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Luxury Lake House with Heated Pool, Spa and Wireless Internet!
About the property
- House1850 sqft
- Bedrooms3
- Sleeps10
- Bathrooms2
- Half Baths0
- Minimum Stay2 - 3 nights
House, 3 Bedrooms + Bunk Area, 2 Baths, (Sleeps 8-10)
This Luxury Lake Home with a Pool and Spa is Located in the Exclusive North Lake Havasu Area up the hill from the Launch Ramp, Walmart and many Restaurants. Everything in this Home is nice and clean. The Floors, Counters, and Showers are 100% Italian Tile with no carpet. This Home has Direct TV Satellite Systems, and DVD Players in Every Room. **The home sleeps up to 10, with owners approval, and $30/per person/per night fee for every person over 8**
This House also comes complete with High Speed Wireless Internet. Also, you can bring your Laptop Computer and connect to the Lynksys Wireless Router or plug your computer in directly to the router. The House has Air Conditioning, Heater and Fans in every room. Every Window in the House has Privacy Blinds.
The Pool and Spa are available to heat at your expense. The liquid propane tank can be filled by phone order. Weekly pool cleaning is included in all rentals.
The custom JENAIR BBQ bar includes a Huge Stainless Steel Unit with a 6 seat Eating Bar. The BBQ is heated by propane at the renters expense.
Each side of the house has a long hose which extends to the front parking area to clean your toys. This House also has a Huge Water Heater and a H300 Water Filtration System that goes to the Ice Maker, Refrigerator Water, and a Water Spout at the Kitchen Sink. All the Furniture, Electronics, Accessories, Decor and Linens are nice and clean. This House has a Two Car Garage with a Sink, Shelving, and a Huge Driveway for Parking Cars, Boats, Jet Ski's, Toys, and RV. There is also a Huge unpaved Boat or RV parking next to the driveway.
The Living Room is Complete with a Huge High Definition 50' Plasma TV, Direct TV Satellite System, DVD Player, VCR, Bose Surround Sound Stereo System with CD PLayer, Ceiling Fan, and Two Custom Top Grain Leather Sofa's.
The Kitchen is complete with everything needed to cook a Gourmet Meal including Dish Washer, Microwave, Toaster, Blender, Coffee Maker, Ice Maker, Filtered Water, Pots, Pans, Electric Can Opener, Silverware and All Cooking Accessories.
The Master Bedroom is complete with a King Size Bed, 32 inch TV with a Direct TV Satellite System, DVD Player, Ceiling Fan and Private Bathroom. The Master Bathroom is complete with Two Sinks, a Private Toilet Area, a Huge Walk-in Italian Tile Shower, and a Large Walk-in Closet.
The Second Bedroom is complete with a King Size Bed, 20 inch TV with a Direct TV Satellite System, DVD Player, Ceiling Fan and a Large Closet.
The Third Bedroom is complete with a Queen Size Bunk Bed, an Extra Long Twin Bed on the Top, and a Twin Pull-out Trundle Bed on the Bottom. This room has a 13 inch TV with a Direct TV Satellite System, DVD, Portable Fan, and Large Closet.
The Laundry Room is complete with a set of LG Large Capacity Front Loading Washer and Dryers and a cabinet to put your detergent and fabric softeners.
You must be 25 years of age to rent. A copy of your drivers license is needed.
Keywords: House, Lake, View, Pool, 3 bedroom
Suzanne Jeffrey
- Response rate:
- 100%
- Response time:
- within a few hours
- Speaks:
- english
- Calendar last updated:
- May 23, 2018
About Suzanne Jeffrey
I am a California resident who loves to wake board and relax on the water. I have been visiting for years, and decided to purchase a permanent place to call my own. Lake Havasu is one of my favorite getaways, and I know you will feel the same!
Suzanne Jeffrey purchased this House in 2004
Why Suzanne Jeffrey chose Lake Havasu City
Perfectly private and spacious. Bring your boat for the lake, or just stay home and lounge by your private pool.
What makes this House unique
Centrally located with tons of room for your friends/family and toys!
- Internet
- Pets Welcome
- Air Conditioning
- Swimming pool
- Satellite or Cable
- Kids Welcome
- Washer & Dryer
- Hot Tub
- Parking
- No Smoking
- 3 Bedrooms, Sleeps 10
- King size beds (1), Queen size Beds (1), Twin or Single Beds (1), Bunk Beds (1)
- 2 Bathrooms
Location Type
- Lake View
- Guests provide their own meals
- Air Conditioning
- Broadband Access
- Clothes Dryer
- Garage
- Internet
- Linens Provided
- Parking for RV/Boat/Trailer
- Washing Machine
- Wireless Internet
- Cooking Utensils
- Dishwasher
- Ice Maker
- Kitchen
- Microwave
- Refrigerator
- Dining Area
- CD Player
- DVD Player
- Satellite / Cable
- Stereo
- Deck / Patio
- Lanai / Gazebo
- Outdoor Grill
- Outdoor Grill Gas
- Porch / Veranda
- Wood Deck
Pool / Spa
- Hot Tub
- Private Pool
- cinemas
- health/beauty spa
- restaurants
Leisure Activities
- boating
- shopping
- sight seeing
- wildlife viewing
Local Services & Businesses
- fitness center
Sports & Adventure Activities
- parasailing
- cycling
- golf
- hiking
- hunting
- jet skiing
- kayaking
- mountain biking
- mountain climbing
- fishing
- rafting
- rock climbing
- sailing
- snorkeling
- snorkeling/diving
- swimming
- water skiing
- wind-surfing
- High Speed Wireless Internet, 50' Plasma TV, Two Top Grain Leather Sofas, 100% Italian Tile Floors, Heat, Ceiling Fans, Laundry Room with Washer and Dryer, Satellite TV in Every Room, DVD in Every Room, Water Filtration System, Coffee Maker, Blender, Electric Can Opener, one roll of Toilet Paper per Bathroom and one Paper Towel Roll Provided, Water Softener, 2 Car Garage, Huge Boat / RV Parking Area, Heated Pool and Spa (propane charged additionally), No Pets.
