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J Am Coll Cardiol, 2005; 46:411-416, doi:10.1016/j.jacc.2005.04.045 (Published online 5 July 2005).
© 2005 by the American College of Cardiology Foundation
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MEETING HIGHLIGHTS

Meeting Highlights of the 8th Annual Scientific Sessions of the Society for Cardiovascular Magnetic Resonance, January 21 to 23, 2005

Christopher M. Kramer, MD*,*, Matthias G. Friedrich, MD{dagger}, Stefan Neubauer, MD{ddagger}, Matthias Stuber, PhD§, Tal Geva, MD||, Charles B. Higgins, MD and Warren J. Manning, MD#

* University of Virginia Health System, Charlottesville, Virginia
{dagger} University of Alberta, Calgary, Canada
{ddagger} Oxford University, Oxford, United Kingdom
§ Johns Hopkins University, Baltimore, Maryland
|| Children’s Hospital, Boston, Massachusetts
University of California, San Francisco, California
# Beth Israel-Deaconess Medial Center, Boston, Massachusetts.

Manuscript received March 17, 2005; revised manuscript received March 22, 2005, accepted April 13, 2005.

* Reprint requests and correspondence: Dr. Christopher M. Kramer, University of Virginia Health System, Departments of Medicine and Radiology, Lee Street, Box 800170, Charlottesville, Virginia 22908. (Email: ckramer{at}virginia.edu).


   Abstract
Top
 Abstract
Best abstract competition
 Clinical science
 Basic science
 Pediatric imaging
 Conclusions
 References
 
Parallel tracks for clinical scientists, basic scientists, and pediatric imagers was the novel approach taken for the highly successful 8th Annual Scientific Sessions of the Society for Cardiovascular Magnetic Resonance, held in San Francisco, California, January 21 to 23, 2005. Attendees were immersed in information on the latest scientific advances in cardiovascular magnetic resonance (CMR) from mice to man and technological advances from systems with field strengths from 0.5 T to 11.7 T. State-of-the-art applications were reviewed, spanning a wide range from molecular imaging to predicting outcome with CMR in large patient populations.

The 8th Annual Scientific Sessions of the Society for Cardiovascular Magnetic Resonance (SCMR) took place January 21 to 23, 2005, at the Hyatt Regency Embarcadero in San Francisco, California. Over 1,000 participants attended the meeting, which offered parallel tracks for clinical cardiovascular magnetic resonance (CMR) scientists, basic CMR scientists, and pediatric imagers, an innovative format that was well received. A pre-conference physician’s clinical introductory workshop was attended by 319 participants, a record number. A three-day concurrent CMR technologist workshop was likewise well attended, with 110 participants, and included a best abstract session. A trainees and students hour offered helpful hints for career advancement in CMR for both basic and clinical trainees alike. An entire session was devoted to issues surrounding training and credentialing guidelines and reimbursement of CMR. An expanded number of oral abstracts were presented in the main meeting, numbering over 110. In total, nearly 400 abstracts were presented, either orally or in poster form, including two moderated poster sessions. Keynote speakers included Valentin Fuster, MD (Mount Sinai Hospital, New York, New York), who spoke on "Imaging the Vulnerable Patient"; Joanne Ingwall, PhD (Brigham and Women’s Hospital, Boston, Massachusetts), who delivered an address entitled "MR Molecular Spectroscopy"; and Kanu Chatterjee, MD (University of California, San Francisco), who led off the CMR in congestive heart failure (CHF) session with an "Overview of the Problem of CHF."


