<div><h4>Normative ranges of biventricular volumes and function in healthy term newborns.</h4><i>Jhaveri S, Battersby E, Stern KWD, Cohen J, ... Vieira MC, Groves A</i><br /><b>Background</b><br />Cardiovascular magnetic resonance (CMR) is increasingly used in newborns with congenital heart disease. However, reporting on ventricular volumes and mass is hindered by an absence of normative data in this population.<br /><b>Design/methods</b><br />Healthy term (37-41 weeks gestation) newborns underwent non-sedated, free-breathing CMR within the first week of life using the \'feed and wrap\' technique. End-diastolic volume (EDV), end-systolic volume (ESV) stroke volume (SV) and ejection fraction (EF) were calculated for both left ventricle (LV) and right ventricle (RV). Papillary muscles were separately contoured and included in the myocardial volume. Myocardial mass was calculated by multiplying myocardial volume by 1.05 g/ml. All data were indexed to weight and body surface area (BSA). Inter-observer variability (IOV) was performed on data from 10 randomly chosen infants.<br /><b>Results</b><br />Twenty healthy newborns (65% male) with a mean (SD) birth weight of 3.54 (0.46) kg and BSA of 0.23 (0.02) m2 were included. Normative LV parameters were indexed EDV 39.0 (4.1) ml/m<sup>2</sup>, ESV 14.5 (2.5) ml/m<sup>2</sup> and ejection fraction (EF) 63.2 (3.4)%. Normative RV indexed EDV, ESV and EF were 47.4 (4.5) ml/m<sup>2</sup>, 22.6 (2.9) ml/m<sup>2</sup> and 52.5 (3.3)% respectively. Mean LV and RV indexed mass were 26.4 (2.8) g/m<sup>2</sup> and 12.5 (2.0) g/m<sup>2</sup>, respectively. There was no difference in ventricular volumes by gender. IOV was excellent with an intra-class coefficient > 0.95 except for RV mass (0.94).<br /><b>Conclusion</b><br />This study provides normative data on LV and RV parameters in healthy newborns, providing a novel resource for comparison with newborns with structural and functional heart disease.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 24 Apr 2023; 25:26</small></div>

<div><h4>MRXCAT2.0: Synthesis of realistic numerical phantoms by combining left-ventricular shape learning, biophysical simulations and tissue texture generation.</h4><i>Buoso S, Joyce T, Schulthess N, Kozerke S</i><br /><b>Background</b><br />Standardised performance assessment of image acquisition, reconstruction and processing methods is limited by the absence of images paired with ground truth reference values. To this end, we propose MRXCAT2.0 to generate synthetic data, covering healthy and pathological function, using a biophysical model. We exemplify the approach by generating cardiovascular magnetic resonance (CMR) images of healthy, infarcted, dilated and hypertrophic left-ventricular (LV) function.<br /><b>Method</b><br />In MRXCAT2.0, the XCAT torso phantom is coupled with a statistical shape model, describing population (patho)physiological variability, and a biophysical model, providing known and detailed functional ground truth of LV morphology and function. CMR balanced steady-state free precession images are generated using MRXCAT2.0 while realistic image appearance is ensured by assigning texturized tissue properties to the phantom labels.<br /><b>Finding</b><br />Paired CMR image and ground truth data of LV function were generated with a range of LV masses (85-140 g), ejection fractions (34-51%) and peak radial and circumferential strains (0.45 to 0.95 and - 0.18 to - 0.13, respectively). These ranges cover healthy and pathological cases, including infarction, dilated and hypertrophic cardiomyopathy. The generation of the anatomy takes a few seconds and it improves on current state-of-the-art models where the pathological representation is not explicitly addressed. For the full simulation framework, the biophysical models require approximately two hours, while image generation requires a few minutes per slice.<br /><b>Conclusion</b><br />MRXCAT2.0 offers synthesis of realistic images embedding population-based anatomical and functional variability and associated ground truth parameters to facilitate a standardized assessment of CMR acquisition, reconstruction and processing methods.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 20 Apr 2023; 25:25</small></div>

