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\begin{document}

\title{Accuracy of Visual Assessment for Quantification of Myocardial Edema
Extension in Takotsubo Syndrome.}



\author[1]{Alberto Cecconi}%
\author[1]{Jorge Salamanca}%
\author[1]{Teresa Alvarado}%
\author[1]{Paula Antuna}%
\author[1]{Susana Hernandez  Muñiz}%
\author[1]{Maria Jose Olivera}%
\author[1]{Paloma Caballero}%
\author[1]{Luis Jesus Jimenez-Borreguero}%
\author[1]{Fernando Alfonso}%
\affil[1]{Hospital Universitario La Princesa}%


\vspace{-1em}



  
  \date{March 13, 2025}


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\begin{abstract}
The aim of this study was to define the correlation between visual
qualitative method and semi-quantitative method for the study of the
extension of myocardial edema by CMR in patients with Takotsubo syndrome
(TTS). We analyzed 22 consecutive patients with a diagnosis of typical
apical TTS. A total of 374 myocardial segments were analyzed. A high
correlation between visual method and the semi-quantitative method of
the T2 SI ratio (Pearson's r = 0.82, p \textless{}0.001) was found. In
the clinical setting the visual method provides a valid and reliable
quantification of myocardial edema extension in patients with TTS.%
\end{abstract}%



\sloppy


\textbf{Abstract:}

The aim of this study was to define the correlation between visual
qualitative method and semi-quantitative method for the study of the
extension of myocardial edema by CMR in patients with Takotsubo syndrome
(TTS).

We analyzed 22 consecutive patients with a diagnosis of typical apical
TTS. A total of 374 myocardial segments were analyzed. A high
correlation between visual method and the semi-quantitative method of
the T2 SI ratio (Pearson's r = 0.82, p \textless{}0.001) was found.

In the clinical setting the visual method provides a valid and reliable
quantification of myocardial edema extension in patients with TTS.

\textbf{Background} . Myocardial edema is characteristic of the acute
phase of Takotsubo syndrome (TTS) and can be easily detected by cardiac
magnetic resonance (CMR) {[}1{]}. In conventional edema sequences, the
presence and extension of edema can be assessed qualitatively by visual
analysis of the signal intensity (SI) or semi-quantitatively by
analyzing the T2 SI ratio between myocardial and skeletal muscle
{[}2{]}. In the clinical practice the qualitative method is widely
accepted in the scenario of acute myocardial infarction, early stages of
myocarditis and sarcoidosis {[}3{]}. However, whether a quantitative
method should be preferred in patients with TTS remains unknown. The aim
of this study was to define the correlation between visual qualitative
method and semi-quantitative method for the study of the extension of
myocardial edema in patients with TTS.

\textbf{Methods} . We included all consecutive patients admitted between
January 2013 and March 2016 with a diagnosis of typical apical TSS
(according to the criteria of the Mayo Clinic), following a prospective
comprehensive and systematic protocol including a CMR study in the acute
phase {[}4{]}. CMR protocol included a specific T2-weighted sequence
(double inversion recovery spin echo with fat suppression) on short- and
long-axis (2-,3-, and 4-chamber) views in a 1.5 Tesla MRI Scanner (Signa
HDXT; General Electric Healthcare\selectlanguage{ngerman}®, Milwaukee, WI, USA), using a
12-channel phased array surface coil and ECG synchronization. All
patients provided informed consent to participate in the study. The
extent of the edema was assessed by accredited experts and expressed as
number of myocardial segments involved using the 17-segments cardiac
segmentation model. The quantification of the edema was performed both
by visual SI and by the semi-quantitative T2 SI ratio. For the T2 SI
ratio, a ROI was drawn in every myocardial segment and then compared
with a ROI localized in the skeletal muscle closest to the heart and to
the center of the reception field of the coil. A value \textgreater{}
1.9 in the T2 SI ratio was considered positive for the presence of edema
in the myocardial segment. Patients negative for edema by T2 SI ratio
were excluded. All the analyses were blind and independent.

