Cardiac Imaging: History
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Michael Cronin
,
Mehreen Seher
,
Shahram Arsang-Jang
,
Aoife Lowery
,
Michael Kerin
,
William Wijns
,
Osama Soliman

Cardiac magnetic resonance imaging emerged as the most definitive modality, offering real-time detection, comprehensive assessment of cardiac function, the ability to detect early myocardial changes, and superior detection of cardiotoxicity when compared to the other imaging modalities. 

  • multimodal imaging
  • cardiac magnetic resonance imaging
  • nuclear imaging

1. Multimodal Imaging

Multimodality imaging is effective in the early detection and monitoring of cardiotoxicity in cancer patients. Previous publications [1] demonstrate that the combination of echocardiography and cardiac MRI provides a more accurate assessment of left ventricular function than either modality alone. However, despite the potential benefits of multimodality imaging, there are some limitations and challenges to its use in clinical practice. These include the cost of imaging, the need for specialized training and expertise to interpret results, and the lack of standardized protocols for imaging and interpretation [2].

2. Echocardiography

Echocardiography is a widely used imaging modality for the assessment of cardiac function. It is non-invasive, portable, relatively inexpensive, and does not use ionizing radiation. Echocardiography via the use of global longitudinal strain (GLS) can provide information on left ventricular ejection fraction (LVEF), regional wall motion abnormalities (RWMA), and valvular function [3]. It is particularly useful in the early detection of cardiotoxicity, when changes in LVEF can be detected before the onset of symptoms [4][5][6][7], with three-dimensional image acquisition preferable due to reduced intra-observer variability [8][9]. A change in LVEF of ≥10 percentage points or a final EF of <53% following high-dose chemotherapy with autologous stem cell transplantation was associated with a higher incidence of cardiac events [5]. A reduction in GLS of at least 15% following anthracycline treatment established a correlation between an increase in the risk of cardiac events, such as heart failure, and cardiovascular death [1]. Further, an elevated risk of later cardiotoxicity was linked to a drop in GLS of at least 2.5% within the first year after anthracycline treatment [2], and a decrease in GLS of ≥10% following treatment with immune checkpoint inhibitors was associated with an increased risk of cardiac events [8]. Global circumferential strain (GCS) is a measure of the myocardial deformation around the left ventricle in a circumferential direction during systole that can be obtained using cardiovascular imaging modalities such as echocardiography and cardiac MRI; however, preliminary studies have not proved clinical benefit [10]. Tissue doppler imaging (TDI) via echocardiography can establish early subtle changes of diastolic impairment treated with anthracyclines [11], with isovolumetric relaxation time and the evaluation standard within most accredited examinations, as well as deceleration time and E and A wave assessments [12]. Within the limitations of echocardiography are limited sensitivity and reproducibility, particularly for the detection of subtle changes in myocardial function [13], as well as a dependence on patient body habits and adequate imaging windows.

3. Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is a versatile imaging modality that can provide information on both cardiac function and structure. It can detect RWMA, changes in LVEF, and myocardial fibrosis. Myocardial fibrosis is a common finding in patients with cardiotoxicity. It is a marker of irreversible damage to the heart muscle and can be detected by late gadolinium enhancement on MRI [14], with an increased risk of subsequent heart failure in patients undergoing chemotherapy [15]. Changes in GLS on MRI are associated with an increased risk of CTRCD [16], with the extent of late gadolinium enhancement being a marker of the severity of CTRCD [17]. Previous publications have described its superiority to echocardiography in the detection of (sub)clinical CTRCD, specifically in lymphoma treated with anthracyclines [18], anthracycline use in breast cancer [17], and also its role in the diagnosis of checkpoint inhibitor therapy-induced myocarditis [19]. Myocarditic changes secondary to immune checkpoint inhibitors constitute a major diagnostic criterion [20] and are defined by the 2018 updated Lake Louise criteria [21], which describe specific features seen during T1-weighted and T2-weighted imaging acquisition. MRI is now recognized for its superior diagnostic accuracy compared to other imaging modalities, such as echocardiography and nuclear medicine imaging. However, the high cost, longer scanning time, dependence on renal function for the use of gadolinium, and lower availability of cardiac MRI in some settings limit its widespread use.

4. Cardiac Computed Tomography

In recent years, cardiac computed tomography angiography (CCTA) has emerged as a valuable tool in the diagnosis and management of various cardiovascular diseases, including coronary artery disease and coronary anomalies [22], where a significant coronary artery stenosis is taken to be >70%. It carries a high spatial resolution, which allows for the detection of small changes in cardiac morphology and function [22]. CCTA utilizes an ECG-gated 64-slice CT scanner, with various image acquisition protocols recognized [23]. It has also been shown to be useful in the assessment of cardiomyopathy. CCTA-derived extra-cellular volume fraction followed similar dynamics when compared to LVEF and GLS measured by TTE in a breast cancer population treated with anthracyclines [24]. A major limitation is the use of ionizing radiation and contrast agents that can pose risks, particularly in patients with renal impairment [25].

