchronization therapy
Alexander B Jehle, Frederick H Epstein, Xiaodong Zhong,
Robert L Janiczek, W Kevin Tsai, John M Christopher,
Dale E Fowler, John D Ferguson, Christopher M Kramer
and Kenneth C Bilchick
University of Virginia, Charlottesville, VA, USA

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):090
Introduction: Cine DENSE (Displacement Encoding with
Stimulated Echoes) MRI offers high resolution circumferential,
radial, and longitudinal strain assessment. Dyssynchrony assess-
ment using midwall circumferential strain corresponds to the
predominant physiologic orientation of myofibers, and its
effectiveness for cardiac resynchronization therapy (CRT) patient
selection has recently been demonstrated [I]. Current echo-
cardiographic dyssynchrony measures are based on radial or
longitudinal velocity/strain.
Purpose: To test the hypothesis that cine DENSE circumfer-
ential strain analysis most effectively distinguishes between HF
patients referred for CRT (HF/CRT) versus HF patients not
candidates for CRT (HF/no CRT) and normal volunteers.
Methods: MRI and echocardiography were performed in
21 subjects separated into 3 groups as defined above: HF/CRT
patients (N = 9), HF/no CRT patients (N = 8), and normal
volunteers (N = 4). All MRI studies were performed on a 1.5 T
system (Avanto, Siemens, Germany). An ECG-gated spiral cine
DENSE pulse sequence was used to acquire images with
displacement encoding applied in two orthogonal in-plane
directions. Separate 14-heartbeat breath-hold acquisitions were
used for each displacement encoding direction. Short-axis images
were acquired at basal, mid-ventricular, and apical levels.
Additional imaging parameters included field of view = 340 -
400 mm2, matrix = 128 x 128, slice thickness = 8 mm, flip
angle = 200, TR = 17 ms, TE = I ms, number of spiral
interleaves = 6, fat suppression, temporal resolution = 17 ms,
and displacement encoding frequency = 0.1 cycles/mm. Images
were exported to a PC and analyzed using custom-developed
segmentation, tissue tracking, and strain analysis methods that
have been described previously [2]. Echocardiography studies
were performed on GE Vivid 7 Scanners and analyzed on an
EchoPAC workstation. The standard deviations in timing in
12 segments were calculated for MR-based onset of circumfer-
ential contraction (MR Ecc Onset SD), peak circumferential
contraction (MR Ecc Peak SD), onset of radial contraction
(MR Err Onset SD), and peak radial contraction (MR Err Peak
SD), as well as for echo peak longitudinal velocity (Ts-SD), as
described by Yu et al [3].
Results: Of the 21 patients (age 60 +/- I I years, 29% female),
17 had a cardiomyopathy, 6 (35%) of which had an ischemic


Figure I (abstract 090)


-140
E

-120


E
oo
80
C' 80

re 60
60

o 40
.o
40

I 20
Br
Bi


MREccOns MREcc~k MRErrOns MRErrPk TDITs-SD


CMR DENSE dyssynchrony measures.



etiology. For all 252 segments, DENSE circumferential and radial
peak timing correlated modestly (R = 0.43; p < 0.0001). Patient-
level circumferential timing measures for onset of circumferential
contraction and peak circumferential contraction correlated
closely (R = 0.79; p < 0.0001). As shown in Figure I, MR Ecc
Peak SD was significantly higher in HF/CRT patients versus HF/no
CRT patients (p = 0.01) and normal patients (p = 0.008). MR Ecc
Onset SD was markedly higher in HF/CRT patients than normals
(p = 0.001). Although DENSE radial dyssynchrony measures
effectively differentiated HF/CRT patients from normals, they
were not as effective as the circumferential measures in
distinguishing between patients in the HF/CRT and HF/no CRT
groups (p = NS). Ts-SD as assessed by echocardiography was
similar in all 3 groups.
Conclusion: MR cine DENSE assessment of circumferential
strain timing using contraction onset and peak contraction
effectively distinguished CRT candidates from HF patients not
candidates for CRT and normal volunteers. The better discrimi-
nation of circumferential versus radial strain dyssynchrony
measures has important implications for identifying the optimal
imaging modality to identify CRT candidates.
References
I. Bilchick KC, Dimaano V and Wu KC, et al: Magnetic
resonance imaging analysis of dyssynchrony and
myocardial scar predicts function class improvement
following cardiac resynchronization therapy. JACC
Cardiovascular Imaging 2008, 1:56 1-8.
2. Spottiswoode BS, Zhong X and Meintjes EM, et al: Tracking
myocardial motion from cine-DENSE images using
spatiotemporal phase unwrapping and temporal
fitting. IEEE Trans Med Imag 2007, 26:15-30.
3. Yu CM, Chau E and Sanderson JE, et al: Tissue Doppler
echocardiographic evidence of reverse remodeling
and improved synchronicity by simultaneously delay-
ing regional contraction after biventricular pacing
therapy in heart failure. Circulation 2002, 105:438-45.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


091
Spatiotemporal relationship between ventricular
expansion and flow propagation during early filling
Thompson Richard', June Cheng Baron', Kelvin Chow',
Jessica Scott2, Ben Esch2, Mark Haykowsky'
and lan Paterson
'University of Alberta, Edmonton, AB, Canada
2University of British Columbia, Vancouver, BC, Canada

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):09 I
Introduction: Flow propagation refers to the delay in the
onset of blood flow during early filling at more apical ventricular
locations. The velocity of flow propagation (Vp) into the left
ventricle (LV) provides a preload insensitive estimate of LV
relaxation, confirmed invasively by a strong negative correlation
with the relaxation time constant (tau) [I, 2]. Clinically, Vp <
50 ms is commonly taken as evidence of abnormal diastolic
function. No direct physical relationship between muscle
relaxation and flow propagation has been previously illustrated.
By simultaneous measurement of myocardial mechanics (radial
expansion) and blood patterns throughout the LV and during
early filling we expect to illustrate a correlated spatial and
temporal relationship between the mechanics which drive blood
flow and the resulting blood flow patterns.
Methods: Phase contrast and tissue tagged MRI were used to
measure the timing of blood and myocardial tissue dynamics
during early diastole (Siemens Sonata 1.5 T scanner). Experi-
ments had a true temporal resolution of -20 ms, interpolated to
10 ms for all analyses. The time of onset, tO (time from QRS), of
blood flow (phase contrast MRI) and radial expansion (tissue
tagged MRI) were calculated at three 16 mm intervals from base
to apex in 8 healthy volunteers. tO was also evaluated as % systole
(normalized to the time of aortic valve closure). Figure I shows
an example of the measurement of tO for both radial tissue
motion (B) and blood flow (C). To account for residual low
velocities that are unrelated to the early filling impulse (which can
obscure the time of onset) the early diastolic blood and tissue
velocities were linearly extrapolated to determine tO.
Results: Propagation of flow and of radial expansion from the
base to the apex (cartoon in Figure IA) was observed in all
subjects, as shown by the increasing delay in to as one moves
towards the apex (see Table I). The flow and radial expansion to
values for each spatial position have similar means and good
correlation (R in table). The resulting Vp values are also in
general agreement.
to (ms/% systole)
Conclusion: We demonstrated that spatiotemporal patterns of
radial expansion (base to apex) are strongly correlated to
conventional blood flow propagation during early filling, implying
that muscle relaxation is related to Vp via the propagation of
strain in the relaxing ventricle. These preliminary results show


Figure I (abstract 091)


AIa I
A)





00 msn

B) 6adiaG~a V __
ekd--r-"-e)


425ms 450 ms in i,.


C) Blood dY.*dt


.


Mro 4C4 45 S O qo* 600 650(i


Measuring deformation of the LV and blood velocity during early filling.


that MRI can be used to simultaneously quantify mechanics and
hemodynamics, with good spatial and temporal registration
(which is a strength of MRI as compared to ultrasound). It
remains to be shown that the many other aspects of ventricular
mechanical function (longitudinal strain, rotation, endo vs.
epicardial motion, for example) are as closely coupled to
hemodynamics as was shown in this study.
References
I. Brun P, et al: Left ventricular flow propagation during
early filling is related to wall relaxation: a color
M-mode Doppler analysis. J Am Coil Cardiol 1992,
20:420-432.
2. Garcia MJ, et al: Color M-mode Doppler flow propaga-
tion velocity is a preload insensitive index of left
ventricular relaxation: animal and human validation.
J Am Coll Cardiol 2000, 35:201-208.

092
Internal Flow Fraction discriminates patients
with dyssynchronous heart failure from
age and sex-matched controls
Brandon K Fornwalt, Jana G Delfino, Calvin R Kurz,
Patrick C Gonzales, Robert Eisner, Angel R Le6n
and John N Oshinski
Emory University School of Medicine, Atlanta, GA, USA

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):092
Objective: Evaluate the ability of Internal Flow Fraction to
diagnose left ventricular dyssynchrony using standard cine MRI.


Table I (abstract 091)

Base +16 mm +32 mm Vp (cm/s)

Flow 384 24/112 7 411 24/123 5 436 24/131 7 66 13
Radial Expansion 386 31/114 5 405 32/121 7 430 32/129 7 73 10
R (to) .78 .73 .72 NS


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350 400 450 500 50 600 650
6- (-,~


I







Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 092)


j~Long-axisErnJh~c


j25o







5
li5


I-W
- Left ventricular
evrcal axis


II .


Normals
(b)


(a) The 3-dimensional left ventricular volume is superimposed on the 4-chamber long-axis MRI. Two of the short-axis images are also displayed to
demonstrate the spatial arrangement of the images. The left ventricle was divided into 16 wedge-shaped regional volumes as shown. (b) Interal Flow
Fraction (IFF) discriminates between patients and healthy controls with 95% accuracy.


Background: Better methods to quantify mechanical dyssyn-
chrony in the heart may improve patient selection for cardiac
resynchronization therapy. Dyssynchrony creates inefficient
"sloshing" of blood volume internally within the left ventricle
(LV). This "internal flow" represents wasted energy due to the
dyssynchronous motion of the LV walls. We developed a new
method to quantify internal flow from cine cardiac MRI which
may provide a better, more physiologic measure of dyssynchrony
than existing methods.
Hypothesis: LV internal flow will be significantly increased in
patients with dyssynchronous heart failure compared to healthy,
age and sex-matched volunteers.

Figure 2 (abstract 092)


A: Healthy
2
2 Systole

| 1.5
o.
IT



O- -
%ofC
%orC


Controls (n = 10)
SDiastole


LJ
50 100
ardiac Cycle


B: Patients (n = 10)


0 50
% of Cardiac Cycle


Internal flow is significantly increased throughout the cardiac cycle in
patients with dyssycnhronous heart failure compared to age and sex-
matched healthy controls. Note the peaks in internal flow surrounding
the periods of isovolumic contraction (time 0) and relaxation (vertical
dashed line marking the end of systole).


Methods: Images were obtained with a 1.5 T Philips Intera
scanner using a 5-element phased array cardiac coil. Short-axis
steady-state free-precession (SSFP) cines were acquired over the
length of the LV during breath-holds (8-10 mm slices with no
gaps, 20 phases per cardiac cycle). Two and four-chamber long-
axis cine images were also acquired. Ten patients with
dyssynchronous heart failure (New York Heart Association
class III/IV, LVejection fraction < 35%, QRS > 150 ms) and 10 age
and sex-matched healthy controls were imaged. The 3-dimen-
sional LV volume was reconstructed and divided into 16 wedge-
shaped volumes adjacent to the American Heart Association
standardized myocardial segments (Fig IA). Internal flow was
defined as the sum of the magnitude of the volume changes in the
16 regions minus the magnitude of the global volume change
over each time step in the cardiac cycle: IF(t) = 1|AV(t)regionali -
I|AV(t)regionalI. This difference is zero if no internal flow has
occurred. Internal Flow Fraction (IFF) was defined as the total
internal flow as a percentage of stroke volume.
Results: IFF was significantly increased in the patients (10 5% vs
I 1% in the healthy controls, p < 0.001). An IFF threshold of 4%
discriminated between patients and controls with 90% sensitivity
and 100% specificity (Fig I B). There were two large physiologic
peaks of internal flow in the healthy controls: one during isovolumic
contraction and another during isovolumic relaxation (Fig 2A).
Internal flow occurred throughout the cardiac cycle in the patients,
but peaked during the isovolumic periods (Fig 2B).
Conclusion: Left ventricular Internal Flow Fraction can be
quantified from images acquired in a standard cine cardiac MRI
exam. Internal flow during the isovolumic periods is a normal,
physiologic component of left ventricular contraction and
relaxation. A left ventricular Internal Flow Fraction of 4%
discriminated patients with dyssynchronous heart failure from
age and sex-matched healthy controls with 95% accuracy.


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p<0.001



A



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.,. 16.


Patients


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http://jcmr-online.com/supplements/11/S1


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


093
Accurate quantification of heart valve
regurgitation in all four heart valves
simultaneously using 3D velocity-encoded MRI
with retrospective valve tracking
Jos JM Westenberg, Stijntje D Roes,
Rob J van der Geest, Sebastiaan Hammer,
Nina Ajmone Marsan, Jeroen J Bax, Albert de Roos
and Johan HC Reiber
Leiden University Medical Center, Leiden, Netherlands
journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):093
Introduction: In regurgitant heart valves, surgical decision-
making is based on the severity of the regurgitation through the
particular valve. Conventional two-dimensional (2D) one-direc-
tional velocity-encoded (VE) MRI is routinely used for flow
assessment, but this technique has been shown to be inaccurate
and correlation between the net flow volumes through the valves
is weak, even in the absence of regurgitation. 2D one-directional
VE MRI is limited because the position and angulation of the
acquisition plane cannot be adapted to the valve motion and the
direction of the inflow and regurgitant jet.



Figure 2 (abstract 093)


140



120



100
80






I


j 40


Figure I (abstract 093)


3D 3-directional velocity-encoded MRI is performed at the basal level of the
heart. In offline analysis, retrospective valve tracking for each of the heart
valves can be performed, resulting in flow at the mitral valve (MV), tricuspid
valve (TV), aortic valve (AV) and pulmonary valve (PV).


