Imaging plays an important role in the diagnosis, management, and prognosis of cardiac conditions. Over the last three decades, cardiac magnetic resonance (CMR) has established itself as a promising imaging tool in the assessment of patients with various cardiac ailments. CMR is now being considered as a one-stop-shop diagnostic test because of its ability to comprehensively assess the heart. The greatest strength of CMR is its ability to characterize the myocardium noninvasively aiding in the diagnosis of patients. Despite its growing use worldwide, the adoption of the modality in India has been relatively slow. One major reason for this is the lack of expertise and resources to perform CMR. Another reason for the slow adoption of CMR in India is the limited understanding of practicing clinicians on how the modality works and what the various clinical applications of CMR are. In this review, we aimed to address these shortcomings by outlining some basics of CMR and its utility in day-to-day practice with a special focus on myocardial tissue characterization.

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Background: Coronary artery disease (CAD) is the most prevalent cardiovascular disease. Even though the definitive diagnosis of CAD is by invasive coronary angiography (CAG), various imaging modalities and their advances have led to the evolution of noninvasive parameters such as epicardial adipose tissue (EAT), which could help in prediction of CAD. However, despite having a good association with CAD, the quantification of EAT is unreliable. The adipose tissue of the atrial septum is considered a surrogate of EAT. We aimed to study the association of interatrial septal thickness (IST) measured by echocardiography with the severity of CAD. Methods: A total of 200 patients with a probable diagnosis of CAD undergoing echocardiography and CAG were studied. The IST was measured using two-dimensional transthoracic echocardiography. The presence or absence, the extent, and the severity of CAD were known by CAG. Relevant statistical analysis was done to look for the association of IST with CAD. Results: The mean age of the population was 51.97 ± 10.19 years and the mean IST was 8.02 ± 3.2 mm. Of the baseline characteristics, age, hypertension, and history of CAD were found to be significantly associated with IST. There was significant association of IST with the presence of any extent of CAD. On multivariate regression analysis, IST was found to be an independent predictor of the presence of CAD, having positive association. A positive correlation (r = 0.868) was found between IST and the severity of CAD. The receiver operating characteristic curve analysis showed that IST >5.7mm predicted the presence of any CAD with a sensitivity of 78.6% and a specificity of 100%. Conclusion: IST, a measure of the adipose tissue of atrial septum, was found to be an independent predictor of the presence and severity of CAD.

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Background: Cardiac myxomas are the most common benign primary cardiac tumors. They present with a variety of nonspecific cardiac and noncardiac symptoms. Six decades into the first description of the tumor, the explanation of noncardiac symptoms remains an enigma. Literature is sparse to look into the histopathological correlation of the symptoms. Materials and Methods: A prospective study of 47 myxoma patients operated on in our center between August 2016 and December 2018 wherein, their demographic data, electrocardiogram (ECG), echocardiography data, hematological and radiological parameters, and histopathological features were analyzed. Results: Among 47 myxoma patients, 27 were female and 20 were male patients, with an average age of presentation being 48.55 ± 14.01 years for females and 43.81 ± 12.98 for males, P = 0.006. Dyspnea was the most common presenting symptom, seen in 37 (78.4%) patients. Tumor plop was more common among patients with embolization. Ninety-four percent of the myxomas were mobile and solitary, causing significant mitral valve obstruction in 69% of cases and mitral valve regurgitation in 79% of patients. Pulmonary artery hypertension because of myxomas was found in 38% of the patients. The left atrial enlargement was the most common ECG abnormality and was found in 13 (27.7%) patients. Elevated serum C-reactive protein was associated with palpitation whereas neutrophilic infiltration of the tumor was associated with chest pain. Three of the patients recruited were recurrent cases. Infective endocarditis was seen in one patient. Conclusion: Echocardiography gives significant information about the tumors, including the site, mobility, morphology, numbers, and the correlation of symptoms which are due to hemodynamic disturbances caused by the tumor. All the myxomas in our study were solitary in nature and most of them were attached to left interatrial septum at the level of fossa ovalis.

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In individuals with an ejection fraction of 40% or less, the use of sacubitril/valsartan significantly lowers mortality or hospitalization. There has been no research related to the effectiveness and safety of sacubitril/valsartan in patients with Duchenne muscular dystrophy (DMD)-associated cardiomyopathy. We hereby report a case of DMD-associated cardiomyopathy and heart failure with reduced ejection fraction who had been on routine guideline-directed medical treatment with no change in clinical or echocardiographic markers. When guideline-directed medical therapy was unsuccessful, sacubitril/valsartan was started which resulted in a significant change in functional class and significant ventricular remodeling, including an improvement in left ventricular (LV) ejection fraction, reduction in LV diastolic diameter, and a reduction in mitral regurgitation.

