Goal 2: Reduce Human Disease

Short comprehensive cardiac MR imaging in post-chemotherapy cancer patients

Critical Challenge

Submitted by (@str0001)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Cardiovascular disease and cancer are frequently identified in the same patient. Both diseases are highly prevalent in the United States population, and cancer or its therapies can result in cardiovascular disease. Early diagnosis and prediction of cardiovascular disease in patients to undergo therapy will identify patients at higher risk for cardiac dysfunction and enable earlier diagnosis of subclinical cardiac dysfunction.

Feasibility and challenges of addressing this CQ or CC :

Cardiovascular magnetic resonance imaging (MR) is a powerful imaging modality for evaluating the heart function. Specifically, MR techniques allow for quantifying regional heart function, e.g. strain and strain rate, and may provide earlier markers of cardiovascular disease development than global measures of heart function, e.g. left ventricular ejection fraction, as estimated by echocardiography. Early identification of subclinical heart failure of post-chemotherapy cancer patients will allow for early and on-time chemotherapy change and personalized treatment.

Name of idea submitter and other team members who worked on this idea : Society of Thoracic Radiology

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Goal 4: Develop Workforce and Resources

Training for radiologist researchers for effective translational research

Critical Challenge

Submitted by (@str0001)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

As targeted therapy and molecular mechanisms of disease are emerging, a mechanism to improve the ability of radiologists to perform translational research is crucial. Such knowledge is essential for collaborative multidisciplinary research that ultimately leads to imaging as disease-specific diagnostic and therapeutic tools to combat pulmonary and cardiovascular disease.

Feasibility and challenges of addressing this CQ or CC :

Knowledge in the molecular mechanisms of disease and the potential for imaging technology to advance via targeted imaging agents, positron emission tomography (PET), functional MR methods, PET/computer tomography, and PET/MR is increasing. The radiologist has in depth expertise within imaging technology, performance of studies, and diagnostic abilities of imaging techniques. A program directed towards developing imagers towards translational imaging research will include in-depth education and training in lung physiology, pulmonary disease mechanisms, multimodality imaging bridging CT, PET/CT, MR and PET/MR, and the molecular techniques. With such knowledge and training, radiologists will be prepared to serve as principal investigators and collaborators in multidisciplinary teams. An understanding of imaging technologies and their capabilities, the clinical challenges, and molecular techniques will enable imagers to provide innovative solutions to diagnostic dilemmas in pulmonary and cardiovascular disease.

Name of idea submitter and other team members who worked on this idea : Society of Thoracic Radiology

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Goal 2: Reduce Human Disease

Predicting and monitoring atherosclerosis progression and vulnerable plaque

How to develop novel methods for predicting and monitoring atherosclerosis progression and vulnerable plaque including biomarkers and imaging?

Submitted by (@societyforvascularsurgery)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Name of idea submitter and other team members who worked on this idea : Society for Vascular Surgery

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Goal 2: Reduce Human Disease

Can one integrate cardiac imaging studies with genetic,clinical, "omics", and historical data to predict disease and personalize

There are many novel imaging modalities, including radiographic, scintigraphic, sonographic, MR-based, and molecular for the heart and vessels. Patients have unique medical "signatures"- genetic risk factor profiles, epigenetic markings, "omics" profiles, and personal clinical and family history as well as symptom constellation and physical exam findings. Can these all be integrated into a single personalized profile ...more »

Submitted by (@dpinsky)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Feasibility and challenges of addressing this CQ or CC :

This will require a combination of informatics, state of the art imaging, and state of the art genetics and omics profiling with integration with the electronic health record.

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Goal 2: Reduce Human Disease

Imaging indicators of metabolic syndrome and cardiopulmonary disease

Critical Challenge

Submitted by (@str0001)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Obesity and metabolic syndrome affect a large portion of the population and affects multiple organ systems. Identifying obesity phenotypes by imaging will impact the significant healthcare issue presented by MetS and could provide a reliable, non-invasive index of disease severity, guide prevention and intervention response.

Feasibility and challenges of addressing this CQ or CC :

Metabolic syndrome, abnormal metabolism, may be potentially linked to obesity and cardiopulmonary disease. Theories exist but are in need of clarification. The relationship between metabolic syndrome and multiple other diseases including chronic obstructive lung disease, coronary atherosclerosis, and obesity warrants further investigation and can be elucidated through imaging. Advances in computed tomography (CT) and magnetic resonance imaging (MR) enable assessment of the cardiopulmonary manifestations, with promising MR techniques to complement high-resolution imaging data achievable with chest CT and coronary CT angiography. Assessment of CT and MR techniques in combination with three-dimensional quantitative analysis of manifestations of metabolic syndrome such as fat deposits derived from different adipocytes (white fat versus brown fat) such as in the subcutaneous, visceral, epicardial, and perivascular regions is feasible with current technology and may enable differentiation of those with varying risks of cardiovascular and pulmonary disease. The association of imaging parameters, metabolic syndrome, and associated diseases are in need of investigation, and knowledge gained may prove crucial for identifying those at risk for metabolic syndrome and at higher risk for complications in the large population of our country affected by obesity.

