Myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) using stress cardiovascular magnetic resonance (CMR) have been shown to identify epicardial coronary artery disease. However, comparative analysis between quantitative perfusion and conventional qualitative assessment (QA) remains limited. The aim of this multicenter study was to test the hypothesis that quantitative stress MBF (sMBF) and MPR analysis can identify obstructive coronary artery disease (obCAD) with comparable performance as QA of stress CMR performed by experienced physicians in interpretation. The analysis included 127 individuals (mean age 62 ± 16 years, 84 men [67%]) who underwent stress CMR. obCAD was defined as the presence of stenosis ≥50% in the left main coronary artery or ≥70% in a major vessel. Each patient, coronary territory, and myocardial segment was categorized as having either obCAD or no obCAD (noCAD). Global, per coronary territory, and segmental MBF and MPR values were calculated. QA was performed by 4 CMR experts. At the patient level, global sMBF and MPR were significantly lower in subjects with obCAD than in those with noCAD, with median values of sMBF of 1.5 mL/g/min (Q1-Q3: 1.2-1.8 mL/g/min) vs 2.4 mL/g/min (Q1-Q3: 2.1-2.7 mL/g/min) (P < 0.001) and median values of MPR of 1.3 (Q1-Q3: 1.0-1.6) vs 2.1 (Q1-Q3: 1.6-2.7) (P < 0.001). At the coronary artery level, sMBF and MPR were also significantly lower in vessels with obCAD compared with those with noCAD. Global sMBF and MPR had areas under the curve (AUCs) of 0.90 (95% CI: 0.84-0.96) and 0.86 (95% CI: 0.80-0.93). The AUCs for QA by 4 physicians ranged between 0.69 and 0.88. The AUC for global sMBF and MPR was significantly better than the average AUC for QA. This study demonstrates that sMBF and MPR using dual-sequence stress CMR can identify obCAD more accurately than qualitative analysis by experienced CMR readers.

Background: Benign cardiac tumours are infrequent in clinical practice and, of these, cardiac myxoma is the one with the highest incidence. Given that a left intraventricular presentation is rare, other differential diagnoses such as papillary fibroelastoma should be considered. Case summary: A 73-year-old woman patient with cardiac mass detected in transthoracic echocardiography (TTE) after a transient ischaemic attack. At TTE 2D–3D, a left intraventricular mass anchored at the level of the anterolateral papillary muscle was detected. Subsequently, cardiac magnetic resonance (CMR) was performed for mass characterization. This revealed behaviour in T1 (isointense with respect to myocardium), T2 (hyperintense), very prolonged T1-mapping (1848 msg), and T2-mapping (161 msg) values, without gadolinium uptake in the first-pass perfusion sequence, but with intense uptake in late enhancement sequences. Previous findings were compatible with a diagnosis of papillary fibroelastoma. The mass was resected intraoperatively and, although its macroscopic appearance pointed to a diagnosis of cardiac myxoma, it was finally confirmed to be a papillary fibroelastoma by pathological anatomy. Discussion: In cases where the size of the mass and its mobility allow tissue characterization by CMR, a diagnosis of papillary fibroelastoma and its differentiation with cardiac myxoma are feasible by this cardiac imaging technique.

This study sought to examine the correlation between left ventricular (LV) myocardial feature tracking (FT) and deep learning-based strain (DLS) analysis in the diagnostic (CMRd) and follow-up (CMRf) cardiac magnetic resonance imaging of patients with acute myocarditis. The retrospective study included 17 patients with acute myocarditis and 20 healthy controls. The CMRd took place within 14 days of symptom onset, while the CMRf took place at least 2 months after the event. The global-circumferential FT (FTc) and global-circumferential DLS (DLSc) were analyzed. The continuous variables were compared using paired t-tests or the Wilcoxon test, whereas Pearson’s test or Spearman’s test was used to evaluate the correlation between the continuous variables. The time between the CMRd and CMRf was 5 months [3–11]. The LV ejection fraction (LVEF) was 55 ± 6 and 59 ± 4%, p = 0.008, respectively, and 94.1% of the patients showed late gadolinium enhancement (LGE) and myocardial edema on the CMRd. Significantly lower FTc (−16.1 ± 2.2% vs. −18.9 ± 1.9%, p = 0.001) and DLSc (−38.1 ± 5.2% vs. −41.3 ± 4.5%, p = 0.015) were observed with respect to the controls. Significant increases in the FTc (−16.1 ± 2.2 vs. −17.5 ± 1.9%, p = 0.016) and DLSc (−38.1 ± 5.2 vs. −39.8 ± 3.9%, p = 0.049) were found between the CMRd and CMRf, which were unrelated to the LGE. The LVEF correlated well with the FTc (r = 0.840) and DLSc (r = 0.760). Both techniques had excellent reproducibility, with high intra- (FTc = 0.980, DLSc = 1.000) and inter-observer (FTc = 0.970, DLSc = 0.980) correlation. There was correlation between the LV DLSc/FTc and LVEF in the patients with acute myocarditis according to the CMRd and CMRf.

Three-dimensional transesophageal echocardiography and 4-dimensional flow magnetic resonance imaging as complementary techniques in the preoperative planning of a mitral paravalvular leak allow the evaluation of its location, shape, and size and qualitative-quantitative analysis of mitral regurgitant orifice. (Level of Difficulty: Intermediate.)