The Role of Cardiovascular MRI in Heart Failure and the Cardiomyopathies

doi:10.1016/j.ccl.2007.02.003

Cardiology Clinics

Volume 25, Issue 1, February 2007, Pages 71-95

https://doi.org/10.1016/j.ccl.2007.02.003 Get rights and content

Heart failure (HF) is a common syndrome related to varied pathophysiologic processes. Individualization of care according to the patient's pathologic and modifiable substrate is of increasing importance. The use of modern cardiovascular MRI (CMR) provides for the centralization of diagnostic testing with the ability to assess cardiac morphology, function, flow, perfusion, acute tissue injury, and fibrosis in a single setting. This offers the potential for a paradigm shift in the noninvasive diagnosis and monitoring of patients with HF. This article outlines a diagnostic approach for the primary use of CMR in the phenotypic characterization, risk stratification, and therapeutic management of patients with HF.

Section snippets

The cardiovascular MRI toolbox

A brief review of the repertoire of pulse sequences commercially available for CMR is crucial in understanding its ability to comprehensively evaluate patients with heart failure. These pulse sequences can be considered the CMR clinician's “toolbox” and include cine imaging using segmented, breath-held steady-state free precession (SSFP) or real-time pulse sequences; morphologic imaging using turbo spin-echo (TSE)-based sequences; perfusion imaging; inversion-recovery delayed-enhancement

A stepwise approach to the undifferentiated heart failure patient using cardiovascular MRI

A standardized, stepwise approach to the performance and interpretation of CMR offers the potential for a rapid and cost-effective diagnostic algorithm for patients who have undifferentiated heart failure. The steps outlined in the following sections illustrate how the information provided within the comprehensive CMR study affords not only differentiation of heart failure etiology but also risk stratification and optimal prescription of medical and invasive care.

Supplemental information provided by cardiovascular MRI

In addition to the assessment of myocardial disease and function, CMR provides valuable and detailed assessments of valvular morphology, function, and hemodynamics. A significant portion of patients presenting with congestive heart failure have primary and/or secondary valve dysfunction that frequently contributes to deteriorating cardiac performance. The combination of routine cine imaging planes and phase contrast flow imaging can provide a comprehensive evaluation of valve disease in

Summary

The evaluation and management of patients who have heart failure and specific cardiomyopathies remains clinically challenging. Essential to the appropriate care of these patients is not only an understanding of the patient's cardiac morphology and function but also identification of pathologic and modifiable substrate. Current care often includes multiple imaging studies during the prescription of incremental therapeutic interventions such as pharmacologic therapies, myocardial

