Discussion (warsztaty z rezonansu magnetycznego serca)

Thank you.Thank you.Uh, at the beginning, Iwould like to, uh, sorry for,um, Dr.Sokolska's lecture.Uh, but I know thatwe will share the good presentation,um, uh, after the congresswith all of the audience and,uh, our participants.Um, thank you very muchfor...Even with the pre-recorded, um,video we had, we couldn't, uh,avoid technical issues.Sorry for that.Um, so thank you, uh,all of the lecturers for yourvery beautiful presentation.Very complex, full of knowledgeand, and practical advices.Now, we have time, uh,for discussion.Maybe not so longbecause we are out of thetime, but we have onequestion on our chat.

So, um, so the question'sabout the mapping.Uh, if, if, uh, themapping is nowadays obligatory in cardiomyopathies,we talked about it alot, and we know that inpublications, for example, those techniquesare very encouraging.But for sure, um, themapping is not available in allCMR labs, for example, inPoland.I don't know, what aboutItaly?Um, so as, uh...I would like to knowyour opinion also, uh, um, asexperts who perform tests, uh,CMR tests on a daily basis.If it's really actual- actually,um, mapping is used in CMR,uh, labs on a dailybasis, uh, if it's included inthe standard protocols, and if,uh, the mapping really influences thechange in diagnosis and treatmentof the patients after, after.So Anna, if I canstart with, with your statement?

Yes, thank you verymuch and good evening, um, everyone.So, um, I think whatyou said is very, uh, important.So if we look atthe, um, latest ESC guidelines thatyou showed, uh, on cardiomyopathy,I think that the use ofmapping is encouraged.Um, and if available, uh,in the scanner, it should probably,uh, be included, uh, atleast when we study patients withsuspected cardiomyopathies.Uh, of course, we have

to face reality. Not all, um, the scanners, uh, already have or are up to date with, uh, parametric mapping. So we need to probably balance and, uh, select maybe those cases where it is mostly beneficial. And I don't know if you all agree, but I think that probably, uh, the hypertrophied, uh, phenotype, uh, is the one that mostly, um, uh, benefits, uh, from, uh, mapping because you get to see probably the extremes of the curve. So if you get very low T1 values, for example, that's specific of Anderson-Fabry disease. And if you have very, very high values, on the other hand, that's quite typical of patients, uh, with amyloid. So if you have a patient with, um, an hypertrophic, uh, phenotype, having the mapping may really make a difference, uh, in patients' diagnosis and management, as well as the T2* mapping maybe in patients with suspected hemochromatosis. And I think these cases, uh, if you can have mapping, that's very helpful.

But to be honest, we were very good at making the diagnosis, uh, also before the advent of mapping, and we have to bear in mind that there's an overlap between, you know, microfibrosis and normal. Um, so, you know, it's probably to get the proper balance. But what I really would like to recommend and stress is that, um, whenever you get a report or you make yourself a report, you always have to make a comparison with the normal T1 and T2 mapping values in your lab and your scanner, because there's a difference between scanner and scanner. So getting just the absolute number makes very little sense. So if you get the report, please pretend to have the normal values in the scanner that the, uh, patient was scanned with. So this is my opinion. I mean, if you have the mapping, you can add it. Uh, if you don't, you can still be very good at diagnosis without it. Probably, um, better to have it in the hypertrophic phenotype.

But, uh, you know, there's a lot of, um, discussion recently about, uh, environmental impact of all the, you know, the tests that we do, and of course, increasing the number of sequences increases the length of a scan, and this is not, uh, environmental-friendly.

So probably select those patientsthat most likely benefit from thosesequences.And if not necessarily needed,I think we can be allhappy with skipping these sequences.At least this is myopinion.I don't know if youagree.Okay.Uh, so maybe you havesomething to add, Dr.Justyna or Professor Mateusz?

I- I completely ag- Yeah,I thought- Okay, so Justyna, youfirst.I' be first.No, no, please.No, no, no.It's, uh...Okay.So I- I, I am,uh, completely agree with Anna.Um, whenever it's possible, it'sperfect to have mapping, especially inhypertrophic, uh, cardiomyopathy.And we had many patientsin, uh, in whom it helped,uh, a lot.I would say that MRIis a little bit like collecting......Puzzles, some pieces of puzzles.And it's never, um, diagnosisis never based on one sequence.So whenever we can havemore of these puzzles to havebetter whole image of thepatients, then it's the better.Uh, so I strongly recommendto, to use, um, MRI labs,uh, where, uh, where theyhave mappings, and I believe thatwe have already enough inPoland, uh, that, uh, that wecan, uh, we can sendpatient with hypertrophic, um, phenotype tothose labs.Of course, not everyone needit.In fact, in our lab,we do it, uh, in everypatient, but for example, whenwe just need to assess viability,uh, or, um, ischemic etiology,then probably we don't have todo it.So yeah, that's my shortcomment.Thank you.Thank you.