   Best abstract competition
Top
 Abstract
 Best abstract competition
Clinical science
 Basic science
 Pediatric imaging
 Conclusions
 References
 
Based on the abstract submission scoring and subsequent presentation at the meeting, a panel of reviewers selected the two best oral clinical science and basic science presentations, the best pediatric oral presentation, and the two best moderated poster presentations. In the prize-winning clinical abstract, researchers from five centers showed in 100 patients the predictive value of infarct size determined in contrast-enhanced images (1). Among the risk factors such as CHF symptoms, ejection fraction (EF), severity of coronary disease, and CMR-derived infarct size, only an infarct size of more than 15% of left ventricular (LV) mass and reduced EF were independent predictors of outcome. In a multivariate analysis, CMR-derived infarct size of more than 15% of LV mass had the highest predicted value for death, with a relative risk of 9.9 (95% confidence interval, 1.6 to 63). In the second-prize clinical abstract, Dr. Timothy Albert (Duke University, Durham, North Carolina) applied contrast-enhanced CMR in 96 patients 4 ± 3 days after acute myocardial infarction (MI) and found that the prevalence of microvascular obstruction as defined by the presence of hypoenhancement surrounded by hyperenhancement decreases over time (2). Whereas microvascular obstruction was present in 60% of 96 patients at 1 to 2 days post-MI and in only 27% at 8 to 14 days, none of a subgroup of 43 patients imaged at 151 days after MI had microvascular obstruction. The top pediatric abstract was presented by Dr. Isabelle Vonder Muhll (Royal Brompton Hospital, London, England) who showed that patients with successful coarctation repair and without arterial hypertension have normal aortic pulsatile hemodynamics and normal LV mass (3).

The winning basic science oral abstract was presented by Dr. Yijen Wu (Carnegie-Mellon University, Pittsburgh, Pennsylvania), who used a CMR approach to visualize single immune cells in acute allograft rejection (4). The group used large iron-oxide particles (mean size, 0.98 µm), so-called Bangs particles, to label a rat model of working lung and heart rejection in a high-field setting at 4.7 T and 11.7 T. A distinct pattern of punctual signal intensity changes was attributed to single-cell labels because the radius of the signal intensity changes exceeded that of the labeled cell by a factor up to 50. The runner-up oral abstract was given by Dr. Patrick Winter (Washington University, St. Louis, Missouri), who presented data on the use of CMR to follow up cholesterol-fed New Zealand white rabbits with early atherosclerosis after treatment with fumagillin-loaded nanoparticles (5). Using {alpha}vß3-targeted paramagnetic particles as a reporter, the investigators could accurately monitor therapeutic success.

Dr. Vinay Pai (New York University and the National Heart, Lung, and Blood Institute) presented a prize-winning moderated poster regarding a new approach for CMR imaging with extremely high temporal resolution (6). The group used a modified multi-echo steady-state free precession (SSFP) sequence combined with parallel imaging techniques. With this approach, called phase train imaging, a temporal resolution of up to 1.5 ms could be achieved, allowing for studies of valvular motion and ventricular dyssynchrony. Another prize-winning moderated poster was given by Dr. Vivek Muthurangu (Kings College, London, England), who used CMR flow data in a two-element Windkessel model to calculate pulmonary vascular resistance without knowing the pulmonary capillary wedge pressure (7). In 15 patients, cardiac catheterization was performed during the CMR study. The CMR flow data were obtained at baseline and after nitric oxide administration and compared with invasive measurements. The investigators reported a mean difference of only 4% at baseline and 2% during nitric oxide. Thus, CMR-derived flow data allow for complete non-invasive quantification of pulmonary vascular resistance.


   Clinical science
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 Abstract
 Best abstract competition
 Clinical science
Basic science
 Pediatric imaging
 Conclusions
 References
 
Controversies in CMR—stress and viability.   In the opening clinical plenary session, new approaches to the assessment of ischemic heart disease were discussed. The importance of both rest imaging to identify artifacts during first-past perfusion imaging during vasodilator stress and late imaging to properly identify regions of myocardial scar as the cause of hypoperfusion was emphasized. The combined use of late gadolinium enhancement with response to low-dose dobutamine in a given segment was discussed as a new approach to assessing viability in segments with nontransmural chronic infarction. The latest data on optimal stress techniques were reviewed, concluding that dobutamine stress function offers the best overall accuracy, whereas vasodilator stress first-pass perfusion imaging may be the most sensitive technique.

