Nael F Osman

Johns Hopkins University, Baltimore, Maryland, United States

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Publications (137)471.12 Total impact

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    ABSTRACT: PurposeAn external driver-free MRI method for assessment of liver fibrosis offers a promising noninvasive tool for diagnosis and monitoring of liver disease. Lately, the heart's intrinsic motion and MR tagging have been utilized for the quantification of liver strain. However, MR tagging requires multiple breath-hold acquisitions and substantial postprocessing. In this study, we propose the use of a fast strain-encoded (FSENC) MRI method to measure the peak strain (Sp) in the liver's left lobe, which is in close proximity and caudal to the heart. Additionally, we introduce a new method of measuring heart-induced shear wave velocity (SWV) inside the liver.Methods Phantom and in vivo experiments (11 healthy subjects and 11 patients with liver fibrosis) were conducted. Reproducibility experiments were performed in seven healthy subjects.ResultsPeak liver strain, Sp, decreased significantly in fibrotic liver compared with healthy liver (6.46% ± 2.27% vs 12.49% ± 1.76%; P < 0.05). Heart-induced SWV increased significantly in patients compared with healthy subjects (0.15 ± 0.04 m/s vs 0.63 ± 0.32 m/s; P < 0.05). Reproducibility analysis yielded no significant difference in Sp (P = 0.47) or SWV (P = 0.56).Conclusion Accelerated external driver-free noninvasive assessment of left liver lobe strain and SWV is feasible using strain-encoded MRI. The two measures significantly separate healthy subjects from patients with fibrotic liver. Magn Reson Med, 2014. © 2014 Wiley Periodicals, Inc.
    Magnetic Resonance in Medicine 07/2014; 74(1). DOI:10.1002/mrm.25379 · 3.57 Impact Factor
  • Ahmed O. Al-Agamy · Nael F. Osman · Ahmed S. Fahmy ·
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    ABSTRACT: Evaluation of cardiac functions using Strain Encoded (SENC) magnetic resonance (MR) imaging is a powerful tool for imaging the deformation of left and right ventricles. However, automated analysis of SENC images is hindered due to the low signal-to-noise ratio SENC images. In this work, the authors propose a method to segment the left and right ventricles myocardium simultaneously in SENC-MR short-axis images. In addition, myocardium seed points are automatically selected using skeletonisation algorithm and used as hard constraints for the graph-cut optimization algorithm. The method is based on a modified formulation of the graph-cuts energy term. In the new formulation, a signal probabilistic model is used, rather than the image histogram, to capture the characteristics of the blood and tissue signals and include it in the cost function of the graph-cuts algorithm. The method is applied to SENC datasets for 11 human subjects (five normal and six patients with known myocardial wall motion abnormality). The segmentation results of the proposed method are compared with those resulting from both manual segmentation and the conventional histogram-based graph-cuts segmentation algorithm. The results show that the proposed method outperforms the histogram-based graph-cuts algorithm especially to segment the thin structure of the right ventricle.
    IET Image Processing 07/2013; 7(5):415-422. DOI:10.1049/iet-ipr.2012.0513 · 0.75 Impact Factor
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    ABSTRACT: Purpose: To evaluate the feasibility of using strain-encoded (SENC) breast magnetic resonance images (MRI) for breast cancer detection by examining the compression and relaxation response properties in phantoms and ex vivo breast samples. Methods: A tissue phantom was constructed to mimic different sizes of breast masses and tissue stiffness. In addition, five human ex vivo whole breast specimens with and without masses were studied. MR data was acquired on a 3T scanner consisting of T(1)-weighted, fat suppressed spin echo T(2)-weighted, and SENC breast images. Mechanical tissue characteristics (strain) of the phantoms and breast tissue samples were measured using SENC imaging in both compression and relaxation modes. The breast tissue specimens were sectioned and stained in the same plane as the MRI for histological evaluation. Results: For the phantom, SENC images showed soft masses with quantitative strain values between 35% and 50%, while harder masses had strain values between 0% and 20%. Combined compression (CMP) and relaxation (REX) breast SENC images separately categorized all masses into three different groups. For breast SENC, the signal intensities between ex vivo breast mass and breast glandular tissue were significantly different (-7.6 ± 2.6 verses -20.6 ± 5.4 for SENC-CMP, and 4.2 ± 1.5 verses 22.6 ± 5 for SENC-REX, p < 0.05). Conclusions: We have demonstrated that SENC breast MRI can be used to obtain mechanical tissue properties and give quantitative estimates of strain in tumors. This feasibility study provides the basis for future clinical studies.
