Online Appendix for the following August 1 iJACC article
TITLE:
Contrast-Enhanced Anatomic Imaging as Compared With Contrast-Enhanced Tissue
Characterization for Detection of Left Ventricular Thrombus
AUTHORS: Jonathan W. Weinsaft, MD, Raymond J. Kim, MD, Michael Ross, MD, Daniel Krauser, MD,
Shant Manoushagian, BA, Troy M. LaBounty, MD, Matthew D. Cham, MD, James K. Min, MD, Kirsten
Healy, MD, Yi Wang, P
H
D, Michele Parker, MS, RN, Mary J. Roman, MD, Richard B. Devereux, MD
APPENDIX
The following is a full description of the CMR and echo imaging protocols.
Imaging Protocol
Cardiac Magnetic Resonance
CMR imaging was performed by dedicated technologists using 1.5 Tesla scanners (General Electric
Signa) with dedicated phased array surface coils. CMR consisted of two components: (1) cine-CMR for anatomical/ functional assessment and (2) DE-CMR for tissue characterization. In accordance with institutional standards, CMR was initially performed without consideration of renal function. Beginning in
December 2006, as a result of a prior United States Food and Drug Administration warning concerning the risks of gadolinium-induced nephrogenic systemic fibrosis in patients with renal dysfunction, 6 patients were screened for renal dysfunction and those with glomerular filtration rate < 30 ml/min/1.73m
2 were excluded from study participation.
Cine-CMR was performed using a steady-state free procession sequence (typical parameters: repetition time (TR) 3.5 msec, echo time (TE) 1.6 msec, flip angle 60°, in-plane spatial resolution 1.9 mm x 1.4 mm).
Following cine-CMR, gadolinium was intravenously administered (0.2 mmol/kg). DE-CMR was initiated 10 minutes thereafter using a segmented inversion recovery sequence.
7 Cine-CMR and DE-CMR images were obtained in matching short- and long-axis planes. Short-axis images were acquired throughout the LV (6-mm slice thickness, 4-mm gap) from the level of the mitral valve annulus through the apex. Long-axis images were acquired in standard two-, three-, and four-chamber orientations. Imaging time was 13:03±5:54

minutes for cine-CMR and, following the 10 minute interval between contrast administration and resumption of imaging, 19:06±5:29 minutes for DE-CMR (p=0.06), including time between breath-holds.
Echocardiography
Transthoracic 2D-echocardiograms were performed by experienced sonographers who had undergone dedicated in-service training regarding the imaging protocol. Echoes were performed using commercially available equipment (General Electric Vivid-7 or Siemens Sequoia). Non-contrast images were acquired in standard parasternal long- and short-axis and apical 2-, 3-, and 4- chamber imaging planes in accordance with American Society of Echocardiography guidelines.
5 A sonographic contrast agent (Definity [Lantheus
Medical Imaging]; perflutren lipid microspheres) was then administered as 3 ml of a diluted intravenous bolus injection (1.3 ml of agitated Definity diluted in 8.7 ml of preservative free saline) and a second injection was administered if necessary to maintain adequate contrast opacification throughout the duration of imaging. For contrast echo, the mechanical index (power) was decreased to < 0.8 (typically 0.3-0.4) and adjusted based on LV cavity opacity. The focal zone position was initially set to the level of the mitral valve in order to provide a comprehensive assessment of the left ventricle and adjusted thereafter to better visualize any localized areas suspicious for thrombus. Imaging was initiated immediately following contrast administration and continued until the LV was imaged in at least three (2-, 3-, 4- chamber) apical imaging planes.
Patients with contrast or non-contrast echoes that acquired fewer than 3 apical views were excluded from the study population.
Following study initiation, the study/IRB protocol was subsequently revised in October 2007 to reflect an interim product labeling change recommended by the United Stated Food and Drug Administration concerning contraindications to use of the echo contrast agent (DEFINITY).
8 In accordance with product manufacturer recommendations between October 2007 – May 2008, patients imaged between October 2007 and the conclusion of the study (November 2007) were excluded from receiving echo contrast if there was evidence of known or suspected cardiac shunts, respiratory failure or severe emphysema, pulmonary emboli or pulmonary hypertension, acute coronary syndrome or acute myocardial infarction, serious ventricular arrhythmias, or worsening or clinically unstable congestive heart failure at the time of imaging. 97% of the study population underwent imaging prior to revision of the study protocol.