A intervenção percutânea com implante de stents constitui-se na principal forma de revascularização miocárdica empregada, e associa-se à redução de sintomas, à melhoria na qualidade de vida e ao aumento da sobrevida em pacientes acometidos por síndrome coronária aguda. Entretanto, o implante de stents pode acompanhar-se de exagerada hiperplasia intimal, principal determinante da reestenose destes dispositivos. Diversos fatores clínicos, anatômicos e técnicos associam-se a maiores taxas de reestenose, porém a hipótese de que o tipo ou a composição da lesão aterosclerótica tratada possa correlacionar-se com o fenômeno ainda não foi esclarecida. Determinar a relação entre a composição da placa aterosclerótica tratada conforme análise pela Histologia Virtual® - e a magnitude da hiperplasia intimal após o implante de stents farmacológicos e não-farmacológicos. No período de setembro de 2008 a novembro de 2009, selecionamos 52 pacientes prospectivos com o diagnóstico de síndrome coronária aguda com ou sem supra ST, submetidos à cinecoronariografia e candidatos à intervenção percutânea. Estes foram randomizados para o tratamento com stents farmacológicos com sirolimus (Cypher® Cordis, Johnson & Johnson) ou com stents não-farmacológicos (Driver®,Medtronic Inc.). O ultra-som com Histologia Virtual® foi realizado antes do tratamento das lesões culpadas, e correlacionou-se o porcentual dos componentes fibrótico, fibrolipídico, núcleo necrótico e cálcio com o grau de hiperplasia intimal, em reestudo ultrasonográfico realizado aos 9 meses. A média de idades foi de 55,3 anos (DP 4,9 anos), sendo 77% homens. Não foram verificadas diferenças significativas entre os grupos no que se refere às variáveis clínicas e angiográficas. A maioria dos pacientes apresentava obstrução coronária uniarterial, e o vaso mais freqüentemente tratado foi a descendente anterior. À Histologia Virtual®, não foram detectadas diferenças em relação ao tipo de placa tratada, sendo predominantes as lesões do tipo fibroateroma e fibroateroma calcificado. O tecido fibrótico foi o componente preponderante [59,6% (DP 15,8%) do volume total das placas analisadas], e cerca de 20% do volume das lesões era composto por núcleo necrótico. Após 9 meses, o reestudo ultrasonográfico foi realizado em 49 (94%) dos pacientes. Tanto o volume como o porcentual de hiperplasia intimal foram significativamente maiores no grupo tratado com stents não-farmacológicos [60,8 mm3 [DP 32 mm3] versus 14 mm3 (DP 9,2 mm3), p<0,0001 e [31,9% (DP 12,9%) versus 8,2% (DP 7,6%) , p<0,0001, respectivamente]. Contudo, não foi observada associação entre os porcentuais dos componentes fibrótico (corr. 0,038, p=0,81), fibrolipídico (corr. 0,109, p=0,49), cálcio (corr. -0,073, p=0,64) e núcleo necrótico (corr. -0,062, p=0,69) das lesões tratadas com o tecido neointimal intra-stent. Os resultados desta investigação prospectiva e randomizada indicam que as informações providas pela Histologia Virtual® na caracterização das placas ateroscleróticas não auxiliam na identificação de lesões mais propensas à reestenose, após o implante de stents farmacológicos e não-farmacológicos. / To the present, little is known about the correlation between modifications in plaque composition at stent edges and the changes in vessel geometry. This study sought to evaluate, by serial grey-scale intravascular ultrasound (IVUS) and Virtual Histology(TM), the modifications in plaque composition at the edges of drug-eluting and bare-metal stents and the correlation of these findings with changes in the measuremntes of vessel, lumen and plaque area at those segments. Single-center, prospective and randomized (1:1) evaluation of 40 patients with acute coronary syndrome treated with bare-metal (Driver(TM), n=20 patients) or drug-eluting stents (Cypher(TM), n=20 patients). Following stent deployment, all individuals underwent gray scale IVUS and Virtual Histology(TM) evaluation, which were repeated at nine months. Primary endpoint included the modification in vessel, lumen and plaque area and in the composition of the plaque in the mean time between the baseline and follow-up procedure. Additionally, we tried to determine a correlation between plaque composition variation and changes in vessel geometry. At the proximal edge of both drug-eluting and bare-metal stents there was a trend to positive vessel remodeling which compensated the modest increase in plaque area. At the distal edge, patients treated with drug-eluting stents had less plaque growth resulting in a larger lumen area at follow-up. By Virtual Histology, there was a marked reduction in the % of fibrotic tissue and necrotic core in both edges of the two stents and a positive, strong correlation was seen between increase in % of fibrofatty component and augmentation in plaque area(r=0.78, p=0.01). The use of drug-eluting stents was not associated with \"edge effect\". On the contrary, patients treated with these devices experienced less plaque growth, especially at the distal edge of the stents. Modifications in plaque composition, with increase in fibrofatty content, might partially explain these findings.

