Background: Imaging of conventional PM’s and ICDs are infrequently performed via MRI. While many studies, including the MagnaSafe Trial have unequivocally supported MRI safety in patients with such devices, the added clinical value has rarely been considered. Accordingly, we performed an observational, IRB-approved, prospective study to determine the 'Additive Value' beyond safety for patients with conventional PM/ICD's undergoing clinical MRI. We hypothesize that MRI in PM/ICD patients is critical to an existing diagnosis and often markedly alters diagnosis and subsequent downstream patient management. Methods: An MRI Device exam (GE 1.5T,WI) pioneered by cardiologists (>90% over 10 yrs; 100% over 20 years) was performed. Subsequently, a series of prospective defining questions using Boolean Logic Construct were answered within 1 week of MRI by both MRI technologist and MRI physicians. Questions : 1) Did the primary diagnosis change? 2) Did the MRI provide additional information to existing diagnosis? 3) Was the pre-MRI (tentative) diagnosis confirmed? 4) Did subsequent patient management change? If 'Yes' was answered to any of the above questions, it was considered that MRI was of value to pt diagnosis and/or impending therapy. Results: Average MRI: 25±14min for 2,008 consecutive patients of which 1,526 (76%) were neuro/neurosurgery, 141 (7%) were musculoskeletal and 341(17%) were CV cases. Upon review: of the N euro/neurosurgery MRIs, 1,376 (89%) provided additional information. The diagnosis changed in 1018 (74%), while medical therapy changed in 977 (71%). In only 124 (9%) did MRI simply confirm original diagnosis. For Cardiac patients, MRI changed the original diagnosis in 235 (69%). MRI did not contribute in 42 (12%) as it was uninterpretable (ICD artifact), while in 64 pts, the diagnosis did not change. Finally, in 146 Orthopedic pts, MRI provided additional information in 143 (98%) and in 130 (89%), changed pt care, and in 4 pts (3%), simply confirmed the diagnosis. Importantly, with careful attention to device reprogramming and scanner sequences, no safety or device issues were encountered in any patient all with tracking for >1 year. Conclusion: Via a dedicated program of MRI in PM/ICD patients adds substantial clinical value to diagnosis and subsequent management justifying ant inherent risk(s). Herein, we propose that yet another impediment to the advancement of CMR-PM/ICD strategies can become routine and often life-changing.

Background: While imaging of conventional PM’s and ICDs is infrequently performed via MRI, many studies, including the MagnaSafe have unequivocally supported MRI safety in such pts. However, the added clinical value is infrequently considered. Accordingly, we performed a prospective study to determine the 'Additive Value' beyond safety for pts with conventional PM/ICD's undergoing MRI. We hypothesized that MRI in PM/ICD pts is fundamental to an existing diagnosis, often markedly altering patient diagnosis and downstream care. Methods: An MRI Device exam (GE 1.5T,WI) pioneered by cardiologists (>90% over 10 yrs; 100% over 21 years) was performed. A series of prospective questions using Boolean Logic Construct were answered within 1 week of MRI by both MRI tech's and MRI MD's. Questions: 1) Did primary diagnosis change? 2) Did MRI provide additional information to existing diagnosis? 3) Was pre-MRI (tentative) diagnosis confirmed? 4) Did subsequent pt management change? If 'Yes' was answered to any questions, MRI was considered of value to pt diagnosis and/or impending therapy Results: Avg MRI: 23±15min for 2,128 consecutive pts of which 1,1617 (76%) were neuro/neurosurgery, 149 (7%) were musculoskeletal and 362 (17%) were CV cases. Upon review: of Neuro MRIs, 1,439 (89%) provided additional information. The diagnosis changed in 1213 (75%) while therapy changed in 1148 (71%). In only 129 (8%) did MRI simply confirm original diagnosis. Cardiac MRI changed original the diagnosis in 253 (70%). MRI did not contribute in 43 (12%) due to uninterpretable (ICD artifact), while in 66 pts, the diagnosis did not change. Finally, in 355, Orthopedic MRI provided additional information in 143 (98%) and in 326 (90%), changed pt care, and in 14 (3%), simply confirmed the diagnosis. Importantly, with careful attention to device reprogramming and scanner sequences, no safety or device issues were encountered in any patient all with tracking for >1 year. Conclusion: A dedicated Universal Program of MRI in PM/ICD patients adds remarkable clinical value to diagnosis and subsequent management justifying any residual risk(s). Accordingly, we propose that yet another hurdle to the advancement of CMR-PM/ICD strategies can become standard and often life-changing.

