Sven Plein

Leeds Teaching Hospitals NHS Trust, Leeds, England, United Kingdom

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Publications (360)1880.37 Total impact

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    ABSTRACT: Aims: Evaluation of patients with primary mitral valve insufficiency (MI) is best supported by quantitative measures. Cardiovascular magnetic resonance imaging (CMR) offers flow and cardiac chamber volume quantification. We studied cardiac remodelling with CMR to determine MI regurgitation volumes (MIVol) related to severe MI. Methods and results: In total, 24, 20, and 28 patients determined to have mild, moderate, and severe primary MI, respectively, were studied. Combining cine stacks with phase-contrast velocity mapping across the ascending aorta, CMR-determined MIVol was reproducibly obtained as the difference between left ventricular (LV) stroke volume and aortic forward flow (Aoflow). With increasing MI severity, MIVol, left heart volumes, and pulmonary venous diameters increased (P < 0.01). Severe MI with LV end-systolic diameter of 40 mm was signified by MIVol >40 mL, MI regurgitant fraction >0.30, LV end-diastolic volume (LVEDV(i)) >108 mL m(-2), and a total left heart volume >188 mL m(-2) with dilated pulmonary veins and a LVEDV/right ventricular EDV ratio >1.2. In severe MI, LV ejection fraction was unaffected, but the Aoflow and the peak ejection rate indexed to LVEDV were lowered (P < 0.05). In surgical patients, the MIVol correlated to the decrease in LV dimension after valve surgery (P < 0.02). Conclusion: CMR provides a reproducible quantitative technique for evaluation of MI, as MIVol and cardiac chamber volumes can be held against diagnostic cut-off values. The Aoflow and peak ejection rate indexed to LVEDV may reveal early LV systolic dysfunction in patients with severe MI. Severe MI is related to lower MI regurgitation volume and fraction than previously believed.
    Full-text · Article · Jan 2016 · European Heart Journal Cardiovascular Imaging
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    ABSTRACT: High reproducibility of LV mass and volume measurement from cine cardiovascular magnetic resonance (CMR) has been shown within single centers. However, the extent to which contours may vary from center to center, due to different training protocols, is unknown. We aimed to quantify sources of variation between many centers, and provide a multi-center consensus ground truth dataset for benchmarking automated processing tools and facilitating training for new readers in CMR analysis. Seven independent expert readers, representing seven experienced CMR core laboratories, analyzed fifteen cine CMR data sets in accordance with their standard operating protocols and SCMR guidelines. Consensus contours were generated for each image according to a statistical optimization scheme that maximized contour placement agreement between readers. Reader-consensus agreement was better than inter-reader agreement (end-diastolic volume 14.7 ml vs 15.2-28.4 ml; end-systolic volume 13.2 ml vs 14.0-21.5 ml; LV mass 17.5 g vs 20.2-34.5 g; ejection fraction 4.2 % vs 4.6-7.5 %). Compared with consensus contours, readers were very consistent (small variability across cases within each reader), but bias varied between readers due to differences in contouring protocols at each center. Although larger contour differences were found at the apex and base, the main effect on volume was due to small but consistent differences in the position of the contours in all regions of the LV. A multi-center consensus dataset was established for the purposes of benchmarking and training. Achieving consensus on contour drawing protocol between centers before analysis, or bias correction after analysis, is required when collating multi-center results.