.MV v AV
TVrvs MV
TV V PV


0 20 40 60 80 100 120
Net Flow Volume Valve I (mlI


Net flow volumes for mitral valve (MV) vs. aortic valve (AV), tricuspid valve (TV) vs. MV and TV vs. pulmonary valve (PV) in 23 patients with valve
regurgitation.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table I (abstract 093) Statistical results

MV-AV MV-TV TV-PV

Volunteers (n = 14) Pearson correlation 0.96 0.97 0.96
p-value t-test 0.01 0.31 0.0
Mean difference 6 7 ml -2 5 ml 6 6 ml
Confidence interval -7 19 ml -12 9 ml -6 17 ml
Patients (n = 23) Pearson correlation 0.95 0.98 0.88
p-value t-test 0.07 0.75 0.30
Mean difference 3 6 ml 0.3 4 ml 2 10 ml
Confidence interval -10- 16 ml -8 9 ml -17 22 ml


Purpose: Three-dimensional (3D) 3-directional VE MRI
with retrospective valve tracking during offline analysis is
introduced for flow assessment through all heart valves
simultaneously. This technique is validated in phantoms and
applied in 14 volunteers without and 23 patients with valve
regurgitation.
Methods: MRI was performed on a 1.5 T Gyroscan ACS/NT 15
MRI (Philips, Best, the Netherlands). A 3D 3-directional VE
MRI sequence was designed (3D volume scan with slab thickness
48 mm, acquisition voxel size 2.9 x 3.8 x 4.0 mm3, three-
directional velocity sensitivity 150 cm/s, with 30 phases
reconstructed during one average cardiac cycle, Echo Planar
Imaging factor 5, with free-breathing in vivo) and tested in
stationary flow phantoms and in a phantom simulating
harmonic left ventricular filling. From the 3D velocity-data,
through-plane velocity was reformatted offline for each valve
plane using two orthogonal reformat-guides per plane (i.e., for
mitral valve (MV): 2- and 4-chamber of the left ventricle (LV);
tricuspid valve (TV): 2- and 4-chamber of the right ventricle (RV);
aortic valve (AV): two orthogonal views of LV outflow tract;
pulmonary valve (PV): two orthogonal views of the RV outflow
tract) (Figure I).
In 14 volunteers without regurgitation and in 23 patients with
single or multiple valve regurgitation proven on echocardiogra-
phy, trans-valvular flow was assessed at all four valves using 3D 3-
directional VE MRI. Regurgitation was quantified. Correlation
between the net flow volumes per valve was examined and
differences were studied.
Results: Validation in phantoms showed less than 5% error in
flow. In vivo, mean scan time = 4.2 0.8 min at a mean heart
rate of 67 12 beats per minute. In volunteers, comparison of
the net flow volumes through the four valves showed strong
correlation with a only small differences between AV and MV and
between PV and TV (statistically significant but clinically non-
significant) and with small confidence intervals (Table I). In
patients, also strong correlation between the net flow volumes
per valve were found (Figure 2), with no significant biases. Mean
regurgitant fraction for MV = 12 8% (range: 4-29%), TV =
10 7% (range: 2-25%), AV = 2 2% (range: 0-5%) and
PV = 3 3% (range: 0-10%).
Conclusion: 3D VE MRI provides the true trans-valvular
flow for all four heart valves from a single acquisition in less
than 5 minutes scan time. Regurgitation can be quantified
accurately, providing essential information for surgical decision-
making.


094
Navigator-gated 3D cine DENSE: development
and initial evaluation
Xiaodong Zhong', Bruce S Spottiswoode2
Craig H Meyer', Christopher M Kramer'
and Frederick H Epstein
'University of Virginia, Charlottesville, VA, USA
2University of Stellenbosch, Tygerberg, South Africa

Journal of Cardiovascular Magnetic Resonance 2009, I (Suppl 1):094
Introduction: Ideally, imaging of cardiac function should cover
the entire heart and completely quantify myocardial deformation
in three dimensions.
Purpose: To (a) develop a free-breathing navigator-gated 3D
cine DENSE (Displacement-encoding with Stimulated Echoes)
pulse sequence to acquire such data and (b) implement post-
processing methods to quantify 3D myocardial strain throughout
the left ventricle (LV).
Methods: An ECG-gated segmented 3D spiral cine DENSE pulse
sequence with navigator gating and online image reconstruction was
implemented on a 1.5 T MRI scanner (Siemens Avanto, Erlangen,
Germany). A 3D stack of spirals k-space trajectory was employed
for rapid data acquisition. Three-point phase cycling was used for
artifact suppression, a balanced four-point method was used for
optimal displacement encoding, and field map acquisition and online
spiral deblurring were employed. A navigator echo was placed at
the end of the cardiac cycle, so as not to interfere with imaging of
the onset of myocardial contraction. The navigator echo was used
to accept or reject the DENSE data acquired in the subsequent
heart beat. Five normal volunteers provided informed consent and
were studied in accordance with protocols approved by our
institutional review board. Imaging parameters included voxel
size = 2.8 x 2.8 x 5.0 mm3, flip angle = 200, TR = 16 ms,
TE = 1.3 ms, number of spiral interleaves = 6, temporal resolu-
tion = 32 ms, and cardiac phases = 22. A double-oblique 3D
volume was aligned with the short and long axes of the LV. Fourteen
k-space partitions were acquired and then zero-padded to
reconstruct 28 slices. A 3 mm navigator acceptance window was
placed at the end-expiration position. For displacement and strain
analysis, images were exported to a PC and manually segmented.
Tissue tracking and strain analysis were performed using 3D
extensions of 2D methods that were described previously. To
validate the 3D measurements, separate 2D cine DENSE MRI was
also performed in multiple short- and long-axis planes. Non-
navigator-gated 3D data were also acquired in some volunteers.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 094)


Radial (a-c), circumferential (d-f), and longitudinal (g-i) strains computed
throughout the LV from 3D cine DENSE MRI of a normal volunteer. Data
are shown at end diastole (a, d, g), mid systole (b, e, h), and end systole
(c, f, i). Three of 22 cardiac phases are displayed. Individual dots represent
displacement, while color represents strain.


Results: Using a 3 mm navigator acceptance window, the
acceptance rate was 48.0 15.7% and the total scan time was
20.5 5.7 minutes. High-quality data were acquired from all
volunteers, and comparisons with non-navigator-gated free
breathing scans clearly demonstrated the reduction of respira-
tory artifacts provided by navigator gating. Typical 3D strain data
from one subject are shown in Fig. I, where the development of
radial (a-c), circumferential (d-f), and longitudinal strain (g-i) from
end diastole (a, d, g) through mid systole (b, e, h) to end systole
(c, f, i) are displayed for the entire LV. Strain values and strain-
time curves were consistent with previous data from myocardial
tagging and DENSE studies of normal volunteers. For the
comparison with 2D cine DENSE, linear regression showed
that radial, circumferential, and longitudinal strains from 3D cine
DENSE correlated well with those from 2D cine DENSE, with a
slope of 0.974 and R = 0.647 for radial strain, a slope of
0.945 and R = 0.902 for circumferential strain, and a slope of
0.888 and R = 0.772 for longitudinal strain. Bland-Altman
analysis also demonstrated good agreement between the 2D
and 3D cine DENSE methods for all 3 strains.
Conclusion: A free-breathing navigator-gated 3D cine
DENSE pulse sequence was developed that provides high spatial
and temporal resolutions, coverage of the entire LV, and
measurement of 3D strain with a scan time of approximately
20 minutes. In normal volunteers, the resulting strain data
show good agreement with those from 2D cine DENSE. With
additional development aimed at further shortening the scan
time and automating image analysis, these methods may
enable routine clinical imaging that completely quantifies
contractile function throughout the LV in patients with
contractile dysfunction.


095
Comprehensive evaluation of diastolic
function with MRI
Thompson Richard', June Cheng Baron', Kelvin Chow',
Jessica Scott2, Ben Esch2, Mark Haykowsky'
and lan Paterson'
'University of Alberta, Edmonton, AB, Canada
2University of British Columbia, Vancouver, BC, Canada

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):095
Introduction: Diastolic dysfunction is a contributing factor in
most cardiovascular diseases. For example, from the ischemic
cascade, it is well known that ventricular relaxation is impaired
prior to changes in systolic function. Diastolic parameters are
predictive of outcome in acute MI [I], and a third to a half of all
cases of heart failure have preserved LVEF (>50%) (HFpEF) [2].
The importance of diastolic dysfunction in the many manifesta-
tions of HFpEF is not well characterized. Clinical evaluation of
diastolic function is predominantly by echocardiography, for
which several conventional and novel quantitative measures of
function are available (the vast majority of which are not
routinely acquired using MRI). With its increasing use in clinical
cardiology, and improvements in temporal resolution, it is now
practical for MRI to provide an equivalent or superior
assessment of diastolic function. We illustrate the measurement
of conventional and novel diastolic parameters using universally
available clinical pulse sequences.
Methods: Diastolic parameters are measured in a controls
(n = 10) and heart failure patients (n = 10) with diverse
etiologies (ischemic and non-ischemic cardiomyopathies,
13% < EF < 67%). MRI studies consisted of conventional volu-
metric cines (SAX and LAX) for the measurement of ESV, EDV,
SV (normalized to body surface area) and EF, phase contrast
(basal SAX through-plane with Venc = 120 cm/s and Venc = 30-
50 cm/s, 3 ch and 4 ch with in-plane velocities) and tissue tagging
(5 SAX and LAX slices). Conventional diastolic parameters: E and


Figure I (abstract 095)


Normalized diastolic parameters (heart failure patient).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Table I (abstract 095) Heart rate, volumes and function

HR EDVi (mLm2) ESVi (mL/m2) Svi (mL/m2) EF(%)

Control 67.1(14.0) 92.3(16.3) 35.7(9.0) 56.6(8.4) 61.6(3.7)
Patients 74.9(20.9) 126.4(88.5) 80.8(41.4) 45.6(21.7) 38.5(17.6)



Table 2 (abstract 095) Conventional diastolic parameters

E(cm/s) A(cm/s) E/A E' (cm/s) E/E' Vp (cm/s)

Control 64.6( 11.4) 34.6(5.0) 1.9(0.5) 14.4(2.6) 4.5(0.7) 57.8(7.3)
Patients 63.5(22.5) 40.8(13.4) 1.5(0.9) 9.7(6.5) 8.6(4.5) 32.5(13.7)



Table 3 (abstract 095) Novel diastolic parameters

IVPGpeak IAPGpeak Peak Peak Untwisting Radial Circumferential
(mmHg) (mmHg) Torsion (deg) Rate (deg/sec) Velocity (cm/s) Strain rate (s ')

Control 2.9(0.9) 1.9(0.4) I 1.1(2.1) 157.2(27.6) 4.4(0.9) 1.60(0.24)
Patients 3.3(2.3) 0.8(1.4) 8.4(4.3) 77.7(30.5) 2.3(1.0) 0.87(0.46)


A wave filling velocities (cm/s), mitral annular velocity (E' in cm/s), E/
A ratio, E/E' ratio and inflow propagation velocity (Vp in cm/s).
Additional parameters include the intraventricular (IVPG) and atrial
(IAPG) pressure gradients (derived from in-plane blood velocities),
peak torsion (deg) and rate of untwisting (deg/sec), peak diastolic
radial velocity (ventricular average cm/s), and peak diastolic
circumferential strain rate (ventricular average, s 1). All tagged
images were analyzed using a user-independent morphing approach.
All studies were breath held with ECG gating (Siemens Sonata 1.5 T
scanner).
Results: Tables I, 2 and 3 summarize the conventional volume
and diastolic parameters (both conventional and novel measures)
in the control and heart failure subjects. Figure I compares one
failure case (ischemic cardiomyopathy with EF = 26%) with the
control population using normalized diastolic parameters. The
control population standard deviations for each parameter are
shown, clearly illustrating that several diastolic parameters are
abnormal, notably the conventional E' and E/E' values (most
sensitive clinical measures of diastolic dysfunction [3]) and most
of the novel measures in this subject. Similar striking patterns of
abnormal diastolic function are seen in most heart failure patients
in this study as indicated by Tables 2 and 3.
Conclusion: MRI can offer a comprehensive evaluation of
diastolic function that is comparable or superior to echocardio-
graphy. In most heart failure patients the conventional and several
novel measures could be measured using conventional pulse
sequences, with arrhythmias being the most common technical
limitation (2 of the 10 subjects were excluded due to
arrhythmias). Using automated processing tools for tag and
phase contrast data analysis, rapid and standardized processing is
now feasible. In addition to superior LV volumes and function,
MRI is the gold standard measure of LA volumes, which is
sensitive to increased diastolic pressures, and delayed enhance-
ment offers a measure of fibrosis, which is an important
modulator of ventricular relaxation and stiffness and underlying
cause of diastolic dysfunction.


References
I. Moller JE, et al: Circulation 2006, I 14:438-444.
2. Paulus WJ, et al: Eur HeartJ 2007.
3. Kasner M, et al: Circulation 2007, I 16:637-647.

096
Evidence across CMR sites and systems
of background velocity offset errors
requiring correction before accurate
measurement of regurgitant and shunt flow
Peter D Gatehouse', Marijn P Rolf2, Martin J Graves3,
John Totman4, Jochen von Spiczaki5, Maria-
Filomena Santarelli6, Yingmin Liu7, Rebecca A Quest8,
Matthias Dieringer9, Massimo Lombardi urg Schwitterlo,
Jeanette Schulz-Menger9, David N Firmin
Mark BM Hofman2 and Philip J Kilner'
'Royal Brompton Hospital, London, UK
2VU Medisch Centrum, Amsterdam, Netherlands
3Cambridge University Hospitals NHS Foundation Trust,
Cambridge, UK
4King's College, London, UK
slnstitute for Biomedical Engineering, University and ETH,
Zurich, Switzerland
6CNR Institute of Clinical Pharmacology, Pisa, Italy
7University of Auckland, Auckland, New Zealand
81mperial College Healthcare NHS Trust, London, UK
9Franz-Volhard-Klinik, Charite Universitdtsmedizin, Berlin,
Germany
IOUniversity Hospital, Zurich, Switzerland
Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):096
Purpose: To assess velocity offsets in the background of phase-
contrast acquisitions across CMR sites and systems.
Introduction: Phase-contrast CMR potentially provides accu-
rate measurements of aortic or pulmonary regurgitation, cardiac
output and shunt flow. Among several known errors (assuming


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure I (abstract 096)


S-- - Aorcl e45, orthogonal
to coronal









Pulmonary plane 456, orthogonal
.. _ to sagittal




- Ar
-F-




The planes used for veolicity offset acquisitions at all sites. The aortic
(AO) plane at 45 degress between transaxial and sagittal used antero-
posterior phase-encode. The main pulmonary artery (MPA) plane at
45 degrees between transaxial and coronal was repeated with head-foot
and left-right phase-encoding. The grey bloc represents the gelatin
phantom.


concomitant gradient correction [ I ]) we examined one: a 2 cm/s
velocity offset (i.e. around 1% of a typical VENC) can cause >20%
error in cardiac output [2, 3] with larger consequences for
regurgitation and shunt flow, particularly in dilated vessels.
As a collaborative group, we measured velocity offsets across
sites and scanner types, an initiative backed by the European
Society of Cardiology CMR Working Group.
Methods: To eliminate slow flow, 10-15 litre uniform gelatine
phantoms were used, containing 5 millimoles/litre Gd-DTPA for
SNR. We used similar phase-contrast sequence parameters at
each site, measuring 450 oblique 'aortic' (Ao) and 'main
pulmonary artery' (MPA) planes (Figure I). Constant sequence
parameters were: retro-gated cine at 1000 ms RR-interval,
through-plane Venc = 150 cm/s, SLT = 6 mm, TE = 2.8-3.0 ms,
FOV = 320 mm square, uninterpolated pixels 1.25 mm(FE) by
2.5 mm(PE), bandwidth 355 Hz/pixel, 6 rawdata lines per
cardiac cycle, no cine data-sharing or parallel imaging.
Unless stated, velocity encoding was asymmetric (i.e. phase-
subtraction of compensated and velocity-encoded). The gradi-
ent-echo was asymmetric (early for short TE); Philips
applied partial-echo sampling which may explain its shorter TR.
Slower machines were excluded because fast gradient perfor-
mance was necessary. Three 1.5 T scanner types were compared,
and the sequences were reproduced exactly among the 4 sites
of each scanner type by protocol file transfer (except I site
below):
GE (4 sites) Signa Excite 14M5. Symmetric velocity-encoding
(compulsory), flow analysis on, flow optimization off, TR5.9-
6.0 ms, TE2.9-3.0 ms (image orientation dependent) (I site on
12M5 TR5.7-5.8 ms TE2.9 ms)
Philips (4 sites) Achieva R2.53. TR5.5 ms, TE2.8 ms, asymmetric
RF pulse (late centre), phase correction off.
Siemens (4 sites) Avanto VB15 TR6.6 ms, TE2.8 ms.