\textbf{Results} . 22 patients were included in the analysis. A total of
374 myocardial segments were analyzed. The median of myocardial segments
with edema was 5 (1-11) using the qualitative method and 6 (0-12) using
the semi-quantitative method. The results showed a positive correlation
between the extent of myocardial edema measured by the visual method and
the semi-quantitative method of the T2 SI ratio (Pearson's r = 0.82, p
\textless{}0.001) (Figure).

\textbf{Discussion} . Postprocessing guidelines support visual analysis
for the assessment of myocardial edema in myocardial infarction, however
they do not state whether this is also appropriate for TTS {[}3{]}. T2
SI ratio and T2 mapping are more accurate than visual assessment
{[}5{]}, but their use is limited in clinical practice because they are
time consuming and the analyses are not widely accessible. Considering
that visual edema assessment by CMR is the most common used method in
the differential diagnosis of myocardial infarction with nonobstructive
coronary arteries (MINOCA) and that TTS may represent up 20\% of MINOCA
patients {[}6{]}, we considered mandatory to test the accuracy of visual
assessment in TTS with a more rigorous methods as T2 SI ratio.

\textbf{Conclusions} . The visual qualitative method presents a high
correlation with T2 SI ratio in the study of myocardial edema by CMR in
patients with TTS. Therefore, in the clinical setting the visual method
provides a valid and reliable quantification of myocardial edema
extension in patients with TTS.

\textbf{Author contributions:}

Concept/design: AC, JS, LJJB, FA; Data analysis/interpretation: AC, JS,
SHM, MJO, PC; Drafting article: AC, JS, LJJB, FA, Critical revision of
article: AC, TA, PA, SHM, MJO, PC, JS, LJJB, FA; Approval of article:
AC, TA, PA, SHM, MJO, PC, JS, LJJB, FA; Statistics: AC, JS; Data
collection: AC, JS, TA, PA.

\textbf{References} :

1. Salamanca, J., et al.,\emph{Temporal Resolution Pattern of Myocardial
Edema in Patients With Takotsubo Syndrome.} J Card Fail, 2018.
\textbf{24} (5): p. 345-346.

2. Eitel, I. and M.G. Friedrich,\emph{T2-weighted cardiovascular
magnetic resonance in acute cardiac disease.} J Cardiovasc Magn Reson,
2011. \textbf{13} : p. 13.

3. Schulz-Menger, J., et al.,\emph{Standardized image interpretation and
post processing in cardiovascular magnetic resonance: Society for
Cardiovascular Magnetic Resonance (SCMR) board of trustees task force on
standardized post processing.} J Cardiovasc Magn Reson, 2013.
\textbf{15} : p. 35.

4. Cecconi, A., et al.,\emph{Predictors of oedema in Tako-Tsubo
cardiomyopathy: new insights into the diabetes paradox.} J Cardiovasc
Med (Hagerstown), 2019.\textbf{20} (6): p. 406-408.

5. Messroghli, D.R., et al.,\emph{Clinical recommendations for
cardiovascular magnetic resonance mapping of T1, T2, T2* and
extracellular volume: A consensus statement by the Society for
Cardiovascular Magnetic Resonance (SCMR) endorsed by the European
Association for Cardiovascular Imaging (EACVI).} J Cardiovasc Magn
Reson, 2017. \textbf{19} (1): p. 75.

6. Tamis-Holland, J.E. and H. Jneid,\emph{Myocardial Infarction With
Nonobstructive Coronary Arteries (MINOCA): It's Time to Face Reality!} J
Am Heart Assoc, 2018.\textbf{7} (13).

\textbf{Figure legends:}

\textbf{Figure.} Correlation between the extent of myocardial edema
measured by the visual method and the semi-quantitative method.

On the left, the regression line is showed. On the right,
mid-ventricular short-axis view, assessment by both methods is
presented.\selectlanguage{english}
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