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Cardiovascular magnetic resonance (CMR) is considered the gold standard imaging modality for myocardial tissue characterization. Elevated transverse relaxation time (T2) is specific for increased myocardial water content, increased free water, and is used as an index of myocardial edema. The strengths of quantitative T2 mapping lie in the accurate characterization of myocardial edema, and the early detection of reversible myocardial disease without the use of contrast agents or ionizing radiation. Quantitative T2 mapping overcomes the limitations of T2-weighted imaging for reliable assessment of diffuse myocardial edema and can be used to diagnose, stage, and monitor myocardial injury. Strong evidence supports the clinical use of T2 mapping in acute myocardial infarction, myocarditis, heart transplant rejection, and dilated cardiomyopathy. Accumulating data support the utility of T2 mapping for the assessment of other cardiomyopathies, rheumatologic conditions with cardiac involvement, and monitoring for cancer therapy-related cardiac injury. Importantly, elevated T2 relaxation time may be the first sign of myocardial injury in many diseases and oftentimes precedes symptoms, changes in ejection fraction, and irreversible myocardial remodeling. This comprehensive review discusses the technical considerations and clinical roles of myocardial T2 mapping with an emphasis on expanding the impact of this unique, noninvasive tissue parameter.

The study sought to assess the prognostic significance of nonischemic myocardial fibrosis (MF) on cardiovascular magnetic resonance (CMR)-both macroscopic MF assessed by late gadolinium enhancement (LGE) and diffuse microscopic MF quantified by extracellular volume fraction (ECV)-in patients with structurally normal hearts. The clinical relevance of tissue abnormalities identified by CMR in patients with structurally normal hearts remains unclear. Consecutive patients undergoing CMR were screened for inclusion to identify those with LGE imaging and structurally normal hearts. ECV was calculated in patients with available T1 mapping. The associations between myocardial fibrosis and the outcomes of all-cause mortality, new-onset heart failure [HF], and an arrhythmic outcome were evaluated. In total 525 patients (mean age 43.1±14.2 years; 30.5% males) were included. Over a median follow-up of 5.8 years, 13 (2.5%) patients died and 18 (3.4%) developed new-onset HF. Nonischemic midwall /subepicardial LGE was present in 278 (52.9%) patients; isolated RV insertion fibrosis was present in 80 (15.2%) patients. In 276 patients with available T1 mapping, the mean ECV was 25.5 ± 4.4%. There was no significant association between LGE and all-cause mortality (HR: 1.36, CI: 0.42-4.42, p = 0.61), or new-onset HF (HR: 0.64, CI: 0.25-1.61, p = 0.34). ECV (per 1% increase) correlated with all-cause mortality (HR: 1.19, CI: 1.04-1.36, p = 0.009), but not with new-onset HF (HR: 0.97, CI: 0.86-1.10, p = 0.66). There was no significant association between arrhythmic outcomes and LGE (p = 0.60) or ECV (p = 0.49). In a multivariable model after adjusting for covariates, ECV remained significantly associated with all-cause mortality (HR per 1% increase in ECV: 1.26, CI: 1.06-1.50, p = 0.009). Nonischemic LGE in patients with structurally normal hearts is common and does not appear to be associated with adverse outcomes, whereas elevated ECV is associated with all-cause mortality and may be an important risk stratification tool.

Myocardial fibrosis as evaluated by cardiovascular magnetic resonance (CMR) plays a central role in pathophysiology of cardiovascular diseases and exhibits sex-specific differences. The goal of our study was to assess sex-related differences in fibrosis in patients with structurally normal hearts. We retrospectively studied patients undergoing clinical CMR at 1.5T with preserved cardiac function and no structural abnormalities. Standardized CMR protocols included cine imaging, T1 mapping, and late gadolinium enhancement (LGE) imaging. LGE presence, extent, and pattern, and extracellular volume fraction (ECV) were evaluated according to sex. The primary outcomes were all cause mortality and new-onset heart failure. Of 525 patients studied (43.1 ± 14.2 years, 69.5% female), 258 (49.1%) exhibited nonischemic LGE. Nonischemic LGE was more common in males (61.3% vs. 43.8%, p  < 0.001), and remained so in multivariable analysis after adjustment for clinical covariates (OR 2.2, CI 1.17–4.13, p  = 0.015). Women had higher ECV values (26.5 ± 4.3% vs. 23.2 ± 3.7, p  < 0.001), and these sex differences remained significant in multivariable analysis (β coefficient = 1.29, p  = 0.02). During 5.8 years follow-up there was no association between primary outcomes and nonischemic LGE. There was a trend towards association between ECV increase and all-cause mortality. The optimal ECV cutoff for all-cause mortality was 31.3% for females and 27.5% for males. Among patients with structurally normal hearts with preserved systolic function referred for clinical CMR exams, nonischemic LGE is more frequently observed in males, whereas ECV values are higher in females. ECV increase may be associated with all-cause mortality, both in female and male cohorts.