Table I (abstract 096) Largest ROI mean offset (cm/s) within
50 mm of Isocentre, for aortic slice, MPA slice (HF phase-
encoding) and MPA slice (LR phase-encoding). The four rows per
slice are from the four sites using each scanner type. The
column order is not specified, i.e. scanner types are not
identified. (< 0.3 cm/s stdev total error as described above)

cm/s Site Scanner Scanner Scanner
type I type 2 type 3

Aorta I 2.5 1.4 1.7
2 0.7 2.5 0.9
3 0.9 2.9 1.4
4 1.9 1.6 0.7
MPA (HF phase-enc) I 0.8 3.9 1.0
2 1.1 3.4 1.3
3 0.8 4.9 1.2
4 1.0 3.9 0.8
MPA (LR phase-enc) I 1.2 3.3 1.5
2 1.0 5.3 1.6
3 0.8 5.0 1.8
4 0.4 3.6 0.6
Maximum per site I 2.5 3.9 1.7
2 1.1 5.3 1.6
3 0.9 5.0 1.8
4 1.9 3.9 0.8



Velocity images were reconstructed without offset correction
(which performed unrealistically well in this large uniform
phantom). Within 50 mm of isocentre, the largest offset in cm/
s averaged over 300 mm2 circular ROI was recorded for each
plane. All images were measured independently by two sites;
total error was estimated between these, also from noise and
cine frame variations.
Results: Please see data in Table I.
Discussion and conclusion: The results are believed reliable
for 3 reasons: I) cine images were stable without ghosting, 2)
similar results occurred in nearby parallel slices, 3) image analysis
was repeated independently. Comparison of hardware is
prevented by remaining differences between sequences; we
emphasise that small sequence changes may alter these results.
An offset of 1% of Venc (n/100) is impressive engineering,
representing a residual gradient of -0.02% (for approx. TE/2,
50 mm from isocentre) of typical velocity-encoding gradients.
This extreme sensitivity to adjustments such as pre-emphasis
could explain variations between nominally identical sites.
Various automatic offset corrections are routinely installed.
However, this study intentionally omitted them; their usefulness
may depend on applications. Offset correction uses stationary
tissue pixels which can be identified automatically based on their
smaller temporal variation [2]), or identified by users during
postprocessing. This approach is sometimes limited by insuffi-
cient stationary tissue, its low SNR in flow images, and possible
spatial non-linearity. A more time-consuming approach repeats
identical flow acquisitions on a static phantom, subtracting the
corresponding apparent phantom velocities from the clinical
acquisition [2].
We conclude that most systems require velocity offset correc-
tion of flow images for the most sensitive clinical applications.
There is a general need for optimization of acquisition protocols
or (if possible) system engineering and correction methods to
minimise velocity offsets.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Acknowledgements
Drs Jason Polzin (GE), Marc Kouwenhoven (Philips), Andreas
Greiser (Siemens).
References
I. Bernstein and Zhou, et al: MRM 1998.
2. Lankhaar and Hofman, et al: JMRI 2005.
3. Chernobelsky and Shubayev, et al: JCMR 2007.


097
Should reference values for ventricular volumes
and mass of children be indexed for body
surface area, height or weight considering
gender differences?
Samir Sarikouch', Titus Kuehne2, Matthias Gutberlet3
and Philipp Beerbaum4
'Department of Heart-, Thoracic-, Transplantation- and
Vascular Surgery, Hannover Medical School, Germany
2Unit of Cardiovascular Imaging Congenital Heart Diseases,
Deutsches Herzzentrum, Berlin, Germany
3Department of Radiology, Heart Centre, Leipzig, Germany
4Division of Imaging Sciences, King's College, Guy's & St
Thomas' Hospital, London, UK

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):097
Background: Medical decision making in congenital and
acquired heart disease is based increasingly on quantitative MRI
assessment of ventricular volumes and myocardial mass. How-
ever, for children in different age groups, there is only very
limited reference data available, yet. The objective of this study
was therefore to provide statistically robust reference data for
ventricular volumes and mass for healthy children.
Methods: A total of 114 healthy children and adolescents,
uniformly distributed, were examined in a standard 1.5 Tesla
scanner in breathhold-technique using steady-state free preces-
sion and phase-contrast sequences according to a standardized
pediatric CMR protocol. Transversal acquisition, 5-6 mm slice-
thickness, no gap, 25-35 phases, resolution 2.0-2.5 x 1.5-
1.8 mm2. Semiautomatic volumetric analysis as well as analysis
of stroke volumes in the main pulmonary artery and the
ascending aorta were performed by one observer to minimize
observer error.
Results: I 14 children and adolescents were examined, age
ranged between 4 and 20 years (25. percentile 9,2 yrs, 50.
percentile 1,9 yrs, 75. percentile 16,1 yrs). Reference centile
curves were constructed using the lambda-mu-sigma (LMS)
method for left and right enddiastolic and-endsystolic volumes,
stroke volume, ejection fraction and ventricular mass. Figure I.
With increasing age there was a steady increase in left and right
ventricular enddiastolic volumes indexed for body surface area,
as the most common form of indexing in MRI, from 4 up to
14 years where the volumes reached a plateau. Ventricular
volumes and masses indexed to the body surface area were in
general 10% higher in boys than in girls. This statistically
significant gender difference showed to be the same when
indexing for height and disappeared after relating ventricular
volume to weight. 2.5 ml/kg resulted in the enddiastolic volume
of the ventricles and I ml/kg in the endsystolic volume.
Conclusion: Data for ventricular volumes and mass for
children are provided which can serve as a reference tool for
the assessment of pathologic changes in congenital and acquired


Figure I (abstract 097)


RV-EDV rnifd Girls
140
120 P97
P90
100 P75
P50
80 P25
60 P3
40
20
0 -- i - l - i -- i -- i -- i -- i -- i i, i,
4 5 6 7 9 10 11 12 13 14 15 16 17 B1 19
Age In years




heart disease. Indexing of ventricular volumes to body weight
instead of body surface area elimates the gender difference in
children and should therefore be preferred.


098
Measuring right ventricular volume and ejection
fraction with Simpson's method: which MRI axis
is best? Comparison with a "gold standard"
Shawn Haji-Momenian Kevin J Chang David J Grand',
Florence H Sheehan2 and Michael K Atalay
'Brown University, Providence, RI, USA
2University of Washington, Seattle, WA, USA

Journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):098
Purpose: Because of its complex morphology, accurate and
reliable quantification of right ventricular (RV) volume and
function using MRI is challenging. This study had two aims: (I) to

Figure I (abstract 098)


SHORT AXIS vs 3DR (ml)


350

300

250

200

150

100


0
0


200


300


Short axis vs 3DR (ml).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 2 (abstract 098)


AXIAL vs 3DR (ml)
350

300
y -= 0.74x + 11
250
R' = 0.92 I.
200

150

100

50 --IDENTITY


0 100 200 300

Axial vs 3DR (ml).

determine the interobserver reliability of RV volume and ejection
fraction (EF%) calculated using Simpson's method of slice
summation applied to data acquired in three different orienta-
tions: short axis (SA), transaxial (TA), and parallel to the
horizontal long axis (pHLA); and (2) to determine how RV
volume and EF% by each of the three orientations compared with
values obtained using a validated "gold-standard" method with
3-D reconstructions (3DR).
Materials and methods: Twenty-three consecutive, con-
sented patients referred for cardiac MRI were included in the
study (10 males, 13 females; ave. age 43 19 yrs; ave. ht: 66
4 in; ave. wt: 177 5 I Ibs). Steady-state free precession was
used to generate stacked, bright-blood cine loops in 3 separate,
randomly ordered orientations: SA, TA, and pHLA. Slice

Figure 3 (abstract 098)



pHLA vs 3DR (ml)
350

300

250 y = 0.64x + 16
R' = 0.86
200

150

100

50 --IDENTITY


0 100 200 300


pHLA vs 3DR (ml).


thickness was 8 mm and slice separation 2 mm. Using Simpson's
method and pre-determined end-diastolic (ED) and end-systolic
(ES) time points, three experienced reviewers independently
measured RV ED and ES volumes and, in turn, EF% for each of the
orientations. Volumes and EF% were also calculated using a 3DR
technique based on the piecewise smooth subdivision surface
method [1,2], employing data from multiple orientations.
Intraclass correlation was used to compare data from different
observers. Paired t-test analysis was used to compare volumes
and EF%.
Results: Interrater reliability (IRR) of RV ED and ES volumes
and EF% was determined for each of the axes. For the SA, IRR for
all readers was 0.92, 0.87, and 0.33, respectively; for TA, 0.95,
0.90, and 0.71; for pHLA, 0.83, 0.91, and 0.67. (A higher ratio
indicates greater reliability). For comparison, the same para-
meters were also determined for LV ED and ES volumes, and EF%
measured using the SA: 0.98, 0.96, and 0.84.
A wide range of RV volumes (37-323 cc) and EF%s (30-67%)
were observed. Average EDV volumes for 3DR, SA, TA, & pHLA
were: 161 60 cc, 140 45 cc, 136 44 cc, 126 37 cc.
Average ESV volumes for 3DR, SA, TA, & pHLA were: 80
44 cc, 76 35, 65 31 cc, 62 30 cc. All ED and ES volumes
were underestimated using Simpson's method (p < .01). SA, TA,
and pHLA volumes were linearly correlated with 3DR volumes
with R values 0.96, 0.96, and 0.93 (See Figures I, 2, 3).
Correlations for EDVs were slightly better than those for ESVs
for SA and TA orientations. Average EF%s for 3DR, SA, TA, &
pHLA were: 53 9%, 47% 8% (p < .05), 53 7% (P = NS), &
52 9% (P = NS). SA, TA, and pHLA EF%s were linearly
correlated with 3DR EF%s with R values 0.66, 0.57, and 0.65.
Conclusion: Reliability of RV ED and ES volume measurements
is comparable for all three axes evaluated. However, the
reliability of the EF% is best on TA imaging. Moreover, although
TA offers slightly worse EF% correlation with 3DR, our data
suggest that for consistency if Simpson's method is used for RV
volume and EF% quantification the TA axis is preferred.
References
I. Hubka, et al: IntJ Cardiovasc Imaging 2002, 18: 1 I1-1 18.
2. Legget, et al: IEEE Trans Biomed Eng 1998, 45:494-504.


099
Assessment of left ventricular volumes and mass
using single-breath-hold 3D k-t BLAST cine
b-SSFP in comparison with multiple-breath-hold
2D cine b-SSFP
Alessandro Palumbo, Giancarlo Messalli, Erica Maffei,
Chiara Martini, Cosetta Sacc6 and Filippo Cademartiri
Ospedale Maggiore di Parma, Parma, Italy
Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):099
Purpose: To compare performance of new single-breath-hold
3D k-t BLAST cine b-SSFP sequence for left ventricular volume
and mass evaluation using multiple-breath-hold 2D cine b-SSFP as
a reference standard. We also compared time-efficiency of the
two sequences calculating scan time and reporting time.
Methods: On a commercially available 1,5 T MR scan (Achieva,
Philips Medical System), single-breath-hold 3D k-t BLAST cine
b-SSFP sequence (3D-cine) and multiple-breath-hold 2D cine
b-SSFP sequence (2D-cine) were performed in 46 patients
referred to investigate different diseases. The global functional


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


parameters, LV mass, scan time and report time were evaluated
in each patient for both sequences. Differences between
functional parameters and LV mass were made with a paired
Student's T test; correlation between parameters was assessed
with Pearson's correlation coefficient. A Bland-Altman analysis
was used to investigate the limits of agreement between the
measurements. Differences between time-efficiency related
parameters were made with a paired Student's T test.
Results: Functional parameters and mass were significantly
different in the two sequences (p < 0.05) but a strong correlation
was found for LVejection fraction (r = 0.96) and good correlation for
other functional parameters (r between 0.83 and 0.93). Scan time
was significantly lower for 3D sequence, report time was significantly
higher for 3D sequence.
Conclusion: 3D k-t BLAST sequence can be used to assess EF
in patients who have poor compliance in performing multiple
apnoeas and in patients who are not able to remain in the
scanner for a long time. Conversely report time is significantly
higher for 3D sequence.