These issues were addressed in several abstract presentations. Quantitative first-pass perfusion magnetic resonance was used to show reduced perfusion at rest in myocardial regions supplied by arteries in patients with severe stenoses (80% to 100% stenoses) that improved after angioplasty (8). A multi-center report (9) derived from the Women’s Ischemic Syndrome Evaluation (WISE) study in 133 women with suspected myocardial ischemia combined an intermediate Framingham score with a global myocardial perfusion index derived from resting perfusion CMR to select patients for x-ray coronary angiography. Each was independently predictive of major adverse cardiovascular events. In a study combining noninvasive modalities, adenosine stress CMR perfusion was used to assign hemodynamic significance to stenoses identified on cardiac computed tomography (CCT) angiography in a subset of 68 patients in which determination of significance was equivocal because of borderline narrowing or heavy calcification (10). Subendocardial perfusion deficits were seen in 10 of the 68 patients in regions jeopardized by stenoses shown on CCT, suggesting a potential complementary role of these techniques.

High-dose dobutamine stress cine MR and late gadolinium enhancement have both been used to effectively predict cardiac events in patients with known obstructive coronary artery disease. After 16-month follow-up of 320 patients, high-dose dobutamine stress cine CMR predicted adverse cardiac events (11) in a 3:1 ratio in those with to those without wall motion abnormalities. Late gadolinium enhancement predicted event-free survival in 257 patients with symptomatic coronary artery disease over a mean follow-up period of 13.8 months (12). By multivariate Cox regression model, the presence of late enhancement was the strongest predictor beyond standard risk predictors.

Late gadolinium enhancement identified microvascular obstruction in 17 of 32 patients within one week after successful percutaneous interventional reperfusion of ST-segment elevation MI (13). Microvascular obstruction was associated with later reperfusion, greater transmurality of infarction, more compromised ventricular function, increased ventricular volumes, and larger infarct mass. Two studies (14,15) reported the effectiveness of late gadolinium enhancement for identifying right ventricular (RV) infarction in patients with acute inferior MI (14,15). Late gadolinium enhancement detected RV involvement in five times more patients with inferior MI than was clinically suspected (15).

CMR in CHF.   The CMR in CHF plenary session highlighted the utility of CMR techniques, including volumetric imaging and late gadolinium enhancement, for identifying the etiology of dilated cardiomyopathy and evaluating pharmacologic, revascularization, and surgical therapies. Novel findings of late gadolinium enhancement in several clinical scenarios were emphasized, including hypertrophic cardiomyopathy after alcohol septal ablation, myocarditis, amyloidosis, and arrhythmogenic RV cardiomyopathy.

A number of abstracts regarding the use of CMR in CHF were presented at SCMR. Patients optimally treated with beta-blockade and angiotensin-converting enzyme inhibition were shown not to have adverse remodeling as demonstrated by CMR (16). Many of these patients with CHF were shown to have impaired elastic properties of the aorta (17). Regression of remote LV mass after alcohol septal ablation for hypertrophic cardiomyopathy was shown, suggesting some degree of afterload dependence of the hypertrophy (18). Late gadolinium enhancement shows myocardial scarring/damage in 24% of patients with sarcoidosis (19) and in 40% of patients with beta thalassemia major (20). In the latter disease, T2* measures of iron loading were seen in 65% of 167 patients screened with a significant relationship between T2* and EF (21). In another study, methods for optimizing the measurements of iron overload were identified (22).

CMR and CCT.   A special Clinical Plenary Session was held comparing CMR with CCT. The safety of pacemakers and implanted cardioverter-defibrillators in the MR environment was discussed, including historical ex-vivo data regarding potential lead heating and pacemaker reprogramming as well as provocative animal data showing safe CMR scanning with modern pacemakers. In all clinical cases, an electrophysiologist with pacemaker scanning tools is present for the CMR examination. The review of CCT included a discussion of risks of increasing levels of ionizing radiation exposure as well as prospective electrocardiographic gating approaches to reducing patient exposure levels.

