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ESC Textbook of Cardiovascular Imaging - sample

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Chapter 8 New technical

Chapter 8 New technical developments in CMR Reza Razavi, Manav Sohal, Zhong Chen, and James Harrison Contents T1 mapping 107 T1 mapping methods 107 Clinical applications of T1 mapping 108 Potential promise and limitations of T1 mapping 109 Atrial CMR 109 CMR of ablation injury 110 Left atrial CMR 110 Pre-ablation imaging 111 Post-ablation imaging 111 Potential promise and limitations of atrial imaging 111 MRI of cardiac implantable electric devices 111 Potential interactions of MRI–CIEDs 112 MRI scanning of non-MR conditional CIEDs 112 MRI conditional CIEDs 112 Effect of CIEDS on scan quality 113 Potential promise and limitations of MRI of patients with CIEDs 113 References 113 T1 mapping Structure, function, regional myocardial scar assessment, and, recently, perfusion assessment have become the cornerstones of routine clinical cardiac magnetic resonance (CMR) imaging applications. In the last two years there has been a tremendous growth in clinical research in the area of T1 mapping to address the need for better myocardial tissue characterization. There is great potential in T1 mapping and its related forms being used as biomarkers for detection and monitoring of disease pathology, response to treatment, and as prognostic indicators to clinical outcomes. The first medical application of magnetic resonance imaging measured longitudinal proton relaxation time, T1, was to detect and characterize tumour [1]. A myocardial T1 map is a parametric reconstructed image where the signal intensity of each pixel represents the T1 longitudinal relaxation time of the corresponding myocardial voxel. The voxel-by-voxel T1 estimation is derived from multiple samplings along the recovery curve following a specific preparation sequence (see Fig. 8.1). It allows true quantitative signal quantification on a standardized scale of image voxel to characterize tissue heterogeneity. This eliminates the influence of imprecise inversion time selection, which is needed to null the apparently normal remote myocardium with standard delayed enhanced CMR. T1 mapping methods There are many ways of assessing T1. Two methods, based on the standard Look-Locker method, have largely been adopted and validated for T1 mapping in the literature [2, 3]. The modified Look-Locker inversion recovery sequence (MOLLI), proposed by Messroghli et al., merges images sampled from eleven different inversion times (TI) from three consecutive inversion–recovery (IR) experiments into one dataset in a 17-heartbeat breath-hold; whereas Shortened Modified Look-Locker Inversion recovery (ShMOLLI), proposed by Piechnik et al., samples from seven different TIs in a 9-heartbeat breathhold. Both methods have been readily applied in T1 mapping data acquisition in patients with a variety of cardiac pathologies. However, both methods are susceptible to underestimation of the true T1 values. Especially at high T1 values, MOLLI demonstrated a greater dependence on heart rate requiring adjustment whereas ShMOLLI required only an empirical adjustment [3–5]. Myocardial fibrosis detection by delayed contrast enhancement CMR sequence is dependent on a greater distribution volume and slower wash-out of contrast agents within tissues of greater extracellular space. The delayed contrast-enhanced CMR pulse sequence has been the gold standard in detecting regional fibrosis. An important drawback of the method is the need for manual selection of IR time to generate an image with signal contrasts between the fibrotic region and apparently non-fibrotic region. Delayedenhancement imaging thus is good at differentiating between ‘normal’ and diseased

Chapter 9 Imaging during cardiac interventions Luis M. Rincón and José L. Zamorano Contents Introduction 116 Catheterization laboratory procedures 116 Patent foramen ovale (PFO) 116 Atrial septal defects (ASDs) 117 Ventricular septal defects (VSDs) 119 Echocardiography in trans-septal catheterization 120 Alcohol septal ablation for hypertrophic obstructive cardiomyopathy 120 Percutaneous closure of left atrial appendage (LAA) 121 Use of echocardiography to guide myocardial biopsy 123 Use of echocardiography to guide pericardiocentesis 123 Use of echocardiography in electrophysiological procedures 123 Introduction 123 Use of echocardiography for cardiac catheter ablation of atrial fibrillation 124 Use of echocardiography for other EP ablation procedures 125 Echocardiography in cardiac resynchronization therapy procedures 125 References 125 Introduction Interventional cardiology has evolved during the last decades and the number of procedures and indications has increased. This offers a new therapeutic option for conditions that previously required surgery or that were not amenable to any intervention. In parallel, cardiac imaging has experienced a similar technological development and it is commonly required in the catheterization laboratory to evaluate, guide and improve results of several percutaneous procedures [1] ( Table 9.1). Percutaneous treatment can offer an alternative to surgery in many cases of nonvalvular structural heart diseases, such as atrial septal defects (ASDs) and patent foramen ovale (PFO), with cardiac imaging routinely used in this context. Atrial fibrillation with pulmonary veins ablation and left atrial appendage percutaneous occlusion are commonly guided by cardiac imaging. Other supraventricular and ventricular tachyarrhythmias ablation procedures performed in the electrophysiology laboratory (EP) have become clinical settings in which imaging can be useful. Echocardiography is routinely used for evaluation, guidance, and follow-up of patients undergoing alcohol septal ablation for hypertrophic cardiomyopathy (HCM). Trans-catheter interventions for valvular heart disease, such as aortic stenosis or mitral regurgitation, are in constant evolution due to their clinical importance and high prevalence. The use of echocardiography in this context is discussed in a separate chapter. Catheterization laboratory procedures Patent foramen ovale Diagnosis and indications of PFO closure The foramen ovale plays a role by letting the blood flow across the atrial septum before birth. Afterwards, right heart pressures and pulmonary resistances decrease due to breathing and left atrial pressure rises with the beginning of pulmonary venous return. Septum primum is then shoved against the septum secundum, and a permanent fusion can be seen by the age of two in most children. Patent foramen ovale (PFO) can occur as a result of an absence in the fusion of the septum primum with the septum secundum, and can be seen in 24–27% of adult population. This persistence can cause a blood flow from the right to the left atrium whenever the pressure is higher in the first. Approximately 30% of survivors of stroke are said to be cryptogenic, and PFO by TEE has been reported to be present in around 50% in comparison with 24% for the general population. This has led clinicians to think that the underlying cause of the stroke was frequently a PFO. In the last two years several clinical trials such as RESPECT, PC Trial, and CLOSURE I have tried

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