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Controversies in clinical CMR: facts and myths

Lecture Session I

Lon Simonetti provided an excellent overview of exercise CMR and potential added clinical value. Exercise is a more potent ad physiologic mode of stress compared to pharmacologic stress, and provides prognostic information from exercise capacity. Supine ergonomic stress permits imaging during exercise but may submaximal stress testing, but offers simultaneous CMR imaging, including assessment of cardiac output, stroke volume and peak systemic flow through great arteries. It can also be used to assess RV function pre- and post-percutaneous pulmonary valve implantation (PPVI), and cardiac output in children after Fontan reparative surgery. Treadmills provide true exercise stress along with prognostic information, and treadmills inside the MRI scanner room have been shown to be feasible and safe in multicentre studies, adding physiologic information together with high spatial resolution imaging on CMR not offered by other cardiac stress testing modalities.

Sofia Mavrogeni discussed the role of CMR in the assessment of patients with rheumatologic diseases, such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), large- and small-vessel vasculitides, inflammatory cardiomyopathies (IM), systematic sclerosis (SSc), mixed connective tissue disease (MTCD) and sarcoidosis. These patient cohorts have frequently have a systematic inflammatory condition, which can affect the cardiovascular system in ways that are subclinical and asymptomatic or atypical in presentation. CMR can often identify subclinical myocardial inflammation, silent myocardial infarctions, subendocardial fibrosis and patterns of heart failure. In conditions like sarcoidosis, CMR findings have prognostic power for death and adverse events. Early identification of CV involvement using CMR may allow opportunities for treatment and risk optimization in patients with rheumatologic diseases.

Gilbert Habib reviewed the utility of CMR and echocardiography in the assessment of LV non-compaction (LVNC). Patients with LVNC present to attention typically around age 40-50 years, with variable impact on LVEF. CMR is superior in delineating cardiac anatomy for this pathology, although echo can provide colour Doppler flow measurements that may help distinguish LV thrombus from a spongy morphology seen in LVNC. Diagnostic criteria using echocardiography and CMR were reviewed. CMR may be especially useful in the differentiation of LVNC from DCM, HCM and idiopathic RCM. In cases of familial LVNC, genetic testing may aid in confirming the diagnosis. Special variants exist, including biventricular NC and RVNC. Over- and under-diagnosis are challenges in LVNC, and combination of echo, CMR and genetic testing may help improve diagnostic confidence.

Alicia Maceira presented the cardiovascular effects of recreational drugs and the role of CMR in patients who use these substances. These included marijuana/cannabis, cocaine, heroin, ecstasy, amphetamines, “legal highs” (mimics of cocaine or cannabis) and alcohol – the substance most associated with cardiac damage.  A couple of larger-sized studies examining the hearts of user of cocaine (soon or short-term after withdrawal) revealed a range of findings including regional wall motion abnormalities, decreased LVEF, oedema (acute withdrawal), non-ischaemic and ischemic fibrosis. In alcoholic cardiomyopathy, the presence of LGE has prognostic significance for adverse cardiac events. CMR is useful in identifying cardiac syndromes and changes in individuals who use recreational substances, and may provide prognostic information in assessing the long-term harmful effects of recreational drugs on the heart.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.