Patients with non-ischemic cardiomyopathy exhibit a range of myocardial fibrosis (MF) patterns on cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) imaging. Data suggests that ring-like MF is associated with worse prognosis. In the present study it was sought to analyze the prevalence of parametric mapping abnormalities in ring-like MF and their prognostic value for arrhythmic events. Patients undergoing clinical CMR at 1.5T/3T were evaluated for ring-like MF defined as midwall/subepicardial fibrosis involving ≥ 3 contiguous left ventricular segments. CMR protocol included cine imaging, T1 and T2 mapping, and LGE. Mean native T1, ECV, and T2 values and a number of mid short axis segments with elevated values were calculated. LGE extent was assessed segmentally. Arrhythmic outcomes were defined as appropriate device shock, premature ventricular contractions ≥ 10%, non-sustained/sustained ventricular tachycardia, or ventricular fibrillation. In total 49 patients (53 ± 17 years, 26.5% female) were analyzed. Many patients had elevated global/segmental mapping values: 45%/76% in native T1, 57%/57% in T2, and 57%/78% in ECV. During median follow-up of 12 months, arrhythmic events occurred in 65% of patients. There was no association between native T1/T2 elevation or number of LGE segments and arrhythmic outcomes. There was a significant association between ECV and arrhythmic outcomes, both septal ECV (p = 0.036) and any segmental ECV elevation (p = 0.03). T1 and T2 myocardial tissue abnormalities are common in patients with ring-like MF. ECV elevation was associated with arrhythmic events in this cohort. Further studies are needed to establish the diagnostic and prognostic value of parametric mapping in patients with ring-like MF.

Etiology of sudden cardiac arrest (SCA) is identified in less than 30% of survivors without coronary artery disease. We sought to assess the diagnostic role of myocardial parametric mapping using cardiovascular magnetic resonance (CMR) in identifying SCA etiology. Consecutive SCA survivors undergoing CMR with myocardial parametric mapping were included in the study. The determination if CMR was decisive or contributory in identifying SCA etiology was made if the diagnosis was unclear prior to CMR, and the discharge diagnosis was consistent with the CMR result. Parametric mapping was considered essential for establishing probable SCA etiology by CMR if the SCA cause could not have been determined without its utilization. If the CMR diagnosis could have been potentially based on the combination of cine and LGE imaging, parametric mapping was considered contributory. Of the 35 patients (mean age 46.9 ± 14.1 years; 57% males) included, SCA diagnosis was based on CMR in 23 (66%) patients. Of those, parametric mapping was essential for the diagnosis of myocarditis and tako-tsubo cardiomyopathy (11/48%) and contributed to the diagnosis in 10 (43%) additional cases. Inclusion of quantitative T1 and T2 parametric mapping in the SCA CMR protocol has the potential to increase diagnostic yield of CMR and further specify SCA etiology, especially myocarditis.

The aim of this study was to compare neointima proliferation in three drug-eluting stents (DES) produced by the same company (Balton, Poland) which are covered with a biodegradable polymer and elute sirolimus (concentration: 1.0 and 1.2 µg/mm2), but have different stent platforms and strut thickness: stainless steel Prolim® (115 µm) and BiOSS LIM® (120 µm) and cobalt-chromium Alex® (70 µm). We analyzed data of patients with quantitative coronary angiography (QCA) and optical coherence tomography (OCT) at 12 months from BiOSS LIM Registry, Prolim Registry and Alex OCT clinical trial. There were 56 patients enrolled, in whom 29 Prolim® stents were deployed, in 11—BiOSS LIM® and in 16—Alex stents. The late lumen loss was the smallest in Prolim® subgroup (0.26 ± 0.17 mm) and did not differ from Alex® subgroup (0.28 ± 0.47 mm). This parameter was significantly bigger in BiOSS® subgroup (0.38 ± 0.19 mm; p < 0.05). In OCT analysis there was no statistically significant difference between Prolim® and Alex® subgroups in terms of mean neointima burden (24.6 ± 8.6 vs. 19.27 ± 8.11%) and neointima volume (28.16 ± 15.10 vs. 24.51 ± 17.64 mm3). In BiOSS® group mean neointima burden (30.9 ± 6.2%) and mean neointima volume (44.9 ± 4.9 mm3) were significantly larger. The morphological analysis revealed that in most cases in all groups the neointima was homogenous with plaque presence only around stent struts. In the QCA and OCT analysis regular DES (Prolim® and Alex®) obtained similar results, whereas more pronounced response from the vessel wall was found in the BiOSS® subgroup.

