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OUR MISSION: TO REDUCE THE BURDEN OF CARDIOVASCULAR DISEASE
Dr. Daniel Messroghli
Pro: Ready for prime time - Valentina Puntmann, FrankfurtContra: Not ready for prime time - James Moon, London
Placed at the end of a long day of exciting sessions on various aspects of CMR, this Pro/Con debate still attracted a large audience of clinicians who were curious to learn from two experts if CMR mapping techniques are “ready for prime time”, i.e. clinical application, or not.
Both speakers focussed on T1 mapping in their talks. As Dr. Puntmann put it: “T2* has been prime time in the assessment of iron load for many years already anyway, and T2 mapping is known to be able to detect myocardial edema – people just have to use it.” So she made her case for the clinical application of T1 mapping. While she does recognize that there are technical problems and disadvantages, she does not think they are unique to T1 mapping. Rather, T1 mapping is just going through the different stages of translation that all novel diagnostic tests and biomarkers have to go through, including steps of validation, qualification, and utilization. Typical applications could be the detection of subclinical disease in conditions such as hypertrophic cardiomyopathy, dilated cardiomyopathy, or systemic lupus erythematodes. Moreover, Dr. Puntmann cited several publications that highlight the utility of T1 mapping in patients with myocarditis.
Dr. Moon started his contra-talk with a short historical review on major interventions that form the basis of today’s use of cardiac T1 mapping. In order to further set the current stage of T1 mapping into perspective, he went back to statements that were issued by the T1 Working Group during one of their first meetings in 2012. Interestingly, the group stated at the time that they expected (and aimed) for T1 mapping to be applied in clinical routine within 5 years. While clearly not all necessary steps (such as large multi-center trials) have been achieved since then, huge progress was made in many regards including the implementation of robust acquisition methods and their availability as commercial products, and the validation of simplified imaging protocols including single-bolus administration of contrast media for the assessment of ECV. Using a compelling chart on the basis of an illustration from Martin Ugander, Dr. Moon explained why he thinks that T1 mapping is ready for clinical use in rare diseases such as amyloidosis and Fabry’s, where the changes in myocardial T1 reach several standard deviations from the mean, but not “ready for prime time” in common conditions such as diffuse myocardial fibrosis, where the combination of biological variation and measurement error leads to large overlap between normal and disease. Despite doing his best to live up to his role as the “con”-speaker, he could not resist to express his fascination about a recent scientific paper from the CMR group in Leeds. The authors had found that ECV is reduced in athletes’ hearts, and thus potentially provides a new means for differentiating physiologic from pathologic left ventricular hypertrophy and remodelling. Doesn’t that sound like prime time yet?
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