Les maladies cardiovasculaires, qui restent l’une des premières causes de mortalité dans le monde, sont le résultat d’altérations interdépendantes de la structure et de la fonction cardiaque couplées aux effets aggravants des maladies métaboliques, du vieillissement et du mode de vie. Dans ce contexte, l’objectif de ma thèse est de proposer et de valider de nouveaux biomarqueurs quantitatifs en imagerie cardiaque, robustes et rapides, pour l’étude de la fonction et de la structure myocardiques ainsi que de leurs liens. Un premier travail a été consacré au développement d’une méthode d’évaluation de la fonction cardiaque, plus précisément de la cinétique de déformation du myocarde sur toutes les cavités cardiaques à partir d’images standards d’IRM ciné. La méthode développée s’est montrée reproductible avec une capacité diagnostique supérieure aux indices cliniques conventionnels. Elle était aussi capable de détecter des altérations cardiaques infra-cliniques liées à l’âge. Le second travail présenté est le développement d’une méthode de quantification de la graisse atriale, à partir d’images de scanner tomodensitométrique, suivi de son évaluation sur une cohorte de sujets sains et de sujets atteints de fibrillation atriale. Finalement, l’interaction entre les paramètres myocardiques structurels et fonctionnels a été étudiée au travers de la première validation chez l’homme de la littérature IRM de la fonction de déformation cardiaque, évaluée avec notre méthode, face à la quantification histologique du substrat tissulaire « graisse-fibrose ». / Cardiovascular diseases, which are still one of the leading causes of death worldwide, are the result of interdependent alterations of the heart structure and function coupled with the aggravating effects of metabolic diseases, aging and lifestyle. In this context, the goal of my thesis is to design and validate new, robust and fast cardiac imaging quantitative biomarkers to characterize myocardial function and structure as well as their relationships. A first work was focused on the development of a method to evaluate cardiac function, specifically myocardial deformation kinetics on all cardiac chambers from standard cine MRI images. The designed method was reproducible and its diagnostic ability was superior to conventional clinical indices. It was also able to detect subclinical age-related heart alterations. The aims of the second study were to develop a method for atrial fat quantification, based on CT images, and to evaluate it on a cohort of healthy subjects and patients with atrial fibrillation. Finally, the interaction between structural and functional myocardial indices was studied through the first in vivo validation in the MRI literature of cardiac deformation function, evaluated using our method, against histological quantification of the “fibro-fatty” tissue substrate.

