Cardiac imaging is the cornerstone of defining the etiology, quantification and management of mitral regurgitation (MR). This continues to be even more so the case with emerging trans-catheter techniques to manage MR. Transthoracic echocardiography remains the first line imaging modality to assess MR but has limitations. Cardiac MRI(CMR) provides the advantages of quantitative non-visual estimation, 3D volumetric data, late gadolinium, T1 and extracellular volume measurements to comprehensively assess mitral valvular pathology, cardiac remodeling and the prognostic impact of therapies. This review describes the superiority, technical aspects and growing evidence behind CMR, and lays the roadmap for the future of CMR in MR.

Hypertrophic cardiomyopathy is a common heritable cardiomyopathy with various clinical phenotypes. A rare spiral variant has been recently reported that has been associated with adverse outcomes and has traditionally been diagnosed using cardiac magnetic resonance. We report a case of the rare variant spiral hypertrophic cardiomyopathy where we used transthoracic echocardiography with an ultrasound enhancing agent to demonstrate the geometry of spiral hypertrophic cardiomyopathy and compared to simultaneous cardiac MRI images. The use of echocardiography with ultrasound enhancing agents may prove to be a valuable tool in identifying the geometry of hypertrophic cardiomyopathy variants in selected patients.

Background. We studied by means of echocardiography and cardiac MRI (CMR) the occurrence of an accessory papillary muscle that unites mostly the left ventricle (LV) apex with the basal or mid antero-septum. Methods. We included all good quality echocardiography and CMR studies as reviewed by two cardiologists and assessed the occurrence of a contractile papillary muscle situated between the LV apex and antero-septum. Results. A contractile accessory papillary muscle situated between the LV apex and the antero-septum was seen in 100% of HOCM patients and 62% of control patients (p=0.05) in the CMR images acquired from a total of 22 HOCM (9) and control (13) patients. The same structure was observed in 241 patients representing 69.5% of all-comers echocardiography studies. The age was 69 ± 17 years on average in the echocardiography arm, patients harboring the antero-septal accessory muscle being older (71.6 + 15.7 years old vs 63.5 ± 18.1 for those without, p=0.0005). We exemplify this structure by parasternal long axis still echocardiography images and clips from 24 patients and CMR SSFP still images and a clip from two HOCM patients and one control. Conclusion. A contractile accessory papillary muscle was observed in more than half of the all-comer echocardiography studies, and in all HOCM patients in the CMR arm. Further research is needed to fully characterize the anatomical and physiological significance of this structure attaching in the immediate vicinity of the LVOT in HOCM and control patients.