5. Nuclear Imaging

Nuclear cardiac scanning is a non-invasive imaging technique that utilizes radiotracers to evaluate myocardial perfusion and function. It is an alternative imaging modality in patients who cannot undergo other imaging modalities (e.g., MRI), with multigated radionuclide angiography (MUGA) and single-photon emission computed tomography (SPECT) further acquisition methods that, via a range of radioisotopes, can assess LVEF and for perfusion defects [26]. Prior examples of its clinical use include PET imaging with fluorine-18-labeled deoxyglucose (FDG) in identifying cardiotoxicity in lymphoma patients treated with anthracyclines [27]. In this case, myocardial glucose uptake was considerably lower in those who suffered cardiotoxicity than in those who did not. The use of radiation and radiotracers within nuclear imaging can pose risks, particularly in pregnant women and patients with renal impairment, which poses some limitations to its use. If a dual-phase study is needed, this can be quite laborious and not feasible for a patient who is traveling a distance to undergo the test.

6. multiple imaging

The use of multiple imaging modalities can be expensive, and there is a need to evaluate the cost-effectiveness of these modalities in different patient populations. Comparative studies that evaluate the costs and benefits of different imaging modalities could help guide clinical decision-making and resource allocation. While many studies have evaluated the utility of imaging modalities in detecting early cardiac dysfunction, there is a need for studies that evaluate the long-term prognostic value of these modalities in predicting adverse cardiovascular outcomes. Predictive models would enable clinicians to identify patients who are at high risk of developing cardiotoxicity, allowing for the implementation of preventive strategies. Individual imaging modalities are effective in detecting cardiotoxicity, but there is a need to evaluate the added value of combining different imaging modalities. Multimodality imaging approaches could provide a more comprehensive assessment of cardiac function and facilitate the early detection of cardiac dysfunction. A summary of the above can be found in Table 1.

Table 1. Gaps in the literature.
1 Lack of standardization in the use of imaging modalities for cardiotoxicity assessment and in the protocol used during image acquisition.
2 There is a need for studies that evaluate the utility of multimodal imaging approaches for cardiotoxicity assessment.
3 Lack of standardization in the interpretation of imaging findings.
4 Lack of research on the cost-effectiveness of different imaging modalities for cardiotoxicity assessment.
5 Insufficient research into the long-term prognostic value of imaging modalities in assessing cardiotoxicity.
6 Evaluation of the utility of multimodality imaging approaches for cardiotoxicity assessment.

This entry is adapted from the peer-reviewed paper 10.3390/jcm12196295

References

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  2. Negishi, K.; Negishi, T.; Hare, J.L.; Haluska, B.A.; Plana, J.C.; Marwick, T.H. Independent and incremental value of deformation indices for prediction of trastuzumab-induced cardiotoxicity. J. Am. Soc. Echocardiogr. 2013, 26, 493–498.
  3. Sawaya, H.; Sebag, I.A.; Plana, J.C.; Januzzi, J.L.; Ky, B.; Cohen, V.; Gosavi, S.; Carver, J.R.; Wiegers, S.E.; Martin, R.P.; et al. Early detection and prediction of cardiotoxicity in chemotherapy-treated patients. Am. J. Cardiol. 2011, 107, 1375–1380.
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  5. Cardinale, D.; Colombo, A.; Sandri, M.T.; Lamantia, G.; Colombo, N.; Civelli, M.; Martinelli, G.; Veglia, F.; Fiorentini, C.; Cipolla, C.M.; et al. Prevention of high-dose chemotherapy-induced cardiotoxicity in high-risk patients by angiotensin-converting enzyme inhibition. Circulation. Circulation 2006, 114, 2474–2481.
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  11. Venturelli, F.; Masetti, R.; Fabi, M.; Rondelli, R.; Martoni, A.; Prete, A.; Bonvicini, M.; Pession, A. Tissue Doppler Imaging for anthracycline cardiotoxicity monitoring in pediatric patients with cancer. Cardiooncology 2018, 4, 6–8.
  12. Mitchell, C.; Rahko, P.S.; Blauwet, L.A.; Canaday, B.; Finstuen, J.A.; Foster, M.C.; Horton, K.; Ogunyankin, K.O.; Palma, R.A.; Velazquez, E.J. Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. J. Am. Soc. Echocardiogr. 2019, 32, 1–64.
  13. Negishi, K.; Negishi, T.; Agler, D.A.; Plana, J.C.; Marwick, T.H. Role of temporal resolution in selection of the appropriate strain technique for evaluation of subclinical myocardial dysfunction. Echocardiography. Echocardiography 2012, 29, 334–339.
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