<div><h4>Cardiovascular magnetic resonance-derived left atrioventricular coupling index and major adverse cardiac events in patients following acute myocardial infarction.</h4><i>Lange T, Backhaus SJ, Schulz A, Evertz R, ... Eitel I, Schuster A</i><br /><b>Background</b><br />Recently, a novel left atrioventricular coupling index (LACI) has been introduced providing prognostic value to predict cardiovascular events beyond common risk factors in patients without cardiovascular disease. Since data on cardiovascular magnetic resonance (CMR)-derived LACI in patients following acute myocardial infarction (AMI) are scarce, we aimed to assess the diagnostic and prognostic implications of LACI in a large AMI patient cohort.<br /><b>Methods</b><br />In total, 1046 patients following AMI were included. After primary percutaneous coronary intervention CMR imaging and subsequent functional analyses were performed. LACI was defined by the ratio of the left atrial end-diastolic volume divided by the left ventricular (LV) end-diastolic volume. Major adverse cardiac events (MACE) including death, reinfarction or heart failure within 12 months after the index event were defined as primary clinical endpoint.<br /><b>Results</b><br />LACI was significantly higher in patients with MACE compared to those without MACE (p < 0.001). Youden Index identified an optimal LACI cut-off at 34.7% to classify patients at high-risk (p < 0.001 on log-rank testing). Greater LACI was associated with MACE on univariate regression modeling (HR 8.1, 95% CI 3.4-14.9, p < 0.001) and after adjusting for baseline confounders and LV ejection fraction (LVEF) on multivariate regression analyses (HR 3.1 95% CI 1.0-9, p = 0.049). Furthermore, LACI assessment enabled further risk stratification in high-risk patients with impaired LV systolic function (LVEF ≤ 35%; p < 0.001 on log-rank testing).<br /><b>Conclusion</b><br />Atrial-ventricular interaction using CMR-derived LACI is a superior measure of outcome beyond LVEF especially in high-risk patients following AMI. Trial registration ClinicalTrials.gov, NCT00712101 and NCT01612312.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 13 Apr 2023; 25:24</small></div>

<div><h4>The incomplete circle of Willis is associated with vulnerable intracranial plaque features and acute ischemic stroke.</h4><i>Wang H, Shen L, Zhao C, Liu S, ... Chai C, Xia S</i><br /><b>Background</b><br />The circle of Willis (CoW) plays a significant role in intracranial atherosclerosis (ICAS). This study investigated the relationship between different types of CoW, atherosclerosis plaque features, and acute ischemic stroke (AIS).<br /><b>Methods</b><br />We investigated 97 participants with AIS or transient ischemic attacks (TIA) underwent pre- and post-contrast 3T vessel wall cardiovascular magnetic resonance within 7 days of the onset of symptoms. The culprit plaque characteristics (including enhancement grade, enhancement ratio, high signal in T<sub>1</sub>, irregularity of plaque surface, and normalized wall index), and vessel remodeling (including arterial remodeling ratio and positive remodeling) for lesions were evaluated. The anatomic structures of the anterior and the posterior sections of the CoW (A-CoW and P-CoW) were also evaluated. The plaque features were compared among them. The plaque features were also compared between AIS and TIA patients. Finally, univariate and multivariate regression analysis was performed to evaluate the independent risk factors for AIS.<br /><b>Result</b><br />Patients with incomplete A-CoW showed a higher plaque enhancement ratio (P = 0.002), enhancement grade (P = 0.01), and normalized wall index (NWI) (P = 0.018) compared with the patients with complete A-CoW. A higher proportion of patients with incomplete symptomatic P-CoW demonstrated more culprit plaques with high T<sub>1</sub> signals (HT<sub>1</sub>S) compared with those with complete P-CoW (P = 0.013). Incomplete A-CoW was associated with a higher enhancement grade of the culprit plaques [odds ratio (OR):3.84; 95% CI: 1.36-10.88, P = 0.011], after adjusting for clinical risk factors such as age, sex, smoking, hypertension, hyperlipemia, and diabetes mellitus. Incomplete symptomatic P-CoW was associated with a higher probability of HT<sub>1</sub>S (OR:3.88; 95% CI: 1.12-13.47, P = 0.033), after adjusting for clinical risk factors such as age, sex, smoking, hypertension, hyperlipemia, and diabetes mellitus. Furthermore, an irregularity of the plaque surface (OR: 6.24; 95% CI: 2.25-17.37, P < 0.001), and incomplete symptomatic P-CoW (OR: 8.03, 95% CI: 2.43-26.55, P = 0.001) were independently associated with AIS.