These were followed by two focused applications of CMR and CCT on the pulmonary veins and coronary imaging. Data were reviewed highlighting the two modalities for imaging of anomalous pulmonary venous drainage and follow-up imaging for patients who have undergone pulmonary vein ablation for atrial fibrillation. A discussion of coronary imaging followed, with impressive images shown for both modalities in the identification of anomalous coronary artery disease and native vessel integrity, and for characterization of coronary artery bypass graft patency. For native vessel disease, 64-slice CCT units seemed to be particularly advantageous (vs. 16-slice CCT) with regard to an abbreviated breath-hold and improved success for imaging of distal segments. Despite the shorter breath-hold duration, similar iodinated contrast volume is needed with increased radiation exposure (vs. 16-slice CCT units).

Comparative studies between CCT and CMR in reference to the gold standard X-ray coronary angiography are becoming increasingly important. In one study, 16-slice CCT and a CMR protocol were compared (23). It was found that in segments interpretable by CCT, it offered the superior diagnostic accuracy when compared with CMR. However, calcifications posed a major challenge for the interpretability of CCT. In a large single-center trial (24) including 92 patients with suspected coronary artery disease, a whole-heart three-dimensional coronary CMR technique including parallel imaging showed outstanding image quality and a high sensitivity (85%), specificity (90%), negative (88%) and positive (88%) predictive value, and accuracy (88%) for the identification of coronary artery disease with X-ray coronary angiography as the gold standard.


   Basic science
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 Abstract
 Best abstract competition
 Clinical science
 Basic science
Pediatric imaging
 Conclusions
 References
 
Lumen, wall, and new contrast mechanisms.   Several leading figures in the field discussed the role of CMR in identifying the vulnerable patient by imaging atherosclerotic plaque using new contrast agents and other mechanisms to identify early plaque and inflammation within plaque. Molecular imaging agents are extending the potential of noninvasive medical diagnosis from gross anatomic descriptions to complicated phenotypic characterizations based on the recognition of unique cell surface biochemical signatures. The MR nanoparticulate agents afford the opportunity not only for targeted diagnostic studies but also for image-monitored site-specific therapeutic delivery, which will offer new clinical approaches to many diseases. Atherosclerotic plaque imaging in the carotid vessels by multi-spectral CMR with the addition of contrast agents for plaque characterization was discussed, including use in multi-center trials of new therapies for atherosclerosis regression and stabilization.

Molecular imaging.   The molecular imaging session reviewed several imaging approaches, including nuclear techniques, CMR, and CMR spectroscopy. It was pointed out that sensitivity for nuclear probes is higher than that of CMR at present. Novel CMR approaches to track cellular therapy using ultra-small particulate iron oxides (USPIO) and gadolinium-based nanoparticles were reviewed in detail.

An entire session of the opening day was devoted to molecular abstracts, including discussion of new contrast agents. A magneto-optical iron oxide agent was applied to image inflamed atherosclerotic plaque in apoE–/– mice (25). Another group used iron particles, small paramagnetic iron oxide particles, conjugated to vascular cell adhesion molecule-1 antibody to identify activated endothelial cells using ex vivo CMR (26). An off-resonance CMR sequence can be used to generate positive rather than negative contrast with USPIOs (27). A novel gadolinium-labeled fibrin-targeted peptide was used to image carotid artery thrombus in a rabbit model, showing that the targeted agent performed better than conventional gadolinium (28). The same compound was used to image left atrial thrombi in a swine model (29). A different gadolinium-based compound, a texaphyrin complex, was shown to improve identification of aortic atherosclerosis in a rabbit model (30). Nanoparticles targeted to {alpha}vß3 or collagen III were used to identify plaque in balloon-stretch injured carotid arteries in a swine model (31). Gadolinium can also be loaded with high-density lipoprotein-like nanoparticles that are then taken up by atherosclerotic plaques that show CMR enhancement after 24 h (32).

New techniques in CMR.   The basic science session on technical advances in the field was an exciting one. Rapid progress is being made in interventional CMR, high-field CMR, massively parallel imaging, novel non-rectilinear k-space trajectories, spectroscopic approaches, and quantitative measures of intramyocardial strain.