    Full-text · Article · Dec 2015 · Journal of Cardiovascular Magnetic Resonance
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    ABSTRACT: Myocardial blood flow (MBF) varies throughout the cardiac cycle in response to phasic changes in myocardial tension. The aim of this study was to determine if quantitative myocardial perfusion imaging with cardiovascular magnetic resonance (CMR) can accurately track physiological variations in MBF throughout the cardiac cycle. 30 healthy volunteers underwent a single stress/rest perfusion CMR study with data acquisition at 5 different time points in the cardiac cycle (early-systole, mid-systole, end-systole, early-diastole and end-diastole). MBF was estimated on a per-subject basis by Fermi-constrained deconvolution. Interval variations in MBF between successive time points were expressed as percentage change. Maximal cyclic variation (MCV) was calculated as the percentage difference between maximum and minimum MBF values in a cardiac cycle. At stress, there was significant variation in MBF across the cardiac cycle with successive reductions in MBF from end-diastole to early-, mid- and end-systole, and an increase from early- to end-diastole (end-diastole: 4.50 ± 0.91 vs. early-systole: 4.03 ± 0.76 vs. mid-systole: 3.68 ± 0.67 vs. end-systole 3.31 ± 0.70 vs. early-diastole: 4.11 ± 0.83 ml/g/min; all p values <0.0001). In all cases, the maximum and minimum stress MBF values occurred at end-diastole and end-systole respectively (mean MCV = 26 ± 5%). There was a strong negative correlation between MCV and peak heart rate at stress (r = -0.88, p < 0.001). The largest interval variation in stress MBF occurred between end-systole and early-diastole (24 ± 9% increase). At rest, there was no significant cyclic variation in MBF (end-diastole: 1.24 ± 0.19 vs. early-systole: 1.28 ± 0.17 vs.mid-systole: 1.28 ± 0.17 vs. end-systole: 1.27 ± 0.19 vs. early-diastole: 1.29 ± 0.19 ml/g/min; p = 0.71). Quantitative perfusion CMR can be used to non-invasively assess cyclic variations in MBF throughout the cardiac cycle. In this study, estimates of stress MBF followed the expected physiological trend, peaking at end-diastole and falling steadily through to end-systole. This technique may be useful in future pathophysiological studies of coronary blood flow and microvascular function.
    Full-text · Article · Dec 2015 · Journal of Cardiovascular Magnetic Resonance
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    ABSTRACT: Morphological and functional parameters such as chamber size and function, aortic diameters and distensibility, flow and T1 and T2* relaxation time can be assessed and quantified by cardiovascular magnetic resonance (CMR). Knowledge of normal values for quantitative CMR is crucial to interpretation of results and to distinguish normal from disease. In this review, we present normal reference values for morphological and functional CMR parameters of the cardiovascular system based on the peer-reviewed literature and current CMR techniques and sequences. Electronic supplementary material The online version of this article (doi:10.1186/s12968-015-0111-7) contains supplementary material, which is available to authorized users.
    Full-text · Article · Dec 2015 · Journal of Cardiovascular Magnetic Resonance
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    ABSTRACT: Diffuse myocardial fibrosis may be quantified with cardiovascular magnetic resonance (CMR) by calculating extra-cellular volume (ECV) from native and post-contrast T1 values. Accurate ECV calculation is dependent upon the contrast agent having reached equilibrium within tissue compartments. Previous studies have used infusion or single bolus injections of contrast to calculate ECV. In clinical practice however, split dose contrast injection is commonly used as part of stress/rest perfusion studies. In this study we sought to assess the effects of split dose versus single bolus contrast administration on ECV calculation. Ten healthy volunteers and five patients ( 4 ischaemic heart disease, 1 hypertrophic cardiomyopathy) were studied on a 3.0 Tesla (Philips Achieva TX) MR system and underwent two (patients) or three (volunteers) separate CMR studies over a mean of 12 and 30 days respectively. Volunteers underwent one single bolus contrast study (Gadovist 0.15mmol/kg). In two further studies, contrast was given in two boluses (0.075mmol/kg per bolus) as part of a clinical adenosine stress/rest perfusion protocol, boluses were separated by 12 minutes. Patients underwent one bolus and one stress perfusion study only. T1 maps were acquired pre contrast and 15 minutes following the single bolus or second contrast injection. ECV agreed between bolus and split dose contrast administration (coefficient of variability 5.04%, bias 0.009, 95% CI -3.754 to 3.772, r2 = 0.973, p = 0.001)). Inter-study agreement with split dose administration was good (coefficient of variability, 5.67%, bias -0.018, 95% CI -4.045 to 4.009, r2 = 0.766, p > 0.001). ECV quantification using split dose contrast administration is reproducible and agrees well with previously validated methods in healthy volunteers, as well as abnormal and remote myocardium in patients. This suggests that clinical perfusion CMR studies may incorporate assessment of tissue composition by ECV based on T1 mapping.
