Contrast-enhanced Cardiac MR Research Articles

Left Ventricular Thrombus Management After Acute Myocardial Infarction in Clinical Practice: Results from LEVITATION Survey and Narrative Review.

Left ventricular thrombus (LVT) after ST-elevation myocardial infarction still presents diagnostic and therapeutic challenges. The LEVITATION survey was designed to take a picture of LVT management in current clinical practice. The survey covered diagnostic, therapeutic, and prophylactic issues and was completed by 104 European cardiac centers. Most of them (59%) were university or tertiary centers. The survey showed anterior apical a-/dyskinesia, large MI, spontaneous echo-contrast, late presentation with delayed PCI, and TIMI flow 0-1 as the most important perceived risk factors for LVT formation. Serial ultrasound imaging is the most used tool to diagnose LVT (88% of the centers), with contrast-enhanced ultrasound and cardiac MR performed in case of poor apex visualization or spontaneous echo-contrast. One third (34%) of the centers uses prophylactic anticoagulation to prevent LVT formation. In the presence of LVT, low molecular weight heparin is the most used in-hospital therapy. At discharge, vitamin K antagonist and direct oral anticoagulants are used in 67 and 32% of the cases, respectively. Triple antithrombotic therapy with aspirin plus clopidogrel and VKA is the most used strategy at discharge (55%), whereas a single antiplatelet therapy is preferred only in the case of moderate-to-high risk of bleeding. To assess LVT total regression, half of the centers use contrast-enhanced ultrasound and/or cardiac-MR. The duration of anticoagulation is usually 3-6months (55%), with long-term prolongation in case of LVT persistence or recurrence. The survey has depicted for the first time the current real-world management of this neglected topic and has highlighted several grey zones that are still present and not supported by evidence.

Myocardial viability imaging using a novel non-breath-hold cardiac MRI protocol: a comparative assessment with 18F-FDG PET

BackgroundDelayed contrast enhancement on cardiac magnetic resonance imaging is a well-established MRI technique for the evaluation of myocardial tissue viability. A comprehensive cardiac MRI protocol for myocardial viability comprises of multiple breath hold sequences to provide information regarding chamber volumes, myocardial mass, and function in addition to viability. However, its routine use is limited mainly by lengthy acquisition time and patient’s inability to hold breath in multiple breath hold sequences. The important question to which the referring cardiologists/cardiac surgeons are seeking answer is that “What are the viable vascular territories that will benefit from revascularization?” In this study, we have analyzed the utility of non-breath-hold rapid delayed contrast-enhanced cardiac MR imaging protocol for myocardial viability assessment with 18-flourodeoxyglucose positron emission tomography (18F-FDG PET) as the reference standard.ResultsForty patients of ischemic heart disease who met the inclusion criteria were included. All patients underwent both 18F-FDG PET and delayed contrast-enhanced cardiac magnetic resonance imaging as per the non-breath-hold protocol. In this free-breathing protocol, the breath hold cine sequences were omitted and, after localizers, post-contrast scans were obtained with a time gap of 15 min post-contrast administration. A total number of 680 myocardial segments and corresponding 120 vascular territories were assessed. MRI and 18F-FDG PET images were analyzed using a 17-segment model as proposed by AHA. Sensitivity, specificity, positive predictive value, and negative predictive value of non-breath-hold rapid delayed contrast-enhanced cardiac MR imaging protocol for assessing myocardial viability (on segment analysis) was 95.5%, 65.59%, 88.0%, and 84.72%, respectively, and of vascular territory analysis were 96.77%, 92.59%, 97.83%, and 89.29%, respectively, in relation to 18F-FDG PET used as the reference standard. Spearman’s rank correlation coefficient is 0.62.ConclusionThis modified non-breath-hold delayed contrast-enhanced cardiac MR imaging protocol is a reliable tool to answer the clinically relevant question of myocardial viability with a significant reduction in acquisition time and overcomes the limiting need of breath hold.

Correction to: Reference ranges of left ventricular structure and function assessed by contrast-enhanced cardiac MR and changes related to ageing and hypertension in a population-based study.

The original version of this article, published on 14 March 2018, unfortunately contained a mistake.

Reference ranges of left ventricular structure and function assessed by contrast-enhanced cardiac MR and changes related to ageing and hypertension in a population-based study.