<br /><b>Conclusions</b><br />This study demonstrated that incomplete A-CoW was associated with enhancement grade of the culprit plaque, and incomplete symptomatic side P-CoW was associated with the presence of HT<sub>1</sub>S of culprit plaque. Furthermore, an irregularity of plaque surface and incomplete symptomatic side P-CoW were associated with AIS.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 06 Apr 2023; 25:23</small></div>

<div><h4>Automated segmentation of long and short axis DENSE cardiovascular magnetic resonance for myocardial strain analysis using spatio-temporal convolutional neural networks.</h4><i>Barbaroux H, Kunze KP, Neji R, Nazir MS, ... Scott AD, Young AA</i><br /><b>Background</b><br />Cine Displacement Encoding with Stimulated Echoes (DENSE) facilitates the quantification of myocardial deformation, by encoding tissue displacements in the cardiovascular magnetic resonance (CMR) image phase, from which myocardial strain can be estimated with high accuracy and reproducibility. Current methods for analyzing DENSE images still heavily rely on user input, making this process time-consuming and subject to inter-observer variability. The present study sought to develop a spatio-temporal deep learning model for segmentation of the left-ventricular (LV) myocardium, as spatial networks often fail due to contrast-related properties of DENSE images.<br /><b>Methods</b><br />2D + time nnU-Net-based models have been trained to segment the LV myocardium from DENSE magnitude data in short- and long-axis images. A dataset of 360 short-axis and 124 long-axis slices was used to train the networks, from a combination of healthy subjects and patients with various conditions (hypertrophic and dilated cardiomyopathy, myocardial infarction, myocarditis). Segmentation performance was evaluated using ground-truth manual labels, and a strain analysis using conventional methods was performed to assess strain agreement with manual segmentation. Additional validation was performed using an externally acquired dataset to compare the inter- and intra-scanner reproducibility with respect to conventional methods.<br /><b>Results</b><br />Spatio-temporal models gave consistent segmentation performance throughout the cine sequence, while 2D architectures often failed to segment end-diastolic frames due to the limited blood-to-myocardium contrast. Our models achieved a DICE score of 0.83 ± 0.05 and a Hausdorff distance of 4.0 ± 1.1 mm for short-axis segmentation, and 0.82 ± 0.03 and 7.9 ± 3.9 mm respectively for long-axis segmentations. Strain measurements obtained from automatically estimated myocardial contours showed good to excellent agreement with manual pipelines, and remained within the limits of inter-user variability estimated in previous studies.<br /><b>Conclusion</b><br />Spatio-temporal deep learning shows increased robustness for the segmentation of cine DENSE images. It provides excellent agreement with manual segmentation for strain extraction. Deep learning will facilitate the analysis of DENSE data, bringing it one step closer to clinical routine.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 30 Mar 2023; 25:16</small></div>

<div><h4>Repeatability and reproducibility of various 4D Flow MRI postprocessing software programs in a multi-software and multi-vendor cross-over comparison study.</h4><i>Oechtering TH, Nowak A, Sieren MM, Stroth AM, ... Barkhausen J, Frydrychowicz A</i><br /><b>Background</b><br />Different software programs are available for the evaluation of 4D Flow cardiovascular magnetic resonance (CMR). A good agreement of the results between programs is a prerequisite for the acceptance of the method. Therefore, the goal was to compare quantitative results from a cross-over comparison in individuals examined on two scanners of different vendors analyzed with four postprocessing software packages.