Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) imaging are two commonly used imaging modalities for evaluating the size and function of the heart. There are advantages and disadvantages associated with both modalities when examining the right ventricle (RV). The RV is positioned partly behind the sternum and lung, sometimes causing shadows in the TTE images. This along with the complex shape of the RV makes volume calculations challenging by 2D TTE. CMR is considered to be the reference method for volume calculations of the ventricles. The valve separating the RV from the right atrium is however often oblique compared to the valve separating the left ventricle from the left atrium. This complicates RV volume calculations using conventional CMR short-axis stack images. The aim of this thesis was to find ways to improve the RV stroke volume and ejection fraction calculations using TTE and CMR. A method, transferring the position of the tricuspid plane from RV long-axis images to short-axis images, was developed to improve the separation of the right atrium from the RV when calculating RV stroke volumes by CMR. The method provided calculations of RV stroke volumes with good agreement to reference volumes. Further, the movements contributing to the RV stroke volume was studied aiming to find new ways of calculating RV stroke volumes and ejection fraction by TTE. A model for RV stroke volume and ejection fraction calculations was evaluated showing underestimation of stroke volumes by TTE compared to CMR, which probably depend on differences in distance measurements using the two modalities. The model provided, however, promising results for ejection fraction calculations which was validated in a study of 37 participants that covered a wide range of EF.

Cardiovascular disease is a leading cause of morbidity and mortality globally. Early diagnostic markers are gaining popularity for better patient care disease outcomes. There is an increasing interest in noninvasive cardiac imaging biomarkers to diagnose subclinical cardiac disease. Feature tracking cardiac magnetic resonance imaging is a novel post-processing technique that is increasingly being employed to assess global and regional myocardial function. This technique has numerous applications in structural and functional diagnostics. It has been validated in multiple studies, although there is still a long way to go for it to become routine standard of care.

Cardiac magnetic resonance (CMR)-derived left ventricular (LV) global longitudinal strain (GLS) provides incremental prognostic information on various cardiovascular diseases but has not yet been investigated comprehensively in patients with Takotsubo syndrome (TS). This study evaluated the prognostic value of feature tracking (FT) GLS, tissue tracking (TT) GLS, and fast manual long axis strain (LAS) in 147 patients with TS, who underwent CMR at a median of 2 days after admission. Long-term mortality was assessed 3 years after the acute event. In contrast to LV ejection fraction and tissue characteristics, impaired FT-GLS, TT-GLS and fast manual LAS were associated with adverse outcome. The best cutoff points for the prediction of long-term mortality were similar with all three approaches: FT-GLS −11.28%, TT-GLS −11.45%, and fast manual LAS −10.86%. Long-term mortality rates were significantly higher in patients with FT-GLS > −11.28% (25.0% versus 9.8%; p = 0.029), TT-GLS > −11.45% (20.0% versus 5.4%; p = 0.016), and LAS > −10.86% (23.3% versus 6.6%; p = 0.014). However, in multivariable analysis, diabetes mellitus (p = 0.001), atrial fibrillation (p = 0.001), malignancy (p = 0.006), and physical triggers (p = 0.006) outperformed measures of myocardial strain and emerged as the strongest, independent predictors of long-term mortality in TS. In conclusion, CMR-based longitudinal strain provides valuable prognostic information in patients with TS, regardless of the utilized technique of assessment. Long-term mortality, however, is mainly determined by comorbidities.