    Full-text · Article · Dec 2015 · Journal of Cardiovascular Magnetic Resonance

  • No preview · Article · Nov 2015 · Circulation
  • Ananth Kidambi · Sven Plein

    No preview · Article · Oct 2015 · European Heart Journal
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    ABSTRACT: Aims: Typically, myocardial perfusion imaging with two-dimensional (2D) cardiovascular magnetic resonance (CMR) acquires data in three to four myocardial slices at a spatial resolution of 2-3 mm. However, accelerated data acquisition can facilitate higher spatial resolution (<2 mm) or three-dimensional (3D) whole-heart coverage (up to 16 slices). This study aims to compare image quality, diagnostic confidence, and quantitation of myocardial ischaemic burden (MIB) between 2D high-resolution and 3D whole-heart perfusion-CMR. Methods and results: Twenty-seven patients with stable angina underwent both high-resolution 2D and whole-heart 3D perfusion-CMR. Total perfusion defect (TPD) and total scar burden (TSB) areas were contoured and expressed as percentage myocardium. MIB was calculated by subtracting TSB from TPD. Image quality, artefact, and diagnostic confidence scores were similar for both techniques (P>0.05). The mean MIB from high-resolution and 3D acquisition was similar (4.3±5.2% vs. 4.1±4.9%; P=0.81), with a strong correlation between techniques (r=0.72; P<0.001). There was no systematic bias for estimates of MIB between techniques [mean bias = -0.17%, 95% confidence interval (CI): -1.7 to -1.3%] and the 95% limits of agreement were -7.5 to 7.2%. When used to categorize MIB as >10% or <10%, there was only fair agreement between the two techniques (κ = 0.29, 95% CI: -0.12 to 0.70). Conclusion: There is strong correlation and broad agreement between estimates of MIB from both techniques. However, the 95% limits of agreement are relatively wide and therefore a larger comparative study is needed before they can be considered interchangeable-particularly around the clinically relevant 10% threshold.
    No preview · Article · Oct 2015 · European Heart Journal Cardiovascular Imaging
  • Pankaj Garg · John P Greenwood · Sven Plein

    No preview · Article · Oct 2015 · Nature Reviews Cardiology
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    ABSTRACT: Background: Diffuse myocardial fibrosis may be quantified with magnetic resonance (MR) by calculating extracellular volume (ECV) fraction from native and post-contrast T1 values. The ideal modified look-locker inversion recovery (MOLLI) sequence for deriving T1 values has not been determined. This study aims to establish if systematic differences exist between suggested MOLLI schemes. Methods: Twelve phantom gels were studied with inversion recovery spin echo MR at 3.0 tesla to determine reference T1. Gels were then scanned with six MOLLI sequences (3s)3b(3s)5b; 4b(3s)3b(3s)2b; 5b(3s)3b with flip angles of both 35° and 50° at a range of heart rates (HRs). In 10 healthy volunteers MOLLI studies were performed on two separate occasions. Mid ventricular native and post contrast T1 was measured and ECV (%) calculated. Results: In phantoms, the co-efficient of variability at simulated HR [40-100] with a flip angle of 35° ranged from 6.77 to 9.55, and at 50° from 7.71 to 11.10. T1 was under-estimated by all MOLLI acquisitions. Error was greatest with longer T1, and increased as HR increased. The 10 volunteers had normal MR studies. Native T1 time was similar for all acquisitions but highest with the 5b(3s)3b 35° scheme (1,189.1±33.46 ms). Interstudy reproducibility was similar for all MOLLIs. Conclusions: The 5b(3s)3b MOLLI scheme agreed best with reference T1, without statistical difference between the six schemes. The shorter breath-hold time of 5b(3s)3b scheme may be preferable in clinical studies and warrants further investigation.