The aim of this study was to analyze the difference in neointima pattern assessed by intravascular ultrasound (IVUS) between two dedicated bifurcation stents, BiOSS® Expert and BiOSS® LIM at 12-month follow-up. This manuscript reports IVUS findings obtained from the analysis of patients enrolled into first-in-man registries initially assessing the BiOSS Expert® (paclitaxel) and BiOSS LIM® (sirolimus) stents. Quantitative angiographic analysis was performed pre, post-stenting, and at follow-up. IVUS examination was performed at 12 months. There were analyzed 34 cases (BiOSS Expert® 11 patients, BiOSS LIM® 23 patients). Procedural characteristics in the two groups were similar, except for rates of main vessel predilatation and FKB/POT, which were higher in BiOSS® LIM group, 54.5 % vs 73.9 % (P < 0.05) and 0 % vs 39.1 % (P < 0.05), respectively. When comparing late lumen loss (LLL) for both stents there were significantly bigger values for main vessel and main branch in the BiOSS® Expert group, but not in side branch. Intravascular ultrasound examination showed that in the BiOSS LIM® group comparing with the BiOSS Expert® group there was lower neointima burden in the whole stent (24.7 ± 7.5 % vs 19.4 ± 8.6 %, P < 0.05) as well as in main vessel (22.8 ± 5.6 % vs 16.9 ± 6.1 %, P < 0.05) and main branch (36.1 ± 6.5 % vs 27.6 ± 8.7 %, P < 0.05), but not at the level of bifurcation (15.1 ± 3.8 % vs 13.6 ± 5.4 %, P = NS). In addition, we found that final kissing balloon/proximal optimization technique (FKB/POT) was associated with significantly smaller value of LLL in main vessel (0.24 ± 0.09 mm vs 0.32 ± 0.14 mm, P < 0.05), which in IVUS analysis resulted in smaller neointima burden in main vessel (13.7 ± 3.9 % vs 18.9 ± 4.45 %, P < 0.05) as well as at the bifurcation site (12.6 ± 4.1 % vs 14.1 ± 2.4 %, P < 0.05). The obtained results suggest that neointima proliferation was the largest in main branches of both stents assessed in quantitative angiography (LLL) as well as in IVUS (neointima burden) and the neointima increase was smaller in BiOSS LIM® stents than in BiOSS Expert® stents. Moreover, the middle part of the stent seems to not to be associated with excessive neointima proliferation and more aggressive protocol of implantation with the use FKB/POT seems to decrease this process.

The aim of this study was to analyze the difference in neointima pattern assessed by intravascular ultrasound (IVUS) between two dedicated bifurcation stents, BiOSS registered Expert and BiOSS registered LIM at 12-month follow-up. This manuscript reports IVUS findings obtained from the analysis of patients enrolled into first-in-man registries initially assessing the BiOSS Expert registered (paclitaxel) and BiOSS LIM registered (sirolimus) stents. Quantitative angiographic analysis was performed pre, post-stenting, and at follow-up. IVUS examination was performed at 12 months. There were analyzed 34 cases (BiOSS Expert registered 11 patients, BiOSS LIM registered 23 patients). Procedural characteristics in the two groups were similar, except for rates of main vessel predilatation and FKB/POT, which were higher in BiOSS registered LIM group, 54.5% vs 73.9% (P<0.05) and 0% vs 39.1% (P<0.05), respectively. When comparing late lumen loss (LLL) for both stents there were significantly bigger values for main vessel and main branch in the BiOSS registered Expert group, but not in side branch. Intravascular ultrasound examination showed that in the BiOSS LIM registered group comparing with the BiOSS Expert registered group there was lower neointima burden in the whole stent (24.7 plus or minus 7.5% vs 19.4 plus or minus 8.6%, P<0.05) as well as in main vessel (22.8 plus or minus 5.6% vs 16.9 plus or minus 6.1%, P<0.05) and main branch (36.1 plus or minus 6.5% vs 27.6 plus or minus 8.7%, P<0.05), but not at the level of bifurcation (15.1 plus or minus 3.8% vs 13.6 plus or minus 5.4%, P=NS). In addition, we found that final kissing balloon/proximal optimization technique (FKB/POT) was associated with significantly smaller value of LLL in main vessel (0.24 plus or minus 0.09 mm vs 0.32 plus or minus 0.14 mm, P<0.05), which in IVUS analysis resulted in smaller neointima burden in main vessel (13.7 plus or minus 3.9% vs 18.9 plus or minus 4.45%, P<0.05) as well as at the bifurcation site (12.6 plus or minus 4.1% vs 14.1 plus or minus 2.4%, P<0.05). The obtained results suggest that neointima proliferation was the largest in main branches of both stents assessed in quantitative angiography (LLL) as well as in IVUS (neointima burden) and the neointima increase was smaller in BiOSS LIM registered stents than in BiOSS Expert registered stents. Moreover, the middle part of the stent seems to not to be associated with excessive neointima proliferation and more aggressive protocol of implantation with the use FKB/POT seems to decrease this process.