BACKGROUND Hypertensive disorders of pregnancy (HDP) can be classified into gestational hypertension, preeclampsia (PRE), and chronic hypertension with superimposed preeclampsia (SPE). OBJECTIVES The purpose of this study was to retrospectively examine the echocardiographic differences in biventricular structure and function in 3 HDP groups of women in comparison to normotensive pregnant controls. METHODS Women with an echocardiogram during or within the first year of pregnancy were identified within our integrated health network. Exclusion criteria included age <18 years, diagnosis of pulmonary embolism, malignancy, autoimmune disease, and structural heart disease. RESULTS We identified a total of 706 subjects (cases: n = 427, normotensive controls: n = 279). Cases were divided into 3 groups: gestational hypertension (n = 57), PRE (n = 291), and SPE (n = 79). In adjusted analyses, echocardiographic parameters demonstrated a graded difference in left ventricular (LV) mass index, relative wall thickness, mitral inflow E, mitral inflow A, septal e', lateral e', E/e', left atrial volume index, tricuspid velocity, and lateral e' velocities with the most profound findings noted in the SPE group. Specifically, adjusted LV mass index (adjusted beta = 14.45, 95% CI: 9.00-19.90) and E/e' (adjusted beta = 2.97, 95% CI: 2.27-3.68) was highest in the SPE group in comparison to controls (P < 0.001). CONCLUSIONS LV remodeling and diastolic filling abnormalities are more common in HDP and are most evident in SPE and PRE. Echocardiography during or immediately after pregnancy may be useful in these high-risk women to identify these abnormalities. The long-term implications of these echocardiographic abnormalities require further study.

Introduction/Background: Quantification of mitral regurgitation (MR) by CMR is performed indirectly by subtracting the aortic forward flow (measured by phase velocity mapping) from the left ventricular stroke volume (LVSV, measured by 3D EDV-ESV). However, 3D volumetric analysis of the LV can be performed by either including papillary muscles in the blood pool “Contour Method” or as part of myocardium “Blood Volume Method”. While both methods are considered acceptable to the Society for Cardiovascular Magnetic Resonance 2020 Guideline, using either method has a significant impact on the calculated LVSV, which in turn affects the calculated mitral regurgitant fraction (MRfr). Moreover, no universal cutoff for MR grading by CMR has been established yet. Research Questions/Hypothesis: We sought to validate which method (Blood Volume or Contour) should be used to quantify MR by comparing the calculated MR grade by CMR (assessed by MRfr) to MR grade by echocardiography (none, trace, mild, moderate, or severe). Methods/Approach: This is a single-center retrospective analysis. CMR studies were analyzed using Medis Suite (Version 4.0.50.2) Software. Each patient was analyzed twice; initially using Contour Method then Blood Volume Method. Results/Data: A total of 100 patients with various grades of MR were included. 83% of patients had a transthoracic echocardiogram (TTE) while 17% had a transesophageal echocardiogram (TEE). 94% of patients had their echocardiogram performed within 6 months of CMR, and 80% performed within 3 months of CMR. We found that the Contour Method tends to over-estimate the severity of MR, especially in patients with small ventricles (Figure 1) and in patients with milder grades of MR (less than moderate). This is because Contour Method yields a higher SV than Blood Volume Method. When compared to echocardiographic grades of MR, Blood Volume Method has a much better performance in quantifying MR severity (Kappa 0.89) than Contour Method (Kappa 0.44, Figure 2 ). Based on Blood Volume method, we suggest cutoffs of MR grading by CMR as listed in Table 1 . Conclusions: In this study, we present evidence that papillary muscles and trabeculations should be excluded from the blood pool in routine volumetric analysis for accurate assessment of LV stroke volume. This practice is not firmly established by current guidelines. We also present evidence-based reference ranges of mitral regurgitation grades according to the mitral regurgitant fraction calculated by CMR.