Reference ranges of left ventricular (LV) parameters from cardiac magnetic resonance (CMR) were established to investigate the impact of ageing and hypertension as important determinants of cardiac structure and function. One thousand five hundred twenty-five contrast-enhanced CMRs were conducted in the Study of Health in Pomerania. LV end-diastolic volume (LVEDV), end-systolic volume (LVESV), stroke volume (LVSV), ejection fraction (LVEF), and myocardial mass (LVMM) were determined using long- and short-axis steady-state free-precession sequences. The reference population was defined as participants without late enhancement, hypertension, and prior cardiovascular diseases. Reference ranges were established by quantile regression (5th and 95th percentile) and compared with an additional sample of treated and untreated hypertensives. LV volumes in the reference population (n = 634, 300 males, 334 females, 52.1 ± 13.3 years) aged between 20-69 years were lower with higher age (p = 0.001), whereas LVEFs were higher (p ≤ 0.020). LVMM was lower only in males (p = 0.002). Compared with the reference population, hypertension was associated with lower LVEDV in males (n = 258, p ≤ 0.032). Antihypertensive therapy was associated with higher LVEF in males (n = 258, +2.5%, p = 0.002) and females (n = 180, +2.1%, p = 0.001). Population-based LV reference ranges were derived from contrast-enhanced CMR. Hypertension-related changes were identified by comparing these values with those of hypertensives, and they might be used to monitor cardiac function in these patients. • Left ventricular function changed slightly but significantly between 20-69 years. • Reference values of BSA-indexed myocardial mass decreased with age in males. • Hypertension was associated with lower LV end-diastolic volume only in males. • CMR may allow assessing remodelling related to hypertension or antihypertensive treatment.

Combination of contrast-enhanced cardiac MR and nuclear myocardial imaging in evaluation of myocardial viability in ischemic cardiomyopathy

Objective To explore the imaging characteristics and the complementarity of contrast- enhanced cardiac magnetic resonance CMR and nuclear myocardial perfusion/metabolic imaging in the evaluation of myocardial viability in patients with ischemic cardiomyopathy. Methods A total of 111 patients with diagnosed coronary artery disease and left ventricular dysfunction were retrospectively enrolled in this study. All patients underwent CMR and nuclear myocardial imaging within 1 month. Cine CMR was employed to evaluate cardiac function and wall motion. Contrast-enhanced CMR and myocardial perfusion/metabolic images were quantitatively assessed using a standard 17-segment and 5-score system. Dysfunctional segments were classified as viable or non- viable based on contrast- enhanced CMR and myocardial perfusion/metabolic imaging, respectively. No enhancement or sub-endocardial enhancement was defined as viable, while transmural enhancement was defined as non-viable. Severely matched perfusion/metabolism defects on nuclear imaging were assigned as non-viable while other patterns were considered as viable.Kappa index was calculated to evaluate the diagnostic concordance in assessing myocardial viability between contrast- enhanced CMR and myocardial perfusion/metabolic imaging. Results Among 1 887 segments in 111 patients, 80.3%(1 516/1 887) were dysfunctional. Of them, 63.3% (959/1 516) were viable and 36.7%(557/1 516) were non-viable on contrast-enhanced CMR, while 79.7%(1 208/1 516) were viable and 20.3% (308/1 516) were non-viable on nuclear myocardial imaging. The two modalities had a moderate concordance (Kappa=0.46, P<0.01). In segments with normal perfusion and metabolism, 73.9% (431/583) had various extent of enhancement but most of them(84.2%, 363/431) were subendocardial. On the other hand, 21.0% (117/557) segments with transmural enhancement had hibernating myocardium on nuclear imaging. Conclusions Contrast-enhanced CMR and nuclear myocardial imaging have a moderate concordance in the evaluation of myocardial viability in ischemic cardiomyopathy. Combination of the two modalities is expected to improve the diagnostic accuracy in assessing myocardial viability. Key words: Myocardium; Magnetic resonance imaging; Nuclear imaging; Myocardial ischemia

Impact of left ventricular late enhancement on pulmonary arterial hypertension in idiopathic dilated cardiomyopathy