Name of idea submitter and other team members who worked on this idea : Society of Thoracic Radiology

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Goal 2: Reduce Human Disease

Functional pulmonary imaging with noninvasive imaging techniques

Critical Challenge

Submitted by (@str0001)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Pulmonary dynamics are altered with diffuse lung disease. Pulmonary function testing is a mainstay for evaluating patients with diffuse lung disease. However, ability to assess alterations of local lung mechanics and physiology may elucidate those patients with varying outcomes and mechanisms of disease. Such local analysis is possible with imaging such as MR and quantitative computed tomography (CT).

Feasibility and challenges of addressing this CQ or CC :

Dynamic magnetic resonance imaging (MR) techniques are available that are capable of evaluating the oxygen delivery and blood flow to regional areas of the lung and measurement of pressures in the heart and vasculature. Additionally, advanced dual-energy CT techniques enable assessment of blood volume within the lungs. Such techniques can be applied to pulmonary vascular and pulmonary parenchymal disease and combinations of the two. For example, an understanding of the cardiopulmonary interaction and phenotyping of pulmonary hypertension is needed. A need exists to determine if advanced CT technology and MR can identify patients with the emerging phenotypes of combined pulmonary hypertension, in which the degree of pulmonary hypertension is greater than expected from cardiac and pulmonary causes. MR can potentially serve as early predictors of these phenotypes, given MR’s ability to evaluate the parenchyma, the pulmonary vasculature, and heart, and in combination with other biomarkers determine appropriate therapy.

Name of idea submitter and other team members who worked on this idea : Society of Thoracic Radiology

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Goal 2: Reduce Human Disease

Detection of rupture prone small aortic aneurysms

Critical challenges in the assessment of aortic aneurysms are: (1) Availability of reliable animal models that simulate the human pathology, (2) Availability of molecular imaging resources – identification of biomarkers, development of targeted imaging probes and pre-clinical imaging methods, and plasma markers that predict whether an aneurysm is prone to rupture or dissection, (3) Bringing together a wide array of multi-disciplinary ...more »

Submitted by (@nhlbiforumadministrator)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Developing clinically viable methods to detect rupture prone aneurysms can lead to better methods of diagnosis and intervention and avoid preventable fatalities

Feasibility and challenges of addressing this CQ or CC :

Several other disease areas including oncological that had similar gap was filled by NIH (NCI) and the challenges were overcome in less than 10 years. The scientific expertise to fill the gap exists, however they work in silos, which need to be brought together to fulfil this gap and is achievable in less than 10 years

Assessment of aortic aneurysms that are prone to rupture or dissection has been an elusive target. Current clinical practice measures the aortic diameter and fails to relate to the pathophysiology and biomechanical properties of the aneurysm in deciding preventive surgery. Critical gap exists in the diagnosis of aneurysm especially with small aneurysms (3 - 5 cm in diameter) that are rupture prone. Based on autopsy about 10 percent of individuals with small abdominal aneurysms had undergone fatal rupture, while 40 percent with diameters of 7-10 cm had intact aneurysm and died from other causes. International Registry of Aortic Dissection found that 40% of thoracic aneurysms dissected at diameters smaller than 5 cm.

Name of idea submitter and other team members who worked on this idea : NHLBI Staff

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Goal 2: Reduce Human Disease

Controversies exist regarding thoracic aortic disease imaging

Controversies exist regarding aortic disease imaging (the aorta as well as the aortic valve, including characterization in the presence of a bicuspid aortic valve (BAV)). Many imaging approaches are optimized for evaluation of coronary artery disease rather than aortic disease. Without accurate characterization, the degree of disease progression may be under estimated, patient symptoms may be discounted, and those who ...more »

Submitted by (@bavtad)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

Imaging specifically tailored to BAV and the thoracic aortic aneurysm population is needed. This includes efforts to identify subtle forms of aortic valve malformation such as the “forme fruste” BAV as described by Sperling and Lubet.

1. Echocardiogram is a useful noninvasive imaging tool, however, it is believed to miss detection of as many as 50% of BAVs.

2. The exercise echocardiogram is useful for evaluation of wall motion abnormality, which may be present in those with coronary artery disease or other underlying sources of myocardial injury. However, this is not a common issue in those with BAV. Rather, accurate assessment of BAV function is necessary. Pressure testing for eccentric AI and the short axis view of the AV area, including clear visualization of both the open and closed valve, may not be employed, and consequently clarity of BAV functioning is not achieved.

3. Although there are open questions about aortic size relative to timing of elective surgery, size of the aorta is a diagnostic parameter, and is frequently done via CT imaging. CT images are typically captured in diastole, which is appropriate for coronary artery disease. However, the aorta will be undersized if measured in diastole. Measurement of the aorta in systole captures the aorta when most distended.

4. Other considerations, such as the presence of bovine arch anatomy, may not be noted, since their relevance may not be appreciated.