Background: Over the last two decades substantial efforts have been aimed at improving acceptability of pacemakers and ICD's in the MRI scanner. Many labs have evaluated the construction, safety, efficacy, reproducibility and more recently, clinical impact value in such legacy devices. In conjunction, there has been extensive effort by the major vendors to develop safe MRI compatible devices. We believe that there remain few reasons for hesitation in more universal useage of any PM/ICD in the MRI bore. Yet, mixing vendor leads and generators remain a major hurdle considerably limiting contemporary MRI usage in nearly all MRI laboratories. Accordingly, we Hypothesize: mixed leads and generators have no distinct safety signal from common devices; whether CIED or non-CIED. Methods: We undertook a retrospective DB analysis to determine safety signals in those patients possessing mixed vendor leads and devices. Comparisons of impedance, amplitude, threshold and battery voltage and patient safety etc. were performed. Results: Patients from 5/2004 to 5/2024, representing 2008 pts with CIED (78%) and non-CIED (22%) underwent an MRI in a dedicated CMR Lab. The majority of the mixed cohort were obtained from the non-CIED cohort (>98%), having no need for generator replacement. Accordingly, 12% of these underwent MRI to include: 76% neurologic, 7% orthopedic and 17% cardiac indications. In safety signals comparisons between standard and mixed lead/generator implants, there were no differences in any implant parameters either pre-MRI or post-interrogation (p=NS). Similarly, there were no peri-MRI pt events reported in the 30d, 180d and 365 day post-MRI scan (p=NS). Importantly, especially for EP considerations, there were no added complications to interrogations. Moreover, utilizing a similar approach to manipulation of MRI parameters for maximum safety intrinsic to dependent/non-dependent PM status was employed regardless of lead/generator configuration yielding no complications. Conclusions: Developing a similar approach to MRI scanning in those patients with mixed vendor lead/generator configurations yielded no difference in a multitude of safety, interrogation, devices and efficacy parameters implementing a similar device interrogation/programming strategy as in traditional devices. This reassurance derived from a large MRI lab suggests, despite inherent incompatibility concerns between vendors while in the magnetic field, suggests no such fears are truly warranted.

Background: Mitral Annular Disjunction (MAD) refers to embryologic fibrous separation between mitral annular ring and basal left ventricular myocardium. Since its original description, the role of MAD in arrhythmic mitral valve prolapse (MVP) has been subject of active research. In this study we sought to assess prognostic and imaging characteristics of MVP patients with and without underlying MAD. Methods: Patients with posterior or bi-leaflet MVP were retrospectively identified via a review of all patients referred to our cardiac magnetic resonance (CMR) imaging laboratory from January 2015 to May 2022. MVP patients were further stratified by underlying MAD status. CMR characteristics including late gadolinium enhancement (LGE) distribution, clinical characteristics, and data on mitral valve intervention were determined. Results: A total of 100 MVP patients undergoing CMR imaging (52 MVP patients with posterior MAD) were retrospectively identified with female comprising 55% of the cohort. MVP patients with MAD were more likely to have an abnormal basal inferolateral/ papillary muscles LGE (51% vs 21%, p<0.01). Posterior MAD longitudinal disjunction gap in ‘mm’ was a predictor of ventricular tachycardia (VT) [1.23, p=0.03)]. Similarly, posterior MAD as a binary variable was predictor of VT (11, p<0.01), ventricular arrhythmia (composite of VT, and non-sustained VT) (2.4, p=0.03), and major adverse cardiac events (MACE) (composite of VT, syncope, and mitral valve intervention) (2.5, p=0.03). Using ROC curve analysis, a disjunction gap of > 4 mm was predictive of VT (AUC-0.71, p<0.01), and incorporation of LGE in ROC model further improved AUC to 0.78 confirmed via Akaike information criterion (p<0.05), see Figure. Conclusion: Abnormal LGE involving basal inferolateral myocardium and papillary muscles may provide substrate for arrythmia in MVP patients. Further, for the first time, a MAD threshold of > 4 mm is demonstrated to stratify the VT risk.