Ces travaux de thèse portent sur le développement de nouvelles modalités d’imagerie cardiovasculaire basé sur l’utilisation de l'imagerie ultrarapide 2D et 3D. Les modalités d’imagerie développées dans cette thèse appartiennent au domaine de de l’élastographie par onde de cisaillement et de l'imagerie Doppler des flux sanguins.Dans un premier temps, la technique de l’élastographie par onde de cisaillement du myocarde a été développée pour les applications cliniques. Une approche d'imagerie non-linéaire a été utilisée pour améliorer l’estimation de vitesse des ondes de cisaillement (ou la rigidité des tissus cardiaques) de manière non invasive et localisée. La validation de cette nouvelle approche de « l’imagerie par sommation cohérente harmonique ultrarapide » a été réalisée in vitro et la faisabilité in vivo a été testée chez l’humain. Dans un second temps, nous avons utilisé cette technique sur des patients lors de deux essais cliniques, chacun ciblant une population différente (adultes et enfants). Nous avons étudié la possibilité d’évaluer quantitativement la rigidité des tissus cardiaques par élastographie chez des volontaires sains, ainsi que chez des malades souffrant de cardiomyopathie hypertrophique. Les résultats ont montré que l’élastographie pourrait devenir un outil d'imagerie pertinent et robuste pour évaluer la rigidité du muscle cardiaque en pratique clinique. Par ailleurs, nous avons également développé une nouvelle approche appelée « imagerie de tenseur élastique 3-D » pour mesurer quantitativement les propriétés élastiques des tissus anisotropes comme le myocarde. Ces techniques ont été testées in vitro sur des modèles de de gels isotropes transverses. La faisabilité in vivo de l’élastographie par onde cisaillement à trois-dimensions a été également évaluée sur un muscle squelettique humain.D'autre part, nous avons développé une toute nouvelle modalité d’imagerie ultrasonore des flux coronariens basée sur l’imagerie Doppler ultrarapide. Cette technique nous a permis d'imager la circulation coronarienne avec une sensibilité élevée, grâce notamment au développement d’un nouveau filtre adaptatif permettant de supprimer le signal du myocarde en mouvement, basé sur la décomposition en valeurs singulières (SVD). Des expériences à thorax ouvert chez le porc ont permis d'évaluer et de valider notre technique et les résultats ont montré que la circulation coronaire intramurale, peut être évaluée sur des vaisseaux de diamètres allant jusqu’à 100 µm. La faisabilité sur l’homme a été démontrée chez l’enfant en imagerie clinique transthoracique.Enfin, nous avons développé une nouvelle approche d’imagerie des flux sanguins, « l’imagerie ultrarapide 3-D des flux», une nouvelle technique d'imagerie quantitative des flux. Nous avons démontré que cette technique permet d’évaluer le débit volumétrique artériel directement en un seul battement cardiaque, indépendamment de l'utilisateur. Cette technique a été mise en place à l'aide d'une sonde matricielle 2-D et d’un prototype d’échographe ultrarapide 3-D développé au sein du laboratoire. Nous avons évalué et validé notre technique in vitro sur des fantômes artériels, et la faisabilité in vivo a été démontrée sur des artères carotides humaines. / This thesis was focused on the development of novel cardiovascular imaging applications based on 2-D and 3-D ultrafast ultrasound imaging. More specifically, new technical and clinical developments of myocardial shear wave elastography and ultrafast blood flow imaging are presented in this manuscript.At first, myocardial shear wave elastography was developed for transthoracic imaging and improved by a non-linear imaging approach to non-invasively and locally assess shear wave velocity measurements, and consequently tissue stiffness in the context of cardiac imaging. This novel imaging approach (Ultrafast Harmonic Coherent Compounding) was tested and validated in-vitro and the in vivo feasibility was performed in humans for biomechanical evaluation of the cardiac muscle wall, the myocardium. Then, we have translated shear wave elastography to the clinical practice within two clinical trials, each one with a different population (adults and children). In both clinical trials, we have studied the capability of shear wave elastography to assess quantitatively myocardial stiffness in healthy volunteers and in patients suffering from hypertrophic cardiomyopathy. The results in the adult population indicated that shear wave elastography may become an effective imaging tool to assess cardiac muscle stiffness in clinical practice and help the characterization of hypertrophic cardiomyopathy. Likewise, we have also translated Shear Wave Elastography into four-dimensions and we have developed a new approach to map tissue elastic anisotropy in 3-D. 3-D Elastic Tensor Imaging allowed us to estimate quantitatively in a single acquisition the elastic properties of fibrous tissues. This technique was tested and validated in vitro in transverse isotropic models. The in-vivo feasibility of 3D elastic tensor imaging was also assessed in a human skeletal muscle.In parallel, we have developed a novel imaging technique for the non-invasive and non-radiative imaging of coronary circulation using ultrafast Doppler. This approach allowed us to image blood flow of the coronary circulation with high sensitivity. A new adaptive filter based on the singular value decomposition was used to remove the clutter signal of moving tissues. Open-chest swine experiments allowed to evaluate and validate this technique and results have shown that intramural coronary circulation, with diameters up to 100 µm, could be assessed. The in-vivo transthoracic feasibility was also demonstrated in humans in pediatric cardiology.Finally, we have developed a novel imaging modality to map quantitatively the blood flow in 3-D: 3-D ultrafast ultrasound flow imaging. We demonstrated that 3-D ultrafast ultrasound flow imaging can assess non-invasively, user-independently and directly volumetric flow rates in large arteries within a single heartbeat. We have evaluated and validated our technique in vitro in arterial phantoms using a 2-D matrix-array probe and a customized, programmable research 3-D ultrafast ultrasound system, and the in-vivo feasibility was demonstrated in human carotid arteries.