<br /><b>Methods</b><br />Eight healthy subjects (27 ± 3 years, 3 women) were each examined on two 3T CMR systems (Ingenia, Philips Healthcare; MAGNETOM Skyra, Siemens Healthineers) with a standardized 4D Flow CMR sequence. Six manually placed aortic contours were evaluated with Caas (Pie Medical Imaging, SW-A), cvi42 (Circle Cardiovascular Imaging, SW-B), GTFlow (GyroTools, SW-C), and MevisFlow (Fraunhofer Institute MEVIS, SW-D) to analyze seven clinically used parameters including stroke volume, peak flow, peak velocity, and area as well as typically scientifically used wall shear stress values. Statistical analysis of inter- and intrareader variability, inter-software and inter-scanner comparison included calculation of absolute and relative error (E<sub>R</sub>), intraclass correlation coefficient (ICC), Bland-Altman analysis, and equivalence testing based on the assumption that inter-software differences needed to be within 80% of the range of intrareader differences.<br /><b>Results</b><br />SW-A and SW-C were the only software programs showing agreement for stroke volume (ICC = 0.96; E<sub>R</sub> = 3 ± 8%), peak flow (ICC: 0.97; E<sub>R</sub> = -1 ± 7%), and area (ICC = 0.81; E<sub>R</sub> = 2 ± 22%). Results from SW-A/D and SW-C/D were equivalent only for area and peak flow. Other software pairs did not yield equivalent results for routinely used clinical parameters. Especially peak maximum velocity yielded poor agreement (ICC ≤ 0.4) between all software packages except SW-A/D that showed good agreement (ICC = 0.80). Inter- and intrareader consistency for clinically used parameters was best for SW-A and SW-D (ICC = 0.56-97) and worst for SW-B (ICC = -0.01-0.71). Of note, inter-scanner differences per individual tended to be smaller than inter-software differences.<br /><b>Conclusions</b><br />Of all tested software programs, only SW-A and SW-C can be used equivalently for determination of stroke volume, peak flow, and vessel area. Irrespective of the applied software and scanner, high intra- and interreader variability for all parameters have to be taken into account before introducing 4D Flow CMR in clinical routine. Especially in multicenter clinical trials a single image evaluation software should be applied.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 28 Mar 2023; 25:22</small></div>

<div><h4>Cardiovascular magnetic resonance for evaluation of cardiac involvement in COVID-19: recommendations by the Society for Cardiovascular Magnetic Resonance.</h4><i>Ferreira VM, Plein S, Wong TC, Tao Q, ... Schulz-Menger J, Kim J</i><br /><AbstractText>Coronavirus disease 2019 (COVID-19) is an ongoing global pandemic that has affected nearly 600 million people to date across the world. While COVID-19 is primarily a respiratory illness, cardiac injury is also known to occur. Cardiovascular magnetic resonance (CMR) imaging is uniquely capable of characterizing myocardial tissue properties in-vivo, enabling insights into the pattern and degree of cardiac injury. The reported prevalence of myocardial involvement identified by CMR in the context of COVID-19 infection among previously hospitalized patients ranges from 26 to 60%. Variations in the reported prevalence of myocardial involvement may result from differing patient populations (e.g. differences in severity of illness) and the varying intervals between acute infection and CMR evaluation. Standardized methodologies in image acquisition, analysis, interpretation, and reporting of CMR abnormalities across would likely improve concordance between studies. This consensus document by the Society for Cardiovascular Magnetic Resonance (SCMR) provides recommendations on CMR imaging and reporting metrics towards the goal of improved standardization and uniform data acquisition and analytic approaches when performing CMR in patients with COVID-19 infection.</AbstractText><br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 27 Mar 2023; 25:21</small></div>