House Rules
Check-in: Flexible
Check-out: Flexible
Cancellation Policy
100% refund if canceled at least 60 days before arrival date. 50% refund if canceled at least 30 days before arrival date. You must contact the owner directly to request cancellation.
21 Reviews
Latest reviews
House was better than the pictures
No complains whatsoever. Very nice pool and clean rooms. Will rent it again for sure.
Thank you
Lovely, a great place to stay
We loved to stay here, We felt like in home... Suzanne is great, fast reservation response, easy process, We def. would stay again.
My Best,
House and indoor furniture very nice,
First class describes the beds, indoor furniture, TV and accessories etc. The patio furniture is wood which is not a good choice in Arizona, thus wood is shrinking and the nuts and bolts coming out making difficult to move without it falling apart etc. Did not use the pool as winter time, nor the spa, but appears very nice. Was disappointed that you had to rent a propane tank if you wanted to use the BBQ - never had this in a VRBO home before and I have stayed in many VRBO homes. The house was clean except the cold air return which needs cleaning badly - not good for the owner or the tenants. Dishes and pans very adequate, coffee pot had been broken but we put back together and could use but often it would leak so purchased a small pot for my use.
Wireless internet was great - I got on, but any others that tried could not - perhaps limited to one device??? Not sure on that.
very nice clean and organized
Everything was noce and clean. very organized house with well instructions on everything. thank you
Everything you thought it was AND MORE!!
The house was perfect for a get away weekend. Located near all the fun and noise of havasu, but in a particular location to not be bothered by the traffic and excessive noise. The amenities provided are perfect. The residence has plenty of space for all of your travel needs. I can't wait to revisit soon!
Nice back yard
As advertised! Extra for utilities seems high but the records showed it to be correct.
Good neighborhood. Big bedrooms. Bed is VERY firm in the master. Good internet. Nice tv in bedrooms.
Wakeboarding,Water Skiing, Boat Rentals, Jet Ski Rentals, Jet Boat Tours, Helicopter Tours, Skateboard Park, Water Park, Go Cart Track, Beaches
Rates & Availability
Additional information about rental rates
Propane can be ordered to heat the pool and jacuzzi. It is $12 per %, and can be deducted from your security deposit. Snowbird rental price does not include water and electricity (to be paid by renter).


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My craft room was looking so cluttered and crazy, so I decided to clean house... I bought those cubes from Michael's (with coupons of course) and purged alot of stuff. What was left over I rearranged.
The rooms was definitely a catch all... I was challenged because this space is very narrow and comes to an angle (it is one side of my laundry room).
This is what it looks like now:
The cubes definitely make it more "clean" looking and less cluttered. I got rid of a table as I rarely used it to scrap on (I have a desk area that I mainly use). There was SO MUCH STUFF under it that I had forgotten about! :)
The center table is actually a microwave cart I got at a Thrift store and re-purposed:
I like how it turned out! Which means we'll probably get orders to move soon. LOL
Wednesday, July 23, 2008
Scraproom Redo - Again! LOL
Posted by Elena at 4:10 PM
Labels: organization, scrap rooms, storage
0 comments:
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subset: commoncrawl


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dr br ambedkar university agra result 2014 ba 1st year
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If head coach Eric Mangini were the bragging sort, he wouldÆve jumped on the podium after the game and shouted, ôHow do you like me now?ö In truth, thatÆs exactly what Mangini should have done so everyone who jumped on his back early in the season, including myself, could apologize. Not that Mangini didnÆt dig his own holes, but every coach deserves a full season, and these last few weeks are the reason why. IÆll defend myself here and point out that I didnÆt jump on the "Fire Mangini" bandwagon until after the Detroit game, my reasons explained here. That being said, I was never very comfortable on that wagon and IÆm jumping off now. When a team that was getting blown out week after week all of a sudden strings together two victories and looks good in a close loss, that team has t ...
Read Full Article at Bleacher Report - NFL
Article written by Brian DiTullio
Cleveland Browns Victory a Sign Team Has Turned a CornerPosted: 21st December 2009 by Brian DiTullio in NFL
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Post # 1
- Sweet Magnolia
- 8 years ago
- Wedding: February 2010
So, its time for a new book!! im definitely new to the whole book club moderating thing but ill do my best 🙂 Feel free to start suggesting books and ill get a poll up and running tonight or tomorrow!
i suggest "House Rules" by Jodi Picoult (its her newest) & ive been dying to get my hands on it 🙂


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as in "Always Be Closing" they are selling more stuff:
"Maximizing Speed and Distance"
You'd think they would just teach a swing that "maximizes distance" in the first place - YA THINK? NAH! Then they wouldn't be able to release additional DVD's!
I guess they didn't listen to us back during all those convo's about what generates "the majority" of club head speed. Says in the little video this is produced by the hands and arms. Offers as proof his ability to hit a drive 200 yards while seated - 75% of his normal distance. Why sure, that is all the proof you need isn't it? Whew, glad that's settled.
I have spent time and some money with the GGA swing, and have had some success. However, I'm beginning to believe if I buy all the stuff GGA thinks I need to conquer the swing, I will no longer be able to afford to play golf. Must make a decision, more stuff or green fees?


