title: Appropriateness and diagnostic yield of cardiac magnetic resonance imaging from a tertiary referral center in the Middle East.
abstract: OBJECTIVE
  Cardiac magnetic resonance imaging (CMRI) is a novel non-invasive modality with many potential indications, and was recently introduced in Lebanon. We sought to assess the appropriateness and diagnostic yield of CMR studies performed at a tertiary referral center from the Middle East since the inception of the program.
  
  
  METHODS
  All patients who underwent CMR studies between January 1(st) 2013 and June 18(th) 2014 were enrolled in this study. CMR reports were retrospectively reviewed. The study indication, clinical history, and findings were extracted and analyzed. The appropriateness of the study was judged according to the 2010 updated Asian Society of Cardiac Imaging guidelines.
  
  
  RESULTS
  There were a total of 142 patients [mean age 42.1 (SD: 18) years, 24.6% females] that underwent CMR study. Two-thirds of studies were performed on an outpatient basis, and outside referrals constituted 16.2% of the entire cohort. The cardiologists referred 122 cases (86%) with main contribution from electrophysiology and imaging specialists. Of the 142 cases, 12 (8.4%) were not indicated and added little value. Of the remaining 130 appropriate studies (appropriateness level A8-A9), one-third had an incorrect diagnosis prior to CMR, and 8% had relevant findings that were missed on other studies but captured by CMR. Furthermore, CMR confirmed the diagnosis in 28% of the cases, provided relevant information on scar burden, shunt quantification, and ruled out infiltrative disease in the remaining patients. Also, CMR demonstrated the presence of scar in 45 of patients, among whom 20 (44%) had significant scar volume quantification (>5% of left ventricular myocardium). Finally, 9% of patients had a relevant extra-cardiac finding that needed further investigation.
  
  
  CONCLUSIONS
  Despite the recent launch of the CMR program at our institution, the majority of studies were appropriately indicated, provided relevant data and were clinically useful. Inappropriate or uncertain studies did not provide relevant data, and should be further minimized to avoid unnecessary costs and downstream testing. Large prospective CMR database with clinical follow-up is needed to provide more insight about cardiovascular disease and outcomes in our population.
authors.affiliation: 1 Division of Cardiovascular Medicine, 2 Division of Radiology, American University of Beirut Medical Center, Beirut, Lebanon ; 3 Heart and Vascular Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Wael
authors.initials: W
authors.lastname: AlJaroudi
authors.affiliation: 1 Division of Cardiovascular Medicine, 2 Division of Radiology, American University of Beirut Medical Center, Beirut, Lebanon ; 3 Heart and Vascular Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Hussain
authors.initials: H
authors.lastname: Isma'eel
authors.affiliation: 1 Division of Cardiovascular Medicine, 2 Division of Radiology, American University of Beirut Medical Center, Beirut, Lebanon ; 3 Heart and Vascular Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Fadi
authors.initials: F
authors.lastname: El Merhi
authors.affiliation: 1 Division of Cardiovascular Medicine, 2 Division of Radiology, American University of Beirut Medical Center, Beirut, Lebanon ; 3 Heart and Vascular Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Tony
authors.initials: T
authors.lastname: Assad
authors.affiliation: 1 Division of Cardiovascular Medicine, 2 Division of Radiology, American University of Beirut Medical Center, Beirut, Lebanon ; 3 Heart and Vascular Imaging Institute, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Mukbil
authors.initials: M
authors.lastname: Hourani
keywords: Appropriateness; Middle East; cardiac magnetic resonance imaging (CMRI); diagnostic yield