Las enfermedades cardiovasculares (ECVs) son la principal causa de mortalidad en el mundo Occidental. El interés de prevenir y tratar las ECVs ha desencadenado un rápido desarrollo de los sistemas de adquisición de imágenes médicas. Por este motivo, la cantidad de datos de imagen recolectados en las instituciones de salud se ha incrementado considerablemente. Este hecho ha aumentado la necesidad de herramientas automatizadas para dar soporte al diagnóstico, mediante una interpretación de imagen confiable y reproducible. La tarea de interpretación requiere traducir los datos crudos de imagen en parámetros cuantitativos, los cuales son considerados relevantes para clasificar la condición cardiaca de un paciente. Para realizar tal tarea, los métodos basados en modelos estadísticos de forma han recibido favoritismo dada la naturaleza tridimensional (o 3D+t) de las imágenes cardiovasculares. Deformando el modelo estadístico de forma a la imagen de un paciente, el corazón puede analizarse de manera integral. Actualmente, el campo de las imágenes cardiovasculares esta constituido por diferentes modalidades. Cada modalidad explota diferentes fenómenos físicos, lo cual nos permite observar el órgano cardiaco desde diferentes ángulos. El personal clínico recopila todas estas piezas de información y las ensambla mentalmente en un modelo integral. Este modelo integral incluye información anatómica y funcional que muestra un cuadro completo del corazón del paciente. Es de alto interés transformar este modelo mental en un modelo computacional capaz de integrar la información de manera global. La generación de un modelo como tal no es simplemente un reto de visualización. Requiere una metodología capaz de extraer los parámetros cuantitativos relevantes basados en los mismos principios técnicos. Esto nos asegura que las mediciones se pueden comparar directamente. Tal metodología debe ser capaz de: 1) segmentar con precisión las cavidades cardiacas a partir de datos multimodales, 2) proporcionar un marco de referencia único para integrar múltiples fuentes de información, y 3) asistir la clasificación de la condición cardiaca del paciente. Esta tesis se basa en que los modelos estadísticos de forma, y en particular los Modelos Activos de Forma, son un método robusto y preciso con el potencial de incluir todos estos requerimientos. Para procesar múltiples modalidades de imagen, separamos la información estadística de forma de la información de apariencia. Obtenemos la información estadística de forma a partir de una modalidad de alta resolución y aprendemos la apariencia simulando la física de adquisición de otras modalidades. Las contribuciones de esta tesis pueden ser resumidas así: 1) un método genérico para construir automáticamente modelos de intensidad para los Modelos Activos de Forma simulando la física de adquisición de la modalidad en cuestión, 2) la primera extensión de un simulador de Resonancia Magnética Nuclear diseñado para producir estudios cardiacos realistas, y 3) un método novedoso para el entrenamiento automático de modelos de intensidad y de fiabilidad aplicado a estudios cardiacos de Resonancia Magnética Nuclear. Cada una de estas contribuciones representa un artículo publicado o enviado a una revista técnica internacional. / Cardiovascular diseases (CVDs) are the major cause of death in the Western world. The desire to prevent and treat CVDs has triggered a rapid development of medical imaging systems. As a consequence, the amount of imaging data collected in health care institutions has increased considerably. This fact has raised the need for automated analysis tools to support diagnosis with reliable and reproducible image interpretation. The interpretation task requires to translate raw imaging data into quantitative parameters, which are considered relevant to classify the patient’s cardiac condition. To achieve this task, statistical shape model approaches have found favoritism given the 3D (or 3D+t) nature of cardiovascular imaging datasets. By deforming the statistical shape model to image data from a patient, the heart can be analyzed in a more holistic way. Currently, the field of cardiovascular imaging is constituted by different modalities. Each modality exploits distinct physical phenomena, which allows us to observe the cardiac organ from different angles. Clinicians collect all these pieces of information to form an integrated mental model. The mental model includes anatomical and functional information to display a full picture of the patient’s heart. It is highly desirable to transform this mental model into a computational model able to integrate the information in a comprehensive manner. Generating such a model is not simply