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Beta-talassemia é uma das doenças genéticas mais comuns no mundo, com graus variados de anemia crônica, tratados por transfusões sanguíneas rotineiras nos casos mais graves. A sobrecarga de ferro acentuada a que esses pacientes são submetidos é a principal responsável pela morbimortalidade, sendo o acúmulo de ferro no miocárdio e a doença cardíaca disso decorrente, a principal causa de morte nessa população. A ressonância magnética cardíaca (RMC) é ferramenta central no acompanhamento desses pacientes, utilizando-se da técnica T2*, capaz de determinar a presença e grau da deposição de ferro no miocárdio, modificando o tratamento da terapia quelante de ferro (TQF). Além disso, outros parâmetros volumétricos e funcionais obtidos no exame de RMC podem estar alterados nesses pacientes. Até a atualidade, inexistem estudos nacionais descrevendo uma população de pacientes beta-talassêmicos pelos parâmetros da RMC. Objetivos: 1. Caracterizar a partir dos diversos parâmetros dos exames de RMC, a população dos pacientes talassêmicos acompanhados no Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto. 2. Avaliar o impacto dos diversos parâmetros da RMC com informações clinicas como mudança terapêutica, ocorrência de insuficiência cardíaca e óbito. Métodos: foram avaliados 44 pacientes com diagnóstico de beta-talassemia em seguimento no serviço de hematologia, para os quais foram solicitados exames de RMC na rotina clínica. Os exames incluíram sequências cine SSFP (steady state free precession) nos diversos planos cardíacos, incluindo uma sequência do eixo curto de ambos os ventrículos, esta utilizada para as medidas de volumes e função ventriculares. A sequência T2* utilizada foi gradiente eco com pré-pulso de saturação do sangue, com aquisição de 9 ecos consecutivos em apenas uma apneia. Sequência semelhante foi obtida para cálculo do T2* hepático. Foi feita revisão dos prontuários dos pacientes para avaliação dos dados clínicos. Resultados: 44 pacientes foram avaliados (25 do sexo masculino 56,8 %), com idade de 23,1±10,3 anos e diagnóstico de beta-talassemia maior em 30 casos (68,2 %) e talassemia intermedia em 14 casos (31,8 %). Foram descritos os volumes, massa e função para ambos os ventrículos, bem como a distribuição da medida do T2* miocárdico. Não foram observadas diferenças desses parâmetros entre os diferentes grupos de impregnação miocárdica pelo T2*. O seguimento médio do estudo foi de 4,0 (±1,1) anos com 4,7 (±1,6) exames por paciente. Foram identificados cinco pacientes com doença cardíaca e dois óbitos. Esses pacientes apresentaram redução significativa do T2* miocárdico, da fração de ejeção do ventrículo direito (VD), massa ventricular direita e esquerda e do volume sistólico final do VD, quando comparados aos indivíduos sem acometimento cardíaco reportado. Conclusão: Caracterizou-se a população de pacientes beta-talassêmicos acompanhados nesta instituição, em relação aos diversos parâmetros da RMC, salientando-se o impacto da introdução do método na mudança terapêutica. A medida do T2* miocárdico está correlacionada ao desenvolvimento de cardiopatia e pior evolução clínica, incluindo óbito. Acometimento do VD pode ser indicador precoce da impregnação miocárdica. / Beta-thalassemia is one of the most common genetic disorders worldwide, with different degrees of chronic anemia, treated with routine blood transfusions in severe cases. Morbidity and mortality is mainly related to the chronic iron overload and iron burden these patients endure. Myocardial iron overload and the development of cardiac disease remain the main cause of death for this population. Cardiac magnetic resonance (CMR) plays a central role in patient management, utilizing T2* sequences, which allows for detection and quantification of myocardial iron deposits, thus prompting changes in iron chelation therapy (ICT). Besides, there are other significant CMR volumetric and functional parameters to present abnormalities in these patients. To the present date, no national data has been published, describing a beta-thalassemia patient population from the standpoint of CMR parameters. Objectives: 1. To characterize, from the different CMR parameters, the beta-thalassemia patient population followed at a Brazilian tertiary hospital. 2. To evaluate the impact of these different CMR parameters, in relation to clinical data, such as therapeutic change, cardiac disease and death. Methods: 44 beta-thalassemia patients followed by the hematology service of this institution were evaluated, to whom CMR exams were performed in routine clinical practice. CMR exams included SSFP (steady state free precession) cine images through the different cardiac planes, including a short axis stack through both ventricles, used to calculate ventricular volumes and function. A gradient echo sequence with a dark blood pre-pulse saturation was used to calculate myocardial T2* values, with 9 consecutive echo times acquisition in one breath hold. A similar sequence was used to determine liver T2* values. Medical records were reviewed for clinical data. Results: 44 patients were evaluated (25 males, 56.8 %), with a mean age of 23,1 (±10,3) years, and diagnosis of betathalassemia major in 30 patients (68,2 %) and beta-thalassemia intermedia in 14 (31,8 %). Ventricular volumes, mass and function were described, as well as myocardial T2* distribution. There were no statistical difference observed among the different CMR parameters and the myocardial T2* degrees. Mean follow up was 4,0 (±1,1) years, with 4,7 (±1,6) exams per patient. Five patients with cardiac disease were identified with two deaths during observation. These patients showed a significantly reduced myocardial T2* and RVEF, and an elevated ventricular mass, for both ventricles, and final systolic right ventricular volume, when compared to patients without cardiac disease. Conclusion: A betathalassemia patient population was characterized through the different CMR parameters, highlighting the impact of CMR introduction to treatment decision. Myocardial T2* is related to cardiac disease development, clinical worsening and death. Right ventricular functional worsening could be an early sign of myocardial iron involvement.