    Medical Physics 12/2012; 39(12):7710-8. DOI:10.1118/1.4749963 · 2.64 Impact Factor
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    ABSTRACT: Purpose:To determine whether chronic pulmonary arterial pressure (PAP) elevation affects regional biventricular function and whether regional myocardial function may be reduced in pulmonary arterial hypertension (PAH) patients with preserved global right ventricular (RV) function.Materials and Methods:After informed consent, 35 PAH patients were evaluated with right heart catheterization and cardiac magnetic resonance (MR) imaging and compared with 13 healthy control subjects. Biventricular segmental, section, and mean ventricular peak systolic longitudinal strain (E(LL)), as well as left ventricular (LV) circumferential and RV tangential strains were compared between PAH patients and control subjects and correlated with global function and catheterization of the right heart indexes. Spearman ρ correlation with Bonferroni correction was used. Multiple linear regression analysis was performed to determine predictors for regional myocardial function.Results:In the RV of PAH patients, longitudinal contractility was reduced at the basal, mid, and apical levels, and tangential contractility was reduced at the midventricular level. Mean RV E(LL) positively correlated with mean PAP (r = 0.62, P < .0014) and pulmonary vascular resistance index (PVRI) (r = 0.77, P < .0014). Mean PAP was a predictor of mean RV E(LL) (β = .19, P = .005) in a multiple linear regression analysis. In the LV, reduced LV longitudinal and circumferential contractility were noted at the base. LV anteroseptal E(LL) positively correlated with increased mean PAP (r = 0.5, P = .03) and septal eccentricity index (r = 0.5, P = .01). In a subgroup of PAH patients with normal global RV function, significantly reduced RV longitudinal contractility was noted at basal and mid anterior septal insertions, as well as the mid anterior RV wall (P < .05 for all).Conclusion:In PAH patients, reduced biventricular regional function is associated with increased RV afterload (mean PAP and PVRI). Cardiac MR imaging helps identify regional RV dysfunction in PAH patients with normal global RV function.© RSNA, 2012Supplemental material:
    Radiology 11/2012; 266(1). DOI:10.1148/radiol.12111599 · 6.87 Impact Factor
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    ABSTRACT: The aim of this study was to explore whether the regional peak longitudinal (LS) and circumferential strains (CS) at the right ventricular (RV) free wall could be used to identify global RV dysfunction in relation to RV ejection fraction (RVEF) and plasma concentration of brain natriuretic peptide (BNP) in pulmonary hypertension (PH). A total of 37 consecutive patients diagnosed with PH and 13 healthy control subjects were included. Fast strain encoded and routine cine MRI was performed. The LS and CS at three RV levels were quantified and their relations with RVEF and BNP were investigated. Receiver operating characteristic (ROC) analysis was employed to assess the diagnostic utility of strain encoded MRI for the detection of low RVEF. Significant correlations with LS were observed for RVEF and BNP. Compared to CS, LS showed better correlation with RVEF. The mid-ventricular level of RV was the most sensitive site for evaluation of RV dysfunction. According to our ROC analysis, LS showed higher sensitivity and specificity to detect low RVEF. Compared to CS, LS showed stronger correlations with RVEF and BNP and could be a good detector of RV dysfunction in PH.