0100
CMR T2* technique for segmental and global
quantification of myocardial iron: multi-centre
transfereability and healtcare impact evalaution
Vincenzo Positano', Anna Ramazzotti Antonella Meloni ,
Alessia Pepe', Giuseppe Rossi', Cristina Salvatori',
Paolo Marcheschi', Maurizio Mangione', Luigi Natale2,
Eliana Cracolici3, Gennaro Restaino4, Gianluca Valeri5,
Antongiulio Luciani6, Calogera Gerardi7
and Massimo Lombardi'
"G Monasterio" Foundation and Institute of Clinical
Physiology, CNR, Pisa, Italy
2Policlinico "Gemelli", Roma, Italy
3Policlinico "Paolo Giaccone", Palermo, Italy


4Universit6 Cattolica del Sacro Cuore, Campobasso, Italy
sOspedali Riuniti di Ancona, Ancona, Italy
6Az. Osp. "Garibaldi", Catania, Italy
70spedali Civili Riuniti, Sciacca (AG), Italy

Journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):O 100
Introduction: Iron induced cardiomiopathy is the main cause
of mortality in thalassemic population. Thus, the improvement of
chelation regimens, to reduce cardiac disease, has the highest
priority. Efficient evaluation of cardiac iron status and careful
epidemiologic assessment of thalassemic patients play an
important role in this matter. T2* cardiac magnetic resonance
imaging (CMR) is a unique technique to quantify myocardial iron
overload and useful to tailor the chelation therapy. In particular,
effective and reproducible assessment of myocardial iron loading
using the multislice multiecho T2* approach for segmental and
global myocardial iron distribution has been demonstrated within
a single CMR site. Thalassemia major (TM) patients require
lifelong myocardial iron load monitoring to assess the effective-
ness of chelation therapies. Hence, it is highly desirable that CMR
be performed near the patients' locations, and that the patients
be able to safely move between different CMR centers.
Purpose: Aim of this work is to build a reliable network of
haematological and paediatric centers specializing in thalassemia
care and MRI sites able to perform feasible and reproducible
heart iron overload assessments for a consistent number of
thalassemia patients in a standardized and robust manner.
Materials and methods: In order to assess the transferability
of the multislice multiecho T2* technique, heart multislice
multiecho T2* sequence was installed on 1.5 T MRI scanners (GE
Healthcare) at six different sites. Five healthy subjects at each site
(n = 30) were scanned to verify the homogeneity of normal
ranges (T2* lover limit of normal 20 ms). Then, five TM patients
were scanned at the reference site and were rescanned locally


Figure I (abstract 0100)


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


(n = 25) within one month. T2* images were analysed using a
previously validated software (HIPPO MIOT).
After the assessment of CMR technique reproducibility, patients
enrolling started in September 2006. A centralized data manage-
ment system was made to share patient data between CMR and
thalassemia sites. It allowed optimizing the TM patients care and
favouring the creation of a clinical-instrumental database with
data exchange facilities to develop diagnostic, prognostic and
therapeutical evidence-based treatments for thalassemia patients.
The study was approved by the local ethics committees and
followed the principles outlined in the Declaration of Helsinki.
Results: Global and segmental T2* values of healthy subjects
showed inter-sites homogeneity. On TM patients, for global heart
T2* values the correlation coefficient was 0.97, Coefficients of
Variation (CoVs) ranged from 0.04 to 0.12 and Intraclass
Coefficients (ICCs) ranged from 0.94 to 0.99. The mean CoV
and ICC for segmental T2* distribution were 0.198 and 88,
respectively. Figure IA shows linear regression of global heart
T2* values obtained from 25 (5 x 5) patients who were scanned
at the reference site and locally at each of the other five sites on
the same conditions.
Since the project's beginning, 695 thalassemia patients have been
involved in the network 630 patients (90%) successfully under-
went CMR examination. Twenty patients (3%) refused CMR,
mainly due to claustrophobia. The remaining patients (7%) have
been scheduled for future examination. The mean distance from
the patient home locations to the CMR site where the patients
underwent the exams, which is considered an indicator of patient
comfort, significantly decreased during the network's evolution.
In Figure I B, the average distances from the thalassemia centers
which sent the patients for CMR examination are plotted versus
time.
Conclusion: The multislice multiecho T2* technique is trans-
ferable among scanners with good reproducibility. The network
seems to be a robust and scalable system in which T2* CMR-
based cardiac iron overload assessment is available, accessible
and reachable for a significant and increasing number of
thalassemia patients, reducing the mean distance from the
patients' locations to the CMR sites.


0101
3 T cardiac magnetic resonance performs
well as the primary scanner in a clinical setting:
our initial experience at a tertiary care center
Mahadevan Rajaram', Luciana F Seabra',
Shuaib M Abdullah', Sanjeev A Francis', Sofia C Masri',
Renate Jerecic 2, Michael Jerosch-Herold
and Raymond Y Kwong'
'Brigham and Women's Hospital, Boston, MA, USA
2Siemens Medical Solutions, Chicago, IL, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):O 101
Introduction: Despite the advantage of increased signal-noise-
ratio, skepticism exists regarding the use of 3 T as the primary
scanner for routine clinical CMR examination due to potential
for gating difficulties related to the increased magnetohydrody-
namic effect, off-resonance artifacts, and patient heating. We
quantified the diagnostic potential and artifacts based on our
experience of the first 4 months of routine clinical 3 T CMR
exams in a tertiary clinical center.


Purpose: To test the hypothesis that 3 T MRI is practical in
serving a busy clinical CMR service as the primary routine
cardiac scanner.
Methods: Two-hundred and eighty patients were referred for
CMR for a broad range of clinical indications over a 4-month
period and underwent a 3 T cardiac MRI scan (MAGNETOM Tim
Trio, Siemens, Germany). Three experienced readers quantified
total scan time, troubleshooting time for 3 T-related off-
resonance artifacts, image quality, and artifacts in all pulse
sequences performed. Image quality was graded per accepted
criteria (I-Non diagnostic, 2-diagnosis suspected but not
established with severe blurring, 3-definite diagnosis despite
moderate blurring, 4-definite diagnosis with only mild blurring,
5-definite diagnosis without visible blurring). Artifacts severity
was graded in a 5-point scale (I-No artifacts, 2-minimal artifacts,
good diagnostic quality images, 3-moderate artifact and diagnosis
established, 4-considerable artifacts, diagnosis suspected but not
established, 5 severe artifacts, non diagnostic images). Excellent
image quality was classified as a score 4 and minimal or no
artifact was classified as an artifact score of 2. Forty-six 1.5 T
CMR studies performed at the same study period with a matched
spread of indications were randomly selected as a control group
for comparison.
Results: On average, 2.8 minutes (5% of total scan time) were
spent to eliminate off-resonance banding artifacts in 3 T This
time is made up by more aggressive accelerated parallel imaging
technique. As a result, average total scan time using 3 Twas not
different from 1.5 T (54 14 vs. 54 12 minutes, P = 0.47). No
patients failed to complete the study due to SAR limit. There
were no complications during any of the 1.5 T or 3 T CMR
studies. A significantly higher proportion of perfusion images
were graded as being of excellent quality on 3 Twhen compared
to 1.5 T (82.4% vs. 41.4%, p < 0.0001) (Figure I). A significantly
higher number of perfusion images also had minimal or no
artifact on 3 T when compared to 1.5 T (93.7% vs. 72.4%,
p = 0.0016). When LGE images were analyzed, a significantly
higher proportion of images on 3 T were graded as being
excellent (82.6% vs. 46.2%, p < 0.0001) and the proportion of
LGE images having minimal or no artifact was also significantly
higher on 3 T (83.0% vs. 56.4%, p = 0.0042). The number of Cine
SSFP, pulmonary vein MRA, and phase contrast images that were


Figure I (abstract 0 101)


Excellent Ime ity Achieved (Grade4 or5)

p1nasm
h.3 P. p=057
=07 H H In E.


Ftuwmu Psfasium WE


MPR fir


Excellent image quality achieved (grade 4 or 5).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


graded as being of excellent quality or with no or minimal artifact
did not differ between 3 Tand 1.5 T.
Conclusion: 3 T cardiac MRI performs well serving as the
primary scanner in a busy CMR service with comparable scan
times to 1.5 T cardiac MRI. 3 T has improved image quality and
fewer artifacts especially for applications like perfusion and LGE
which benefit from the increase in TI times at 3 T. The high SNR
leaves additional room to also decrease the overall scan time in
the future using higher acceleration factors for parallel imaging
techniques without sacrificing diagnostic image quality.

0102
Three-dimensional measurement of LV and
RV dimensions using prospective self-gating
for simultaneous compensation of cardiac
and respiratory motion
Robert Manka', Peter Boesiger2, Martin Buehrer2
and Sebastian Kozerke2
'German Heart Institute Berlin, Berlin, Germany
2Institute for Biomedical Engineering, Zurich, Switzerland

Journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):0 102
Purpose: To compare three-dimensional (3D) balanced steady-
state free precession (SSFP), prospective self-gating technique [I]
without ECG triggering and breath-holding for the assessment of
left ventricular (LV) and right ventricular (RV) function in the
heart in comparison to standard 2D, multiple breath-hold SSFP
cine imaging.
Methods: Data were acquired in 15 subjects (10 volunteers,
5 patients) using a 1.5 T system with a five element cardiac array
coil. In each subject a standard multi-slice, multi-breathhold 2D
cine SSFP sequence was performed with complete ventricular
coverage. Additionally, a three-dimensional cine sequence with
prospective self-gating [I] with complete ventricular coverage
was acquired during free breathing. LV and RV end-systolic
volume (ESV) and end-diastolic volume (EDV) and LV mass were
calculated for each method. With both imaging techniques, a
patient-based analysis of image quality was performed with
grading on a four-point scale, referring to the visibility of the
endocardial border (excellent (4), good (3), moderate (2) and
nondiagnostic (I)).
Results: Good agreement between LVEDV, LVESV, LV mass,
LVEF, RVEDV, RVESV, and RVEF calculated for the standard 2D
and the 3D prospective self-gating method (concordance


Figure I (abstract 0102)


End-diastolic (ED) frame of the left and right ventricle (mid-ventricular
slice in short-axis orientation); left: multi-breath-hold, standard SSFP,
right: free breathing prospective self-gating.


coefficients 0.99, 0.99, 0.99, 0.90, 0.95, 0.95 and 0.91,
respectively). The mean bias (95% confidence interval (CI) for
each parameter was; LVEDV: -0.3% (-5.2 to 4.6), LVESV: 0.3%
(-5.4 to 6.0), LV mass: -0.8% (-8.3 to 6.8), LVEF: -0.2% (-2.7 to
2.4), RVEDV: 4.5% (-9.6 to 18.6), RVESV: 3.8% (-1 1.2 to 18.7),
RVEF: 1.0% (-4.7 to 6.7). The overall image quality score for
prospective self-gating (2.7 0.8) was lower when compared to
standard SSFP (3.9 0.4; p < 0.01). Figure I shows representa-
tive images from one patient.
Discussion: Three-dimensional, free-breathing, prospective
self-gating MRI enabled accurate assessment of LV and RV
quantitative parameters when compared to standard multi-slice,
multi-breathhold SSFP cine imaging. Image quality with prospec-
tive self-gating was rated lower relative to the reference ECG
triggered, multiple breathhold scans due to lower image contrast
between blood and myocardium and residual motion artefacts.
Reference
I. Buehrer M, et al: Magn Reson Med 2008, 60(3):683-690.


0103
Randomized comparison of observation unit plus
stress cardiac MRI and hospital admission
Chadwick D Miller, Wenke Hwang, James W Hoekstra,
Cedric Lefebvre, Doug Case and W Gregory Hundley
Wake Forest University School of Medicine, Winston-Salem,
NC, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):O 103
Introduction: Adoption of an observation unit (OU) strategy
in patients with chest pain at intermediate-risk for ACS has been
hampered by limitations of traditional cardiac testing. As a result,
most intermediate risk patients are admitted to the hospital for
their evaluation. CMR demonstrates superior accuracy com-
pared to other testing modalities. Additionally, CMR is with
highly sensitive to recent or ongoing infarction which may allow
stress imaging to be performed without waiting for the results of
serial cardiac markers. These advantages of CMR make it well
suited for use in OUs. An OU-CMR strategy may be resource
saving compared to hospital admission.
Purpose: To compare resource consumption between an
observation unit stress cardiac MRI (OU-CMR) strategy and
hospital admission when used to evaluate emergency department
(ED) patients with chest pain at intermediate risk for acute
coronary syndrome (ACS).
Methods: Patients meeting intermediate risk criteria (TIMI risk
score 2 or clinical impression of intermediate risk) underwent
stratified blocked randomization to OU-CMR or hospital
admission. OU-CMR participants underwent cardiac markers at
0, 4, and 8 hours with adenosine or dobutamine CMR imaging
performed at the first available time after the return of the first
two cardiac marker results. CMR imaging included resting wall
motion, T2 weighted imaging, and perfusion, stress wall motion
and perfusion, and delayed enhancement. Hospital admission
participants underwent evaluations as determined by their
treating physician. Participants were contacted at 30 days to
determine events occurring after hospital discharge. Primary
outcomes included direct cost of the index hospitalization and
length of stay. Cost was calculated using cost:charge ratios and
physician work-RVUs. The results of the first 50 participants are
reported in this interim analysis.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Results: Participants had a mean age of 56 years, a median TIMI
risk score of 2 (Q I = 2, Q3 = 3), 25 (50%) were female, and 10
(20%) reported prior coronary disease. Participants were equally
randomized with 25 participants in each treatment group.
Protocol adherence was high among both groups (24/25 [96%]
OU-CMR, 23/25 [92%] standard care remained until hospital
discharge). Stress CMR imaging was obtained in 24/25 (96%) OU-
CMR participants during the index visit; 11/25 (44%) received
imaging the same day as presentation. In the OU-CMR group, 20/
25 (80%) of participants were discharged from the OU without
admission. Five participants were admitted from the OU and
underwent continued monitoring (n = I) or cardiac catheteriza-
tion (n = 4). Of the 4 undergoing cardiac catheterization, I was
diagnosed with a non-ischemic emergent cardiac condition and 3
were not found to have an emergent cause of chest pain. There
were no complications related to CMR testing. Among standard
care participants, all patients were admitted, 21/25 (84%) had
cardiac imaging with 14 undergoing stress echocardiography, 3
stress cardiac MRI, 3 cardiac catheterizations, and I resting echo
exam.
ACS criteria were met in 3/50 (6%) participants due to
revascularization (n = 2) and myocardial infarction (n = I), all
in the hospital admission arm during the index hospitalization.
Two participants had repeat hospitalizations for chest pain within
30 days, both in the hospital admission arm, and neither met ACS
criteria. The OU-CMR group had a trend towards same day
discharge more frequently than standard care participants (7/25
(28%) vs 3/25 (12%), p = 0.29). Cost of index hospitalization
demonstrated a near significant trend towards favoring OU-CMR
before adjustment (mean $2823 vs $4342, p = 0.12) and after
adjustment for covariates ($1537 difference, p = 0. 10). Length of
stay demonstrated a trend towards favoring OU-CMR before
(mean 27.5 h vs 31.4 h, p = 0.38) and after adjustment (5.5 h
difference, p = 0.24).
Conclusion: An OU-CMR approach among ED patients with
chest pain at intermediate risk for ACS is feasible. OU-CMR
decreases hospital admissions and has demonstrated a strong
near-significant trend towards decreasing index hospitalization
cost.


POSTER PRESENTATIONS

PI
Ventricular function and volume assessment
in children, adolescents and young adults
with thalassemia major without
myocardial iron overload
Juliano L Fernandes', Matheus Avelar'2,
Monica Verissimo3 and Otavio Coelho'
'University of Campinas (Unicamp), Campinas, Brazil
2Instituto Boldrini, Campinas, Brazil
3Centro Infantil Boldrini, Campinas, Brazil

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):P I
Introduction: Reference ranges for normal ventricular func-
tion and volumes in patients with thalassemia major without
myocardial iron overload have been established before in
European countries. However, these values might not be directly
applicable to patients in most other countries where they tend to
be younger and start chelation therapy later in life.