Introduction: Worsening TR following either PPM or ICD implantation is an emerging clinical challenge. Early recognition of this entity is essential in guiding treatment. Hypothesis: Despite many technological advances in electrophysiology, transvenous lead placement currently remains an integral part of cardiac device implantation procedures. While worsening of TR post-device does not seem to be surprising, it is counter-intuitive and eventually leads to right-sided heart failure symptoms. Methods: We searched electronic databases from inception to January 2023 for published studies that reported incidence of TR worsening post-device implantation. Log odds ratio was used to summarize group differences. Results: Our analysis included 29 studies with 66,590 participants. Patients with device implantation (n=1,008) were significantly more likely to develop worsening TR as compared to controls (n=58,605) (OR: 3.18, p<0.01). Amongst a total of 7,777 patients, pooled incidence of at least one-degree worsening of TR post-implantation was 23%. Worsening TR significantly increases mortality (HR 1.42, p=0.02). Larger right atrial area (OR 1.11, p<0.01) is significantly associated with an increased risk of worsening TR, while males are less likely to develop this complication as compared to females (OR 0.74, p<0.01). Importantly, there is no statistically significant difference between the type of implanted device (ICD vs PPM) and post-device TR. Further, RV dysfunction, pulmonary artery pressure, baseline mitral regurgitation, LVEF, baseline atrial fibrillation, and age have no association with worsening TR. Conclusions: A substantial number of patients undergoing PPM or ICD implantation are at an increased risk of worsening TR. Importantly, in this largest review to date incorporating over 66,000 patients, this significantly increases mortality by greater than 140%, accordingly deserving more recognition and clinical attention in the current era.

Assessment of therapeutic interventions in patients with pulmonary arterial hypertension (PAH) suffers from several commonly encountered limitations: (1) patient studies are often too small and short-term to provide definitive conclusions, (2) there is a lack of a universal set of metrics to adequately assess therapy and (3) while clinical treatments focus on management of symptoms, there remain many cases of early loss of life in a seemingly arbitrary distribution. Here we provide a unified approach to assess right and left pressure relationships in PAH and pulmonary hypertension (PH) patients by developing linear models informed by the observation of Suga and Sugawa that pressure generation in the ventricle (right or left) approximately follows a single lobe of a sinusoid. We sought to identify a set of cardiovascular variables that either linearly or via a sine transformation related to systolic pulmonary arterial pressure (PAPs) and systemic systolic blood pressure (SBP). Importantly, both right and left cardiovascular variables are included in each linear model. Using non-invasively obtained cardiovascular magnetic resonance (CMR) image metrics the approach was successfully applied to model PAPs in PAH patients with an r2 of 0.89 (p < 0.05) and SBP with an r2 of 0.74 (p < 0.05). Further, the approach clarified the relationships that exist between PAPs and SBP separately for PAH and PH patients, and these relationships were used to distinguish PAH vs. PH patients with good accuracy (68%, p < 0.05). An important feature of the linear models is that they demonstrate that right and left ventricular conditions interact to generate PAPs and SBP in PAH patients, even in the absence of left-sided disease. The models predicted a theoretical right ventricular pulsatile reserve that in PAH patients was shown to be predictive of the 6 min walk distance (r2 = 0.45, p < 0.05). The linear models indicate a physically plausible mode of interaction between right and left ventricles and provides a means of assessing right and left cardiac status as they relate to PAPs and SBP. The linear models have potential to allow assessment of the detailed physiologic effects of therapy in PAH and PH patients and may thus permit cross-over of knowledge between PH and PAH clinical trials.