Feasibility and challenges of addressing this CQ or CC :

Current imaging technology is widely available in most medical communities. It is very feasible, by focusing on valvular and aortic conditions separately from coronary artery disease, to optimize imaging for these conditions and make these imaging approaches broadly available to patients.

Name of idea submitter and other team members who worked on this idea : Arlys Velebir, Bicuspid Aortic Foundation

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Goal 3: Advance Translational Research

Comprehensive Assessment of Cardiovascular Physiology: Imaging of Structure, Function and Blood Flow

The development of cardiovascular disease is associated with changes in structure, function and blood flow within a complex and highly interconnected system. Current diagnostic tools focus on individual elements of the cardiovascular system and/or relatively simple parameters which do not reflect the true underlying pathophysiology. A novel multi-modular and multi-parametric approach based on new and promising imaging ...more »

Submitted by (@mmarkl)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

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Goal 3: Advance Translational Research

Applying Imaging in Chronic Lung Diseases

How can chest CT or other imaging tools be optimally used to characterize expression and progression of chronic lung disease?

Submitted by (@jdc000)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Compelling Question (CQ)

Details on the impact of addressing this CQ or CC :

Chest CT scans provide anatomical information on disease pattern and severity that cannot be readily obtained otherwise. These imaging studies could be essential in reclassifying chronic lung diseases more effectively and in assessing disease progression more accurately.

Feasibility and challenges of addressing this CQ or CC :

The increasing use of chest CT scans for lung cancer screening will provide a large number of imaging studies that could transform pulmonary research in multiple chronic lung diseases. However, the images will need to be appropriately collected and analyzed.

Name of idea submitter and other team members who worked on this idea : Ed Silverman, James Crapo and COPDGene Executive Committee

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Goal 2: Reduce Human Disease

Noninvasive biomarkers for characterizing cardiovascular disease

Critical Challenge

Submitted by (@str0001)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Phenotypical characterization of cardiovascular disease with computed tomography (CT) and magnetic resonance imaging (MR) to individualize targeted therapies for coronary artery and myocardial disease. Coronary artery disease is a major cause of patient death in the United States. Nonischemic myocardial disease includes entities with clinically heterogeneous presentations and is thus challenging to manage.

Feasibility and challenges of addressing this CQ or CC :

Currently CT and MR technology allows dynamic evaluation of the perfusion and contractility of the heart. Quantitative measures of disease burden, such as atherosclerotic plaque composition and myocardial texture imaging biomarkers (such as T1 mapping, activation mapping, flow pattern analysis, delayed myocardial enhancement), are possible. Positron emission tomography (PET)/MR, which combines metabolic with functional evaluation, is currently available and facilitates the development of targeted molecular-imaging techniques. Metrics derived from these techniques may serve to stratify patients noninvasively and direct appropriate therapies. Such imaging methods address noninvasive evaluation of cardiovascular disease, including ischemic heart disease but also myocardial diseases that include secondary and infiltrative cardiomyopathies, hypertrophic cardiomyopathy, and organ rejection in the scenario of transplantation.

Name of idea submitter and other team members who worked on this idea : Society of Thoracic Radiology

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Goal 2: Reduce Human Disease

Low-dose and non-ionizing imaging for chronic lung disease

Critical Challenge

Submitted by (@str0001)

Is this idea a Compelling Question (CQ) or Critical Challenge (CC)? : Critical Challenge (CC)

Details on the impact of addressing this CQ or CC :

Imaging plays a crucial role in the initial evaluation of patients with suspected or surveillance of those with confirmed diffuse chronic lung disease. Attention towards developing alternative non-ionizing imaging technologies and evaluating the efficacy of radiation dose saving techniques will impact a large patient population.

Feasibility and challenges of addressing this CQ or CC :

Imaging, particularly computed tomography (CT) plays a major role in the evaluation of diffuse pulmonary disease. High resolution CT (HRCT) characterizes parenchymal patterns of lung disease, identifies areas amenable to biopsy, and aids in decisions pertaining to workup and therapy of lung disease. With multidetector CT technology, volumetric HRCT enables evaluation of the entire lung volume for diffuse lung disease. The utility of CT needs to be balanced with the exposure of patients to ionizing radiation, particularly younger-aged individuals who are more sensitive to ionizing radiation. In CT, dose-saving techniques enable imaging of the parenchyma at ultra-low dose levels. Additionally, an understanding of low radiation-dose CT techniques that preserve the diagnostic ability for diffuse lung disease, while maintaining the precision of quantitative measures, is needed. Magnetic resonance imaging (MR) is underutilized as an imaging tool given respiratory motion and limitations in spatial resolution. A need exists to develop and apply MR imaging techniques with spatial resolution approaching that of high resolution CT. Promising advances in the MR technology has occurred, and continued development and application will provide alternative and non-ionizing options for imaging patients with diffuse lung disease affecting both the parenchyma and airways.

Name of idea submitter and other team members who worked on this idea : Society of Thoracic Radiology

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