Methods 71 consecutive patients (p) with DCM, left ventricular systolic dysfunction (LVEF<35%) and normal coronary angiography followed in an outpatient HF clinic, were prospectively enrolled in two institutions. All p had to be in stable clinical condition in the last month. Exclusion criteria were: contraindications for contrast-enhanced cardiac MR (ce-CMR), significant impairment of lung function by clinical criteria or spirometry and history of thromboembolic disease. All patients underwent ECG, echo, blood test and a ce-CMR study in a Philips Intera ® 1.5 T scanner, which included cine imaging, phase contrast in the main pulmonary artery and aorta and late enhancement (LE). Postprocessing was performed with QMASS 7.2 ® (Medis, The Netherlands). PVR was calculated following the equation: 19.38 -(4.62*Ln pulmonary artery average velocity) (0.08 x RVEF %)

High reproducibility of adenosine stress cardiac MR myocardial perfusion imaging in patients with non-ischaemic dilated cardiomyopathy

ObjectiveTo evaluate the reproducibility of first-pass contrast-enhanced cardiac MR (CMR) myocardial perfusion imaging in patients with non-ischaemic dilated cardiomyopathy (NIDCM).DesignProspective observational study.SettingSingle centre, tertiary care hospital.Participants6 outpatient participants with NIDCM.OutcomeReproducibility...

Magnetic Resonance Assessment of Prevalence and Correlates of Right Ventricular Abnormalities in Isolated Left Ventricular Noncompaction

The aim of the present study was to evaluate the prevalence and correlates of right ventricular (RV) noncompaction (RVNC), RV systolic dysfunction, and RV myocardial fibrosis in patients with isolated left ventricular (LV) noncompaction (LVNC). For this purpose, cine and contrast-enhanced cardiac magnetic resonance imaging (MRI) was used. A total of 56 consecutive patients with isolated LVNC were included in the study. The diagnosis of isolated LVNC was based on the presence of standard cardiac MRI and clinical criteria. For each patient, cine and contrast-enhanced cardiac MR images were analyzed to evaluate the prevalence and correlates of RVNC, RV dysfunction, and late gadolinium enhancement (a surrogate of myocardial fibrosis) involving the RV. Mean age of the patient population was 45 ± 19 years; 35 patients (63%) were men. RVNC was observed in 5 patients (9%). Impaired RV systolic function was observed in 9 patients (16%). Late gadolinium enhancement was not observed in any RV segment. No association was found between wall motion abnormalities and noncompaction at RV segmental level (φ coefficient 0.041, p = 0.26). At multivariate analysis, LV ejection fraction was the only variable independently related to RV ejection fraction (β = 0.62, p <0.001). In conclusion, RV systolic dysfunction is present in a non-negligible proportion of patients with isolated LVNC; LV systolic function is the only variable independently related to RV systolic function.

Improved fat water separation with water selective inversion pulse for inversion recovery imaging in cardiac MRI

To develop an improved chemical shift-based water-fat separation sequence using a water-selective inversion pulse for inversion recovery 3D contrast-enhanced cardiac magnetic resonance imaging (MRI). In inversion recovery sequences the fat signal is substantially reduced due to the application of a nonselective inversion pulse. Therefore, for simultaneous visualization of water, fat, and myocardial enhancement in inversion recovery-based sequences such as late gadolinium enhancement imaging, two separate scans are used. To overcome this, the nonselective inversion pulse is replaced with a water-selective inversion pulse. Imaging was performed in phantoms, nine healthy subjects, and nine patients with suspected arrhythmogenic right ventricular cardiomyopathy plus one patient for tumor/mass imaging. In patients, images with conventional turbo-spin echo (TSE) with and without fat saturation were acquired prior to contrast injection for fat assessment. Subjective image scores (1 = poor, 4 = excellent) were used for image assessment. Phantom experiments showed a fat signal-to-noise ratio (SNR) increase between 1.7 to 5.9 times for inversion times of 150 and 300 msec, respectively. The water-selective inversion pulse retains the fat signal in contrast-enhanced cardiac MR, allowing improved visualization of fat in the water-fat separated images of healthy subjects with a score of 3.7 ± 0.6. Patient images acquired with the proposed sequence were scored higher when compared with a TSE sequence (3.5 ± 0.7 vs. 2.2 ± 0.5, P < 0.05). The water-selective inversion pulse retains the fat signal in inversion recovery-based contrast-enhanced cardiac MR, allowing simultaneous visualization of water and fat.