Introdução: A miocardiopatia chagásica (MC) apresenta pior prognóstico que as etiologias isquêmica e não isquêmica de miocardiopatia, e acarreta alto custo. A fibrose miocárdica (FM) detectada pela Ressonância Magnética Cardíaca (RMC) mostrou-se um fator preditor independente de risco aumentado em diversas etiologias de insuficiência cardíaca. Na MC, a FM foi associada com marcadores conhecidos de pior prognóstico, como a disfunção ventricular esquerda e arritmia ventricular. Nossa hipótese é que a FM é um fator preditor independente de pior prognóstico na MC. Objetivos: Buscamos estabelecer o valor prognóstico da FM detectada pela RMC na predição de uma combinação de desfechos duros ou do desfecho secundário mortalidade por todas as causas. Adicionalmente, avaliamos se o valor prognóstico da FM é independente do Escore de Rassi. Métodos: Pacientes com MC foram incluídos retrospectivamente após a realização da RMC, que avaliou volumes e função cardíacos, além de quantificar a FM. Dados clínicos, de imagem e seguimento foram registrados, e o desfecho primário foi a combinação de mortalidade por todas as causas, transplante cardíaco, terapia antitaquicardia ou choque apropriado pelo cardiodesfibrilador implantável e morte súbita cardíaca abortada; o desfecho secundário foi mortalidade por todas as causas. Resultados: Foram incluídos no estudo130 pacientes, a maioria de mulher (53,9%), com idade média de 53,6±11,5 anos. A maioria dos pacientes (68,4%) não tinha sintomas de insuficiência cardíaca, apesar da dilatação ventricular esquerda (54%) e alterações da contratilidade (65,9%) serem comuns. A RMC mostrou dilatação do ventrículo esquerdo (volume diastólico final indexado médio de 118,6±50,5ml/m²) e disfunção sistólica (fração de ejeção média de 43,2±16,3%) e a FM foi identificada em 76,1%, massa média de 15,2±16,5g. Ao longo do seguimento médio de 6,8 anos, 58 (44,6%) pacientes atingiram o desfecho combinado e 45 (34,6%) faleceram. A MF associou-se ao desfecho primário como variável contínua (Razão de risco (RR) ajustada 1,031 (Intervalo de Confiança (IC) 95% 1,013-1,049; p=0.001) e nos pacientes com FM extensa ( >= 12,3g) (RR ajustado 2,107 (IC 95% 1,111-3,994I; p=0,022)) de forma independente ao Escore de Rassi. A FM expressa como variável contínua também se associou à morte por todas as causas (RRajustado1,028 (IC 95% 1,005-1,051; p=0,017)) de forma independente do Escore de Rassi, exceto quando analisada como variável categórica. Conclusões: A fibrose miocárdica é um preditor independente de pior prognóstico na miocardiopatia chagásica. Nossos dados apoiam o uso da RMC para estratificar melhor o risco nessa população e, possivelmente, guiar o tratamento / Background: Chagas cardiomyopathy (CC) portends worse prognosis than ischemic and other non-ischemic cardiomyopathies and carries a high economic burden. Myocardial fibrosis (MF) detected by cardiac magnetic resonance (CMR) has been demonstrated as an independent predictor of increased risk in several etiologies of heart failure. In CC, MF has been associated with know risk factors of poor outcome, such as left ventricular dysfunction and ventricular arrhythmia. We hypothesized that MF is an independent predictor of worse prognosis in CC. Objectives: we sought to determine the prognostic value of MF detected by CMR in predicting a combined endpoint of hard events or the secondary outcome of all-cause mortality. In addition, we evaluated if the prognostic value of MF is independent of the Rassi risk score. Methods: patients with CC were retrospectively followed after CMR evaluation of cardiac volumes, function and MF quantification. Clinical, imaging and follow-up data were recorded and the primary outcome was a combination of all-cause mortality, heart transplantation, anti-tachycardia pacing or appropriate shock from an implantable cardiac defibrillator and aborted sudden cardiac death; the secondary outcome was all-cause death. Results: 130 patients were included in the study, with a majority of females (53.9%) and a mean age of 53.6±11.5 years. Most patients (68.4%) had no symptoms of heart failure, even though left ventricular dilatation (54%) and wall-motion