    The international journal of cardiovascular imaging 08/2012; 29(2). DOI:10.1007/s10554-012-0105-6 · 1.81 Impact Factor
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    ABSTRACT: To study myocardial perfusion reserve and myocellular metabolic alterations indicated by triglyceride content as possible causes of diastolic dysfunction in patients with type 2 diabetes mellitus, preserved systolic function, and without clinically evident coronary artery disease. Patients with type 2 diabetes mellitus (n = 42) underwent cardiac magnetic resonance (CMR) for quantification of 1) myocardial contractility by strain-encoded MR (SENC); 2) myocardial triglyceride content by proton magnetic resonance spectroscopy ((1) H-MRS); and 3) myocardial perfusion reserve during pharmacologic hyperemia. Age-matched healthy volunteers (n = 16) also underwent CMR to acquire normal values for myocardial strain and perfusion reserve. Stress CMR procedures were successfully performed in all subjects, and no regional inducible perfusion defects were observed in type 2 diabetes mellitus patients. Diastolic strain rate and myocardial perfusion reserve were significantly impaired in patients with type 2 diabetes mellitus compared to control subjects (P < 0.001 for both). Interestingly, impaired diastolic function in type 2 diabetes mellitus was not associated with impaired myocardial perfusion reserve (r = 0.12, P = NS). Conversely a significant association was observed between diastolic dysfunction and myocardial triglyceride content (r = -0.71, P < 0.001), which proved to be independent of age, gender, diabetes duration, blood pressure, and fasting blood glucose. Myocardial steatosis may represent an early marker of diabetic heart disease, triggering subclinical myocardial dysfunction irrespective of myocardial perfusion reserve.
    Journal of Magnetic Resonance Imaging 04/2012; 35(4):804-11. DOI:10.1002/jmri.22879 · 3.21 Impact Factor
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    The International Journal of Cardiovascular Imaging 01/2012; · 1.81 Impact Factor
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    ABSTRACT: The purpose of this study was to determine the prognostic value of strain-encoded magnetic resonance imaging (SENC) during high-dose dobutamine stress cardiac magnetic resonance imaging (DS-MRI) compared with conventional wall motion readings. Detection of inducible ischemia by DS-MRI on the basis of assessing cine images is subjective and depends on the experience of the readers, which may influence not only the diagnostic classification but also the risk stratification of patients with ischemic heart disease. In all, 320 consecutive patients with suspected or known coronary artery disease underwent DS-MRI, using a standard protocol in a 1.5T MR scanner. Wall motion abnormalities (WMA) and myocardial strain were assessed at baseline and during stress, and outcome data including cardiac deaths, nonfatal myocardial infarctions ("hard events"), and revascularization procedures performed >90 days after the MR scans were collected. Thirty-five hard events occurred during a 28 ± 9 month follow-up period, including 10 cardiac deaths and 25 nonfatal myocardial infarctions, and 32 patients underwent coronary revascularization. Using a series of Cox proportional-hazards models, both resting and inducible WMA offered incremental information for the assessment of hard cardiac events compared to clinical variables (chi-square = 13.0 for clinical vs. chi-square = 26.1 by adding resting WMA, p < 0.001, vs. chi-square = 39.3 by adding inducible WMA, p < 0.001). Adding visual SENC or quantitative strain rate reserve to this model further improved the prediction of outcome (chi-square = 50.7 vs. chi-square = 52.5, p < 0.001 for both). In a subset of patients (n = 175) who underwent coronary angiography, SENC yielded significantly higher sensitivity for coronary artery disease detection (96% vs. 84%, p < 0.02), whereas specificity and accuracy were not significantly different (88% vs. 94% and 93% vs. 88%, p = NS for both). Strain-encoded MRI aids the accurate identification of patients at high risk for future cardiac events and revascularization procedures, beyond the assessment of conventional atherogenic risk factors and resting or inducible WMA on cine images. (Strain-Encoded Cardiac Magnetic Resonance Imaging as an Adjunct for Dobutamine Stress Testing; NCT00758654).
    Journal of the American College of Cardiology 09/2011; 58(11):1140-9. DOI:10.1016/j.jacc.2011.03.063 · 16.50 Impact Factor

  • American Thoracic Society 2011 International Conference, May 13-18, 2011 • Denver Colorado; 05/2011
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    ABSTRACT: Early detection of breast lesions using mammography has resulted in lower mortality rates. However, some breast lesions are mammography occult, and magnetic resonance imaging (MRI) is recommended, but it has lower specificity. It is possible to achieve higher specificity by using strain-encoded (SENC) MRI and/or magnetic resonance elastography. SENC breast MRI can measure the strain properties of breast tissue. Similarly, magnetic resonance elastography is used to measure the elasticity (ie, shear stiffness) of different tissue compositions interrogating the tissue mechanical properties. Reports have shown that malignant tumors are three to 13 times stiffer than normal tissue and benign tumors. The investigators have developed a SENC breast hardware device capable of periodically compressing the breast, thus allowing for longer scanning time and measuring the strain characteristics of breast tissue. This hardware enables the use of SENC MRI with high spatial resolution (1 × 1 × 5 mm(3)) instead of fast SENC imaging. Simple controls and multiple safety measures were added to ensure accurate, repeatable, and safe in vivo experiments. Phantom experiments showed that SENC breast MRI has higher signal-to-noise ratio and contrast-to-noise ratio than fast SENC imaging under different scanning resolutions. Finally, the SENC breast device reproducibility measurements resulted in a difference of <1 mm with a 1% strain difference. SENC breast magnetic resonance images have higher signal-to-noise ratio and contrast-to-noise ratios than fast SENC images. Thus, combining SENC breast strain measurements with diagnostic breast MRI to differentiate benign from malignant lesions could potentially increase the specificity of diagnosis in the clinical setting.