    No preview · Article · Oct 2015
  • Khaled Alfakih · Sven Plein

    No preview · Article · Sep 2015 · European Heart Journal Cardiovascular Imaging
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    ABSTRACT: To examine factors associated with false-negative cardiovascular magnetic resonance (MR) perfusion studies within the large prospective Clinical Evaluation of MR imaging in Coronary artery disease (CE-MARC) study population. Myocardial perfusion MR has excellent diagnostic accuracy to detect coronary heart disease (CHD). However, causes of false-negative MR perfusion studies are not well understood. CE-MARC prospectively recruited patients with suspected CHD and mandated MR, myocardial perfusion scintigraphy, and invasive angiography. This subanalysis identified all patients with significant coronary stenosis by quantitative coronary angiography (QCA) and MR perfusion (1.5T, T1 -weighted gradient echo), using the original blinded image read. We explored patient and imaging characteristics related to false-negative or true-positive MR perfusion results, with reference to QCA. Multivariate regression analysis assessed the likelihood of false-negative MR perfusion according to four characteristics: poor image quality, triple-vessel disease, inadequate hemodynamic response to adenosine, and Duke jeopardy score (angiographic myocardium-at-risk score). In all, 265 (39%) patients had significant angiographic disease (mean age 62, 79% male). Thirty-five (5%) had false-negative and 230 (34%) true-positive MR perfusion. Poor MR perfusion image quality, triple-vessel disease, and inadequate hemodynamic response were similar between false-negative and true-positive groups (odds ratio, OR [95% confidence interval, CI]: 4.1 (0.82-21.0), P = 0.09; 1.2 (0.20-7.1), P = 0.85, and 1.6 (0.65-3.8), P = 0.31, respectively). Mean Duke jeopardy score was significantly lower in the false-negative group (2.6 ± 1.7 vs. 5.4 ± 3.0, OR 0.34 (0.21-0.53), P < 0.0001). False-negative cardiovascular MR perfusion studies are uncommon, and more common in patients with lower angiographic myocardium-at-risk. In CE-MARC, poor image quality, triple-vessel disease, and inadequate hemodynamic response were not significantly associated with false-negative MR perfusion. J. Magn. Reson. Imaging 2015. © 2015 The Authors Journal of Magnetic Resonance Imaging published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine.
    No preview · Article · Aug 2015 · Journal of Magnetic Resonance Imaging
  • Pankaj Garg · John P Greenwood · Sven Plein

    No preview · Article · Jul 2015 · European Heart Journal – Cardiovascular Imaging
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    ABSTRACT: The CE-MARC study assessed the diagnostic performance investigated the use of cardiovascular magnetic resonance (CMR) in patients with suspected coronary artery disease (CAD). The study used a multi-parametric CMR protocol assessing 4 components: i) left ventricular function; ii) myocardial perfusion; iii) viability (late gadolinium enhancement (LGE)) and iv) coronary magnetic resonance angiography (MRA). In this pre-specified CE-MARC sub-study we assessed the diagnostic accuracy of the individual CMR components and their combinations. All patients from the CE-MARC population (n = 752) were included using data from the original blinded-read. The four individual core components of the CMR protocol was determined separately and then in paired and triplet combinations. Results were then compared to the full multi-parametric protocol. CMR and X-ray angiography results were available in 676 patients. The maximum sensitivity for the detection of significant CAD by CMR was achieved when all four components were used (86.5 %). Specificity of perfusion (91.8 %), function (93.7 %) and LGE (95.8 %) on its own was significantly better than specificity of the multi-parametric protocol (83.4 %) (all P < 0.0001) but with the penalty of decreased sensitivity (86.5 % vs. 76.9 %, 47.4 % and 40.8 % respectively). The full multi-parametric protocol was the optimum to rule-out significant CAD (Likelihood Ratio negative (LR-) 0.16) and the LGE component alone was the best to rue-in CAD (LR+ 9.81). Overall diagnostic accuracy was similar with the full multi-parametric protocol (85.9 %) compared to paired and triplet combinations. The use of coronary MRA within the full multi-parametric protocol had no additional diagnostic benefit compared to the perfusion/function/LGE combination (overall accuracy 84.6 % vs. 84.2 % (P = 0.5316); LR- 0.16 vs. 0.21; LR+ 5.21 vs. 5.77). From this pre-specified sub-analysis of the CE-MARC study, the full multi-parametric protocol had the highest sensitivity and was the optimal approach to rule-out significant CAD. The LGE component alone was the optimal rule-in strategy. Finally the inclusion of coronary MRA provided no additional benefit when compared to the combination of perfusion/function/LGE. Current Controlled Trials ISRCTN77246133.