abnormalities (65.9%) were common. On CMR, left ventricular dilatation (mean end-diastolic volume index 118.6±50.5ml/m²) and dysfunction (mean ejection fraction 43.2±16.3%) were observed and MF was found in 76.1%, with a mean mass of 15.2±16.5g. Over a mean follow-up of > 6.2 years, 58 (44.6%) patients reached the combined endpoint and 45 (34.6%) patients died. Myocardial fibrosis mass was associated with the primary outcome both as continuous variable (adjusted HR 1.031 (1.013-1.049 95% CI; p=0.001) and in patients with extensive MF ( >= 12.3g) (adjusted HR 2.107 (1.111-3.994 95% CI; p=0.022), independently from the Rassi Score. Myocardial fibrosis mass expressed as a continuous variable was also associated with all-cause death (adjusted HR 1.028 (1.005-1.051 95% CI; p=0.017) independently from the Rassi Score, but not when analyzed as a categorical variable. Conclusions: Myocardial fibrosis is an independent predictor of adverse outcome in Chagas cardiomyopathy. Our data support the use of CMR in better stratifying risk in this population and possibly guiding therapy

Introdução: A história natural da insuficiência mitral associa-se a décadas de remodelação ventricular esquerda com fibrose intersticial. A fronteira entre o processo adaptativo e a miocardiopatia dilatada demanda avaliação clínico-histológica. Atualmente, sabe-se que o melhor método empregado para quantificar as alterações decorrentes do remodelamento que acomete o ventrículo esquerdo é a biópsia miocárdica, que analisa a doença, somente após a cirurgia ou no post mortem. O presente estudo visa avaliar a fibrose miocárdica associada à insuficiência mitral crônica, através de estudo pela Ressonância Magnética, de maneira não invasiva, precoce e rápida. Objetivos: Avaliar a capacidade e a aplicabilidade da ressonância magnética cardíaca de detectar a fibrose miocárdica na insuficiência mitral crônica importante, tendo como referência a biópsia miocárdica. Métodos: Foram selecionados 52 pacientes portadores de IM crônica pura ou associada a estenose mitral leve, com PVM e DR, e com indicação cirúrgica. Todos os pacientes foram reavaliados pelo EcoDopplercardiograma e realizaram ressonância magnética cardíaca para avaliação da função ventricular, volumes e índice de massa ventricular esquerda, através da cine-ressonância e pela técnica do realce tardio miocárdico, com injeção de 0,2 mmol/kg de contraste gadolínio para a detecção de FM, sendo submetidos a cirurgia de plástica ou troca de válvula mitral com bióspsias miocárdicas, retiradas de locais padrão, na parede lateral do ventrículo esquerdo. Todas foram coradas pela técnica do hematoxilinaeosina, e as positivas para FM, confirmadas pelo corante picrossirius, que cora colágeno, e quantificadas pelo aparelho do quantimet. Resultados: Os pacientes foram divididos em quatro grupos, conforme a RM e a biópsia. A RM diagnosticou FM em 18 pacientes, concordantes com a BM (RMC/BM +). A RM foi negativa para FM em 33 pacientes, sendo 28 concordantes com a BM (RMC/BM -). Observou-se discordância de RM com a BM, em 7 casos falsos negativos (RMC-/BM +). A sensibilidade da RMC à fibrose foi de 72%, especificidade de 100%, e acurácia de 86,3%. Nos grupos distintos estudados, a sensibilidade, especificidade e acurácia foram de 64,7%, 100% e 82,4%, respectivamente, na PVM, e de 97,5%, 100% e 92,9%, respectivamente, na DR. O índice Kappa foi de 0,724 (p<0,001) para o grupo total; 0,665 (p<0,001) para PVM e 0,857(p<0,001) na DR. VDF, VSF e IMVE tiveram correlação positiva e significativa com a porcentagem de fibrose, sendo que, quanto maiores esses valores, maior a porcentagem de fibrose. Conclusão: RMC teve boa concordância com a BM, em relação aos achados de FM / Introduction: The natural history of mitral insufficiency (MI) is associated to decades of left ventricular remodelation with intersticial fibrosis. The frontier between adaptative process and dilatade miocardiopaty needs clinic and histologic evaluation. Now a days , we know that the best method to quantify the alterations of remodelation in left ventricule is myocardial biopsies which analyses the illness only after surgery or post morten. This actual study aims to