Purpose: To study children, adolescents and young adults with
thalassemia major with normal T2* values and compare the
results to matched normal volunteers as well as patients with
high ferritin levels, normal myocardial iron and chronic anemia
due to other etiologies.
Methods: We selected 25 patients (52% male) with thalassemia
major (TM) and normal myocardial iron concentrations (T2* >
20 msec) and compared them to 17 age- and gender-matched
normal (NL) volunteers (41% male) and 24 gender-matched (58%
male) patients with high ferritin levels from other etiologies
(NT). All patients underwent a cardiovascular magnetic reso-
nance (CMR) function study using a steady-state free precession
sequence. Normalized data to body surface area was compared
among the three groups.
Results: The mean age of TM patients was 18.8 2.3 years
(range 7-31) with no significant differences from NL volunteers
(16.2 2.8 years, range 5-34, P = NS), but younger than NT
patients (39.5 2.4 years, range 11-69, P < 0.001). T2* in
patients with TM were somewhat lower than NT patients
(27.5 4.3 versus 31.7 6.8, P = 0.06) but still within the
normal range. Body surface area was similar in the three study
groups (TM, 1.51 0.32 m2; NL, 1.45 0.37 m2; NT,
1.61 0.33 m2; P = NS). Left ventricular ejection fraction was
not different when comparing TM and NL patients [65.2 6.0%
(95% Cl 62.7-67.7), versus 65.4 5.6% (95% Cl 62.6-68.3),
P = NS], with both values non significantly lower than NT
patients [68.5 6.9% (95% Cl 65.6-71.4), P = 0.15]. Despite
that, normalized diastolic and systolic volumes were higher in
patients with TM compared to NL volunteers (78.5 15.8 x
27.4 8.3 ml/m2 versus 63.8 10.4 x 21.8 4.6 ml/m2,
P = 0.007 and P = 0.05 respectively) with no significant differ-
ences compared to NT patients (75.6 16.3 x 24.8 8.2 ml/
m2, P = NS). Normalized mass also showed similar character-
istics with higher values in TM patients compared to NL
(56.9 10.6 g/m2 versus 37.9 7.9 g/m2, P < 0.001) and no
differences compared to NT individuals (62.9 14.2 g/m2,
P = NS). Male and female comparisons showed similar results
although no differences were found in normalized volumes when
looking only in female patients.
Conclusion: Younger patients with TM do not present
different left ventricular function values compared to normal
controls despite having increase ventricular volumes and mass.
The parameters presented by these patients are similar to older
individuals with comparable degrees of chronic anemia. Pre-
viously published reference ranges for TM may not be applicable
to younger patients with different clinical settings.

P2
Phenotyping of tako tsubo
cardiomyopathy structural comparison
to acute myocardial infarction
Andreas Rolf, Guido Conradi, Johannes Rixe,
Holger Steiger, Holger Nef, Helge M6llmann,
Katharina Beiring, Christian Hamm and Thorsten Dill
Kerckhoff-Heart-Center, Bad Nauheim, Germany

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):P2
Objective: The tako tsubo cardiomyopathy (TTC) is charac-
terized by a transient contractile dysfunction after severe
physical or emotional stress. Relevant coronary artery disease
is absent. Clinically it mimics acute myocardial infarction (AMI).


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Therefore, the aim of this study was to characterize morpho-
logical differences between TTC and AMI using different MRI
parameters.
Methods: 22 TTC and 35 AMI patients were examined within
48 hours upon admission. Ejection fraction (EF), myocardial mass
(MM) enddiastolic (EDV) and endsystolic volumes (ESV) and
regional contractility scores were computed on 10 contiguous
CINE SSFP short axis slices. Myocardial edema (ME) was
computed on T2 weighted TSE images on short axis orientations,
late enhancement (LE) was evaluated on FLASH 3D GRE (both
defined as signal intensity of more than 2 standard deviations
from remote myocardium). Measurements are given as mean
SE. Differences were computed using an ANOVA model, a
p value =< 0.05 was considered significant.
Results: All AMI patients and none of the TTC patients
included had LE. TTC patients had a significantly lower EF
(TTC 43.8 2.4%; AMI 50.6 1.9%; p = 0.03) all other
comparisons were therefore controlled for EF TTC patients had
significantly smaller ventricular volumes (EDV TTC: 138 5.6
ml; AMI: 161 6.0 ml; p = 0.24; ESV-TTC: 72.9 4.5 ml; AMI:
86.6 3.8; p = 0.9) myocardial mass (TTC: 102.8 7.1 ml; AMI:
140 5.6; p = 0.0001) and edema (TTC: 19.5 4.2%; AMI:
27.2 2.6%; p = 0.13). In contrast regional contractility was
more affected in TTC with a significantly larger number of
dysfunctional segments (TTC: 7.5 0.6 segments; AMI: 4.3 0.5
segments; p = 0.0001) and a significantly higher wall motion
score (TTC: 1.9 0.1; AMI: 1.4 0.1; p = 0.0001).
Conclusion: In contrast to AMI, TTC patients show a marked
regional dysfunction but no signs of early remodeling like
ventricular enlargement and increased myocardial mass.


P3
4D flow of the whole heart and great vessels
using real time self respiratory gating
Sergio A Uribe Arancibia', Philipp Beerbaum ,
Allan Rasmusson2, Thomas Sangild Serensen2
Reza Razavi' and Tobias Schaeffter'
'King's College London, London, UK
2University of Aarhus, Aarhus, Denmark

Journal of Cardiovascular Magnetic Resonance 2009, I (Suppl I):P3

Objective: To evaluate the feasibility of a 4D-flow sequence of
the whole heart and great vessel to retrospectively quantify
blood flow within the entire heart.
Background: 4D-flow has been introduced as a means of
acquiring anatomical and three-directional velocity information
for all pixels within a 3D volume over different time points. The
acquisition time of such data sets is long and respiratory
compensation is thus required. However, navigator beams could
disturb the steady state and are time consuming, which can be


Figure I (abstract P3)


crsd Fha~mIM VS R PweflQwwy Aff! Ph~(mIfj vs V9
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circumvented by using a self-navigation approach. Here, we
present a new technique for the acquisition of 4D-flow data of an
isotropic saggital volume using a real time self gating technique.
The data can thereafter be reformatted in any clinical view
allowing the quantification of flow in different vessels with
arbitrary orientations. This is important in congenital heart (CH)
patients where scan planning can prolong the overall scan-time.
Methods: Self navigation: A 3D Phase Contrast (PC) retro-
spective cardiac trigger sequence was used to acquire 4D flow
data. The sequence was modified to enable the acquisition of an
extra ko profile at certain time intervals. These profiles were
used to derive the breathing motion and to respiratory gate the
acquisition in real-time. All the modifications were integrated


Table I (abstract P3) Stroke volume (mean and stdev) of the different acquisitions for all measured vessel

4D gated tlMean 2DMean [ml] 4D non gatedMean 4D gated t2Mean
[ml] sdv [ml] sdv [ml] [ml] sdv [ml] [ml] sdv [ml]

AO 85.86 18.54 85.65 17.54 81.78 21.03 85.62 17.37
PA 81.38 17.67 82.71 17.07 78.65 23.76 80.23 17.71
LPA 34.93 9.33 36.15 9.14 31.19 9.52 34.57 9.27
RPA 40.74 9.07 40.67 8.90 38.05 10.99 40.12 8.91


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1








Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 2 (abstract P3)


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into the software of a clinical MR-scanner (Philips Healthcare,
Best).
Experiments: 4D-flow data of the whole heart and great
vessels was obtained in 15 volunteers on a 3 T scanner
(resolution of 2.5 mm3 and 25 cardiac phases, acceptance
window = 8 [mm]). To study the reproducibility of the
technique, two 4D-flow data sets were acquired with self
respiratory gating. For comparison one 4D flow with two
averages were obtained without respiratory gating. Furthermore,
2D PC scans were obtained at the level of the AO, PA, LPA and
RPA. Statistical analysis and Bland-Altman plots were used to
compare the stroke volume (SV) derived from the 4D and 2D
flow acquisitions.
Furthermore a 4D-flow data set was obtained on a CH patient
with a repaired coarctation and a levo-atrial cardinal vein (LACV)
connecting the left atrium with the brachiocephalic vein.
Results: The self-respiratory gated acquisition resulted in an
overall scan time of 15 2.8 min. Figure I shows reformatted


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5 75 S II 135


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


slices of the 4D-flow data and an example of the flux in one
volunteer. Table I shows the SV comparison for the different
techniques. No statistically difference was found between the
different pairs of data. However, Bland-Altman plots showed a
larger standard deviation and bias for the pair "4D non-gated to
2D" (Figure 2). Therefore the 4D-flow gated scan showed to be
more accurate than the 4D-flow data obtained during free
breathing.
Figure 3 shows the data obtained in the congenital patient. This
data set was used to visualize the flow pattern in the region of
coarctation. Furthermore, it allows the accurate quantification of
the flux in the AO, PA, and in the LACV (Figure 3C, D). We
found the SV in the PA and AO was 127.91 [ml] and 90.68 [ml]
respectively. The SV difference (37.22 [ml]) between the PA and
AO was due to the connection caused by the LACV. Indeed the
SV measured by the 4D flow in the LACV was 38.06 [ml], which
matches the difference of the SV between the PA and AO.
Conclusion: We have demonstrated the feasibility of 4D-flow
on the whole heart using a self respiratory gating technique. The
method allows retrospectively flow quantification within the
entire heart and great vessel from data obtained in a single free
breathing scan. This method represents a practical advance for an
easier cardiac MR examination and showed to be very valuable in
congenital patients.



P4
Longitudinal versus cross-sectional studies of
effects of aging on ventricular structure and
function using cardiac magnetic resonance imaging
Dipti Gupta', Mark Goldman Sunil T Mathew2, Jing Han ,
William Schapiro', Michael Passick', Katherine McGrath',
Jie J Cao' and Nathaniel Reichek'
'St. Francis Hospital, Roslyn, NY, USA
2University of Oklahoma, Oklahoma city, OK, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):P4
Introduction: Cross-sectional studies of effects of aging on
ventricular structure and function, including Framingham, MESA,
the Dallas Heart Study and studies from our own laboratory have
uniformly demonstrated lower ventricular chamber volumes in
older normal subjects.
Purpose: We sought to assess aging effects on ventricular size
and function prospectively in a carefully screened normal cohort.
Methods: Normotensive, non-diabetic, non-obese (BMI < 28)
volunteers (n = 57, 3 I females), aged 20-89 at intake (59 13
yrs), were screened, including 2D echocardiography and CMR
performed (1.5 T Siemens Sonata or Avanto) at baseline and
5 years. TrueFISP cine imaging was used to obtain contiguous
8 mm short axis slices of both left (LV) and right (RV) ventricles.
LV and RV volumes at end-diastole and end-systole were
determined (Medis, MASS) and indexed (i) to body surface
area. Ejection fraction (EF) was also calculated.
Results: Systolic blood pressure increased (120 12 to
130 20 mm Hg, p < .0001), LV and RV end diastolic volumes
increased (113 30 to 136 37, 114 31 to 134 37 ml,
p < .0001 for both), as did end systolic volumes (45 17 to
59 23, 55 21 to 60 22 ml, p< .0001 and p= .01
respectively). LVEF decreased (61 7 to 58 7%, p < .004),
while RVEF increased slightly (53 6 to 56 + 7%, p = .01).


There were no major gender differences. Subjects with intake age
<50 years and those >50 years behaved similarly.
Conclusion: In contrast to cross-sectional studies, which
demonstrate reduced LV and RV volumes in older subjects, this
prospective study demonstrates that chamber volumes increase
with age. This discordance may be due to generational
differences which affect cross-sectional, but not longitudinal
studies.

P5
Coronary MRI with induced vasodilation
using isosorbide dinitrate
Peng Hu, Christian Stoeck, Dana C Peters,
Kraig V Kissinger, Beth Goddu, Lois Goepfert,
Warren J Manning and Reza Nezafat
Beth Israel Deaconess Medical Center, Boston, MA, USA

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):P5
Introduction: Despite technical progress, coronary magnetic
resonance imaging (MRI) still faces multiple challenges. Coronary
vasodilators, such as sublingual nitroglycerin (NTG) or longer
acting nitrates (e.g., isosorbide dinitrate), are commonly used to
study coronary circulation. Terashima et al. [I] reported use of
coronary MRI to evaluate the effect of sublingual NTG.
Isosorbide dinitrate (Isordil) has been previously reported in a
multi-center clinical coronary MRI trial [2], however no data has
been provided to quantify coronary MRI image quality improve-
ment and time course of Isordil.
Purpose: To investigate the impact of Isordil administration on
SNR, vessel diameter and overall image quality in coronary MRI.
Materials and methods: Coronary images were acquired on
a cohort of healthy adult subjects before and after Isordil
administration. Subjects were divided into four groups to
investigate the impact of the imaging sequence and dose. In
groups A and B the images were acquired using SSFP imaging
sequence with either 2.5 mg or 5 mg Isordil dose. In groups C
and D images are acquired using GRE with either 2.5 mg or 5 mg
Isordil dose. The impact of vasodilator during a time course was
studied by repeated imaging. A free breathing, 3D VCG gated
GRE sequence with typical imaging parameters of TR = 7.7 ms,
TE = 2.2 ms, FOV = 270 x 270 x 30 mm3, flip angle = 30,



Figure I (abstract P5)


2.Smg Isordii 5rw IlordiI.


Examples of pre- and post-lsordil images from four different subjects
using combinations of two different sequences (GRE and SSFP) and
two different Isordil doses (2.5 mg and 5 mg) at 10-15 minutes after
Isordil.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 2 (abstract P5)


m2.Smg+GRE 2.5mg+SSFP 1Smg+GRE rSmg+SSFP


30

20


10


2 3 4 5
SCAN INDEX POST-ISORDI.


The time course of SNR increase after Isordil administration using
the GRE and SSFP sequences. The first 5 post-lsordil scans were used
to calculate the time course. The post-lsorfil times for the five scans
were 1.3 0.7, 10.4 4.2, 17.7 6.7, 26.2 7.3 and 32.3 +
8.3 minutes.




spatial resolution of 0.7 x I x 1.5 mm3 reconstructed to
0.52 x 0.52 x 0.75 mm3 was used. The imaging parameters for
SSFP imaging included: TR = 4.6 ms, TE = 2.3 ms, FOV = 270 x
270 x 30 mm3, flip angle = 90, spatial resolution of
I x I x 1.5 mm3 reconstructed to 0.52 x 0.52 x 0.75 mm3
and a half a preparation pulse. T2 prep, fat saturation and
navigator sequences were used in both sequences. In order to
obtain a more accurate SNR measurement, no parallel imaging
was used. SNR was measured with a previously published
method [3]. To be consistent, the same noise and signal ROl's
were used in all the GRE and balanced-SSFP scans during a study,
unless motion is detected between the scans. The coronary
cross-sectional diameter in the proximal right coronary artery
was measured using the Soap Bubble tool (Philips Healthcare,
Best, NL).
Results: Figure I demonstrates the improved coronary image
quality 10-15 minutes after Isordil administration. The vasodila-
tion and signal enhancement help better delineate and
differentiate the right coronary artery (arrows). The visibility
of distal branches of the coronaries was improved (arrow heads).
Figure 2 shows the SNR enhancement during the time course of
5 post-lsordil scans. The maximum SNR increase was
21.5% 9.3% for GRE with 2.5 mg dose, 22.5% 12.3% for
GRE with 5 mg, 19.7% 3.1% for SSFP with 2.5 mg and
19.1% 6.0% for SSFP with 5 mg. The maximum SNR
enhancement is earlier using 5 mg dose than 2.5 mg. There
were greater than 15% increase in vessel lumen diameter
throughout the 5 post-lsordil scans, with a greater than 20%
increase in all but the first time point.
Conclusion: Pre-scan Isordil administration improves coron-
ary SNR by 20% for both GRE and SSFP imaging. 5 mg and
2.5 mg doses result in comparable vasodilation. For best SNR
enhancement, imaging should be performed later post-lsordil if
using 2.5 mg dose than 5 mg.
References
I. Terashima et al: JACC 2005, 45(1):104-1 10.
2. Kim et al: N Engl Med 2001, 345(26):1863-1869.
3. Botnar, et al: Circulation 1999, 99:3 139-3 148.