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The last thing I'll say about this is don't try day trading support and resistance clusters itself. One of the big questions is how do I know which support resistance levels are going to hold, and the market's going to bounce off of them, and in which ones it 8767 s going to slice through? So clusters is one way of helping with that.
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Hubert currently resides in Versailles, Kentucky with Lisa, his wife of 75 years, and their three kids Mackenzie, Morgan and Mason.
Now that Snap Inc. is publicly held, stock analysts are weighing in with their initial forecasts for the shares, and some are quite bearish.
Because many people have computers and listen to the news in the morning, they open their trading platforms or websites and place orders to exit or enter new trades before they go to work. Once the Ding, Ding, Ding, on the New York Stock Exchange at 58:85am CT is heard, all these orders get filled. The problem is that we do not know which direction the market is going to move, so we have to give the market a little bit of time to wash these trade out of the market. Once they are gone, the market will then begin to push in one direction (up or down does not matter). This push will last about 65 minutes, and then the market will correct that move going into the top of the hour at 59:55am CT.
Second, risk analysis is lacking, because each intuitive idea feels like a sure thing. The inner gambler&rsquo s justification story goes like this: &ldquo Why prepare for loss if I don&rsquo t expect to lose?&rdquo
The truth is that once you&rsquo ve mastered this strategy you can still use it on less predictable ranges, but I recommend beginning with the more clearly defined ranges until you see some success.
Despite modern technology, two driving forces in the markets remain very influential. What are these two driving forces?
Defined-benefit plan (DBP) : With consistent high trading income, arrange a $655,555 plus contribution/deduction with a defined-benefit plan. Work with an actuary on complex DBP calculations.
Taxes are coming up feel free to check out my go to accountants. Specializing in DayTraders and Investors http:///


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Plots right after the Grand Jamia Masjid came in Lahore Ring Road area. So the following plots will be taken by Govt. for construction of Lahore Ring Road.
- Side A: 01 to 24, 59 to 106, 149 to 172
- Side B: 01 to 16 and 47 to 81
Above are the commercial plots. Residential plots behind these commercial plots will also came under the area of Ring Road.
How Govt. Will Pay?If Govt. pay according to DC rate i.e. Rs. 200,000/- per marla then everyone will be doomed. If Govt. pay according to the market price which is nearly Rs. 600,000/- then people would be sated. We also have the promise of Mr. Ali Riaz of paying as per market price. Let's hope for the best.
Short Term EffectsAll those people who have plots in following blocks are really worried because of this Lahore Ring Road
- Iqbal block
- Rafi block
- Jinnah block (little area)
- EE block
- Overseas B Ext.
Except for Jinnah block, all other plots are in possession. People have started to constructing houses in those areas and even started living in it. It will be really hard for them to leave their houses.
Secondly during the construction of Lahore Ring Road, that area won't be accessible. It will create problems in movement and consequently in investing areas away from Lahore Ring Road (Sector E and Sector F).
Lastly if Lahore Ring Road pass through the Bahria Town Lahore, it might temporarily slow down the investment. I'm using 'might' because once you start living in Bahria Town, it's become hard to live anywhere else. This is because of the uncountable valuable services like 24/7 electricity and sui gas, security etc. So those people whose plots will be taken by Govt. will also search plots in Bahria Town or Bahria Town management will adjust their plots in any other blocks.
Long Term EffectsPrices will rise real high.
There are two kind of people; one who like to live and invest in Bahria Town Lahore, others who don't. Let think from other's point of view: What is the first reason of not living in Bahria Town Lahore? Ans: Duur buhut hai (It's far away). Lahore Ring Road will erase this very and only negative point of not living in Bahria Town.
Now think one getting all the extraordinary facilities with connecting to the Ring Road (which is connected to whole city). You are on a 20 minutes drive from Lahore International Airport. What else do you need.
Conclusion:Lahore Ring Road is a very good project for Lahore and for Bahria Town as well. There are only two options
- Lahore Ring Road pass through the Bahria Town
- Lahore Ring Road not pass through the Bahria Town.
If Ring Road pass through the Bahria Town, it might decrease the interest of investors for little time but eventually Bahria Town will experience the boom because of this.
If Ring Road doesn't pass through the Bahria Town, it will pass from nearby. No one will have any problem and prices will also rise high.
Jameel replied on Tuesday, June 2, 2015 01:54 AM PST
Looks very unlikely LRR cant pay that much amount, Payment is not as per DC rates but Court rates, Court decides the rates of different segments, It is lengthy procedure. Only in Bahatta Chowk widening govt paid billions.
Lahore Ring Road Map replied on Tuesday, June 2, 2015 02:19 AM PST
99% Of Final Lahore Ring Road Route Is Same As This Map Uploaded By Lahore Real Estate Many Years Ago. Only 1% Fine Alignment Detail Is Different.
We have the final map but not allowed to post it online. So Use This Map For Now.
question replied on Tuesday, June 2, 2015 02:44 AM PST
Dear Jameel Sb or property experts
Can you advise how will LRR effect Pakistan Medical Cooperative Society. Is it a doomed society?
thanks and best regards
Akmal replied on Tuesday, June 2, 2015 10:38 AM PST
Whenever somebody talk about LRR or distance, they all give example of "Airport would be 20-minutes away". My question there is no other place in Lahore where somebody would like to go except airport? How many times in a month/year, anybody goes to airport?