    Academic radiology 03/2011; 18(6):705-15. DOI:10.1016/j.acra.2011.01.006 · 1.75 Impact Factor
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    ABSTRACT: Composite Strain Encoding (CSENC) is a new Magnetic Resonance Imaging (MRI) technique for simultaneously acquiring cardiac functional and viability images. It combines the use of Delayed Enhancement (DE) and the Strain Encoding (SENC) imaging techniques to identify the infracted (dead) tissue and to image the myocardial deformation inside the heart muscle. In this work, a new unsupervised segmentation method is proposed to identify infarcted left ventricular tissue in the images provided by CSENC MRI. The proposed method is based on the sequential application of Bayesian classifier, Otsu's thresholding, morphological opening, radial sweep boundary tracing and the fuzzy C-means (FCM) clustering algorithm. This method is tested on images of twelve patients with and without myocardial infarction (MI) and on simulated heart images with various levels of superimposed noise. The resulting clustered images are compared with those marked up by an expert cardiologist who assisted in validating results coming from the proposed method. Infarcted myocardium is correctly identified using the proposed method with high levels of accuracy and precision.
    Proceedings of SPIE - The International Society for Optical Engineering 03/2011; 7962:84-. DOI:10.1117/12.877098 · 0.20 Impact Factor
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    Journal of Cardiovascular Magnetic Resonance 02/2011; 13:1-2. DOI:10.1186/1532-429X-13-S1-O6 · 4.56 Impact Factor
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    Journal of Cardiovascular Magnetic Resonance 02/2011; 13(Suppl 1). DOI:10.1186/1532-429X-13-S1-P279 · 4.56 Impact Factor
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    ABSTRACT: The purpose of this study was to assess predictors of MRI-identified septal delayed enhancement mass at the right ventricular (RV) insertion sites in relation to RV remodeling, altered regional mechanics, and pulmonary hemodynamics in patients with suspected pulmonary hypertension (PH). Thirty-eight patients with suspected PH were evaluated with right heart catheterization and cardiac MRI. Ten age- and sex-matched healthy volunteers acted as controls for MRI comparison. Septal delayed enhancement mass was quantified at the RV insertions. Systolic septal eccentricity index, global RV function, and remodeling indexes were quantified with cine images. Peak systolic circumferential and longitudinal strain at the sites corresponding to delayed enhancement were measured with conventional tagging and fast strain-encoded MRI acquisition, respectively. PH was diagnosed in 32 patients. Delayed enhancement was found in 31 of 32 patients with PH and in one of six patients in whom PH was suspected but proved absent (p = 0.001). No delayed enhancement was found in controls. Delayed enhancement mass correlated with pulmonary hemodynamics, reduced RV function, increased RV remodeling indexes, and reduced eccentricity index. Multiple linear regression analysis showed RV mass index was an independent predictor of total delayed enhancement mass (p = 0.017). Regional analysis showed delayed enhancement mass was associated with reduced longitudinal strain at the basal anterior septal insertion (r = 0.6, p < 0.01). Regression analysis showed that basal longitudinal strain remained an independent predictor of delayed enhancement mass at the basal anterior septal insertion (p = 0.02). In PH, total delayed enhancement burden at the RV septal insertions is predicted by RV remodeling in response to increased afterload. Local fibrosis mass at the anterior septal insertion is associated with reduced regional longitudinal contractility at the base.