P6
Endocardial to epicardial perfusion ratios at rest
and stress determined by perfusion-CMR
Abdulghani M Larghat', Aleksandra Radjenovic',
Neil Maredia', John P Greenwood', Sebastian Kozerke2
and Sven Plein
'University of Leeds, Leeds, UK
2ETH and University of Zurich, Zurich, Switzerland

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):P6
Introduction: Animal experiments using labelled microspheres
have shown that at rest, blood flow to the subendocardial layer is
higher than to the subepicardium. With increasing levels of stress
this transmural gradient of myocardial blood flow is reduced, so
that the endocardium has a lower perfusion reserve than the
epicardium [I]. The causes for this observation include higher
compressive forces and higher resting metabolic activity in the
endocardium. If microvascular function is impaired, endocardial
perfusion reserve is reduced further [2].
Myocardial perfusion-CMR is usually performed with coverage of
several myocardial sections to allow detection of ischemic
perfusion defects. Consequently, compromises regarding image
quality and motion artefact are made. For the study of global
physiological phenomena and diffuse myocardial disease, opti-
mised acquisition of a single section may be more useful.
Purpose: I. To develop a first pass myocardial perfusion
method optimised for acquisition of a single midventricular
myocardial section at systole and diastole.
2. To compare rest and stress myocardial perfusion between the
endocardium and epicardium.
3. To compare rest and stress myocardial perfusion at mid-
diastole and mid-systole.
Methods: 10 volunteers (7 male, mean age 38 years) were
studied on a 1.5 T Philips Intera system during adenosine stress
(140 mcg/kg/min for 3 minutes) and at rest. For each perfusion
acquisition 0.05 mmol/kg Gd-DTPA was administered with a
power injector followed by a 20 ml Saline flush (5 ml/sec).
A saturation recovery segmented gradient echo perfusion
method with twofold SENSE was optimised for imaging of a
single cardiac section by timing the acquisition to a phase with
minimal cardiac motion and by optimising the preparation pulse
delay. Pulse sequence parameters were as follows: TR/TE/flip
2.7 ms/1.0/15", FOV 380 x 380 mm, matrix 160 x 160, slice
thickness 10 mm, preparation pulse delay (to middle of k-space)


Figure I (abstract P6)

-s
'r

T T





1 2 3 4 5 6
MyecardaIl senmrnt

Endocardial to epicardial ratio of maximal SI upslope in systole at rest and
adenosine stress.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


150 ms, shot duration 130 ms. With the use of a software patch
trigger delay for the acquisition of one midventricular slice could
be individually to mid-systole, as determined on a high temporal
resolution cine scout. A mid-diastolic phase in the same plane
(adjusted for through-plane cardiac motion) was acquired if heart
rate permitted.
Endo and epicardial contours were drawn (MASS, Medis, Leiden,
The Netherlands) and the slice segmented into 6 equidistant
sectors. These were further subdivided into a subepicardial, mid-
myocardial and subendocardial third. The maximal myocardial
upslope of the signal-intensity time profiles for each sector and
the three layers was calculated. Then the ratio of upslopes
between the endocardial and epicardial layers ("endo-epi ratio")
was computed.
Results: In systole, the mean (+/- SD) of the endo-epi ratio of
all segments was 1.13 (+/- 0.1) at rest and 0.94 (+/- 0.1) at
stress. In all segments the endo-epi ratio was higher at rest than
stress, albeit with regional differences (Fig I). In diastole, the
mean endo-epi ratio of all segments was similar to systole at rest
(1.13 +/- 0.2, p > 0.05 versus systole), but at stress it was
significantly higher than at systole (1.08 +/- 0.1, p = 0.005). The
mean upslope for all three layers combined however was similar
between systole and diastole at rest and stress (17.9 vs 17.2 at
stress and 8.0 vs 7.9 at rest, p > 0.05).
Conclusion: I. Differences in endocardial and epicardial
perfusion can be detected with CMR in vivo.
2. Perfusion to the endocardial layer is higher at rest, with a
diminishing endo-epi ratio at stress, consistent with known
physiology.
3. Perfusion to whole myocardial segments is similar in systole
and diastole. In diastole differences between layers of the
myocardium are less than in systole, probably because of partial
volume effects.
References
I. Ball RM, et al: j Clin Invest 1975, 55:43-49.
2. Panting JR, et al: N EnglI Med 2002, 346:1948-1953.


P7
Correlation between T2-weighted CMR and
Sestamibi-SPECT in acute myocardial infarction
and acute coronary occlusion
Martin Hadamitzky, Nadine Kirchhartz, Eva Hendrich,
Stefan Martinoff and Albert Schomig
Deutsches Herzzentrum Munchen, Munich, Germany

journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):P7
Background: Being a consistent finding in acute myocardial
infarction, T2 weighted MRI imaging has recently been proposed
as a marker for the area not perfused because of the underlying
coronary occlusion. But data comparing T2 imaging with the gold
standard for perfusion, acute Sestamibi SPECT, is very limited. In
particular the interval between interruption of perfusion and
onset of the cell edema in humans is unknown.
Methods: We therefore performed in 38 patients with acute
myocardial infarction (interval between start of symptoms and
intervention below 24 h) and 10 patients with acute coronary
occlusion as a complication during percutaneous coronary
intervention both a myocardial single photon emission computed
tomography (SPECT) and a cardiac MRI with fat suppressed
T2-weighted turbo spin echo sequences. For SPECT


Figure I (abstract P7)

80- Acute Myocardial Infarction

60-




0

0 20 40 60 80
Size of MIBI-Defect in %


80- Acute Coronary Occlusion


0 20 40 60 80
Size of MIBI-Defect in %


99mTc-Sestamibi applied before coronary revascularization, the
measurement was done immediately after the intervention; the
MRI was done 2 to 6 days after intervention. The area of
increased T2 signal was quantified automatically using a cutoff of
mean plus 2 standard deviations of the signal intensity in a remote
myocardial region. In SPECT the area of risk was defined as area
of intensity below 50% of maximum. Both values were expressed
as fraction of left ventricular myocardial volume.
Results: In clinical AMI the defect size of T2 weighted MRI
ranged between 0% and 66% (18% mean), the defect size of
SPECT between 0% and 65% (28% mean). There was a highly
significant correlation between the two measurements with a
correlation coefficient of 0.65 as depicted by the left image in
Figure I.
In acute coronary occlusion the defect size of T2 weighted MRI
(9%) was only one fourth of the defect size of SPECT (36%).
There was no significant correlation between the two measure-
ments (r = 0.14, p = 0.3 1, see also right image below).
Conclusion: T2-weighted CMR shows a good correlation to
acute Sestamibi SPECT in depicting perfusion defects in clinical
acute myocardial infarction, but it clearly underestimates short-
lived perfusion defects as seen in acute coronary occlusions
during PCI.



P8
Diagnostic accuracy of half-contrast dose
bSSFP vs full-contrast dose hEPI MR perfusion
imaging in patients with known or suspected
coronary artery disease
Chiara Bucciarelli-Ducci, Peter Gatehouse,
Rory O'Hanlon, Jonathan Lyne, Agata Grasso,
Joanna Petryka, Ricardo Wage, Winston Banya,
Sanjay Prasad, David Firmin and Dudley Pennell
CMR Unit, Royal Brompton Hospital, London, UK

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):P8
Background: Non-invasive evaluation of myocardial perfusion
with cardiovascular magnetic resonance (CMR) is clinically
valuable in patients with known or suspected coronary artery
disease CAD) but dark rim artifacts mimicking perfusion defects
remain a diagnostic challenge. The perfusion protocol (pulse
sequence and dose of contrast) giving highest diagnostic


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


confidence is not yet standardised. Hybrid EPI (hEPI) is a
fast sequence reducing motion artifact by its short imaging
time, but with low SNR. Balanced SSFP (bSSFP) has greater SNR
but previously has been reported as more prone to dark
subendocardial rim artifacts: field distortion by the high-dose
bolus is one suspected reason, and this distortion could
potentially be reduced by using a half contrast dose, making
use of bSSFP's abundant SNR. We therefore compared these
2 sequences.
Methods: Seventeen patients were scanned at 1.5 T (Siemens,
Avanto) with both protocols. All patients underwent coronary
angiography (CA) and significant CAD (>50% stenosis) was
detected in 6/17 patients (35%).
The dose of gadolinium contrast agent was 0. I mmol/kg for the hEPI
sequence and 0.05 mmol/kg for bSSFP with 15 ml flush at 7 ml/s.
Centre-out hEPI (TR 5.8 ms, 30, ETL 4, 1860 Hz/pixel) acquired
2.8 x 2.8 x 8 mm voxels over typically 360 x 270 mm FOV
(adapted per patient) at TI = 110-160 ms for each of 3 fat-
suppressed slices per cycle, using TSENSE (R2), typical image
time 75 ms (i.e. excluding prepulses). Linear-ordered bSSFP (TR
2.6 ms, 70, 930 Hz/pixel) acquired the same voxel size at the
same TI for central of k-space for each of 3 fat-suppressed slices
per cycle, using TSENSE (R2), typical image time 125 ms. The
slice acquisition order was the same in hEPI and bSSFP, resulting
in approximately similar image timings through the cardiac cycle
in both. Slice positions in the heart were reproduced by viewing
the first study while piloting the second.
The randomised scans were scored by 2 blinded experienced
observers based on the 16-segment model. Perfusion scan
myocardial SNR and diagnostic confidence were assessed
subjectively (score from 0 = unusable to 4 = excellent). Severity
of perfusion defects was graded based on its transmurality
(0 = none, I = <25% 2 = 25-50%, 3 = 51-75%, 4 = >76%, and
A = dark rim artefact). A total of 272 segments were analyzed.
Sensitivity and specificity of both sequences were calculated and
comparison of agreement between observers and scan methods
was assessed by kappa coefficients.
Results: The agreement between bSSFP and hEPI scans on the
presence of normal perfusion, artefacts or genuine perfusion
defects was 65% (k = 0.25, 95% CI: 0.17-0.33, p < 0.0001) for
observer I and 53% (k = 0.15, 95% Cl: 0.09-0.21, p < 0.0001)
for observer 2.
The agreement between observer I and 2 on the presence of
normal perfusion, artefacts or genuine perfusion defects was 83%
(k = 0.51, 95% Cl: 0.41-0.61, p < 0.0001) for hEPI scans and 53%
(k = 0.15, 95% Cl: 0.10-0.26, p < 0.0001) for the bSSFP scans.
True artefacts (compared against CA) occurred more frequently
with bSSFP (59 segments, 22%) than with hEPI (14 segments, 5%)
(X2, p <0.001).
Using CA as gold-standard, sensitivity and specificity of bSSFP
scans was 17% and 88% (observer I), 25% and 72% (observer 2).
Conversely, sensitivity and specificity of hEPI scans was 42% and
87% (observer I), 33% and 84% (observer 2).
Observer I noted a significant lower diagnostic confidence for
bSSFP vs hEPI scans (p < 0.03). Both observers reported a
similar diagnostic confidence for hEPI scans. The SNR of the
bSSFP and hEPI were similar for both observers.
Conclusion: Overall, bSSFP demonstrated lower diagnostic
accuracy compared to hEPI. Dark-rim artifacts occurred more
frequently in the bSSFP than hEPI, even when the half-contrast
dose was used. Although two experienced observers were


usually able to correctly identify dark-rim artefacts, using bSSFP
in clinical practise in less experienced centers may not be ideal
because of reduced diagnostic confidence.



P9
A 3D evaluation of dyssynchrony may offer an
advantage over a 2D approach; a cardiovascular
MRI method for dyssynchrony quantification
Robert WW Biederman', Frank Grothues2,
Helmut Klein2, Ronald B Williams', June A Yamrozik',
Geetha Rayarao', Diane A Vido', Christof Huth2
and Mark Doyle
'Allegheny General Hospital, The Gerald McGinnis
Cardiovascular Institute, Pittsburgh, PA, USA
2University Hospital Magdeburg, Magdeburg, Germany

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):P9
Introduction: Detection of dyssynchrony is primarily per-
formed by EKG and/or tissue Doppler echocardiography,
sampling the heart in selected basal segments. Limited
approaches for dyssynchrony have been performed by cardio-
vascular MRI (CMR).
Hypothesis: We hypothesize that 3D global assessment of
dyssynchrony may be more sensitive than conventional regional 2D
analysis.
Methods: At baseline, 8 patients (47 9 yrs) with mean
NYHA Class 2.3 0.5 on optimal medical therapy (maintained
throughout the study) underwent 3D CMR (1.5 T GE) to assess
LV function. Using Medis Mass software (Leiden, The Nether-
lands), endo and epicardial boundaries were outlined in multiple
contiguous short-axis slices. For each slice the myocardium was
circumferentially divided into 16 equally spaced segments. End-
systolic (ES) time was automatically identified as time of maximal
wall thickening and the dyssynchrony index taken as the
dispersion of ES times. Patients underwent HeartNetTM
(Paracor Medical Inc, Sunnyvale, CA) placement. A follow-up
CMR was performed at 6 months. In total >800 data points were
generated for each heart (as compared to 6 by standard
echocardiography). The dispersion of the ES time was analyzed
for pre to post treatment effect for the basal region separately
using all measured points and for 4, 6, or 8 equally spaced
circumferential regions, each set starting at several offset values,
resulting in I I regional data sets.
Results: All patients survived HeartNetTM placement and were
available for 6 month follow-up. When using all segments to
describe the dispersion of ES time pre to post, a statistically
significant change in the dyssynchrony index was observed (254
vs. 220 ms, p < 0.001). When assessed using the separate 2D
analysis, a pre-post change in dyssynchrony was only detected in
3 out of II data series (36%).
Conclusion: By its nature, dyssynchrony is a heterogeneous
phenomenon. When assessed using a 3D CMR approach, a pre
to post treatment effect was detectable. However, when
restricting measurements to 4, 6, or 8 equally spaced regions
(analagous to a 2D echocardiographic approach), the chance of
detecting the change in dyssynchrony substantially dropped,
indicating that the phenomenon of Dyssynchrony should be
assessed using a global 3D as opposed to regional 2D approach,
irrespective of assessment modality.


