The American College of Cardiology (ACC) and American Heart Association (AHA) have just published Guidelines for the Evaluation and Diagnosis of Chest Pain. ACC and AHA engaged several leading members from SCMR in tireless efforts over several years’ work to complete this document; on behalf of the society, I extend my personal gratitude to everyone who was involved. Endorsed by SCMR, the guidelines recognize that CMR has a critical role in the timely, accurate, and cost-effective evaluation of patients with chest pain. These recommendations reflect decades of highest-quality clinical trial data accrued by meticulous investigators from many centers around the world. While not fully capturing all the available peer-reviewed evidence, as European Society for Cardiology guidelines have done for several years, the writing committee has significantly advanced American clinical practice guidelines in 2021 and is to be commended.

Patients with chest pain entrust clinicians with their health to answer: What can you do to determine the cause of my chest pain? How can you alleviate my symptoms and prevent me from suffering complications? Clinicians ask: How can I accurately establish diagnosis, select effective management, and optimize my patients’ outcomes and prognosis? Finally, payors and health systems seek effective resource utilization in the care delivered. Thanks to well-established diagnostic accuracy, prognostic efficiency, and cost-effectiveness, CMR delivers high value across the board to patients, clinicians, payors, and health systems. Used in conjunction with high-sensitivity troponin, the preferred blood biomarker per the guidelines, CMR reliably establishes the cause of chest pain and anginal equivalents with or without detectable myocardial injury. Further, it does so with the needed precision across a broad range of ischemic and non-ischemic mechanisms, each with distinct treatment requirements.

It is now incumbent upon all of us who are entrusted with the care of the patient—clinicians, scientists, trainees, and administrative partners—to work together to improve access to standardized, validated, and efficient CMR. Such techniques have been available for several decades and can be done on MR scanners in most settings, enabling the translation of guidelines to daily practice. It is also time to overcome historical barriers such as misaligned compensation models and restrictive facility schedules to fully realize our mission to improve cardiovascular health. With a diverse and talented membership advancing the field around the world, SCMR is at the forefront of the global pivot to higher value cardiovascular care. Thank you for all you do to bring this to fruition in your community.

Subha Raman, MD FSCMR

Members, don't forget to renew here! Do you live in any of these World Bank Category countries? If so, you can save on your renewal and should click now before the end of the year! We are excited to continue to provide you with workshops, Scientific Sessions discounts, and FSCMR recognition!

Don't forget to click on the Facebook and Twitter icons to stay updated between newsletters. Thank you all for your continued enthusiasm and advocacy for CMR!

SCMR is delighted to announce the 2022 Travel & Registration Awards for the 25th Annual Scientific Sessions. The purpose of the award is to encourage and facilitate wider attendance to the meeting by all students, trainees, young professionals, and established professionals with special circumstances from all countries. Review requirements and apply for an award by 22 December 2021.

In support of these agencies’ efforts, SCMR encourages CMR practitioners to use their relevant regional mechanisms for vaccine adverse event reporting (such as VAERS in the U.S.) to report any suspected cases with CMR findings if obtained. Also, the SCMR registry affords a platform for participating members to share images and clinical data with a global community.

Twitter-based #WhyCMR journal watch 📚⌚—join the online discussion!

1.   GLS independently predicts death or ICD shock 📈⚡

2.  BOLDly assessing different sarcomeric variants on oxygen reserve in HCM 🌬️💔

3.   4D-CMR wall shear stress predicts progressive BAV-aortopathy ☮️💢😤🧱🧊

4.   Scar complexity matters in ventricular arrhythmias 💓❄️〽

5.   T2* shows flozins increase iron utilization in HF (EMPATROPISM-FE) ♻️

6.   Automated in-line pulmonary transit time predicts MACE 🤖🤯😎

7.   CMR insights into impaired myocardial energetics in HFpEF 💪💚🕵️‍♀️

8.   CMR biomarkers for left atrial evaluation 🧲✨

9.   CXR cardiothoracic ratio overrated? CMR investigates! ❗❓🧲🕵️‍♀️

10. 10 class 1 or 2a CMR indications in new chest pain guidelines 📢

On 21 July 2021, experts Chiara Bucciarelli-Ducci, MD, and Colin Berry, MD, presented the Siemens Healthineers webinar Novel Insights into MINOCA and INOCA: Resolving Diagnostic Dilemmas and discussed the potential of diagnostic imaging for risk assessment and prognosis in MINOCA and INOCA patients. This webinar highlighted the added value of CMR, CT, and Angio imaging in both acute and chronic ischemia without obstructive coronary arteries. The recording of this innovative session is now available on the SCMR Online Learning Portal.