Myocardial fibrosis in isolated left ventricular non‐compaction and its relation to disease severity

The aim of the present study was to evaluate the prevalence and extent of myocardial fibrosis in patients with isolated left ventricular non-compaction (LVNC) and to determine its relation to clinical status and LV systolic function. The cardiac magnetic resonance imaging (MRI) database of our institution was searched for all patients with a first diagnosis of isolated LVNC. The diagnosis of isolated LVNC was based on the presence of standard cardiac MRI and clinical criteria. For each patient, cine and contrast-enhanced cardiac MR images were analysed to evaluate LV systolic function and the prevalence and extent of late gadolinium enhancement (LGE), a surrogate of myocardial fibrosis. A total of 42 patients (mean age 46 ± 20 years, 62% male) were identified. Late gadolinium enhancement was observed in 23 (55%) patients with isolated LVNC, occupying 4.8 ± 6.7% of the LV mass. Both the presence and extent of LGE were significantly related to the number of abnormal clinical features (i.e. symptomatic status, resting electrocardiogram abnormalities, and 24 h Holter monitoring abnormalities; P < 0.001 and P= 0.001, respectively). Similarly, LGE was more prevalent and extensive in patients with LV ejection fraction (EF) < 50% compared with patients with LVEF ≥ 50% (90 vs. 23%; P< 0.001 and 8.9 ± 7.6 vs. 1.1 ± 2.4%; P< 0.001, respectively). At multivariate analysis, both the presence and extent of LV LGE were independently related to LVEF (β = -0.63; P < 0.001 and β = -0.62; P< 0.001, respectively). Myocardial fibrosis is related to clinical disease severity and LV systolic dysfunction in isolated LVNC.

Multimodal visualization of a retrocardial bronchial artery aneurysm with rare origin from the distal descending aorta

An 89-year-old woman in good clinical condition was admitted with intermittent thoracic pain and chronic hypertension. Clinical examination and laboratory tests revealed no significant results. Because of a suspicious retrocardial mass on the routine chest radiograph, a contrast-enhanced cardiac MR examination (1.5 T) was conducted. The MR images displayed a vascular structure between the right atrium and the spine with a diameter of three centimeter and eccentric thrombosis (Fig. 1a). The perfused lumen was 1-cm-wide. A vascular connection between the descending aorta into the aneurysm was detected by MR angiography (Fig. 1b). We, therefore, raised the diagnosis of a bronchial artery aneurysm with an atypical origin from the distal descending aorta, whereas almost all hitherto described aneurysms originate from the aortic arch or the proximal descending aorta [1–3]. The contrast-enhanced multislice CT-scan confirmed the diagnosis of a retrocardial bronchial artery aneurysm originating from the distal descending aorta with arteriosclerosic calcifications. The complete course of the bronchial artery through the aneurysm into the pulmonary parenchyma was displayed by the curved reformation (Fig. 2). There were no signs of active bleeding or perforation. In addition, pulmonary indurations were diagnosed in the basal right lung, probably as residuum of recurrent pulmonary infections. To prevent the future rupture of the aneurysm and secondary complications, we recommended a percutaneous

Contrast-enhanced cine cardiac MR detects impairment of coronary microvascular perfusion in patients after acute myocardial infarct

Contrast-enhanced cine cardiac MR detects impairment of coronary microvascular perfusion in patients after acute myocardial infarct

Extended coverage first-pass perfusion imaging using slice-interleaved TSENSE.

Parallel imaging applied to first-pass, contrast-enhanced cardiac MR can yield greater spatial coverage for a fixed temporal resolution. The method combines rate R=2 acceleration using TSENSE with shot-to-shot interleaving of two slices. The square root R SNR loss is largely compensated for by a longer effective repetition time (TR) and increased flip angle associated with slice interleaving. In this manner, increased spatial coverage is achieved while comparable or better image quality is maintained. Single-heartbeat temporal resolution was accomplished with spatial coverage of eight slices at heart rates up to 71 bpm, six slices up to 95 bpm, and four slices up to 143 bpm. Experiments in normal subjects (N=6) were performed to assess signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) values.

Contrast-enhanced cardiac MR imaging.

Contrast-enhanced cardiac MR imaging.