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CMR for Identifying the Substrate of Ventricular Arrhythmia in Patients With Normal Echocardiography
2020, JACC: Cardiovascular Imaging
This study sought to determine whether cardiac magnetic resonance (CMR) may identify structural heart disease (SHD) in patients with ventricular arrhythmia who had echocardiography ruled out pathological findings.
Approximately one-half of sudden cardiac deaths are attributable to malignant VA. Echocardiography is commonly used to identify SHD that is the most frequent substrate of VA.
A single-center prospective study was conducted in consecutive patients with significant VA, categorized as >1,000 but <10,000 ventricular ectopic beats [VEBs]/24 h; ≥10,000 VEBs/24 h; nonsustained ventricular tachycardia, sustained ventricular tachycardia, or a history of resuscitated cardiac arrest, and no pathological findings at echocardiography, requiring a clinically indicated CMR. Primary endpoint was CMR detection of SHD. Secondary endpoints were a composite of CMR detection of SHD and abnormal findings not specific for a definite SHD diagnosis.
A total of 946 patients were enrolled (mean 41 ± 16 years of age; 64% men). CMR studies were used to diagnose SHD in 241 patients (25.5%) and abnormal findings not specific for a definite SHD diagnosis in 187 patients (19.7%). Myocarditis (n = 91) was the more frequent disease, followed by arrhythmogenic cardiomyopathy (n = 55), dilated cardiomyopathy (n = 39), ischemic heart disease (n = 22), hypertrophic cardiomyopathy (n = 13), congenital cardiac disease (n = 10), left ventricle noncompaction (n = 5), and pericarditis (n = 5). The strongest univariate and multivariate predictors of SHD on CMR images were chest pain (odds ratios [OR]: 2.52 and 2.38, respectively) and sustained ventricular tachycardia (ORs: 2.67 and 2.23, respectively).
SHD was able to be identified on CMR imaging in a sizable number of patients with significant VA and completely normal echocardiography. Chest pain and sustained ventricular tachycardia were the strongest predictors of positive CMR imaging results.
Diagnostic Challenges of Chagas Cardiomyopathy and CMR Imaging
2015, Global Heart
Citation Excerpt :
In the context of myocardial ischemic disease, this means the establishment of the myocardial infarction extension and viability. In other cardiomyopathies, this enables the evaluation of the necrosis and/or myocardial fibrosis pattern formation and, through this, the etiology of the cardiomyopathy can be inferred [12]. During the natural evolution of Chagas disease, 30% to 40% of patients will progress to chronic forms, at the rate of 2% to 3% per year.
Chagas disease comprises a poorly understood and studied clinical scenario, and the Chagas cardiomyopathy is the more representative field of these difficulties. Different from other cardiomyopathies, there is a discrepancy between its severity and poor prognosis and the low efficiency specific diagnostic and therapeutic available tools. Recently, cardiac magnetic resonance has evolved as an important cardiologic method of detailed and accurate myocardial evaluation. It has already been proved as a valuable test for cardiac functional and structural analysis. Considering the vast area that must be studied and researched regarding this cardiomyopathy, cardiac magnetic resonance is being considered an important recent tool for this purpose. The current use of this imaging method for Chagas cardiomyopathy is reviewed. For the proper image interpretation, the relevant pathophysiological aspects are remembered and the natural history of the Chagas disease is briefly reviewed.
Prognostic impact of combined late gadolinium enhancement on cardiovascular magnetic resonance and peak oxygen consumption in ambulatory patients with nonischemic dilated cardiomyopathy
2014, Journal of Cardiac Failure
Peak oxygen consumption (peak VO₂) and late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) are prognostic in heart failure. We investigated whether LGE-CMR and peak VO₂ combined had additive value in risk stratifying patients with nonischemic dilated cardiomyopathy (DCM).
Fifty-seven DCM patients underwent CMR and cardiopulmonary exercise testing. Cardiac events were cardiac death, hospitalization for decompensated heart failure, or lethal arrhythmia. Twenty-five (44%) were LGE-positive. The median peak VO₂ was 18.5 mL·kg^-1·min^-1. On multivariate analysis, positive LGE (P = .048) and peak VO₂ (P = .003) were independent cardiac event predictors. Cardiac event risk was significantly higher with positive LGE and peak VO₂ < 18.5 mL·kg^-1·min^-1 than with negative LGE and peak VO₂ ≥ 18.5 mL·kg^-1·min^-1 (hazard ratio 12.5; 95% CI 1.57–100; P = .017). In 3 patient groups (group A: no LGE, peak VO₂ ≥ 18.5 mL·kg^-1·min^-1, n = 18; group B: positive LGE or peak VO₂ < 18.5 mL·kg^-1·min^-1, n = 24; group C: positive LGE and peak VO₂ < 18.5 mL·kg^-1·min^-1, n = 15) during follow-up (71 ± 32 months), group C had higher cardiac event rates than the others.
Combined assessment of LGE-CMR and peak VO₂ provides additive prognostic information in ambulatory DCM.
PET/MRI: Current state of the art and future potential for cardiovascular applications