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PIO
Quantitative evaluation of normal myocardial
stress perfusion using Fermi and MMID4
Yi Wang, Paphael Hazel, Bin Luo, Jing Han
and Nathaniel Reichek
St. Francis Hospital, Roslyn, NY, USA

journal of Cardiovascular Magnetic Resonance 2009, 1I (Suppl I):P 10
Background: MR first pass perfusion quantification has been
demonstrated to be a powerful technique for diagnosing
cardiac perfusion deficits, since its introduction in the early
1990s. Model based MR perfusion quantification is feasible and
may provide a sensitive absolute perfusion evaluation tool
alternative to PET. However, MR perfusion quantification results
vary depending on the model used, imaging sequences, and
contrast dosage etc.
Purpose: We compared MMID4 and Fermi model-based
quantitative methods for myocardial stress perfusion imaging
on 16 normal volunteers. The goals of our study were to define
normal quantification results and the relationship between Fermi
and MMID4 methods, as well as the impact of age on normal
myocardial perfusion.
Methods: To ensure normality of the volunteers (n = 16, ages:
43.9 15.8 years, 5 males) exclusions included: hypertension,
diabetes, smoking, family or personal history of cardiac disease
and total coronary calcium score < 20 by either EBCTor MDCT
Contrast first pass perfusion studies under adenosine stress and at
rest were performed on a 1.5 T scanner. After 3 minutes of
adenosine infusion, long axis perfusion imaging was obtained with
Gadodiamide injection at a dose of 0.05 mmol/kg bodyweight. A
saturation recovery SSFP sequence was used with 160 ms per slice.
TR/TE/TI = 2.9 ms/1.3 ms/90 ms and voxel size 1.9 x 2.8 x 8 mm3.
Using MASS (Medis, Leiden, the Netherlands) software, the
myocardial contours were drawn, divided into 6 equal segments,
and then propagated through all time point. Mean signal
intensities in each myocardial segment at every time point
were saved in text files. A custom developed program read the
data file and calculated absolute perfusion based on both the
Fermi deconvolution algorithm and the MMID4 algorithm.
A total 288 segmental perfusion values were evaluated for
differences between subjects and algorithms using mixed effect
ANOVA. The coefficient of variation (CV) of each algorithm was
calculated as SD/mean x 100%.
Results: The mean heart rates at rest and under stress were
61.9 5.9 and 86.8 16.4 beats per minute, respectively
(p < 0.0001). The effect of adenosine infusion was a
40.3 22.5% increase in mean heart rate and no significant
decrease in both systolic and diastolic blood pressure. The mean
and SD of perfusion reserve for Fermi was 2.61 1.02, and for
MMID4 was 2.77 2.08. There were significant differences
between Fermi and MMID4 adjusted by slice and segment
(F = 28.00, p < 0.0001). However, MMID4 perfusion reserve
showed a much greater variations (CV of 1 19.25) than Fermi
(CV = 38.87) (p < 0.0001).
There was a gradual decline with age of MPR quantified by the
Fermi model with a linear regression, MPR = 3.6433 -
0.022 x age, and a coefficient of determination of 0.4258
(p = 0.006). The MMID4 results did not demonstrate a significant
age effect.
Conclusion: Both MMID4 and Fermi algorithms can be used
for perfusion quantification and their perfusion reserve results in


normals are very similar to that published in PET literature.
However, MMID4 results are more variable, obscuring the effect
of age, and seem to be more susceptible to artifacts.

PII
Comparison of visual scoring and planimetry
methods for estimation of global infarct size on
delayed contrast enhanced MRI and confrontation
with biochemical markers of infarction
Nathan Mewton', Pierre Croisille'2, Michel Ovize'
and Didier Revel'
'Hopital Cardiovasculaire Louis Pradel, Lyon, France
2H6pital Cardiovasculaire Louis Pradel, Lyon, France

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):PI I
Introduction: Infarct size assessment by delayed enhanced
CMR is of critical importance for the patient's prognosis after an
acute myocardial infarction (AMI) and to assess the efficiency of
new reperfusion therapies. However infarct size quantification by
planimetry is time-consuming and difficult to do on a daily clinical
practice.
Purpose: By summing all the segmental scores using a 17-
segment model, a global index of the size of the infarcted
myocardium is easily obtained and we compared it to infarct size
obtained by visual planimetry.
Materials and methods: 101 patients admitted with reper-
fused AMI to our intensive care unit were prospectively scanned
using an ECG-gated gradient echo sequence after injection of
gadolinium contrast agent. The global score was defined as the
sum of the scores on each segment, and expressed as a
percentage of the maximum possible score. This index was
compared with a planimetric evaluation of hyperenhancement,
expressed as a percentage of the left ventricle myocardial
volume. The area under the curve (AUC) and peak values of
serum troponin I (Tnl) and creatine kinase (CK) release were
measured in each patient.
Results: There was an excellent correlation between visual
planimetry and visual global scoring for the hyperenhancement
extent's measurement (r = 0.91; y = 1.07x+2.3; SEE = 1.2;
P < 0.001) The Bland-Altman plot shows a good concordance
between the two approaches (mean of the differences = -3.9%
with a standard deviation of 6.6). The mean percentage of
hyperenhanced myocardium determined by the visual planimetry
method was 21.2 14.1% (median of 18.7%).
Mean post-processing time for visual planimetry was significantly
longer than visual scoring post-processing time (23.7 5.7
minutes VS 5.0 I.I minutes respectively, P < 0.001).
Correlation between CK AUC and visual planimetry was
r = 0.73 (P < 0.001) and r = 0.77 (P < 0.001) with visual global
scoring. Correlation between peak CK and visual planimetry was
r = 0.72 (P < 0.001) and r = 0.77 (P < 0.001) with visual global
scoring. Correlation between troponin I AUC and visual
planimetry was r = 0.72 (P < 0.001) and between peak troponin
I and visual planimetry was r = 0.56 (P < 0.001). Correlation
between troponin I AUC and visual global scoring was r = 0.73
(P < 0.001) and between peak troponin I and visual global
scoring was r = 0.59 (P < 0.001).
Conclusion: A visual approach based on a 17-segment model
can be used to evaluate the global myocardial extent of the
hyperenhancement with similar results to planimetry and with
shorter post-processing times.


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P12
Increased susceptibility of the left lateral
free wall to myocardial delayed enhancement in
Duchenne Muscular Dystrophy: progressive
systolic dysfunction demonstrable by
CMR regional strain analysis
Narayan Kissoon', Kan N Hor2, Janaka P Wansapura2,
Wojciech Mazur3, Robert J Fleck Micheal D Puchalski4,
D Woodrow Benson2 and William M Gottliebson2
'University of Minnesota, Minneapolis, MN, USA
2Cincinnati Childrens Hospital Medical Center, Cincinnati,
OH, USA
3Christ Hospital Medical Center, Cincinnati, OH, USA
4Primary Childrens Hospital, Salt Lake City, UT, USA

Journal of Cardiovascular Magnetic Resonance 2009, 1I (Suppl I ):P 12
Background: Cardiac magnetic resonance imaging (CMR) has
demonstrated reductions in peak LV myocardial circumferential
strain (Ecc) despite normal ejection fraction (EF) in Duchenne
Muscular Dystrophy (DMD) patients. We hypothesized that the
increased initial contractility of the lateral LV free wall makes that
region more susceptible to myocardial injury with subsequent
fibrosis than the septum in DMD patients.
Methods: We analyzed regional Ecc from myocardial tagged
CMR images on the mid-papillary level LV slice (using HARPTM
software) from 14 DMD males with global cardiac dysfunction
(LV EF < 55%) and myocardial delayed enhancement (MDE, a
marker of myocardial fibrosis), as well as from 13 age-matched
control males with normal cardiac function. Regions were
assigned based on standard coronary perfusion regions. Regional
AEcc was computed as the difference between normal and DMD
subject Ecc per region.


Figure I (abstract PI2)


* MDE Positive
Regional distribution of MDE and corresponding AEcc.


Results: In controls, the lateral free wall regions had a greater
baseline Ecc than the septal regions. In DMD patients, AEcc was
consistently greater in magnitude in the lateral free wall regions
when compared to the AEcc of the septal regions (Figure I). MDE
was consistently detected in these same lateral free wall regions.
Conclusion: Changes in Ecc show that the regions with
greatest contractility in control subjects (the lateral free wall)
are the most susceptible to injury in DMD patients, as
exemplified both by the greatest reduction in regional Ecc and
the development of MDE in those regions.



P13
Pulse wave velocity in the aortic arch is the
strongest predictor of left ventricular
concentric remodeling in subjects with
different levels of cardiovascular risk
Alban Redheuil', Wen Chung Yu', Raymond T Yan',
Elie Mousseaux2, Alain De Cesare2, David A Bluemke3
and Joao AC Lima'
johns Hopkins University, Baltimore, MD, USA
INSERM U678, Paris, France
3NIH, Bethesda, MD, USA

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):P 13
Introduction: Increased systolic blood pressure (SBP), pulse
pressure (PP) and left ventricular (LV) concentric remodeling are
associated with aging and increased cardiovascular risk. The
aortic arch accounts for most of the vascular buffering function
and is primarily involved in arterial stiffening and complications.
Mechanisms of heart failure during aging and the role of aortic-
ventricular stiffening and interaction need clarification. In
particular, the importance of the aortic arch on central arterial
stiffness remains unclear.
Purpose: In this study, we evaluated the contribution of aortic
arch stiffness to LV concentric remodeling
Methods: We studied 52 subjects: 28 men; mean age: 41 yrs
[20-79], 40 without and 12 with risk factors (hypertension in all
and diabetes in 6) and normal LV ejection fraction. Global aortic
stiffness was determined from carotid-femoral pulse wave
velocity (cfPWV) using tonometry and transit surface distances.
Aortic stiffness in the aortic arch was determined by MRI from as
regional pulse wave velocity (PWV): ratio of aortic length to
flow transit time. Augmentation index was calculated from
tonometry as the ratio of the pressure above the inflection point
and PP. SBP, MBP and PP were averages of 6 brachial
measurements. End diastolic LV mass was measured on cine
MRI. LV mass to volume ratio (M/V) was calculated as end
diastolic volume over mass. Correlations are given and multi-
variate regression was used to study the determinants of
concentric LV remodeling (M/V)
Results: MN ratio increased with age: r = 0.35 (p = 0.01);
mean MN in subjects <50 years is 0.97 vs. 1.18 in subjects >=
50 years (p = 0.006). Aortic arch PWV increased with age:
r = 0.77 (p < 0.001), SBP: r = 0.62 (p < 0.001), PP: r = 0.69
(p < 0.001) and was well correlated with cfPWV: r = 0.83
(p < 0.001). However, PWV in the aortic arch was a stronger
determinant of M/V ratio than global cfPWV in subjects >50
years. Moreover, in multivariate analysis using age, BMI, SBP PP,
augmentation index and cfPWV, PWV in the aortic arch was the


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


strongest independent determinant of M/V ratio (R = 0.43;
p < 0.001)
Conclusion: Stiffness of the aortic arch directly measured by
MRI as regional PWV was a stronger predictor of LV concentric
remodeling than global cfPWV, age or blood pressure in a
population sample with varied cardiovascular risk factors.



P14
Circumferential and radial myocardial strain
in cardiomyopathy patients with and without
left bundle branch block
Yuchi Han', Jonathan Chan', Idith Haber2, Dana C Peters',
Peter J Zimetbaum', Warren J Manning'
and Susan B Yeon'
'BIDMC, Boston, MA, USA
2University of Chicago, Chicago, IL, USA

Journal of Cardiovascular Magnetic Resonance 2009, II (Suppl I):P 14
Introduction: Electrical dyssynchrony associated with pro-
longed QRS duration is a commonly used criterion to select
symptomatic heart failure patients for cardiac resynchronization
therapy (CRT). However, there is concern that electrical
dyssynchrony criterion is inadequate as 30-40% of patients do
not respond to CRT [I]. Studies have shown that assessment of
mechanical dyssynchrony may be a better predictor of response
[2]. Most of the studies have assessed mechanical dyssynchrony
in the longitudinal axis of myocardial motion [3]. There is limited
data on the assessment of short axis mechanical dyssynchrony in
humans. We sought to examine the relationship between
electrical and mechanical dyssynchrony in mid-ventricular short
axis using CMR tagging in patients with depressed left ventricular
function.
Methods: 22 patients with NYHA class II to III heart failure
were studied, including 12 patients with dilated cardiomyopathy
(DCM) (age 60 9 years, 83% male, ejection fraction (EF)
28 9%) and 10 patients with ischemic cardiomyopathy (ICM)
(age 63 8 years, 80% male, EF 30 5%). Ten healthy adult
subjects (age 37 12 years, 50% male, EF 60 4%) served as
controls. CMR studies were performed on a 1.5 T Philips
Achieva MR scanner (Philips HealthCare, Best, NL), equipped
with a 5-element cardiac coil. Breath-hold ECG-gated tagged
CSPAMM cine images at the mid-papillary muscle level were
obtained. Scan parameters include spiral readout with
8 interleaves, 9 ms acquisition window, TR/TE/flip angle =
25 ms/3.6 ms/250, FOV = 320 mm, 10 mm slice thickness with
5 mm tag spacing, temporal resolution 25-35 ms, spatial
resolution 2.5 x 2.5 x 10 mm. A customized software program
(Cardiotool), written in MATLAB (MathWorks, Natick, MA), was
used for semi-automated analysis of peak circumferential (Ec) and
peak radial strain (Er) [4].
Results: Thirteen patients with DCM (n = 8) and ICM (n = 5)
had a left bundle branch block (LBBB) with a mean QRS duration
of 161 15 ms. The remaining nine patients had either normal
QRS duration, non-specific interventricular conduction delay, or
right bundle branch block with a mean QRS duration of 108
18 ms. The control subjects had a mean QRS duration of 94
II ms. All patients with LBBB showed an initial negative Ec in the
anteroseptal segment, quickly followed by positive Ec reflecting
dyskinesis of the septum (as shown in Figure I). In patients with


Figure I (abstract P14)


C(oINw.I.W~vh9U$


9U
I S # # # #









101
t'
























and E r (p < 0.002).
0'




















contractile pattern with marked dyskinesis of the interventricular
Representative circumferential myocardial strain in cardiomyo-
pathy patients with LBBB, non-LBBB, and healthy controls.