<div><h4>Developing a medical device-grade T phantom optimized for myocardial T mapping by cardiovascular magnetic resonance.</h4><i>Topriceanu CC, Fornasiero M, Seo H, Webber M, ... Moon JC, Captur G</i><br /><b>Introduction</b><br />A long T<sub>2</sub> relaxation time can reflect oedema, and myocardial inflammation when combined with increased plasma troponin levels. Cardiovascular magnetic resonance (CMR) T<sub>2</sub> mapping therefore has potential to provide a key diagnostic and prognostic biomarkers. However, T<sub>2</sub> varies by scanner, software, and sequence, highlighting the need for standardization and for a quality assurance system for T<sub>2</sub> mapping in CMR.<br /><b>Aim</b><br />To fabricate and assess a phantom dedicated to the quality assurance of T<sub>2</sub> mapping in CMR.<br /><b>Method</b><br />A T<sub>2</sub> mapping phantom was manufactured to contain 9 T<sub>1</sub> and T<sub>2</sub> (T<sub>1</sub>|T<sub>2</sub>) tubes to mimic clinically relevant native and post-contrast T<sub>2</sub> in myocardium across the health to inflammation spectrum (i.e., 43-74 ms) and across both field strengths (1.5 and 3 T). We evaluated the phantom\'s structural integrity, B<sub>0</sub> and B<sub>1</sub> uniformity using field maps, and temperature dependence. Baseline reference T<sub>1</sub>|T<sub>2</sub> were measured using inversion recovery gradient echo and single-echo spin echo (SE) sequences respectively, both with long repetition times (10 s). Long-term reproducibility of T<sub>1</sub>|T<sub>2</sub> was determined by repeated T<sub>1</sub>|T<sub>2</sub> mapping of the phantom at baseline and at 12 months.<br /><b>Results</b><br />The phantom embodies 9 internal agarose-containing T<sub>1</sub>|T<sub>2</sub> tubes doped with nickel di-chloride (NiCl<sub>2</sub>) as the paramagnetic relaxation modifier to cover the clinically relevant spectrum of myocardial T<sub>2</sub>. The tubes are surrounded by an agarose-gel matrix which is doped with NiCl<sub>2</sub> and packed with high-density polyethylene (HDPE) beads. All tubes at both field strengths, showed measurement errors up to ≤ 7.2 ms [< 14.7%] for estimated T<sub>2</sub> by balanced steady-state free precession T<sub>2</sub> mapping compared to reference SE T<sub>2</sub> with the exception of the post-contrast tube of ultra-low T<sub>1</sub> where the deviance was up to 16 ms [40.0%]. At 12 months, the phantom remained free of air bubbles, susceptibility, and off-resonance artifacts. The inclusion of HDPE beads effectively flattened the B<sub>0</sub> and B<sub>1</sub> magnetic fields in the imaged slice. Independent temperature dependency experiments over the 13-38 °C range confirmed the greater stability of shorter vs longer T<sub>1</sub>|T<sub>2</sub> tubes. Excellent long-term (12-month) reproducibility of measured T<sub>1</sub>|T<sub>2</sub> was demonstrated across both field strengths (all coefficients of variation < 1.38%).<br /><b>Conclusion</b><br />The T<sub>2</sub> mapping phantom demonstrates excellent structural integrity, B<sub>0</sub> and B<sub>1</sub> uniformity, and reproducibility of its internal tube T<sub>1</sub>|T<sub>2</sub> out to 1 year. This device may now be mass-produced to support the quality assurance of T<sub>2</sub> mapping in CMR.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 20 Mar 2023; 25:19</small></div>

<div><h4>Complementary prognostic value of stress perfusion imaging and global coronary flow reserve derived from cardiovascular magnetic resonance: a long-term cohort study.</h4><i>Nakamura S, Ishida M, Nakata K, Takafuji M, ... Dohi K, Sakuma H</i><br /><b>Background</b><br />Phase-contrast cine cardiovascular magnetic resonance (CMR) quantifies global coronary flow reserve (CFR) by measuring blood flow in the coronary sinus (CS), allowing assessment of the entire coronary circulation. However, the complementary prognostic value of stress perfusion CMR and global CFR in long-term follow-up has yet to be investigated. This study aimed to investigate the complementary prognostic value of stress myocardial perfusion imaging and global CFR derived from CMR in patients with suspected or known coronary artery disease (CAD) during long-term follow-up.<br /><b>Methods</b><br />Participants comprised 933 patients with suspected or known CAD who underwent comprehensive CMR. Major adverse cardiac events (MACE) comprised cardiac death, non-fatal myocardial infarction, unstable angina, hospitalization for heart failure, stroke, ventricular arrhythmia, and late revascularization.