title: Coronary microvascular ischemia in hypertrophic cardiomyopathy - a pixel-wise quantitative cardiovascular magnetic resonance perfusion study.
abstract: BACKGROUND
  Microvascular dysfunction in HCM has been associated with adverse clinical outcomes. Advances in quantitative cardiovascular magnetic resonance (CMR) perfusion imaging now allow myocardial blood flow to be quantified at the pixel level. We applied these techniques to investigate the spectrum of microvascular dysfunction in hypertrophic cardiomyopathy (HCM) and to explore its relationship with fibrosis and wall thickness.
  
  
  METHODS
  CMR perfusion imaging was undertaken during adenosine-induced hyperemia and again at rest in 35 patients together with late gadolinium enhancement (LGE) imaging. Myocardial blood flow (MBF) was quantified on a pixel-by-pixel basis from CMR perfusion images using a Fermi-constrained deconvolution algorithm. Regions-of-interest (ROI) in hypoperfused and hyperemic myocardium were identified from the MBF pixel maps. The myocardium was also divided into 16 AHA segments.
  
  
  RESULTS
  Resting MBF was significantly higher in the endocardium than in the epicardium (mean ± SD: 1.25 ± 0.35 ml/g/min versus 1.20 ± 0.35 ml/g/min, P<0.001), a pattern that reversed with stress (2.00 ± 0.76 ml/g/min versus 2.36 ± 0.83 ml/g/min, P<0.001). ROI analysis revealed 11 (31%) patients with stress MBF lower than resting values (1.05 ± 0.39 ml/g/min versus 1.22 ± 0.36 ml/g/min, P=0.021). There was a significant negative association between hyperemic MBF and wall thickness (β=-0.047 ml/g/min per mm, 95% CI: -0.057 to -0.038, P<0.001) and a significantly lower probability of fibrosis in a segment with increasing hyperemic MBF (odds ratio per ml/g/min: 0.086, 95% CI: 0.078 to 0.095, P=0.003).
  
  
  CONCLUSIONS
  Pixel-wise quantitative CMR perfusion imaging identifies a subgroup of patients with HCM that have localised severe microvascular dysfunction which may give rise to myocardial ischemia.
authors.forename: Tevfik F
authors.initials: TF
authors.lastname: Ismail
authors.forename: Li-Yueh
authors.initials: LY
authors.lastname: Hsu
authors.forename: Anders M
authors.initials: AM
authors.lastname: Greve
authors.forename: Carla
authors.initials: C
authors.lastname: Gonçalves
authors.forename: Andrew
authors.initials: A
authors.lastname: Jabbour
authors.forename: Ankur
authors.initials: A
authors.lastname: Gulati
authors.forename: Benjamin
authors.initials: B
authors.lastname: Hewins
authors.forename: Niraj
authors.initials: N
authors.lastname: Mistry
authors.forename: Ricardo
authors.initials: R
authors.lastname: Wage
authors.forename: Michael
authors.initials: M
authors.lastname: Roughton
authors.forename: Pedro F
authors.initials: PF
authors.lastname: Ferreira
authors.forename: Peter
authors.initials: P
authors.lastname: Gatehouse
authors.forename: David
authors.initials: D
authors.lastname: Firmin
authors.forename: Rory
authors.initials: R
authors.lastname: O'Hanlon
authors.forename: Dudley J
authors.initials: DJ
authors.lastname: Pennell
authors.forename: Sanjay K
authors.initials: SK
authors.lastname: Prasad
authors.forename: Andrew E
authors.initials: AE
authors.lastname: Arai
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D002312:Cardiomyopathy, Hypertrophic / Q000175:diagnosis* / Q000473:pathology / Q000503:physiopathology; D003287:Contrast Media; D003326:Coronary Circulation; D003331:Coronary Vessels / Q000503:physiopathology*; D005260:Female; D005355:Fibrosis; D006801:Humans; D006940:Hyperemia / Q000503:physiopathology; D007090:Image Interpretation, Computer-Assisted; D008279:Magnetic Resonance Imaging; D008297:Male; D008833:Microcirculation; D055806:Microvessels / Q000503:physiopathology*; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000175:diagnosis* / Q000473:pathology / Q000503:physiopathology; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D009206:Myocardium / Q000473:pathology; D009942:Organometallic Compounds; D011237:Predictive Value of Tests; D012720:Severity of Illness Index; D013997:Time Factors; D014665:Vasodilator Agents
chemical_list: D003287:Contrast Media; D009942:Organometallic Compounds; D014665:Vasodilator Agents; C090600:gadobutrol