The diagnosis and management of heart failure is one of modern medicine’s success stories. As both cardiac imaging and treatment modalities have evolved, the prognosis for managing structurally diseased hearts has improved dramatically [1]. Firmly ensconced in this process are ACE inhibitors, ARBs, Beta blockers, ARNIs, MRAs and CRT [2]. With the advent of the SGLT2 trials heralding CV benefit beginning with EMPA-REG OUTCOME in 2015 [3] and culminating most recently in the publication of the DELIVER trial in 2022[4,5], a new concept in HF treatment has also been established. Now part of guideline directed management of all forms of symptomatic heart failure with and without DM2, SGLT2i therapy has gained wide acceptance

Cardiovascular Disease (CVD) is one of the leading causes of death worldwide and its prevalence is expected to continue to rise in the coming years [1]. The American Heart Association (AHA) estimates that one in three people will experience CVD at some point in their lifetime [2]. Coronary Artery Disease (CAD) and ischemic stroke are the most common clinical manifestations of CVD [3]. Despite the efforts to decrease the disease’s incidence and prevalence through primary and secondary prevention strategies, the risk continues to be substantial. This highlights the need to identify accurate and reliable predictors of future cardiovascular events for risk stratification and personalized preventive strategies. Lipoproteins have gained attention as potential predictive values due to their involvement in atherogenesis and plaque formation.

Aim: So far, invasive procedures, such as heart catheterization, are state of the art to investigate blood oxygenation levels in humans. For patients who suffer of chronical heart disease and renal failure BOLD (blood oxygenation level dependent) is an effective, but still frail imaging method. This study aimed to validate the use of Magnetic Resonance Imaging (MRI) with a dynamic T2 preparation pulse and a weighted subtraction afterwards as a competitive imaging method to assess blood oxygenation in a phantom and healthy volunteers.

Methods: MRI was performed with a dynamic T2 preparation pulse followed by a weighted subtraction of the dynamic T2 sequences to investigate different blood oxygenation levels in an Extracorporeal Membrane Oxygenation (ECMO) pump (phantom). Afterwards, healthy volunteers (age 30 to 45 years without chronic disease) were enrolled and imaged with identical cardiac MRI protocols. Finally, we compared the oxygenation levels obtained with Blood Oxygenation Level-Dependent (BOLD) imaging and bedside gas analysis with those obtained with the dynamic T2 preparation pulse.

Results: The Signal-to-Noise Ratios (SNRs) of the subtracted images acquired with the T2 preparation pulse sequence for both the phantom and 19 healthy volunteers (mean age 25 ± 10 years) were significantly negatively correlated with the oxygenation level assessed by BOLD imaging (r = -0.6479, p = 0.0227 and r = -0.7754, p < 0.003, respectively). The phantom’s Contrast-to-Noise Ratio (CNR) and the healthy volunteers’ CNRs and SNRs in the ascending aorta and pulmonary artery measured on the T2 images were significantly correlated with the oxygenation level measured by blood gas analysis (p < 0.05). The BOLD imaging and blood gas analysis measurements of the oxygenation level were significantly negatively correlated (r = -0.965, p < 0.008), and the oxygenation levels in the pulmonary artery measured with BOLD imaging demonstrated a positive association with that as assessed by blood gas analysis (p < 0.05).

Conclusion: Non-invasive measurement of blood oxygenation using a dynamic T2 preparation pulse is feasible in healthy patients. Unlike existing state of-the-art methods involving invasive measurements, this method does not require the use of radiation or contrast agents, thus critical patients with renal failure, could be investigated by cardiac MRI in a competitive method to BOLD. Further work is necessary to validate this technique in a clinical setting.

Translational Perspective: The dynamic T2 preparation pulse MRI sequence is able to distinguish between oxygenated and deoxygenated blood with little effort without the need for radiation or contrast agents and can therefore be implemented in clinical settings.

Aim: The aim of this study was to investigate whether vessel wall imaging using magnetic resonance imaging (MRI) with a T2 preparation pulse with dynamic implementation could accurately predict a proxy for atherosclerosis, carotid artery intima media thickness as measured by ultrasound. Ultrasound is still investigator dependent and a follow up of the femoral artery on its way to the foot and especially of the wall thickness is not possible due to anatomical reasons. Peripheral Arterial Disease (PAD) is a common disease in developed countries and it would be very helpful to have a predictive marker such as vessel wall thickness.

Methods: Five healthy volunteers and seven patients with known PAD underwent MRI of the femoral artery on a 1.5-T scanner with a SENSE-XL-Torso coil (Philips GmbH Market DACH, Hamburg, Germany) using TRANCE and a dynamic T2 preparation pulse afterwards. These measurements were compared with intima media thickness of the carotid artery as assessed by ultrasound.

Results: As measured by MRI, patients with PAD had significantly thicker vessel walls than healthy volunteers (p < 0.01). Carotid artery thickness matched femoral artery in patients with known PAD (Pearson r = -0,99, p < 0,014). Interobserver reproducibility was good (bias = -0.0088, 95% limits of agreement = -0.1089 to 0.09123), and ultrasound imaging results correlated closely to those from MRI (Pearson r = -0.99, p < 0.027).

Conclusion: Conducting MRI with a dynamic implementation of a T2 preparation pulse seems to be an adequate, non-invasive method to assess vessel wall thickness as a prognostic factor for atherosclerosis without using contrast agent.