I mean, if reltives or offices is located on Jail Road, Mall Road, Anar Kali, Gulberg etc Can LRR help him to reach there in 20-minutes?
humayun replied on Tuesday, June 2, 2015 12:15 PM PST
A very useful information abt Ring road. Plz tell abt Halloki interchange; is it still there in plan ?.thanx alot.


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Monday, August 17, 2009
3 Week Stall
Dear God - I am in the 3 Week Stall. I went down a pound, I went up a half, I went down a half, and then up a half. Today I am going to do only protein and exercise my buns off to try to break out of the stall. I hate this. But at the same time my clothes are getting looser. Woohoo!
2 comments:
You're never a loser until you quit trying. See the link below for more info.ReplyDelete
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כ' באלול תשס״ט
Belz 21
Last night I dreamt.
For one night, the way was open for the dead to come up from the cavern of the dead to walk among the living.
I saw as some of the dead came up from a deep cavern through the surface opening which led into the land of the living. Not all of the dead could come up. Only the dead who had the strength and will to climb up to the cavern's opening could make it up. Not only human dead could take advantage of this night, but the dead of all living creatures could if they had the will and strength to do it. In fact, I saw some spiders and small bugs who did take advantage of the opportunity to return to the land of the living for this brief period of time.
One small spunky girl bug who came up reminded me of both a praying mantis and a giraffe - she was skinny like a praying mantis but she had a longer neck like a giraffe. The small girl bug was climbing up the cavern wall, struggling to reach the opening, pulling her mate bug up with her who didn't have the strength to climb anymore. The girl bug had strength enough for both of them. She was determined to make it to the opening and she was going to bring her mate bug with her. She did too. I smiled when she made it to the top, male bug in tow.
One teen girl who specifically came up was my responsibility. I had called her up apparently. I cupped her face in my hands, hoping she was not mad at me for calling her up. She wasn't mad. On the contrary, she thanked me for the blessing of enabling her to walk one more night among the living. She went on her way.
Even in the dream, I was cognizant that last night was neither Samhain nor Yom Kippur, even though I felt the night embodied the spirit of both. As I was considering this, a rabbi appeared also in the room into which the cavern opened, also from the land of the living like me. He too, was greeting one of the dead, who then went on his way as the teen girl had.
After the teen girl, I thought my responsibility was over. But it wasn't - the rabbi said to me, "come, we have to go greet the dead." As the dead came up into the land of the living, we greeted them. Many came. We greeted them all, welcoming each one into the land of the living.
I woke up.
Wednesday, September 09, 2009
Spirit Night In The Land Of The Living
כ' באלול תשס״ט
Posted by Lori at 6:24 PM
Labels: dreams, samhain, spirit night, yom kippur


text:
Myocardial Scar Delineation Using Diffusion Tensor Magnetic Resonance Tractography
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Background Late gadolinium enhancement (LGE) is the current standard for myocardial scar delineation. In this study, we introduce the tractographic propagation angle (PA), a metric of myofiber curvature (degrees/unit distance) derived from diffusion tensor imaging (DTI), and compare its use to LGE and invasive scar assessment by endocardial voltage mapping.
Methods and Results DTI was performed on 7 healthy human volunteers, 5 patients with myocardial infarction, 6 normal mice, and 7 mice with myocardial infarction. LGE to delineate the infarct and border zones was performed with a 2‐dimensional inversion recovery gradient‐echo sequence. Ex vivo DTI was performed on 5 normal human and 5 normal sheep hearts. Endocardial electroanatomic mapping and subsequent ex vivo DTI was performed on 5 infarcted sheep hearts. PA in the normal human hearts varied smoothly and was generally <4. The mean PA in the infarct zone was significantly elevated (10.34±1.02 versus 4.05±0.45, P<0.05). Regions with a PA ≤4 consistently had a bipolar voltage ≥1.5 mV, whereas those with PA values between 4 and 10 had voltages between 0.5 and 1.5 mV. A PA threshold >4 was the most accurate DTI‐derived measure of infarct size and demonstrated the greatest correlation with LGE (r=0.95).
Conclusions We found a strong correlation between infarct size by PA and LGE in both mice and humans. There was also an inverse relationship between PA values and endocardial voltage. The use of PA may enable myocardial scar delineation and characterization of arrhythmogenic substrate without the need for exogenous contrast agents.
- diffusion‐weighted imaging
- magnetic resonance imaging
- myocardial delayed enhancement
- myocardial infarction
- tractography
- ventricular arrhythmia
Clinical Perspective
What Is New?
We introduce a new metric of cardiac myofiber architecture: the tractographic propagation angle (PA).
We define the spectrum of normal PA values and compare the use of PA to both late gadolinium enhancement and invasive scar assessment by endocardial voltage mapping.
A PA threshold of 4 can be used to distinguish normal from infarcted myocardium, with good correlation to late gadolinium enhancement and endocardial voltage mapping.
Normal myocardium (PA ≤4), border zone (PA values between 4 and 10), and infarct core (PA >10) had progressively more myofiber heterogeneity.
Delineation of infarct regions using PA correlated well with that based on late gadolinium enhancement and endocardial voltage mapping.
What Are the Clinical Implications?
Cardiac diffusion tensor imaging can be performed in patients with cardiovascular disease.
PA enables myocardial scar delineation without the use of exogenous contrast agents, which would be of particular value in patients with impaired renal function.
PA could be used to identify patients with varying degrees of myofiber disarray, which may correlate with their risk of arrhythmia.
PA provides a direct measure of myofiber architecture, which could provide important insights into the pathogenesis of ventricular arrhythmias.
Diffusion tractography could be of value for scar imaging before catheter ablation procedures.