Welcome to the first Congenital Heart Disease Corner of the SCMR Newsletter! I am Kanwal Farooqi, one of the pediatric cardiac advanced imagers at Columbia University Irving Medical Center/Morgan Stanley Children’s Hospital in New York City. This will be an opportunity to bring some wonderful congenital heart disease (CHD) content to our SCMR readers, including the most common uses of CMR for patients with CHD, exciting cases, and new and innovative technologies being used for CHD.

To kick off, let us talk about atrial septal defects (ASD), which can be a source of left to right shunting (in the absence of elevated right ventricular and pulmonary artery pressures).

Types: Secundum ASD, Primum ASD, sinus venous ASD (+/- partial anomalous pulmonary venous return), coronary sinus septal defect.

Figure 1. Demonstrating different types of atrial septal defects (ASD). From Lai, W.W., Mertens, L.L., Cohen, M.S., & Geva, T. (2009). Echocardiography in pediatric and congenital heart disease: From fetus to adult (2nd ed.). Wiley-Blackwell.

Utility of CMR: 1) Calculate Qp:Qs to assess degree of shunting, 2) Assess right ventricular size and function, and 3) Assess pulmonary veins. If PAPVR is suspected, we will typically utilize contrast because pulmonary veins can be challenging to visualize on 3D SSFP imaging. The images below are from a patient with a superior sinus venosus ASD (red arrow) and PAPVR of the RUPV to the superior vena cava (red star). Findings consistent with need for repair include a Qp:Qs greater than or equal to 2:1, with right ventricular dilation.

Kanwal Farooqi, MD

Department of Pediatrics,

Columbia University, New York, United States

As more imaging centers and hospitals acquire 3T MRI scanners, off-resonance artifacts happen more frequently. Off-resonance is a minor deviation in the local spin's resonant frequency concerning the nominated scanner center frequency. Main field inhomogeneity or magnetic susceptibilities are causes of off-resonance artifacts. The magnetic field (B0) is never wholly homogenous over the volume of the heart. However, some variations may occur because of the magnetic field susceptibility around the heart. Most tissues are diamagnetic; they create a magnetic field that slightly opposes the applied magnetic field. The differences in diamagnetism can distort the main field at interfaces between tissues. The B0 field inhomogeneities cause resonance frequency offsets, where the local frequency deviates from the scanner’s center frequency, leading to off-resonance effects. Balanced steady-state free precession (bSSFP) sequences have the highest sensitivity to magnetic field inhomogeneities. Off-resonance artifacts can be corrected from local variations by performing manufacturer shims over the heart and reducing the size of the shim volume tightly around the heart. Frequency artifacts can also be modified by repeating the image and adjusting the delta frequency (adjustments can be made by -150 hz to +150 Hz). Another technique would be to reacquire the image with a wideband bSSFP, increasing the bandwidth.

CMR uses both spin-echo (SE) and gradient-echo (GRE) pulse sequences. SE sequences refocus the excited signal with a 180-degree pulse or pulses, making them more resistant to off-resonance effects and allowing longer TE values than GRE sequences. SE sequences are disadvantaged by their limited temporal resolution and sensitivity to motion and flow. GRE sequences allow for a faster imaging time; however, because they do not have a refocusing pulse, this sequence is generally T2*, not T2 weighted. The excitation pulses of GRE sequences are limited to a low flip-angle and have inherently low signal-to-noise ratio but are less sensitive to off-resonance effects than bSSFP sequences. bSSFP sequences can use higher flip-angles and shorter TRs than GRE, increasing SNR and decreasing acquisition time but at the cost of an increase in sensitivity to field inhomogeneity and frequency offsets.