    Full-text · Article · Jul 2015 · Journal of Cardiovascular Magnetic Resonance
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    ABSTRACT: Background Outcomes following aortic valve intervention may differ according to gender. It has been suggested that men and women adapt differently to aortic stenosis (AS) but the effect of gender on left ventricular (LV) remodelling following valve intervention is not well described. We sought to establish using cardiac magnetic resonance (CMR) imaging, the reference standard non-invasive technique for the assessment of LV mass (LVM) and function, whether there was any difference between genders in LV remodelling in severe AS at baseline and reverse remodelling six months following aortic valve intervention. Methods 100 patients (60 men) with symptomatic severe AS undergoing surgical or percutaneous aortic valve intervention were prospectively recruited between April 2009 and March 2014. Patients with contraindications to CMR were excluded and all patients provided informed written consent. All patients underwent an identical 1.5T CMR protocol (Intera, Philips) prior to and at a median of 6 months following aortic valve intervention (IQR 5–6 months). Multi slice, multiphase imaging was carried out using a standard steady-state free procession pulse sequence in axial and short axis to cover the entire left heart. Quantitative analysis was performed using dedicated computer software (CVI42, Circle Cardiovascular Imaging, Alberta, Canada). Results Basic demographic, clinical and echocardiographic data can be seen in Table 1. Women were older than men but were similar in terms of co-morbidity, surgical risk and valvular haemodynamics. At baseline, women had lower indexed LVM (LVMi) than men and a smaller indexed LV end diastolic volume (LVEDVi). Baseline LV ejection fraction (LVEF) and indexed left atrial volume (LAVi) were similar between sexes. Following valvular intervention, LVMi was significantly reduced in both sexes, however, this was more marked in men (18.28 ± 10.63 vs 12.69 ± 8.84, p = 0.007). There was an improvement in LV longitudinal function and a decrease in LAVi in men but not in women. Neither group experienced a significant change in LVEF following intervention (men 54.84 ± 12.94% to 56.52 ± 10.50%, p = 0.093; women 58.61 ± 10.57 to 60.20 ± 11.00, p = 0.129). Both groups also experienced a significant reduction in LVEDVi following valve intervention, with a trend towards a more pronounced reduction in men (men 11.55 ± 20.31 ml/m2 vs women 5.39 ± 14.10 ml/m2, p = 0.141). Conclusion Men and women with AS remodel differently with more hypertrophy and larger LV cavity size in men. Six months following valvular intervention, men but not women experience an improvement in LV longitudinal function and a decrease in left atrial size. These surrogate markers of a reduced left atrial pressure may be accounted for by the greater magnitude of LVM regression seen in men.