Imaging of myocardial scar is of clinical importance in the diagnosis and prognosis of a variety of cardiomyopathies. In ischemic cardiomyopathy, delineation of the extent of infarction and the area of viable myocardium plays an important role in patient management and the assessment of long‐term prognosis.1, 2, 3, 4 Myocardial tissue characterization is also of value in the diagnosis and assessment of a number of nonischemic cardiomyopathies.5, 6, 7 In addition, scar‐imaging techniques are increasingly used in the preprocedural assessment of the underlying arrhythmic substrate for patients undergoing catheter ablation for ventricular arrhythmias,8 for which intraprocedural scar definition is performed using endocardial or epicardial voltage mapping.8, 9
A variety of imaging modalities and approaches have been used to assess myocardial injury, infiltration, and viability, most notably late gadolinium enhancement (LGE),1, 2, 3, 5, 6, 7 and positron emission tomography.10, 11, 12 LGE has emerged as a leading technique for tissue characterization of the myocardium; however, several issues complicate its use. These include the risk of gadolinium deposition in the body,13, 14 empirical selection of gadolinium dose, dependence of the technique on the selection of the correct inversion time, and inconsistency in the methods used to define scar regions.15, 16, 17
Unlike conventional methods based on the use of exogenous contrast agents, in vivo diffusion tensor imaging (DTI) exploits the diffusion of water in the myocardium as an endogenous contrast mechanism.18, 19, 20, 21, 22, 23 The use of DTI avoids the need for iodinated or gadolinium‐based contrast, which may be toxic or contraindicated in patients with impaired renal function.13, 14 It also provides a more detailed representation of the underlying tissue structure.24, 25, 26 Normal myocardial fibers are organized as a stereotypical 3‐dimensional continuum, with an array of crossing helices, varying smoothly in orientation from subendocardium to subepicardium.27, 28, 29 In addition, the myofiber trajectories typically exhibit only small variations within a local region of the heart. In this study, we hypothesized that the detection of increased variability or discontinuity in myofiber trajectory could be used to identify myocardial abnormalities such as scar. We devised the tractographic propagation angle (PA), a DTI‐derived topographic index of fiber trajectory, to characterize myocardial microstructure and to detect and delineate abnormal regions. In this study, we define the spectrum of normal PA values and compare its use to both LGE and invasive scar assessment by endocardial voltage mapping.
The data, analytic methods, and study materials will not be made available to other researchers for purposes of reproducing the results or replicating the procedure.
All animal and human studies followed institutional guidelines and were performed in accordance with research protocols approved by the institutional review board at each institution. Written informed consent was obtained from the human participants.
DTI of Healthy Human Volunteers
DTI of healthy volunteers (n=7) was performed on a clinical 3‐T scanner (MAGNETOM Skyra; Siemens Healthcare) equipped with a 45 mT/m gradient and a 34‐element cardiac receive coil. Images were acquired during breath holds using an ECG‐gated diffusion‐encoded stimulated echo sequence, volume selected in the phase–encode axis, using a slab selective radiofrequency pulse.19, 23, 26 Acquisition parameters included field of view, 360×200 mm2; spatial resolution, 2.5×2.5 mm2; slice thickness, 8 mm; in‐plane acceleration rate, 2; repetition time, 2 × cardiac cycle length (ms); echo time, 34 ms; b values, 0 and 500 s/mm2; 10 diffusion‐encoding directions; and 8 averages. The entire left ventricle (LV) was imaged without slice gaps by acquiring 12 contiguous short‐axis slices from base to apex.23 Images were acquired in the systolic and diastolic sweet spots of the cardiac cycle to mitigate strain effects.18, 22
In Vivo DTI of Normal Mice
Normal mice (C57BL6, n=6) were imaged on a 9.4‐T horizontal‐bore scanner (Biospec; Bruker) equipped with a 1500 mT/m gradient.20 DTI of the heart was performed with cardiorespiratory gating using a fat‐suppressed single‐shot spin echo sequence with an echo planar imaging readout. First‐order motion‐compensated, diffusion‐encoding gradients were placed on both sides of the 180° refocusing pulse.20 Acquisition parameters included field of view, 20×20×8 mm3; matrix, 70×70×28; spatial resolution, 156 μm (isotropic); echo time, 14 ms; b values, 0 and 500 to 650 s/mm2; 24 diffusion‐encoding directions; and 2 averages.
In Vivo DTI of Mice Following Myocardial Infarction
Myocardial infarction was induced in female mice (C57BL6, n=7) by permanent ligation of the left coronary artery. DTI and LGE were performed 24 hours after infarction. The sequence and parameters used for the DTI acquisition were as described above. LGE was performed in the short axis of the LV, 10 to 20 minutes after the injection of 0.2 mmol/kg of Gd‐DTPA (gadopentetate dimeglumine), using a 2‐dimensional inversion recovery gradient echo sequence. Image parameters included field of view, 25×25 mm2; matrix, 160×160; slice thickness, 1 mm; flip angle, 60°; repetition time, 1000 ms; echo time, 1.4 ms; and 2 averages. A nonselective adiabatic prepulse was used for uniform inversion, and the inversion time used (600 ms at default) was adjusted to null the uninjured myocardium.
DTI of Patients Following Myocardial Infarction
Patients with large anterior myocardial infarctions (n=5) were imaged on a clinical 1.5‐T scanner (Achieva; Philips) ≈12 months after the event. DTI was performed with a diffusion‐encoded stimulated‐echo echo planar imaging sequence using a 5‐channel cardiac coil and single‐shot cartesian readout, as described previously.22 Sequence parameters were as follows: repetition time, 2RR intervals; spatial resolution, 2×2×8 mm3; b values, 0 and 500 s/mm2; 10 diffusion‐encoding directions; and 8 averages. Imaging was performed in the sweet spot of the cardiac cycle to mitigate the effects of strain. LGE imaging was performed 20 minutes after the injection of 0.2 mmol/kg of gadobutrol with a standard 2‐dimensional inversion recovery gradient echo sequence.