For cardiovascular magnetic resonance coronary angiography (MRCA), the ease of use, near-isotropic spatial resolution, and speed of scan times require further improvement. For these reasons, a strong focus on the technical development of MRCA was seen at SCMR. The combination of most advanced 32-channel receiver technology, coil architecture, and parallel imaging showed promise for substantially abbreviated scanning times in MRCA (33). Isotropic spatial resolution and a significant improvement in ease of use was reported for a self-navigated whole-heart coronary MRCA technique that avoids tedious plan scanning and navigator placement (34). In another study (35), an excellent correlation between interventional MRCA using selective gadolinium injection and X-ray coronary angiography was reported in an animal model. Similarly, experimental in-vitro studies with polarized 13C show great promise for selective and exclusive visualization of the coronary arterial tree (36).

Murine CMR.   Genetically manipulated mouse models play an ever-increasing role in cardiovascular research because they allow the study of the functional effects of deleting or augmenting a specific gene and its product in mice; CMR is emerging as the most appropriate technique for cardiac phenotyping because of the miniature size of the mouse heart and its fast heart rate.

Many methodologic advances in murine CMR were on display, including three-dimensional deformation analysis of the temporal evolution of myocardial dysfunction in mice post-MI (37). Cardiovascular magnetic resonance with ferumoxtran-10 particles taken up by macrophages allows accurate assessment of inflammation accompanying myocardial infarction (38). Infarct expansion using late gadolinium enhancement was shown, and investigators showed that infarct size expressed as the percent of LV mass decreased with time, but increased when expressed as percent of LV circumference (39). The first successful implementation of in vivo 1H-MR spectroscopy in mice was reported from a 2-µl voxel in the interventricular septum with quantification of metabolites such as creatine, lipids, and taurine (40).

Applications of CMR to transgenic mouse models included the use of bradykinin B2 receptor knockout and angiotensin-2-receptor overexpression mice to show that post-infarct remodeling in angiotensin-2 receptor overexpressed mice is not influenced by the absence of the bradykinin B2 receptor (41). Overexpression of growth hormone in the brain was shown to lead to impaired cardiac function and energetics as well as depletion of myocardial catecholamine levels (42). Attenuation of post-MI LV dilation and dysfunction was shown in inducible nitric oxide synthase (iNOS) knockout mice, highlighting the important role of iNOS-derived nitric oxide in remodeling (43).

3-T/interventional CMR.   The state of the art in high-field CMR and interventional CMR was emphasized, including MR-compatible equipment needs, CMR-guided electrophysiologic procedures, and CMR guidance of delivery of genes and stem cells in animal models. Combined CMR and X-ray systems are being used to guide interventions in congenital heart disease, including closure of atrial septal defects and stenting for pulmonic valve stenosis or aortic coarctation. The potential pitfalls and artifacts as well as the potential improvements in signal-to-noise ratio at higher field strengths were discussed at length. At higher field strength, the expected improvement in the signal-to-noise ratio may be particularly beneficial for MRCA. A recently completed study comparing 1.5-T and 3-T coronary CMR in patients with suspected coronary artery disease (44) showed that 1.5-T methodology could easily be adopted at 3-T, but in-depth analysis and improvement of individual sequence components is still necessary to take full advantage of the higher field strength.


   Pediatric imaging
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 Abstract
 Best abstract competition
 Clinical science
 Basic science
 Pediatric imaging
Conclusions
 References
 
This year the SCMR introduced the first multi-day program dedicated to CMR of congenital and acquired pediatric heart disease. An initiative to form a Pediatric Study Group within SCMR was approved by the SCMR Board of Trustees. Some of the unique challenges of imaging patients with congenital heart disease (CHD) were addressed, including CMR-guided cardiac catheterization in children, the comparison with CCT in children with vascular anomalies, and the optimal method for sedation of infants and young children. Advances in CMR applications, in particular in subgroups of patients with CHD, were discussed, including those with bidirectional cavopulmonary anastomosis, functional single ventricle, repaired tetralogy of Fallot, and aortic coarctation.