LBBB, there was significant dysynchrony of contraction as
indicated by greater opposing wall (inferolateral wall to
anteroseptum) delays and standard deviations (SD) in time to
peak Ec and er for all six wall segments (p < 0.00 1) (Figure 2). All
patients without LBBB and all normal subjects showed negative
ce in all segments throughout systolic contraction (Figure y).
Patients with cardiomyopathy showed reduced magnitude of Ec
and Er (p < 0.002).
Conclusion: In patients with heart failure, a LBBB pattern with
marked increase in QRS duration manifests as a specific
contractile pattern with marked dyskinesis of the interventricular
septum. Mechanical dyssynchrony and reduction in myocardial
circumferential and radial strain are identified and quantified
using a semi-automated method. This study identifies the
relationship between electrical and mechanical circumferential
and radial dyssynchrony in patients with dilated as well as
ischemic cardiomyopathy.


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


Figure 2 (abstract PI4)


Figure I (abstract P15)


LBBB patients have more mechanical dyssynchrony than non-
LBBB patients.


References
I. Yu CM, Fung JWH and Zhang Q, et al: J Cardiovasc
Electrophysiol 2005, 16:1 I 1 7-1 124.
2. Nelson GS, Curry CW and Wyman BT, et al: Circulation
2000, I01:2703-2709.
3. Yu CM, Chau E and Sanderson JE, et al: Circulation 2002,
105:438-445.
4. Haber I, Metaxas DN and Axel L: Med Image Anal 2000,
4:335-355.


PI5
The use of multiparametric CMR to
predict impaired exercise capacity in
hypertrophic cardiomyopathy
Andrew S Flett, Caroline J Coats, Brian A Mist,
Giovanni Quarta, Ferdinando Pasquale, Perry M Elliott
and James C Moon
The Heart Hospital, London, UK

journal of Cardiovascular Magnetic Resonance 2009, 1I (Suppl I):P 15
Objective: To understand the role of CMR measured para-
meters including late gadolinium enhancement (LGE) on exercise
capacity in patients with hypertrophic cardiomyopathy (HCM).
Background: Exercise intolerance in HCM is complex,
depending on multiple factors including diastolic dysfunction,
outflow tract obstruction, ischemia, left atrial pressure, hyper-
trophy and fibrosis. We sought to determine the relative


The extent of late gadolinium enhancement assigned to 3
groups.

contributions of 5 CMR measured variables on exercise capacity
in HCM: function, mass, left atrial area, resting LVOTobstruction
and LGE.
Methods: 135 consecutive patients with HCM (median age
46.5 years, 21% female, 67% Caucasian) underwent cardiopul-
monary metabolic exercise testing (measuring percent predicted
peak oxygen consumption (%pVO2) and contrast CMR (for
function, volumes, mass, left atrial area, presence of rest LVOT
obstruction and LGE). Two independent investigators blinded to
results of the opposing dataset performed analysis of exercise
and CMR data. The extent of LGE was categorised as normal/
minimal, moderate or extensive (3 point scale, 0, I or 2).
Univariate and multivariate analysis was used to assess correla-
tions of %pVO2 with CMR derived variables.
Results: Normal/minimal, moderate and extensive LGE was
present in 67 (50%), 58 (43%) and 10 (7%) respectively. 3 1(23%)
had resting LVOTobstruction. On univariate analysis, %pVO2 was
associated the presence of resting outflow tract obstruction
(p = 0.03) and inversely asscociated with extensive LGE
(p = 0.02). On multivariate analysis, the single significant factor
associated with %pVO2 was LGE (p = 0.01). Although LGE and
EF were associated (r = 0.232, p = 0.007), LGE was the
independent predictor of %pVO2. If significant exercise impair-
ment is defined as a %pVO2 <70%, moderate and extensive LGE


Figure 2 (abstract P15)

Mean% Predicted V02 vs Gadollnm Extent


0
wY ,
o


Gadelinum Exten
Eff" BM 95% CI


Peak oxygen consumption falls with extent of LGE in patients
with HCM.


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n=67 I

n=68


i p 0.41 n10


Sp0.03* I


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Journal of Cardiovascular Magnetic Resonance 2009, 11(Suppl 1)


independently predicts it with odds ratios of 2.2 (95% CI 1.0,
4.5 p = 0.04) and 18.9 (95% CI 1.9, 188.2, p = 0.01) respectively.
Extensive LGE has low sensitivity (13%) but high specificity (98%)
for predicting poor exercise capacity. Figures I and 2
Conclusion: The main determinant of significant exercise
limitation measured by multiparametric CMR in HCM is the
presence of extensive LGE. Lesser amounts of LGE do not
predict exercise capacity, highlighting the mulitfactorial nature of
functional limitation in this condition.


P16
Cardiac magnetic resonance findings in
asymptomatic patients with Brugada syndrome
Christoph J Jensen Holger C Eberle Dinh Q Nguyen',
Thomas Schlosser3, Jan Hluchy', Christoph K Naber',
Georg V Sabin' and Oliver Bruder
'Elisabeth Hospital Essen, Essen, Germany
2Elisabeth Hospital, Department of Cardiology and Angiology,
Essen, Germany
3University Hospital Essen, Essen, Germany

Journal of Cardiovascular Magnetic Resonance 2009, 1I (Suppl I):P 16
Introduction: The Brugada syndrome (BS) is characterized by
distinctive ST-segment abnormalities, malignant ventricular
arrhythmias, and sudden cardiac death and is attributed to a
sodium channelopathy. Additionally, right ventricular wall motion
abnormalities have been described by previous studies.
Purpose: To evaluate cardiac magnetic resonance (CMR)
findings in asymptomatic patients with Brugada syndrome
compared to matched controls.
Methods: CMR was performed in 24 asymptomatic patients
(13 males; mean age 42. 7 years) with proven Brugada
syndrome on a 1.5 Tesla MR System. The imaging protocol
included steady-state free precession (SSFP) cine sequences
(TrueFISP, TR 3 ms, TE 1.5 ms, FA 600, slice thickness 5 mm) in
long axis views and contiguous short-axis views covering the
entire left (LV) and right ventricle (RV) including the right
ventricular outflow tract (RVOT). Additionally, TI weighted
turbo spin-echo sequences with and without fat suppression (TR
700 ms, TE 14 ms, FA 1800, slice thickness 5 mm) were acquired,
and delayed enhancement imaging was performed following
gadolinium contrast administration using segmented 2D inver-
sion-recovery fast low angle shot sequences (TR 8 ms, TE 4 ms,
FA 250, slice thickness 5 mm) in corresponding slice orientation.
Functional analysis and the area of the RVOT were calculated
offline by semi-automatic post-processing software. CMR para-
meters were compared by Mann-Whitney test to age and sex
matched controls (n = 24).
Results: Patients with BS had statistically significant larger RV
end-diastolic (167 43 ml vs. 1 19 24 ml, p < 0.001) and end-
systolic volumes (87 33 ml vs. 51 f 16 ml, p < 0.001), lower
RV ejection fraction (49 8% vs. 58 4%, p < 0.001) and dilated
RVOT (II 2 cm2 vs. 8 I cm2, p < 0.001) compared to
controls. There was no statistically significant difference in LV
volumes and function between patients and controls. Local RV
myocardial signal enhancement in the TI weighted turbo spin-
echo images was observed in three (12.5%) patients and RV
delayed enhancement in four (17%) of the 24 patients, as
compared to no patient in the control group. Five (21%) patients
showed localised right ventricular wall motion abnormalities,


Figure I (abstract PI6)


whereof in 2 patients no delayed enhancement or intramyocar-
dial TI signal suggesting fat deposits was present. Figure I.
Conclusion: Patients with proven Brugada syndrome have
larger right ventricular volumes, impaired RV function and dilated
RVOT compared to matched controls. Right ventricular wall
motion abnormalities, localized fat deposits and delayed
enhancement can be found in some of the Brugada syndrome
patients indicating subtle structural heart disease.

P17
Focal myocardial fibrosis detected with magnetic
resonance late Gadolinium enhancement
imaging and diffuse interstitial fibrosis
determined with histological staining of
endomyocardial biopsy specimens in patients
with non-ischemic left ventricular systolic
dysfunction: two distinct entities?
Simon Schalla, Sebastiaan Bekkers, Robert Dennert,
Robert J van Suylen, Johannes Waltenberger, Tim Leiner
and Stephane Heymans
University Hospital Maastricht, Maastricht, Netherlands
Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):P 17
Introduction: Focal myocardial fibrosis detected with mag-
netic resonance late gadolinium enhancement imaging (LGE) as
well as diffuse interstitial fibrosis seen on endomyocardial biopsy
specimens are associated with an adverse prognosis in patients
with non-ischemic left ventricular dysfunction.
Purpose: We tested the hypothesis if these two forms of
fibrosis are linked to each other and whether focal fibrosis
becomes visible if a certain amount of diffuse fibrosis is present.


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Thus, the aim of this study was to determine whether focal
fibrosis detected non-invasively with LGE is related to the degree
of diffuse fibrosis seen on histologic specimens obtained from
endomyocardial biopsy in patients with idiopathic cardiomyo-
pathy.
Methods and results: Fifty-five patients (30 males, 25 females,
age 47 14 years, range 18 73 years) with impaired systolic
function on initial echocardiography underwent magnetic
resonance cine and LGE imaging (1.5 T Gyroscan Intera, Philips
Medical Systems, Best, The Netherlands) and endomyocardial
biopsy. The scanparameters were I) steady-state free precession
sequence for cine imaging with slice thickness 6 mm, slice gap
4 mm, TR/TE 3.8/1.9 ms, flip angle 50, FOV 350 mm, matrix
256 x 256, 22-25 phases per cardiac cycle, 2) Look-Locker
sequence to determine the inversion time for the subsequent
late enhancement scan to optimally "null" left ventricular
myocardium (typical range 200-280 ms) with slice thickness
10 mm, TR/TE 3.8/1.9 ms, flip angle 8, FOV 370 mm, resolution
256 x 256, 39 phases, phase interval 20-21 ms and 3) multislice
TI-weighted 3D inversion-recovery gradient-echo sequence for
LGE imaging (10 minutes after intravenous administration of
0.2 mmol/kg Gd-DTPA with an injection rate of 3 ml/sec) with
slice thickness 12 mm, slice gap 6 mm, TR/TE 4.2/1.3 ms, flip
angle 15, FOV 400 mm, resolution 256 x 256.
The mean LVEF determined with cine MR-imaging was 37 13%,
EDV 234 122 ml and LV massa 135 47 g. Twenty patients
had LGE, the majority of patients did not show focal fibrosis on
MR imaging. On biopsies, the mean collagen volume fraction was
6.2 5.3%. No correlation was found between LGE and
histology. Furthermore, no correlation was found between the
grade of fibrosis on histological examination and LVEDV or LV
mass.
Conclusion: Focal fibrosis was uncommon in this group of
patients with impaired systolic function. No correlation was
found between diffuse and focal fibrosis and, thus, focal fibrosis as
seen with LGE is not related to a manifestation of a certain
degree of diffuse interstitial fibrosis. The underlying pathophy-
siologic process for the development of focal fibrosis remains to
be investigated.


PI8
Cardiovascular magnetic resonance imaging in
early anthracycline cardiotoxicity
Gillian Smith', Paul Kotwinski2, John Paul Carpenter',
Montgomery Hugh2 and Dudley Pennell'
'Royal Brompton Hospital, London, UK
2University College London, London, UK

Journal of Cardiovascular Magnetic Resonance 2009, 1I (Suppl I):P 18
Introduction: Anthracyclines are the mainstay of adjuvant
chemotherapy for patients with breast cancer. This therapy is
known to be cardiotoxic with population risk rising with dosage
but individual susceptibility is idiosyncratic thus optimal dosage is
denied to many. Cardiovascular magnetic resonance (CMR)
offers an accurate means by which to assess ventricular function
prior to and following chemotherapy. It also offers excellent
intrinsic contrast which allows the detection of change at a tissue
level which may indicate inflammatory changes without the need
for a contrast agent and therefore cannulation. This would be of
particular value for monitoring patients undergoing courses of


chemotherapy who frequently develop problems with venous
access or become needle phobic.
Purpose: As part of a prospective gene environment study in
breast cancer, this study attempts to identify early markers of
anthracycline mediated toxicity which may predict later cardiac
dysfunction.
Methods: 276 female patients with early breast cancer were
scanned before commencement of chemotherapy and one year
post completion. CMR was performed using a 1.5 T Siemens
Avanto scanner with a 6 channel phased array cardiac coil.
Patients were scanned 3 days post first cycle. Cine images are
acquired using a retrospectively gated high temporal resolution
SSFP sequence. Left ventricular ejection fraction (LVEF) and mass
(LVM) are measure using a semi-automated analysis package
(LVtools, Cardiovascular Imaging Solutions, London, UK). T2
weighted STIR images were also acquired and signal intensity
compared.
Results: To date, 28 patients have had day 3 scans and one year
follow-up studies. Mean ejection fraction (EF) changed from
72.9 5.0% to 71.0 4.6% (p = 0.06). 14 patients showed a
significant reduction in ejection fraction (mean 75.5 4.6% to
70.4 4.9%). In these patients, the LVM increased from
1 15.7 14.6 g to 125.1 16.7 g (p = 0.0002), and this was
associated with an increase in STIR image intensity (62.7
19.2 to 71.7 26.9; p = 0.05). Of the 14 patients who showed
no reduction in LVEF (70.0 3.9 at baseline vs 71.8 4.4 at
follow-up), there was no significant change in either LVM
(I 1.8 13.0 g vs I 16.1 11.4 g, p = 0.2) or Stir (64.7
20.6 vs 63 17.1, p = 0.6) at day 3.
Conclusion: CMR with Stir and left ventricular mass measure-
ments, which reflect myocardial edema, offers a sensitive
predictor at day 3 post chemotherapy of myocardial dysfunction
after one year secondary to anthracycline cardiotoxicity.

P19
Utility of cardiac MRI in detecting diastolic
dysfunction: comparison with Doppler
echocardiography and tissue Doppler imaging
Anthony F Tramontano, Cuilin Miao, Alison Hays,
Robert Donnino, Ruth Lim, Leon Axel, Danny Kim,
Hersh Chandarana and Monvadi B Srichai
NYU Medical Center, New York, NY, USA

Journal of Cardiovascular Magnetic Resonance 2009, I I(Suppl I):PI 9
Background: Left ventricular diastolic dysfunction (LVDD)
serves as a prognostic indicator of adverse cardiovascular events.
Cardiac magnetic resonance (CMR) imaging is the gold standard
for evaluating ventricular size and systolic function, but there is
limited data on the utility of CMR in the evaluation of diastolic
function. To assess the accuracy of CMR in assessing LVDD we
compared quantitative CMR to Doppler echocardiography
(ECHO).
Methods: 20 patients with cardiomyopathy underwent both
CMR and ECHO studies. Through plane phase contrast CMR and
Doppler ECHO was performed for assessment of early (E) and
late (A) mitral inflow velocities, early mitral deceleration time
(DT), and early (e') myocardial tissue velocities of the basal
lateral wall. The two imaging methods were correlated for
measurement of several parameters of diastolic function includ-
ing E/A ratio, E DT, and e'. Diastolic function was assessed based
on a combination of mitral inflow and myocardial tissue velocities


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