    American Journal of Roentgenology 01/2011; 196(1):87-94. DOI:10.2214/AJR.09.4114 · 2.73 Impact Factor
  • Ahmed A Harouni · Michael A Jacobs · Nael F Osman ·
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    ABSTRACT: Breast cancer is the most common cancer among women and the second highest cause of cancer-related death. Diagnostic magnetic resonance imaging (MRI) is recommended to screen high-risk patients. Strain-Encoded (SENC) can improve MRI's specificity by detecting and differentiating masses according to their stiffness. Previous phantom and ex-vivo studies have utilized SENC to detect cancerous masses. However, SENC required a 30% compression of the tissue, which may not be feasible for in-vivo imaging. In this work, we use finite element method simulations and phantom experiments to determine the minimum compression required to detect and classify masses. Results show that SENC is capable of detecting stiff masses at compression level of 7%, though higher compression is needed in order to differentiate between normal tissue and benign or malignant masses. With on-line SENC calculations implemented on the scanner console, we propose to start with small compressions for maximum patient comfort, then progress to larger compressions if any masses are detected.
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    Abdallah G. Motaal · Nael F. Osman ·
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    ABSTRACT: The strain encoding (SENC) technique encodes regional strain of the heart into the acquired MR images and produces two images with two different tunings so that longitudinal strain, on the short-axis view, or circumferential strain on the long-axis view, are measured. Interleaving acquisition is used to shorten the acquisition time of the two tuned images by 50%, but it suffers from errors in the strain calculations due to inter-tunings motion of the heart, which is the motion between two successive acquisitions. In this work, a method is proposed to correct for the inter-tunings motion by estimating the motioninduced shift in the spatial frequency of the encoding pattern, which depends on the strain rate. Numerical data is generated to test the proposed method and real images of human subjects are used for validation The results show an improvement in strain calculations so as to relax the imaging constraints on spatial and temporal resolutions and improve image quality.
    Proceedings of the 8th IEEE International Symposium on Biomedical Imaging: From Nano to Macro, ISBI 2011, March 30 - April 2, 2011, Chicago, Illinois, USA; 01/2011
  • A.S. Fahmy · N.F. Osman · H.A. Shalaby ·
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    ABSTRACT: Stimulated echo acquisition mode (STEAM) is a generic imaging technique that lies at the core of many magnetic resonance imaging (MRI) techniques such MRI tagging, displacement encoded MRI, black-blood cardiac imaging. Nevertheless, tissue deformation causes frequency shift of the MR signal and leads to severe signal attenuation. In this work, a maximum likelihood estimator for the signal amplitude is proposed and used to correct the image artifacts. Numerical simulation and real MR data are used to test and validate the proposed method.
    Intelligent Computer Communication and Processing (ICCP), 2011 IEEE International Conference on; 01/2011
  • Ahmed O Al-Agamy · Nael F Osman · Ahmed S Fahmy ·
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    ABSTRACT: In this work, we propose an algorithm for segmenting the ascending and descending aorta from magnetic resonance phase contrast images, also referred to as MR flow imaging. The proposed algorithm is based on the active contour model combined with some refinements. In addition, false segmentation results due to severe image artifacts are automatically detected and corrected. The developed algorithm features three practical advantages: (1) fast; (2) requires minimal user interaction; and (3) robust to the changes in the algorithm parameters (e.g. same parameter set is used for all datasets). The algorithm is tested and validated on a number of datasets with different image qualities. The preliminary results show very satisfactory segmentation of the ascending and descending aorta even when the flow images are severely distorted.