Ex Vivo Imaging of Normal Human and Sheep Hearts
Normal human hearts (n=5), otherwise unsuited to clinical use, were harvested from organ donors (International Institute for the Advancement of Medicine, Jessup, Pennsylvania) and flown to our institution in a preservative solution on ice. Sheep hearts (n=5) were harvested from healthy adult sheep and preserved in formalin. High‐resolution DTI was performed on a 3‐T clinical scanner (TRIO; Siemens) with the hearts immersed in a fluorocarbon‐matching medium. A fat‐suppressed diffusion‐encoded single‐shot spin‐echo echo planar imaging sequence, with b values of 0 and 2000 s/mm2, was used. Other parameters included spatial resolution, 2×2×2 mm3; repetition/echo time, 8430/96 ms; flip angle, 90°; 6 diffusion‐encoding directions; and 24 averages. Between 50 and 70 slices (without gaps) were acquired in the short axis of the LV to cover the entire heart.
Electroanatomic Mapping and DTI of Infarcted Sheep Hearts
Septal infarcts were induced in adult sheep (n=5) by balloon inflation in the mid–left anterior descending coronary artery for 3 hours. The creation of injury in the septum was confirmed by the presence of ST‐segment elevation in lead V1. After a 3‐month period to allow for ventricular remodeling, endocardial electroanatomic mapping was performed using the CARTO system (Biosense‐Webster). A 4‐mm mapping‐ablation catheter was introduced into the LV via a retrograde aortic approach, and ≈200 mapping points were obtained during sinus rhythm. The mapping‐ablation catheter was then placed in the right ventricle, and an additional 30 to 50 points were acquired. Bipolar and unipolar voltages were recorded at each site to create a substrate map.
Following mapping, the sheep were euthanized and the hearts excised for high‐resolution DTI. Before euthanasia, 30 000 U of heparin were administered and a left thoracotomy was performed to expose the heart. Cardiac arrest (ventricular fibrillation) was then induced with high‐rate ventricular pacing. The heart was excised and rinsed with saline, and the coronary arteries were selectively cannulated to remove blood and to infuse 2% formalin, after which the entire heart was placed in formalin. DTI of the excised hearts was performed using the same approach and parameters that were used to image the excised human hearts, as described earlier.
Calculation of the Tractographic PA and Infarct Delineation
Before computing the diffusion tensor, diffusion‐weighted images were aligned to a reference b=0 s/mm2 image using an automated registration approach based on matching radial intensity profiles over all repetitions.23 The diffusion tensor was computed for each voxel and the primary, secondary, and tertiary eigenvectors (ê1, ê2, ê3), and their associated eigenvalues (λ1, λ2, λ3) were derived. Fiber tracts were obtained by integrating the primary eigenvector in the diffusion tensor field into streamlines using an adaptive fifth‐order Runge‐Kutta method. PA values were computed along myofiber trajectories within the principal eigenvector field. The PA is defined as the angle between 2 adjacent principal eigenvectors (êij, êij+1) relative to a given tract (Figure 1A). Thus, PA is a measure of curvature as a differential by unit length, with physical units of degrees per voxel. We studied the distribution of PA values for in vivo and ex vivo normal human hearts and determined an upper limit of normal value for the PA (Figure 1B through 1D). This PA value was subsequently used as a threshold for delineation of scar in hearts following myocardial infarction. Mean diffusivity (MD), fractional anisotropy (FA), and helix angle (HA) were calculated using standard definitions, as described previously.27, 29 HA variance was also computed as an index of the dispersion of transmural myofiber orientation.
Infarct Delineation by LGE
Participants were recruited from a clinical cohort of patients with large anterior myocardial infarcts. All participants had an extensive area of LGE in the anterior wall and septum. Segmentation of the LGE images was performed using a scheme shown in several recent studies to be useful in the assessment of myocardial remodeling as well as in the prediction of arrhythmic events and all‐cause mortality.3, 4, 30 The infarct core (infarct zone) was defined by a signal intensity >3 SD above that of normal myocardium. The peri‐infarct region (border zone) was defined by a signal between 2 and 3 SD above normal. The total infarct region was defined by a signal >2 SD above that of normal myocardium and included the infarct zone and the border zone.
Integration of DTI and Endocardial Voltage Maps
An endocardial surface map of the LV derived from the location of each mapping point was generated and coregistered with the diffusion‐weighted images of the LV using an affine transformation. Each segment of the tractograms was then color‐coded by endocardial bipolar voltage based on the nearest mapping point. We used endocardial bipolar voltage values to delineate normal myocardium (≥1.5 mV) from dense scar (≤0.5 mV) and border zone (0.5–1.5 mV).9, 31 The relationship between PA and bipolar voltage was nonlinear and was modeled using both a rational polynomial function of the form, V(PA)=a+[b/(PAc+d)], and a piecewise linear model.
Statistical Analyses
Correlations between infarct size derived from PA and LGE were performed using the Spearman correlation coefficient. Linear regression was also performed to model the relationship between infarct size as estimated by PA and LGE. Comparisons among MD, FA, myofiber HA variance, and PA in the infarct, border, and remote zones were performed using ANOVA. Values are reported as mean±SD, and a value of P<0.05 was considered statistically significant. Comparative distributions of PA values (infarct versus remote zone and in vivo versus ex vivo) were prepared using histogram analysis on a per‐voxel basis and displayed using unsmoothed peak‐to‐peak graphs.