Figure. GRE B0 inhomogeneities at different TEs. Short-axis images acquired with a GRE sequence at two different TEs: 2 ms (left) and 10 ms (right). The arrows point at two local field distortions (RV apex of the heart and in the proximity of a pulmonary vessel) that generate signal loss in the surrounding region as TE becomes larger.

Join us for our upcoming webinar, Multimodality Imaging in Hypertrophic Cardiomyopathy, featuring Drs. Christopher M. Kramer, Iacopo Olivotto, Steve R. Ommen, and Lynette Teo and moderated by Dr. Upasana Tayal. 

Register by 10 am CST on 9 December.

Dr. Javier López Opitz (pictured right),

Cardiologist–Cardiac Imaging,

INCIC, Santiago, Chile

The Cardiovascular Radiology Educational Forum (CVRef) is a purely academic initiative undertaken by the Department of Cardiovascular Radiology and Endovascular Interventions of the All India Institute of Medical Sciences (AIIMS), New Delhi, under the expert guidance of Professor Priya Jagia. CVRef aims to provide a forum where leading practitioners in the field of cardiovascular imaging can collaborate and disseminate their knowledge to cardiac healthcare professionals, especially those from emerging world countries.

As part of this initiative, CVRef successfully organized the first AIIMS Primer in Cardiovascular Radiology on 20–21 November 2021 in a hybrid fashion, bringing together 40 national and international experts and more than 600 delegates from over 10 countries. The program consisted of talks on basic and advanced topics in the field of CMR. In resonance with its "living network" philosophy, CVRef envisions acting as a liaison between leading institutions to increase the outreach of CMR not only within India, but also to the emerging world countries, especially those in the Indian subcontinent.

Vineeta Ohja, MD

Department of Cardiovascular Radiology,

AIIMS, New Delhi, India

The SCMR 2020 Case of the Week series was published in the Journal of Cardiovascular Magnetic Resonance on 11 October 2021. This open-access digital archive provides a means of further enhancing the education of those interested in CMR and a means of more readily identifying these cases using PubMed or a similar search engine.

The SCMR Case of the Week editors would like to thank their wonderful team of associate editors and reviewers. Please continue to submit your best illustrative cases and enjoy the 2020 series!

Left: 4D Flow 3D rendering. A labeled still-frame outlining the right atria (RA) and left (LA) atria, and right (RV) and left (LV) ventricles. The location of the unroofed coronary sinus is shown as a dotted line with an arrow demonstrating the direction of the shunt flow near the OS of the coronary sinus. From Case 20-01: Diagnosis of a coronary sinus atrial septal defect by 4D flow MRI. Jason G. Mandell, MD, MS; Adam Christopher, MD; Laura J. Olivieri, MD; Yue-Hin Loke, MD; Division of cardiology, Children's National Hospital, Washington, DC, USA.

Right: Still frame 3D reconstruction of aortic arch. Right sided aortic arch with a left descending aorta (DAo) and aberrant left subclavian artery (LSCA). AAO ascending aorta, LCCA left common carotid artery, RCCA right common carotid artery, RSCA right subclavian artery. From Case 20-04: It's Not ARVD! Afiachukwu Onuegbu, MD; Jina Chung, MD; Division of Cardiology, Harbor UCLA Medical Center.

The SCMR web site hosts “Case of the Week”—a case series designed to present case reports demonstrating the unique attributes of CMR in the diagnosis or management of cardiovascular disease. Each clinical presentation is followed by a brief discussion of the disease and unique role of CMR in disease diagnosis or management guidance. By nature, some of these are somewhat esoteric, but all are instructive. Recently we have published the case archive from 2020 in JCMR as a means of further enhancing the education of those interested in CMR and as a means of archiving this incredible resource from our members on PubMed. 

Please use this link for a filtered PubMed list of all CMR-related manuscripts for November 2021—more than 300 in total!