    Full-text · Conference Paper · Jun 2015
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    ABSTRACT: sec> Background Giant cell arteritis (GCA) is the commonest primary systemic vasculitis affecting older people. Dilatation of the aorta may occur as a late complication and is believed to arise from damage to the aortic wall from inflammation. Objectives To determine the prevalence of thoracic aortic dilatation and assess aortic stiffness by CMR in patients with GCA diagnosed at least 2 years previously. Method Consecutive patients recruited to the UK GCA Consortium study were invited. 49 patients (median disease duration 4.5 years) underwent CMR at 3.0T (Philips Achieva TX). Cine images were acquired to measure the diameter of the ascending aorta (AsAo) and descending aorta (DsAo) at the level of the main pulmonary artery (MPA) and aortic arch from luminal edge-to-edge. Aortic stiffness was assessed by aortic distensibility (AD) and pulse-wave velocity (PWV). For AD, cine images (50 phases) were acquired in a plane transverse to AsAo at the level of MPA. Aortic contours were drawn manually at the times of minimal/maximal distension. For PWV, through-plane phase contrast velocity mapping was performed perpendicular to AsAo/DsAo at the level of MPA. Velocity-time curves were derived and the distance between the two locations measured to calculate PWV using the transit-time method. Results Patient characteristics: Mean age 73 ± 6 years, female gender 35 (71%), biopsy-positive 31 (63%), body surface area (BSA) 1.8 ± 0.2 m2, systolic blood pressure (BP) 148 ± 20 mmHg, pulse pressure 75 ± 21 mmHg. CMR measurements in Table 1 . Abstract 87 Table 1 CMR findings in GCA patients 30 (61%) patients had dilated thoracic aortas – corrected to BSA and applied to CMR nomograms [Davis et al . 2014. JCMR 16(1):9]. 5 (10%) patients had dilated AsAo at surgical intervention thresholds according to AHA/ACC guidelines. Aortic stiffness was increased with lower AD (median [IQR] 0.9 [0.8]10–3 mmHg-1) and higher PWV (11 ± 3 m/s) than normal ranges Aquaro et al .1Disease duration did not correlate with aortic measurements. 10/11 biopsy-negative and 17/31 biopsy-positive patients had dilated aortas. Age, body mass index (BMI) and BP were similar between dilated and non-dilated aorta groups. There was a female to male preponderance in the dilated group (26/35 vs. 4/30 respectively, P < 0.01). There was no gender difference with respect to patient characteristics. Conclusion Dilatation of the thoracic aorta and arterial stiffness are common in patients with GCA. There is female preponderance in dilatation without differences in basic demographics. In biopsy-negative patients, under-treatment and/or variability in phenotype could explain increased aortic dilatation. Further investigation will be required to evaluate the effect of severity, treatment length/type, disease duration and cardiovascular risk factors on aortic morphology and function. Reference Aquaro, et al .Observational study of regional aortic size referenced to body size: productionof a cardiovascular magnetic resonance nomogram Davis et al. J Cardiovasc MagnReson 2014; 16 :9, doi:10.1186/1532-429X-16-9 </sec
    Full-text · Conference Paper · Jun 2015
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    ABSTRACT: Background A variety of CMR methods for detecting intramyocardial haemorrhage (IMH) has been proposed, including T2-weighted imaging (T2w), T2-mapping and T2* mapping. IMH detected by T2w imaging is associated with adverse LV remodelling and adverse outcome post acute myocardial infarction (MI). We compare the sensitivity, specificity, CNR and SNR of the three IMH imaging techniques. Methods Twenty patients underwent CMR at 3T (Achieva TX system, Philips Healthcare, Best, The Netherlands) within 3 days following reperfused ST-elevation MI. Black blood, cine, T2w, T2-mapping, T2*-mapping and LGE imaging (0.1 mmol/kg gadolinium DTPA) were performed in identical short axis locations using the ‘3 of 5’ approach. Data were evaluated offline using commercial software (cvi42 v4.1.5, Circle Cardiovascular Imaging Inc., Calgary, Canada). On the LGE images showing the largest infarct volume, infarct size was determined by using a semi-automated histogram-based thresholding method. This slice was evaluated for visual presence of IMH by the three methods. Signal intensity (SI) and respective standard deviation of SI (SD) were measured for the infarcted myocardium, remote myocardium and any IMH (if present). SNR was computed for each using the formula = 0.655((SI)/(SD)). CNR was determined comparing contrast-to-noise of infarcted myocardium to IMH (SNRi-SNRIMH). Results Of the twenty patients, 55% (n = 11) had IMH on T2w-imaging. The mean (±standard deviation) SNR and CNR values are listed in Table 1. The visual assessment of T2w imaging correlated strongly to T2-maps (r = 0.69; p = 0.001) and to the T2*-maps (r = 0.60; p = 0.005). The SNR for IMH and infarct zone were significantly different for only T2w imaging (Figure 1). Quantitative CNR for T2w imaging correlated strongly to visual assessment of all three imaging modalities (T2w- r = 0.650; p = 0.002, T2-map- r = 0.454; p = 0.04, T2*-map- r = 0.603; p = 0.005). The CNR for T2-maps and T2*-maps did not show similar correlation to the visual assessment. Conclusion Quantitative and qualitative T2w-imaging assessment for IMH is superior to T2-mapping and T2*mapping.