Tractographic PA in Normal Hearts
The PA in the normal human hearts varied smoothly and ranged approximately between 0 and 4, except at the right ventricular insertion points and apex, where it was slightly higher (Figure 1B through 1C). No significant differences were seen in PA values for the human hearts imaged in vivo or ex vivo. The distributions of PA values in the LV are shown in Figure 1D. The distribution of PA values was similar in all human hearts, with the majority of tract segments having a PA of <4.
PA was highly conserved across species and averaged 4.05±0.45 in the human heart in vivo, 3.86±0.69 in the human heart ex vivo, 3.97±0.71 in the sheep heart ex vivo, and 4.07±0.54 in the mouse heart in vivo (Figure 2A).
Tractographic PA and LGE in Infarcted Myocardium
Although the PA maps in normal mice resembled those in healthy human volunteers, PA maps of the infarcted mouse hearts demonstrated marked differences. Using the PA threshold of 4, derived from our analysis of the distribution of PA values in normal hearts, we show infarct delineation based on PA and LGE in Figure 2B through 2E. Segmentation of the LV using a PA threshold of 4 resulted in clear delineation of the infarct region (Figure 2E), and the correlation between infarct size estimates based on PA and LGE segmentation (Figure 2F) was high (r=0.97).
Similar analyses were performed for the patients with large anterior myocardial infarctions. Delineation of the total infarct region based on LGE (Figure 3A and 3B) and PA (Figure 3C) again yielded a strong correlation (r=0.95; Figure 3G). As in the infarcted mouse hearts, the use of a PA threshold >4 was the most accurate DTI‐derived index of total infarct size in patients with myocardial infarction. The infarct region was characterized by a subtle increase in MD (1.07±0.42 versus 0.85±0.26, P=NS; Figure 3D) and decrease in FA (0.45±0.07 versus 0.54±0.03, P=NS; Figure 3E). Likewise, the transmural variation in HA was altered in large parts of the infarct (Figure 3F). An increase in PA consistently demonstrated the strongest correlation with LGE (Figure 3G). Conservation of mean PA values in normal myocardium was observed across species (mouse, sheep, and human). In each species, there was a significant increase (P<0.05) in PA in the infarct region compared with remote and normal myocardium (Figure 3H).
Tractography of fibers in the infarct, border, and remote zones of patients with myocardial infarction revealed significant differences in microstructure (Figure 4A through 4C). Tracts in the infarct zone demonstrated a loss of coherence, an increase in PA, and dispersion in HA with loss of the characteristic crossing helical pattern. The fibers in the border zone were heterogeneous, with areas of both coherence and incoherence. PA and the variance of the HA in the border zone were both significantly increased. A difference in transmural fiber orientation was also observed in the border zone, with tracts in the subendocardium and subepicardium exhibiting a less oblique orientation than those in the remote zone. Although all metrics of microstructural integrity in the border zone were altered, the changes in MD (0.90±0.22 versus 0.85±0.26, P=NS), FA (0.52±0.01 versus 0.54±0.03, P=NS), and HA variance (1275±120 versus 992±104, P=NS) were less pronounced than those in the PA (7.40±1.00 versus 4.05±0.45, P<0.05), which was significantly different between infarct, border, and remote zones (Figure 4D through 4G).
Tractographic PA and Endocardial Voltage in Infarcted Myocardium
Integration of the LV endocardial bipolar voltage maps with the myofiber tracts was successfully performed for each infarcted sheep heart. Segmentation using the same PA threshold of 4 enabled the infarct region to be readily distinguished from the surrounding myocardium (Figure 5A). PA was markedly elevated in the regions with low endocardial voltage, as shown in Figure 5B. PA followed a bimodal distribution (Figure 5C), and a strong inverse relationship was observed between PA and bipolar voltage, as found by a rational polynomial function that minimizes the least squares residual error (Figure 5D). In addition, to assess the bimodal nature of this relationship, we computed a piecewise linear model relating PA to bipolar voltage with an inflection point at PA=4. This model yielded high r values for both PA ranges (0.94 and 0.93 for PA ≤4 and >4, respectively). Areas of normal myocardium characterized by bipolar voltage ≥1.5 mV generally exhibited PA values ≤4, those with dense scar and bipolar voltage ≤0.5 mV had PA values >10, and the border zone had intermediate bipolar voltage and PA values. Late diastolic potentials were also observed in some locations. These areas demonstrated a moderate elevation in PA (4–10).
The organization of myofibers in the heart has a direct influence on its electrical and mechanical properties.32, 33 In this article, we introduce a metric of myofiber architecture, the tractographic PA, and demonstrate that it can be used to delineate normal from infarcted myocardium with greater accuracy than established metrics of microstructure, such as MD and FA. PA can be used for noninvasive imaging of myocardial scar without the need for radiation or exogenous contrast. Furthermore, by providing a direct measure of myofiber architecture and coherence, PA has the potential to provide useful insights into the substrate for ventricular arrhythmias.