evaluate myocardial fibrosis associated with cronic MI, through the study with magnetic resonance (MR), in a not invasive, early and quickly way. Objectives: Evaluate capacity and applicability of the magnetic resonance in detection of myocardial fibrosis in chronic important mitral insufficiency in reference with myocardial biopsis. Methods: It was selected 52 patients with pure chronic MI or associated with mild mitral stenosis, with cirurgical indication. All of the patients were reevaluated by EcoDopplercardiogram and it was done cardiac MR to evaluate ventricular function, volumes and left ventricular mass rate through MR cine and myocardial late realce techinique with 0,2 mmol/Kg with gadoline contrast and myocardial fibrosis (MF) detection and being undergone plastic or mitral valvular changes surgery with myocardial biopsis (MB) were taken from the left ventricular lateral wall. All of them were colored with hematoxilin eosine and the positives were confirmated with picrossirius and quantified with quantimet device. Results: Patients were divided in four groups according to MR and biopsies. MR diagnosticated MF in 18 patients agreed with MB (MR / MB +). MR was negative for MF in 33 patients where 28 agreed with MB (MR / MB -). We observated discordance with MR and MB in 7 cases false negatives (MR- /MB+). The sensibility of MR to fibrosis was 72%, specificity was 100% and acurace was 86,3%. In the distinct groups studied, we see sensibility, specifity and acure were 64,7%, 100 % and 82,4% respectivity in PVM and 97,5%, 100% and 92,9% respectivity in reumathic disease. The Kappa indice is 0,714 (p<0,001) for the total group; 0,665 (p<0,001) for PMV and 0,857 (p<0,001) in RD. There is a positive correlation and significative between fibroses percentage with VDF, VSF, IMVE of the MR. So the higher the values, higher the fibrosis percentage. Conclusion: MR had a good concordance with MB in relation to found the MF in IMC

Cardiac magnetic resonance (CMR) imaging is the gold standard imaging technique for assessment of ventricular dimensions and function. CMR also allows assessment of ventricular deformation but this requires additional imaging sequences and time consuming post processing which has limited its widespread use. A novel CMR analysis software package, ‘feature tracking’ (Tom Tec, Germany) can measure ventricular deformation directly from cine CMR images. This thesis seeks to further our understanding of the feasibility of feature tracking to assess myocardial deformation and volumetric measures. Chapter 3 validates normal ranges for deformation parameters and compares values against traditional tagging measures. The work identifies global circumferential strain measures as being the most reproducible. In chapters 4 and 5, feature tracking values for left and right ventricular strain are compared with echocardiography derived speckle tracking indices of deformation. For left ventricular (LV) parameters, circumferential and longitudinal strain are most consistent and for the right ventricular (RV) measures, assessment of free wall strain using feature tracking shows promise and with modifications in algorithms is likely to further improve in the future. Chapter 6 assesses the ability of feature tracking to measure diastolic function. The results show that radial diastolic velocities and longitudinal diastolic strain rates can predict diastolic dysfunction (as diagnosed by echocardiography) with acceptable levels of sensitivity and specificity, particularly when used in combination. 11 The use of feature tracking to provide automated measures of ventricular volumes, mass and ejection fraction is assessed in chapter 7. Feature tracking in this context shows acceptable correlation but poor absolute agreement with manual contouring and further adjustments to algorithms is necessary to improve its accuracy. This work offers insights into the use of feature tracking for the assessment of ventricular deformation parameters. It is a technique with advantages over CMR tagging methods and given the speed of post processing has the potential to become the CMR preferred assessment for strain quantification in the future.