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3D myocardial deformation analysis from cine MRI as a marker of amyloid protein burden in cardiac amyloidosis: validation versus T1 mapping

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Abstract

Cardiac amyloidosis (CA) is a significant contributor to heart failure with preserved ejection fraction and is appreciating expanding therapeutic options. Non-invasive tools aimed at accurate identification and surveillance of therapeutic response are of immediate and expanding need. While native and post-contrast T1 mapping quantify expansion of the extra-cellular compartment from amyloid protein deposition, 3D strain analysis of non-contrast cine images offers unique advantages relevant to high prevalence of renal insufficiency in this population and reduced dependency on field strength, pulse sequence, and vendor implementation. We aimed to evaluate global and segmental associations between 3D strain and T1 mapping in patients with cardiac amyloidosis. Twenty consecutive patients with confirmed CA were recruited and underwent a standardized cardiovascular magnetic resonance imaging protocol at 3 T including using multi-planar cine imaging and T1 mapping using a shortened modified look-locker inversion recovery sequence. T1 mapping was performed pre- and (when permitted by renal function) post-contrast and measured for segmental T1 values. Spatially-matched 3D strain-based measures were similarly calculated. Mean left ventricular ejection fraction was 61 ± 21% (range 30–73%). Mean global native T1 was 1308 ± 96 ms. Post-contrast T1 and partition coefficient were 558 ± 104 ms and 0.85 ± 0.31, respectively. Global myocardial strain values were 8.1 ± 2.9% in the longitudinal direction, − 9.2 ± 3.4% in the circumferential direction, and 41.7 ± 22.8% in the maximum principal direction. Segmental analyses confirmed relative worsening in T1 values and reductions in strain values in the basal myocardial segments with relative sparing of the apical segments. Significant associations between T1 and strain-based measures were observed globally and segmentally, with the strongest associations found both globally and segmentally in the circumferential and minimum principal directions of deformation. This study identifies strong associations between 3D myocardial strain and T1-mapping based markers of regional amyloid protein deposition. These findings support expanded investigation of myocardial strain as a surrogate marker of response to novel therapeutic strategies in patients with cardiac amyloidosis.

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Abbreviations

CA:

Cardiac amyloidosis

ACE:

Angiotensin converting enzyme

ARB:

Angiotensin II receptor blocker

AL:

Amyloid light chain

ATTR:

Amyloid transthyretin

COPD:

Chronic obstructive pulmonary disease

CMR:

Cardiovascular magnetic resonance imaging

HFpEF:

Heart failure with preserved ejection fraction

LV:

Left ventricular

RV:

Right ventricular

LA:

Left atrial

LVEF:

Left ventricular ejection fraction

RVEF:

Right ventricular ejection fraction

ShMOLLI:

Shortened modified look-locker inversion recovery

LGE:

Late gadolinium enhancement

QOL:

Quality of life

RRSR:

Relative regional strain ratio

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Acknowledgements

Dr. White received salary support from the Heart and Stroke Foundation of Alberta during this study.

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Author notes

  1. Na’ama Avitzur and Alessandro Satriano have contributed equally to this manuscript.

Authors and Affiliations

  1. Stephenson Cardiac Imaging Centre, University of Calgary, #0700, SSB, Foothills Medical Centre, 1403-29th St. NW, Calgary, AB, T2N2T9, USA

    Na’ama Avitzur, Alessandro Satriano, Muhammad Afzal, Mariam Narous, Yoko Mikami, Reis Hansen, Gary Dobko, Jacqueline Flewitt, Carmen P. Lydell, Andrew G. Howarth, Nowell M. Fine & James A. White

  2. Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada

    Carmen P. Lydell

  3. Department of Cardiac Sciences, University of Calgary, Calgary, AB, Canada

    Andrew G. Howarth, Nowell M. Fine & James A. White

  4. Siemens Medical Solutions USA Inc., Chicago, IL, USA

    Kelvin Chow

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  1. Na’ama Avitzur
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Corresponding author

Correspondence to James A. White.

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Conflict of interest

Ms. Na’ama Avitzur declares that she has no conflict of interest. Dr. Alessandro Satriano declares that he has no conflict of interest. Dr. Muhammad Sarim Afzal declares that he has no conflict of interest. Ms. Mariam Narous declares that she has no conflict of interest. Dr. Yoko Mikami declares that she has no conflict of interest. Mr. Reis Hansen declares that he has no conflict of interest. Mr. Gary Dobko declares that he has no conflict of interest. Mrs. Jacqueline Flewitt declares that she has no conflict of interest. Dr. Carmen P. Lydell declares that she has no conflict of interest. Dr. Andrew G. Howarth receives consulting fees from Amgen. Dr. Kelvin Chow is employed by Siemens Medical Solutions USA. Inc. Dr. Nowell M. Fine receives consulting fees from Novartis and Pfizer. Dr. James A. White received salary support from the Heart and Stroke Foundation of Alberta during this study, receives research grants from Circle Cardiovascular Inc., and is a shareholder of Cohesic Inc.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

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Informed consent was obtained from all individual participants included in the study.

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Avitzur, N., Satriano, A., Afzal, M. et al. 3D myocardial deformation analysis from cine MRI as a marker of amyloid protein burden in cardiac amyloidosis: validation versus T1 mapping. Int J Cardiovasc Imaging 34, 1937–1946 (2018). https://doi.org/10.1007/s10554-018-1410-5

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