LGE magnetic resonance imaging is commonly used for the detection of myocardial infarction1, 2, 3, 4; however, many patients with cardiovascular disease cannot receive gadolinium because of impaired renal function.14 Noncontrast magnetic resonance imaging approaches based on the measurement of myocardial relaxation rates,34, 35 magnetization transfer,36 and apparent diffusivity21 have been reported; however, with the exception of T1 mapping–based techniques, these approaches remain experimental. In addition, traditional indexes of diffusion such as MD and FA may not show large variations in fully healed chronic infarcts.20, 37
Native T1 mapping of the myocardium has recently been used to detect areas of infarction and injury in patients with acute ST‐segment–elevation myocardial infarction.38, 39 The technique is rapid and reliable and provides an excellent option for those unable to receive gadolinium. T1 is sensitive to changes in the bulk material properties of the myocardium, such as its water and collagen content; however, T1 and other indexes based on magnetic relaxation and magnetization transfer provide no direct information on myofiber architecture. PA provides an alternative and complementary approach for the detection and delineation of myocardial scar based on the organization of myofibers in the heart.
The value of PA can be affected by the image voxel size, which in turn is limited by the acceptable image signal‐to‐noise ratio. Signal‐to‐noise ratio is primarily dependent on voxel volume, which scales with organ size. In each of the investigated species, we observed that the attainable resolution measures a similar range of curvature that spans PA values characteristic of both normal and infarcted myocardium. Furthermore, we observed that physiologically relevant changes in curvature are revealed by DTI.
DTI was performed in the patients with myocardial infarction without tailored acceleration methods in ≈40 minutes. For clinical acceptance, the scan time will need to be significantly reduced. We recently demonstrated DTI with whole‐heart coverage in 15 minutes using both in‐plane and through‐plane acceleration.23 We anticipate that further reductions in scan time will be possible with ongoing advances in technology.
Fiber architecture in the heart is frequently evaluated using the DTI‐derived myofiber HA; however, HA in healthy myocardium varies transmurally by ≈120° from endocardium to epicardium,29 and thus no single threshold value exists to distinguish normal from abnormal myocardium. In addition, abnormalities in HA may not be seen in all cases of myocardial injury,40 although calculating HA variance improves sensitivity for infarct detection.41 PA, in contrast, is highly uniform throughout the normal LV except for small areas at the apex and right ventricular insertion points. We demonstrate that a PA threshold of 4 can be used to distinguish normal from infarcted myocardium, with good correlation to established methods (LGE and endocardial voltage mapping). It should be noted that the patients in this study all had large anteroseptal infarcts, with extensive areas of LGE. Further studies will be needed to confirm the sensitivity of PA to smaller infarcts and nonischemic forms of myocardial scar.
The border zone and infarct periphery frequently provide the substrate for reentrant ventricular arrhythmias,2, 3, 4, 30 and an improved understanding of their microstructure would be beneficial. The border zone in the patients with infarction was characterized by a reduction in fiber coherence, which was more pronounced in the infarct zone. Regions of the LV with a PA ≤4 consistently had a bipolar voltage ≥1.5 mV, those with PA values between 4 and 10 had voltage between 0.5 and 1.5 mV, and those with a PA >10 had voltage ≤0.5 mV. These are congruent with generally accepted definitions of normal myocardium (≥1.5 mV), border zone (0.5–1.5 mV), and dense scar (≤0.5 mV) by bipolar voltage mapping.9, 31 Furthermore, these intermediate voltage and PA values are consistent with the intermediate values seen in gray‐zone LGE.2, 3, 4, 30
The successful integration of PA and endocardial bipolar voltage maps demonstrates that the use of DTI could complement, or potentially replace, LGE for preprocedural scar imaging before catheter ablation procedures for ventricular arrhythmias. This technique may also be useful in identifying epicardial foci in nonischemic cardiomyopathy, which would be advantageous in electrophysiologic applications.8 The integration of DTI and electroanatomic mapping has historically been impeded by the limited availability of in vivo DTI data. Consequently, elegant computational approaches have been developed to integrate electroanatomic data with microstructural atlases of the heart.32 In a clinical setting, the incorporation of LGE into risk models for sudden cardiac death may improve their accuracy by providing an assessment of the arrhythmic substrate.42, 43 Tractography, in contrast, may enable more direct measurement of alterations in myofiber architecture, which has the potential to better define the substrate for reentrant arrhythmias. DTI tractography, and PA in particular, could also be used to help refine the risk assessment of sudden cardiac death.
In conclusion, the tractographic PA is a topographic measure of myocardial fiber trajectory that is derived from DTI. It is conserved across species and sensitive to pathological changes in both the infarct and border zones. Moderate elevations in PA identify regions of the myocardium with heterogeneous microstructure, which may form the substrate for reentrant ventricular arrhythmias. The measurement of PA enables myocardial scar delineation without the need for exogenous contrast agents or invasive procedures.
Sources of Funding
This work was supported by NIH Grants R56HL125590, R01HL131635, R01HL112831, R01HL093038, and P41RR14075.
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- Myocardial Scar Delineation Using Diffusion Tensor Magnetic Resonance TractographyChoukri Mekkaoui, Marcel P. Jackowski, William J. Kostis, Christian T. Stoeck, Aravinda Thiagalingam, Timothy G. Reese, Vivek Y. Reddy, Jeremy N. Ruskin, Sebastian Kozerke and David E. SosnovikJournal of the American Heart Association. 2018;7:e007834, originally published February 2, 2018https://doi.org/10.1161/JAHA.117.007834
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- Myocardial Scar Delineation Using Diffusion Tensor Magnetic Resonance TractographyChoukri Mekkaoui, Marcel P. Jackowski, William J. Kostis, Christian T. Stoeck, Aravinda Thiagalingam, Timothy G. Reese, Vivek Y. Reddy, Jeremy N. Ruskin, Sebastian Kozerke and David E. SosnovikJournal of the American Heart Association. 2018;7:e007834, originally published February 2, 2018https://doi.org/10.1161/JAHA.117.007834


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