a visualization challenge. It requires having a methodology able to extract relevant quantitative parameters by applying the same principle. This assures that the measurements are directly comparable. Such a methodology should be able to: 1) accurately segment the cardiac cavities from multimodal datasets, 2) provide a unified frame of reference to integrate multiple information sources, and 3) aid the classification of a patient’s cardiac condition. This thesis builds upon the idea that statistical shape models, in particular Active Shape Models, are a robust and accurate approach with the potential to incorporate all these requirements. In order to handle multiple image modalities, we separate the statistical shape information from the appearance information. We obtain the statistical shape information from a high resolution modality and include the appearance information by simulating the physics of acquisition of other modalities. The contributions of this thesis can be summarized as: 1) a generic method to automatically construct intensity models for Active Shape Models based on simulating the physics of acquisition of the given imaging modality, 2) the first extension of a Magnetic Resonance Imaging (MRI) simulator tailored to produce realistic cardiac images, and 3) a novel automatic intensity model and reliability training strategy applied to cardiac MRI studies. Each of these contributions represents an article published or submitted to a peer-review archival journal.

Cardiovascular disease varies by ethnicity in the UK. South Asians (SA) have higher coronary heart disease (CHD) and diabetes prevalence, while African-Caribbeans (AfC) have greater stroke, but intriguingly lower CHD rates despite higher blood pressures and diabetes risk than Europeans. Conventional risk factors do not fully explain such differences. This cross-sectional study tested the hypothesis that the hormones, vitamin D measured as 25(OH)D and aldosterone, would be independently associated with intermediate cardiovascular outcome markers in these ethnic groups. Community-dwelling men 40-80 years old (AfC: n=67, 55±10yr; SA: n=68, 55±10yr; European: n=63, 57±8yr) were sampled from Greater Manchester’s multi-ethnic population. The intermediate markers examined were aortic pulse wave velocity (aPWV), left ventricular (LV) mass and function, and carotid intima media thickness (CIMT), measured non-invasively by ultrasound, and hemodynamic profiling methods (the Arteriograph) in the total sample and by magnetic resonance imaging (MRI) in a subsample of 50. Adjusted for age, systolic blood pressure and diabetes, mean(SE) aPWV by the Arteriograph, was 0.5(0.2) m/s higher in SA than AfC and Europeans (p=0.01), which paralleled known cross-ethnic CHD risk differences in the UK. By MRI, aPWV along the descending aorta in SA was 0.7(0.3) and 0.8(0.3) m/s higher than that in AfC and Europeans, but aPWV along the aortic arch was not significantly different. Unlike aldosterone, 25(OH)D was independently and inversely correlated with aPWV (unstandardised B(SE)=-0.013[0.004] m/s, p<0.001), and partly explained the ethnic variation in aPWV. Similar inverse correlations were found between 25(OH)D and LV concentricity measured by echocardiography and MRI. Compared to Europeans, SA and AfC, had 21(3) and 14(3) nmol/L lower mean(SE) 25(OH)D, respectively (p<0.01). Mean(SE) of relative wall thickness, an index of LV concentricity by echocardiography, was 0.05(0.01) higher in SA and AfC than Europeans. Lower 25(OH)D levels were also associated with higher myocardial deformation rates measured by MRI myocardial tagging (n=50), supporting previous animal experimental evidence. A one standard deviation (SD) decrease in 25(OH)D was associated with a 0.38 SD increase in absolute systolic strain rate (p=0.003) and 0.22 SD rise in diastolic strain rate (p=0.04). Right and left CIMT showed different relations with 25(OH)D and aldosterone. Left-right CIMT differences varied by ethnicity and were related to SA ethnicity and aldosterone levels. Two related technical studies investigated the relatively new method of hemodynamic profiling, the Arteriograph, used here. The results suggested a standardisation method of aortic length estimation for purely central aPWV, which significantly improved aPWV agreement between the Arteriograph and MRI (reference method here), and was used for calibrating the Arteriograph aPWV in the above-mentioned results for the total sample. Future well-designed trials are necessary to investigate any cause-effect relationship between vitamin D deficiency and the unfavourable cardiovascular intermediate outcomes found here in a cross-sectional design and multi-ethnic background.