    No preview · Article · Jun 2015 · Heart (British Cardiac Society)
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    ABSTRACT: The European Society of Cardiology (ESC) and UK National Institute for Health and Care Excellence (NICE) have recently published guidelines for investigating patients with suspected coronary artery disease (CAD). Both provide a risk score (RS) to assess the pre-test probability for CAD to guide clinicians to undertake the most effective investigation. The aim of the study was to establish whether there is a difference between the two RS models. We retrospectively reviewed records of 479 patients who presented to a UK district general hospital with chest pain between August 2011 and April 2013. The RS was calculated using ESC and NICE guidelines and compared. From the 479 patients, 277 (58%) were male and the mean age was 60 years. The mean RS was greater using NICE guidelines compared with ESC (66.3 vs 47.9%, 18.4% difference; p<0.0001). The difference in mean RS was smaller in patients with typical chest pain (13.0%). When we divided the cohort based on NICE criteria into 'high'- and 'low'-risk groups, the difference in the mean RS was 24.3% in the 'high'-risk group (p<0.001) compared with 2.8% in the 'low'-risk group. The UK NICE risk score model overestimates risk compared with the ESC model. © Royal College of Physicians 2015. All rights reserved.
    Full-text · Article · Jun 2015 · Clinical medicine (London, England)
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    ABSTRACT: Background Cardiac studies of patients with rheumatoid arthritis (RA) have demonstrated abnormalities in left ventricular (LV) remodelling that is associated with development of heart failure and cardiovascular (CV) morbidity and mortality1,2. No studies to date have evaluated for changes in myocardial and vascular function in treatment-naïve early RA (ERA). Objectives To evaluate whether patients with newly diagnosed, treatment-naïve ERA demonstrate myocardial and vascular changes on cardiac MRI (CMR) compared with matched controls. Methods Sixty-six ERA patients fulfilling ACR/EULAR classification criteria and with no CVD history underwent 3.0T CMR (Philips Achieva TX) at a cardiology-CMR unit. All patients had symptoms for less than 1 year, were DMARD treatment-naïve and with minimum disease activity score (DAS28) ≥3.2. Thirty healthy controls (HC) were matched by age, sex and blood pressure. Standard balanced steady state free precession cine images were acquired and LV dimensions calculated. For aortic distensibility, multi-phase SSFP cine images (50 phases) were acquired in a plane transverse to the ascending aorta at the level of the pulmonary artery bifurcation. Aortic contours were drawn by manual planimetry of the endovascular–blood pool interface at the times of minimal and maximal distension. Additional parameters measured include strain analysis and extracellular volume (results awaited). Body surface area (BSA) index values are presented. Results Patients in ERA and HC groups were similar mean (SD) age [49.4 (13.08) and 46.7 (11.4) respectively, p=0.33] and systolic BP [122 (23) and 126 (16) respectively, p=0.18]. Mean (SD) BSA was lower in the ERA group vs HC [(1.83 (0.22) vs 1.9 (0.21) respectively, p=0.09]. In the ERA group, median (IQR) ESR, CRP and mean (SD) DAS28 were 39.5 (28.7)mm/hr, 18.9 (27.1)mg/L and 5.65 (1.6) respectively. 