Two groups reported on the use of late gadolinium enhancement in congenital heart disease, including anomalous origin of the left coronary artery from the pulmonary artery (45) and postoperative CHD (46). One group described their initial experience with CMR in a 3-T scanner for evaluation of CHD (47), showing improvements in signal-to-noise ratio and shorter acquisition times as a result of the use of parallel imaging. On the other hand, susceptibility artifacts, especially with the use of the SSFP, were pronounced and significantly limited cine imaging in infants. Good agreement between flow measurements by CMR and catheterization was shown in 17 pediatric patients who were sedated with oral chloral hydrate and breathed freely, validating the free breathing method of measuring flow (48). Another study found that measurements of RV and LV dimensions were not significantly different when measured by real-time cine CMR (acquisition time, ~1 min) and by electrocardiograph-triggered SSFP (acquisition time, ~10 min) (49). Interstudy reproducibility of CMR evaluation of RV dimensions in 10 adult patients with repaired tetralogy of Fallot showed a coefficient of variability of ≤5% for RV end-diastolic and end-systolic volume, ejection fraction, and mass (50). A study on the effect of metallic implants on CMR’s ability to evaluate the anatomy and ventricular function in 100 patients with Fontan circulation found that metallic implants produced image artifacts that precluded a complete volumetric assessment in 20% (51).


   Conclusions
Top
 Abstract
 Best abstract competition
 Clinical science
 Basic science
 Pediatric imaging
 Conclusions
References
 
The 2005 SCMR meeting brought together a wide array of interests in the field of SCMR, including basic scientists, clinician scientists, practitioners, technologists, nurses, and trainees, for a highly successful meeting. The combination of practical clinical information and cutting-edge basic science presented at the meeting epitomizes the very bright future of the field.


   References
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 Best abstract competition
 Clinical science
 Basic science
 Pediatric imaging
 Conclusions
 References
 

  1. Kaushal R, Fieno D, Radin M, et al. Infarct size is an independent predictor of mortality in patients with coronary artery disease(abstr) J Cardiovasc Magn Reson 2005;7:39.
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  3. Vonder Muhll IF, Swan L, Kraidly M, et al. Normal aortic compliance and left ventricular mass late after repair of aortic coarctation(abstr) J Cardiovasc Magn Reson 2005;7:75.
  4. Wu YL, Foley L, Hitchens K, et al. Non-invasive in vivo "histology"visualizing single immune cells in acute allograft rejection after heterotopic heart transplantation with micrometer-sized iron oxide containing particles. (abstr) J Cardiovasc Magn Reson 2005;7:7.
  5. Winter PM, Morawski AM, Caruthers SD, et al. Serial quantification of targeted fumagillin therapy using {alpha}vß3-targeted paramagnetic nanoparticles in early atherosclerosis at 1.5T(abstr) J Cardiovasc Magn Reson 2005;7:3.[Medline]
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  34. Stehning C, Boernert P, Nehrke K, Eggers H, Stuber M. Free-breathing whole heart MRI with 3D-radial SSFP and self-navigated image reconstruction(abstr) J Cardiovasc Magn Reson 2005;7:56-57.
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  40. Schneider JA, Tyler DJ, Fischer A, et al. Cardiac 1H-MR spectroscopy in normal and Guanidinoacetate N-Methyltransferase (GAMT) deficient mice in vivo(abstr) J Cardiovasc Magn Reson 2005;7:106.
  41. Isbell DC, Voros S, Yang Z, et al. Bradykinin B2 receptor does not mediate the anti-remodeling effects of the angiotensin II type 2 receptor following myocardial infarction(abstr) J Cardiovasc Magn Reson 2005;7:27.
  42. Bohlooly M, Bollano E, Mobini R, Soussi B, Thornell J, Omerovic E. Selective cerebral overexpression of growth hormone alters cardiac function, morphology, energy metabolism and catecholamines in transgenic mice(abstr) J Cardiovasc Magn Reson 2005;7:80.
  43. Epstein FH, Yang Z, Roy RJ, Xu Y, Berr SS, French BA. CMR demonstrates reduced post-infarct left ventricular remodeling in mice with iNOS inhibition(abstr) J Cardiovasc Magn Reson 2005;7:29.
  44. Hackenbroch M, Meyer C, Schmiedel A, et al. Coronary MRA at 3.0 Tesla compared to 1.5 Teslainitial results in patients with suspected coronary artery disease. (abstr) J Cardiovasc Magn Reson 2005;7:61-62.
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