Uh, ma- thank you.My comment is, uh, uh,that, uh, I agree completely thatwe should perform, uh, T1or T2 and T2* mapping insome populations.In our unit, uh, weused to perform a mapping in,uh, every patient, but westopped doing this because the protocolswere too long and ittook too many times, uh, toomuch time to, uh, studythe patient.And now, we perform this

mapping in three situation obligatory, inhypertrophic phenotype, uh, in suspectedmyocarditis and in suspected sarcoidosis.And I think that these,uh, three, uh, diseases, uh, itis crucial to have mappingnowadays.Thank you.

Thank you very much foryour opinions.I, I think...So we can conclude thatit's maybe not obligatory in everypatient, but i- it isgood to have it in, inour CMR labs.And, um, of course, some,some patients, um, it can behelpful in diagnosis in somepatients, but we will see whatfuture brings, yes?Because this technique is still,um, uh, is developing and, uh,there are, uh, a lotof studies on this, for example,progno- prognostic role of mapping.Uh, we have another question.

So, uh, now, uh, wehave question about the quantitative, uh,LGE measurement.Is this...If it is a standard,uh, because the...In the, um, uh, participant,um, uh, c- l- c- CMRlabs, this parameter is notincluded in their results.And, uh, for example, inthe guidelines, we know that ishelpful, uh, in risk stratification.So, um, what about this,uh, issue?Uh, you include c- uh,quantity of LGE in percentage inyour r- results?So maybe I will start,uh, now.Uh, this topic is very,uh, close to my heart, becausethe first publication which Imade, uh, concerning CMR was, uh,about standardization of, uh, LGE,uh, uh, quantification in patients with,uh, hypertrophic cardiomyopathy.We do not, uh, give,uh, the, uh, the numbers.Uh, the first reason, veryprosaic, is that we currently donot have software to dothis.The second one is that,uh, there is lack of standardization,complete lack of standardization, howto measure, uh, LGE?

Should...Which techniques should be used?Two standard deviation, six standarddeviation, full width at half maximum,uh, and others are a-all, uh, any, or visual assessment,uh, is also, uh, used,uh, in the publication.So, uh, we do not,uh, use it, but I thinkit's crucial for some societiesto tell us how to measureLGE, how to quantify LGE,which techniques should be used.

So maybe, Anna, y- whocan share here?Uh- Yeah.I, I totally agree.Totally agree.Nothing more to add.Uh, absolutely, I agree.There's no standardization.So you know, it's randomnumbers in the end.So it can be, youknow- Sure.Sure....We need to be cautiouswhen we get to numbers becausethat may have implications, forexample, in HCM and ICD implantation,you know, the gray zone.Yeah.That's, uh- You have apercentage, but there's no way...Nobody tells you how toget to that number.So it's...Could be dangerous.I totally agree.

Yeah, but the clinicians arereading, yeah, the guidelines, and theyare wanted to havethis number- Yes....With CMR result.Okay.And Anna, you just said?May- maybe it's- Yeah, okay.Yeah, stay.I, I, I will justa short comment.So in our lab, we,uh, we give number when wesee, uh, from even fromvisual assessment that LGE is, uh,there is quite a lotof LGE.And it, uh, really thenhelps clinicians that they will seethis number, 15 or more,and, uh, and think about ICD.But only when we reallyfirst visualize, um, and we seethat it's quite a lot,and then we perform this, uh,measurement.This is also because it'sextra work.Um, but when there isjust a small, um, small LGE,then we don't perform itin numbers.And, uh, what Mateusz said,it's very important, that we don'thave standardized, uh, method.

Uh, there are papers suggestingusing, um, even, I think, yourfive or six standard deviations.Um, and that's what weusually use, so we......Use a five standard uhdeviation uh and compare this withremote, uh, myocardium, but alsowe check this in, uh, visualassessments, so we also checkit, um, with another technique.

Uh, and when there issome discrepancies, then we give, uh,the, this minimum and maximumnumber.Uh, but yes, so uh,I, I believe that when cliniciansreally wanted to have thisnumber, it would be re- reallyhelpful when they also writeit, uh, in question that pleaseprovide some, um, assessmentof the quantity of this LGE.Yeah, that's right, yeah.Good point.