54 (82%) and 48 (73%) patients were ACPA and RF positive respectively. Table 1 details CMR parameters. Aortic distensibility was significantly reduced in ERA patients compared to HC (median ± IQR, 3.19±2.16 10-3mmHg-1 versus 4.4±2.1 10-3mmHg-1, p=0.001). Other measures of arterial stiffness including aortic stiffness index, compliance and strain showed similar significant differences. Left ventricular and right ventricular end-systolic and end-diastolic volumes were all significantly lower in the ERA vs HC. A trend for lower LVmass index in the ERA group was observed and seemed to be associated with seropositivity (see table 2). Evidence for overt inflammation/fibrosis was seen in 4 patients with focal non-ischaemic patterns of LGE. Conclusions This first CMR study in treatment-naive ERA demonstrates abnormalities at the earliest stage of RA. Reduced vascular function, ventricular volumes, and trend change in LV geometry suggest an early cardiomyopathy. This might imply higher risk for CV morbidity and mortality at time of diagnosis. Further investigation will clarify the natural history, clinical implications and the scope to modify outcome with effective RA therapy. References Disclosure of Interest None declared
    No preview · Article · Jun 2015 · Annals of the Rheumatic Diseases
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    ABSTRACT: Aortic stenosis is the commonest valve defect in the developed world and is associated with a high mortality once symptomatic. There is a difference in the way that male and female hearts remodel in the face of chronic pressure overload: women develop a concentrically hypertrophied, small cavity left ventricle (LV), whereas men are more prone to the development of eccentric hypertrophy. At a cellular level, there is an increase in collagen and metalloproteinase gene expression in males suggesting a different regulation of extracellular volume composition according to sex. Male hearts with aortic stenosis appear to have more fibrosis than their female comparators. The trigger for this appears to be in part related to estrogen receptor signaling, but other factors such as renin-angiotensin activation, nitric oxide, and circulating noradrenaline levels may also be implicated. Treatment options include surgical valve replacement (SAVR) and more recently transcatheter aortic valve replacement (TAVR). Female sex may be a risk factor for adverse outcome following SAVR and conversely appears to confer a survival advantage when undergoing TAVR. Whether the lower mortality seen following TAVR in women compared with men (despite their increased age and frailty) reflects their longer life expectancy, smaller annular size (and less post-TAVR aortic regurgitation), more favorable LV reverse remodeling, or more likely, a combination of these factors remains to be established.
    No preview · Article · May 2015 · Journal of Women's Health

Publication Stats

5k Citations
1,880.37 Total Impact Points

Institutions

  • 2015
    • Leeds Teaching Hospitals NHS Trust
      Leeds, England, United Kingdom
  • 2007-2015
    • University of Leeds
      • Multidisciplinary Cardiovascular Research Centre
      Leeds, England, United Kingdom
  • 2011-2014
    • King's College London
      • • Cardiovascular Division
      • • Department of Cardiovascular Imaging
      • • Division of Imaging Sciences and Biomedical Engineering
      Londinium, England, United Kingdom
  • 2013
    • Sapienza University of Rome
      • Department of Radiological, Oncological and Pathological Sciences
      Roma, Latium, Italy
  • 2011-2012
    • ICL
      Londinium, England, United Kingdom
  • 2005
    • WWF United Kingdom
      Londinium, England, United Kingdom
  • 2003
    • University of Leipzig
      Leipzig, Saxony, Germany
  • 2001-2003
    • British Heart Foundation
      Londinium, England, United Kingdom
    • Texas Heart Institute
      Houston, Texas, United States
    • The Bracton Centre, Oxleas NHS Trust
      Дартфорде, England, United Kingdom