    Biomedical Engineering Conference (CIBEC), 2010 5th Cairo InternationalBiomedical Engineering Conference (CIBEC), 2010 5th Cairo International; 12/2010
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    ABSTRACT: PURPOSE Right ventricular (RV) function monitoring is critical in patients with pulmonary hypertension (PH). However, RV regional function assessment is challenging using current MR tagging tools. Thus, the purpose of this study was to evaluate regional longitudinal ventricular deformation (ELL) acquired by free breathing single heart beat fast strain encoded imaging (fast-SENC) in relation to global ventricular dysfunction markers and pulmonary hemodynamics in PH patients. METHOD AND MATERIALS 49 subjects [34 PH patients (mean pulmonary arterial pressure mPAP = 39.9±11.8 mmHg) and 15 age matched controls] were examined using short axis real time single heart beat fast-SENC MRI as well as cine imaging. All patients underwent right heart catheterization (RHC). Segmental (15 RV and 16 LV segments), slice (basal, mid and apical), as well as global (average of all segments) peak systolic ELL were quantified for both ventricles and correlated with ventricular function parameters derived by cine MRI and RHC indices. RESULTS PH patients demonstrated reduced ELL at all RV levels compared to normal subjects. [Basal (-18.0 vs. -21.1, p=0.02), mid (-16.9 vs. -21.5, p<0.01) and apical (-17.4 vs. -21.3, p<0.01)]. On segmental analysis, reduced ELL was noted in all segments (p<0.05) except basal lateral and inferior septal insertion at all levels. Reduced global RV ELL was correlated with elevated mPAP (r= 0.6, p<0.001), pulmonary vascular resistance index (r= 0.8, p<0.001) as well as reduced RV function parameters [RV ejection fraction (RVEF) and RV stroke volume index, p<0.01]. Also, RV ELL was correlated with reduced LV end-diastolic (r = -0.53, p<0.01) and end-systolic (r = -0.46, p<0.01) volume indices. In the LV, reduced ELL was consistently noted at the antero-septal regions of basal (-13.4 vs. -17.8, p<0.01) and mid slices (-16.4 vs. -19.2, p=0.04). Reduced LV antero-septal ELL correlated with reduced RVEF in PH patients (r= -0.5, p<0.01 for all). On regression analysis including mPAP, RV EF and RV mass index, mPAP was an independent predictor of reduced global RV ELL (β=0.17, p=0.02). CONCLUSION In PH patients, reduced RV ELL measured by fast-SENC MRI is associated with increased afterload and correlates with RV and LV global dysfunction. CLINICAL RELEVANCE/APPLICATION Single heart beat fast-SENC MRI may serve as a reliable tool to detect early biventricular dysfunction in PH patients.
    Radiological Society of North America 2010 Scientific Assembly and Annual Meeting; 12/2010
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    ABSTRACT: This study evaluated the value of systolic and diastolic deformation indexes determined by strain-encoded imaging to predict persistent severe dysfunction at follow-up in patients after reperfused acute myocardial infarction (AMI) in comparison with late gadolinium enhancement (LGE). Animal studies suggest that regional diastolic function provides information about myocardial viability after AMI. However, data in humans are sparse. Twenty-six patients underwent magnetic resonance imaging 3 ± 1 days after successfully reperfused ST-segment elevation myocardial infarction and at a follow-up of 6 months. Cine, strain-encoded, and LGE images were acquired. Peak systolic circumferential strain (E(cc)) and early diastolic strain rate (E(cc)/s) were calculated for each segment at baseline and at follow-up. A cutoff E(cc) value of -9% was used to define severe dysfunction at follow-up. A total of 312 segments were analyzed; 119 segments showed abnormal baseline function. Thirty-five segments showed severe dysfunction at follow-up, which was defined as E(cc) at follow-up <9%. The area under the curve for E(cc)/s was 0.82 (95% confidence interval [CI]: 0.72 to 0.89), for E(cc) 0.74 (95% CI: 0.64 to 0.83), and for LGE 0.85 (95% CI: 0.77 to 0.92). A comparison of receiver-operating characteristic curves demonstrates that LGE is not significantly different than E(cc)/s but is significantly different than E(cc) (p = 0.32 vs. p < 0.05) for prediction of severe dysfunction at follow-up. Regional diastolic function provides similar accuracy to predict persistent severe dysfunction at follow-up to LGE and is superior to regional systolic function in patients after AMI. Diastolic deformation indexes may serve as a new parameter for assessment of viability in patients after AMI. (SENC in AMI Study; NCT00752713).
    Journal of the American College of Cardiology 09/2010; 56(13):1056-62. DOI:10.1016/j.jacc.2010.02.070 · 16.50 Impact Factor

Publication Stats

3k Citations
471.12 Total Impact Points


  • 1997-2012
    • Johns Hopkins University
      • • Department of Radiology
      • • Department of Electrical and Computer Engineering
      Baltimore, Maryland, United States
  • 2008-2011
    • Heidelberg University
      • Department of Cardiology
      Heidelberg, Baden-Wuerttemberg, Germany
  • 2009-2010
    • Nile University
      Al Qāhirah, Al Qāhirah, Egypt
  • 2003-2006
    • Johns Hopkins Medicine
      • • Department of Pathology
      • • Department of Biomedical Engineering
      Baltimore, Maryland, United States