<br /><b>Results</b><br />During follow-up (median, 5.3 years), there were 223 MACE. Kaplan-Meier curve analysis revealed a significant difference in event-free survival among tertile groups for global CFR (log-rank, p < 0.001) and between patients with and without ischemia (p < 0.001). The combination of stress perfusion CMR and global CFR enhanced risk stratification (p < 0.001 for overall), and prognoses were comparable between the subgroup with ischemia and no impaired CFR and the subgroup with no ischemia and impaired CFR (p = 0.731). Multivariate Cox proportional hazard regression analysis showed that impaired CFR remained a significant predictor for MACE (hazard ratio, 1.6; p = 0.002) when adjusted for coronary risk factors and CMR predictors, including ischemia. The addition of impaired CFR to coronary risk factors and ischemia significantly increased the global chi-square value from 88 to 109 (p < 0.001). Continuous net reclassification improvement and integrated discrimination with the addition of global CFR to coronary risk factors plus ischemia improved to 0.352 (p < 0.001) and 0.017 (p < 0.001), respectively.<br /><b>Conclusions</b><br />During long-term follow-up, stress perfusion CMR and global CFR derived from CS flow measurement provided complementary prognostic value for prediction of cardiovascular events. Microvascular dysfunction or diffuse atherosclerosis as shown by impaired global CFR may play a role as important as that of ischemia due to epicardial coronary stenosis in the risk stratification of CAD patients.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 16 Mar 2023; 25:20</small></div>

<div><h4>Association of cardiovascular magnetic resonance diastolic indices with arrhythmia in repaired Tetralogy of Fallot.</h4><i>Kikano SD, Weingarten A, Sunthankar SD, McEachern W, ... Soslow JH, Chew JD</i><br /><b>Background</b><br />Patients with repaired Tetralogy of Fallot (rTOF) experience a high burden of long-term morbidity, particularly arrhythmias. Cardiovascular magnetic resonance (CMR) is routinely used to assess ventricular characteristics but the relationship between CMR diastolic function and arrhythmia has not been evaluated. We hypothesized in rTOF, left ventricular (LV) diastolic dysfunction on CMR would correlate with arrhythmias and mortality.<br /><b>Methods</b><br />Adolescents and adults with rTOF who underwent CMR were compared to healthy controls (n = 58). Standard ventricular parameters were assessed and manual planimetry was performed to generate filling curves and indices of diastolic function. Chart review was performed to collect outcomes. Univariate and multivariable logistic regression was performed to identify outcome associations.<br /><b>Results</b><br />One-hundred sixty-seven subjects with rTOF (mean age 32 years) and 58 healthy control subjects underwent CMR. Patients with rTOF had decreased LV volumes and increased right ventricular (RV) volumes, lower RV ejection fraction (RVEF), lower peak ejection rate (PER), peak filling rate (PFR) and PFR indexed to end-diastolic volume (PFR/EDV) compared to healthy controls. Eighty-three subjects with rTOF had arrhythmia (63 atrial, 47 ventricular) and 11 died. Left atrial (LA) volumes, time to peak filling rate (tPFR), and PFR/EDV were associated with arrhythmia on univariate analysis. PER/EDV was associated with ventricular (Odds ratio, OR 0.43 [0.24-0.80], p = 0.007) and total arrhythmia (OR 0.56 [0.37-0.92], p = 0.021) burden. A multivariable predictive model including diastolic covariates showed improved prediction for arrhythmia compared to clinical and conventional CMR measures (area under curve (AUC) 0.749 v. 0.685 for overall arrhythmia). PFR/EDV was decreased and tPFR was increased in rTOF subjects with mortality as compared to those without mortality.<br /><b>Conclusions</b><br />Subjects with rTOF have abnormal LV diastolic function compared to healthy controls. Indices of LV diastolic function were associated with arrhythmia and mortality. CMR diastolic indices may be helpful in risk stratification for arrhythmia.<br /><br />© 2023. The Author(s).<br /><br /><small>J Cardiovasc Magn Reson: 13 Mar 2023; 25:17</small></div>