Die vorliegende Arbeit untersucht die grundsätzliche Machbarkeit, Radiofrequenzimpulse (RF) der Ultrahochfeld (UHF) Magnetresonanztomographie (MRT) (B0≥7.0T) für therapeutische Verfahren wie die RF Hyperthermie oder die lokalisierte Freigabe von Wirkstoffträgern und Markern zu nutzen. Im Rahmen der Arbeit wurde ein 8-Kanal Sened/Empfangsapplikator entwickelt, der bei einer Protonenfrequenz von 298MHz operiert. Mit diesem weltweit ersten System konnte in der Arbeit experimentell bewiesen werden, dass die entwickelte Hardware sowohl zielgerichtete lokalisierte RF Erwärmung als auch MR Bildgebung und MR Thermometrie (MRTh) realisiert. Mit den zusätzlichen Freiheitsgraden (Phase, Amplitude) eines mehrkanaligen Sendesystems konnte aufgezeigt werden, dass der Ort der thermischen Dosierung gezielt verändert bzw. festgelegt werden kann. In realitätsnahen Temperatursimulationen mit numerischen Modellen des Menschen, wird in der Arbeit aufgezeigt, dass mittels des entwickelten Hybridaufbaus eine kontrollierte und lokalisierte thermische Dosierung im Zentrum des menschlichen Kopfes erzeugt werden kann. Nach der erfolgreichen Durchführung dieser Machbarkeitsstudie wurden in theoretischen Überlegungen, numerischen Simulationen und in ersten grundlegenden experimentellen Versuchen die elektromagnetischen Gegebenheiten von MRT und lokal induzierter RF Hyperthermie für Frequenzen größer als 298MHz untersucht. In einem Frequenzbereich bis zu 1.44GHz konnte der Energiefokus mit Hilfe spezialisierter RF Antennenkonfigurationen entscheidend weiter verkleinert werden, sodass Temperaturkegeldurchmesser von wenigen Millimetern erreicht wurden. Gleichzeitig konnte gezeigt werden, dass die vorgestellten Konzepte ausreichende Signalstärke der zirkular polarisierten Spinanregungsfelder bei akzeptabler oberflächlicher Energieabsorption erzeugen, um eine potentielle Machbarkeit von in vivo MRT bei B0=33.8T oder in vivo Elektronenspinresonanz (ESR) im L-Band zu demonstrieren. / The presented work details the basic feasibility of using radiofrequency (RF) fields generated by ultrahigh field (UHF) magnetic resonance (MR) (B0≥7.0T) systems for therapeutic applications such as RF hyperthermia and targeted drug delivery. A truly hybrid 8-channel transmit/receive applicator operating at the 7.0T proton MR frequency of 298MHz has been developed. Experimental verification conducted in this work demonstrated that the hybrid applicator supports targeted RF heating, MR imaging and MR thermometry (MRTh). The approach offers extra degrees of freedom (RF phase, RF amplitude) that afford deliberate changes in the location and thermal dose of targeted RF induced heating. High spatial and temporal MR temperature mapping can be achieved due to intrinsic signal-to-noise ratio (SNR) gain of UHF MR together with the enhanced parallel imaging performance inherent to the multi-channel receive architecture used. Temperature simulations in human voxel models revealed that the proposed hybrid setup is capable to deposit a controlled and localized RF induced thermal dose in the center of the human brain. After demonstrating basic feasibility, theoretical considerations and proof-of-principle experiments were conducted for RF frequencies of up to 1.44GHz to explore electrodynamic constraints for MRI and targeted RF heating applications for a frequency range larger than 298MHz. For this frequency regime a significant reduction in the effective area of energy absorption was observed when using dedicated RF antenna arrays proposed and developed in this work. Based upon this initial experience it is safe to conclude that the presented concepts generate sufficient signal strength for the circular polarized spin excitation fields with acceptable specific absorption rate (SAR) on the surface, to render in vivo MRI at B0=33.8T or in vivo electron paramagnetic resonance (EPR) at L-Band feasible.