Uh, also, Ana, uh, becauseyou said that, uh, previously,um, arrhythmogenic cardiomyopathy was, uh,was, uh, only, um, the caseof the right ventricle,you said that is not true,that it can also affectthe left ventricle, but still inguidelines, ESC guidelines from thelast year, we have this definitionin the chapter that arrhythmogenic,uh, cardiomyopathy of right ventricle.So what, what do youthink about it?Why they do not changethe, the name?

Well, this is adifficult question.I, I don't know.Um, of course, I thinkthere's a long, uh, history tothe right ventricular involvement whilethe left and the biventricular aremore recent.Um, a- a- again, the,the left, uh, dominant, uh, hasclearly loads of overlap, forexample, with how myocarditis may lookin CMR, so, um, alsothe Padua criteria mentioned you shoulddo genetic testing, um, youknow, to, uh, help yourself, uh,in between the two, um,features, but I think diagnosis sometimesvery difficult and that's whyit's a multiparametric approach, and as,um, as we said previously,you can never rely on thesingle parameter and this appliesto CMR, CT and echo.I think it's the puttingthe pieces of the puzzle togetherthat help with the diagnosis.

And with regards to will,um, left dominant be included inthe next guidelines?I don't know.We' see.I guess we' see ifit's going to be included ornot.Yeah.Uh, okay.And, uh, we have anotherquestion on the, on the chat.Uh, what about artificial it-intelligence?So I don't know, howdo you imagine your workat CMR labs in a

few years?Artificial intelligence will, will changesomething?Uh, I have shown you,uh, two publication on differentiation, uh,between hypertrophic cardiomyopathy and hypertensiveheart disease using deep learning and,uh, the results were prettygood, uh, because, uh, artificial intelligencecan, uh, uh, introduce intothis, uh, mathematic, uh, uh, mathematic,uh, theory, uh, many, manyparameters which, uh, we cannot, uh,see with our eye, uh,and, uh, the machines can dothis and I think, uh,it will be future.Of course, it will bealways checked by a physician, uh,and I think it's, uh,helpful, but it won't, uh, replaceradiologists- Yeah....Cardiologists or, uh, any otherphysician who, uh, performs CMR.Yeah.So yes, you will stillhave a job.Okay.I hope.

Uh, another question, a trickyquestion to Ana.Uh, we have...We know that people performingCMR believe that endomyocardial biopsies arenowadays unnecessary.So what is your opinion?Well, I think you know,Agata, what's my opinion.Yeah.So, um, I'm, I'ma bit biased, I have tosay, 'cause, um, in myclinical practice, I take care ofpatients with, um, myocarditis, inflammatoryheart diseases, and we, uh...I, I mean, I'm luckyenough to work in a centerwhere we can perform endomyocardialbiopsy, not always easily.Uh, so I think, youknow, s- some people say thatCMR is sort of a,a virtual biopsy.I mean, I've heard thisterm.Um, I think, you know,it's true to a certain extent.Um, it helps a lot,you know.I mean, sometimes we lookat a MRI scan and weknow exactly what the diagnosisis.But it...I think, I mean, atleast today, I don't know inlike 20 or 30 years

time, but it does not providehistology, right?And, uh, for example, whenit comes to myocarditis, it willnever tell you if there'sa virus in the myocardium orif it's a lymphocytic orgiant cell myocarditis, and we doknow that, uh, different typesof myocarditis, um, are treated differently.So, you know, I thinkthat CMR will not replace, um,endomyocardial biopsy and I thinkwe should never...We should- shouldn't even bevery surprised because if we thinkat cancer, for example, wedo CT and we do knowthat the patient, based onCT images, has this or thatcancer, but we still performbiopsy to, to treat the patient.So I think it's rathercomplementary information than, um, one techniquereplacing the other.So, um, I don't think,you know, that e- there willnever be a role againfor biopsy or in the futureCMR will, you know, notbe complementary anymore.So I, I think itgives different, uh, information and maybewhat we may do isuse CMR to guide, um, maybeor m- give a strongerindication to endomyocardial biopsy.I don't know if thatanswers your question.

No, it's all right.It, it increase the probabilitythat we will find something inbiopsies.Okay, thank you.Thank you, uh, all ofyou for your lectures, for yourtime.Uh, thank you, Ana, forconnecting from the Italy, and weare running- Thank you forhaving me....Out of time.My pleasure.So yes.Uh, I would like toalso thank, uh, thank you to,to the entire audience forparticipating in our congress and we,we hope this is notlast edition and I wish youa very nice weekend andrest, so goodbye.Thank you very much.Bye-bye.Thank you.Bye.Thank you very much.Bye-bye.Thank you.