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Endomyocardial fibrosis (EMF) affects approximately 12 million persons worldwide and is an important cause of restrictive cardiomyopathy in the developing world, with the highest prevalence reported in sub-Saharan Africa, South Asia, and South America. EMF is characterized by apical infiltration with fibrotic tissue in one or both ventricles, often associated with thrombus in early stage of the disease, calcification in late stage of the disease, and typical symptoms of restrictive heart failure. Clinical evaluation, transthoracic echocardiography, and characteristic Doppler findings of restrictive physiology are sufficient to diagnose EMF in most of the cases. However, few cases may require cardiac magnetic resonance due to poor echo window or shadowing due to apical calcification. Tissue characterization ability of cardiac magnetic resonance imaging has evolved further in the era of parametric mapping. We plan to showcase the incremental value of parametric mapping (T1/T2 mapping) in staging, prognostication, and management in two cases of EMF.

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Genetically determined deficiency of connective tissue predisposes to the prolapsed mitral valve and an abnormal fibrous annulus including mitral annulus disjunction and dehiscence of aortomitral annular fibrosa. In a more severe phenotype, there may be abnormal aortic tissue, leading to annuloaortic ectasia. This report describes a 2-year-old male child who presented with failure to thrive and was found to have Barlow's syndrome with bileaflet mitral valve prolapse and mitral annulus disjunction, annuloaortic ectasia, and a pseudoaneurysm of interannular fibrosa. The case is reported for its interesting unifying linkage among various defects.

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A 21-year-old girl presented with an episode of ventricular tachycardia in September 1991. She was found to have a large (8 cm × 5 cm) mass in the right ventricle and was operated. The mass was full of thrombi and fresh blood that was evacuated. She remained asymptomatic till May 2022, when she presented with another episode of ventricular tachycardia. She also had a history of effort angina of 2 months' duration. Multimodality imaging evaluation revealed a large calcific cystic mass in the right ventricular free wall with an unruptured aneurysm of the right sinus of Valsalva, a markedly distorted right ventricular cavity, and the Brugada pattern of electrocardiogram. The case is reported for its rarity, long follow-up, and strikingly high-quality images.

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A 26-year-old female patient who had surgical closure of the ventricular septal defect with an autologous pericardial patch and mitral valve repair for the cleft mitral valve in early childhood at age 4 and then subsequently mitral valve replacement with a bioprosthetic valve in 2011 at the age of 16 years, was found to have a large cystic mass protruding into the right ventricular inflow on echocardiography during a late routine examination in 2012. The cystic mass identified on echocardiography was shown to be an aneurysmal dilatation of the autologous pericardial patch used for the repair of the ventricular septal defect. As the third corrective surgery would have been inherently complicated with risk to the conduction system, she has been followed conservatively for the last 10 years without any significant complaints except mild dyspnea. This case illustrates that the pericardial patch aneurysm is relatively stable and surgery is rarely indicated unless the aneurysm causes mechanical compression or obstruction of the right ventricular inflow or outflow.

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Primary cardiac lymphoma (PCL) is an extranodal non-Hodgkin's lymphoma exclusively located in the heart and/or pericardium. It is frequently found in immunocompromised patients and is fatal unless timely diagnosed and treated. Untreated, it has a mean survival time of 6 months. The differential diagnosis includes other malignant cardiac neoplasms. Among the imaging modalities, echocardiography is emerging as an indispensable investigation for the early diagnosis and follow-up of these patients, although histopathology gives the final diagnosis. Here, we present three cases of PCL in immunocompetent patients, out of whom two were adults and one was a child. Two patients presented with pericardial tamponade and a third with complete heart block. On echocardiography, lymphoma was located in the right heart chambers in all three cases with the presence of significant pericardial effusion. Histopathological examination showed diffuse large B-cell lymphoma in adults and T-cell lymphoblastic lymphoma in the child. All three patients received chemotherapy. Only two patients survived. The child remained asymptomatic, while the adult male had a relapse after 6 months of completion of the first chemotherapy regimen. The diagnosis of PCL is difficult due to nonspecific clinical manifestations. At present, the main course of treatment is chemotherapy, although surgery may be required in some cases. Among the available imaging modalities, echocardiography is a cost-effective and readily available investigation for the early detection of the tumor.

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This report describes a 62-year-old postmenopausal female patient who presented with cardiogenic shock, wide QRS complete heart block (CHB), left ventricular apical ballooning with severe systolic dysfunction, and normal coronary angiogram. She underwent permanent pacemaker implantation and showed a disappearance of apical dyskinesis and significant improvement in left ventricular function over the next 1 week. CHB was persistent at follow-up. Relevant literature with regard to this unique combination is discussed.

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