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Positron emission tomography-magnetic resonance imaging (PET/MRI) is emerging as a novel diagnostic modality with exciting potential for a role in multiple cardiovascular applications. The combination of the high sensitivity of PET tracers with the excellent spatial resolution and tissue characterization of cardiac MRI will provide complementary information in a variety of cardiac pathologies. While initial efforts have focused on the combination of MRI and PET for assessment of coronary artery disease, cardiomyopathy, viability, and inflammation, this new technology holds enormous potential for molecular cardiovascular imaging. This article will review the development of PET/MRI, review the current research, and discuss potential future applications.
Added value of cardiac magnetic resonance in etiological diagnosis of ventricular arrhythmias
2013, Revista Portuguesa de Cardiologia
A ressonância magnética cardíaca (RMC) tem vindo a adquirir grande relevância na avaliação diagnóstica de um espectro cada vez mais amplo de cardiomiopatias, incluindo as que apresentam potencial arritmogénico.
Avaliação do valor acrescentado da RMC no diagnóstico etiológico de arritmias ventriculares, quando a investigação convencional inicial com outros métodos complementares de diagnóstico não é conclusiva.
Estudaram-se retrospetivamente os doentes que realizaram RMC para esclarecimento da etiologia de arritmias ventriculares, entre 2005-2011 (n = 113). Foram incluídos apenas doentes com arritmias ventriculares documentadas. Constituíram critérios de exclusão a obtenção de diagnóstico definitivo por exame complementar, de diagnóstico realizado previamente e a presença de história prévia sugestiva de doença coronária (antecedentes de síndrome coronária aguda ou história de angor típico, de elevação de biomarcadores de necrose miocárdica ou teste de isquemia positivo, quando realizado). Os resultados da RMC foram considerados relevantes quando sugeriram um diagnóstico provável.
Dos 113 doentes incluídos, 57,5% eram homens. A idade média foi 41,7 ± 16,2 anos. Quanto à arritmia documentada, 38,1% dos doentes foram referenciados por taquicardia ventricular/fibrilhação ventricular (FV/TV mantida) e 61,9% por extrassistolia ventricular com menor complexidade (ESV). A RMC mostrou alterações sugestivas de um diagnóstico específico em 42,5% dos doentes, foi totalmente normal em 36,3% e mostrou alterações inespecíficas nos restantes. Nos casos de referenciação por FV/TV mantida a RMC foi diagnóstica em 60,4% dos casos, enquanto nos casos de ESV foi-o em 31,4%.
Os diagnósticos prováveis mais frequentes foram displasia arritmogénica do ventrículo direito, não compactação ventricular e miopericardite. Assinala-se que, apesar da ausência de evidências clínicas sugestivas pelos critérios atrás referidos, 6,2% dos doentes apresentaram áreas de realce tardio com distribuição e características atribuíveis a doença coronária obstrutiva.
A RMC proporciona valor acrescentado no diagnóstico etiológico de arritmias ventriculares quando exames mais acessíveis ou realizados previamente não são conclusivos. A percentagem de doentes em que foi conclusiva foi de 42,5% (60,4% nos casos de referenciação por FV/TV mantida) e em que foi totalmente normal foi de 36,3%.
Cardiac magnetic resonance (CMR) imaging is increasingly important in the diagnostic work-up of a wide range of heart diseases, including those with arrhythmogenic potential.
To assess the added value of CMR in etiological diagnosis of ventricular arrhythmias after an inconclusive conventional investigation.
Patients undergoing CMR between 2005 and 2011 for investigation of ventricular arrhythmias were included (n=113). All had documented arrhythmias. Those with a definite diagnosis from a previous investigation and those with evidence of coronary artery disease (acute coronary syndrome, typical angina symptoms, increase in biomarkers or positive stress test) were excluded. CMR results were considered relevant when they fulfilled diagnostic criteria.
Of the 113 patients, 57.5% were male and mean age was 41.7±16.2 years. Regarding the initial arrhythmia, 38.1% had ventricular fibrillation/sustained ventricular tachycardia (VF/VT) and 61.9% had less complex ventricular ectopy. CMR imaging showed criteria of a specific diagnosis in 42.5% of patients, was totally normal in 36.3%, and showed non-specific alterations in the remainder. In VF/VT patients, specific criteria were found in 60.4%, and in 31.4% of those with less complex ectopy.
The most frequent diagnoses were arrhythmogenic right ventricular dysplasia, ventricular non-compaction and myopericarditis. It is worth noting that, although there was no evidence of previous coronary artery disease, 6.2% of patients had a late gadolinium enhancement distribution pattern compatible with myocardial infarction.
CMR gives additional and important information in the diagnostic work-up of ventricular arrhythmias after an inconclusive initial investigation. The proportion of patients with diagnostic criteria was 42.5% (60.0% in those with VF/VT), and CMR was completely normal in 36.6%.
The Prognostic Role of Late Gadolinium Enhancement Magnetic Resonance Imaging in Patients With Cardiomyopathy
2013, Canadian Journal of Cardiology
Citation Excerpt :
Amyloid fibril deposition provides marked expansion of the myocardial interstitium, as well as associated fibrosis, each leading to retention of gadolinium-based contrasts. The typical pattern of HE is a diffuse or global pattern that initiates at the subendocardium and migrates progressively toward the epicardium in both the LV and RV (see Fig. 1F).1 The prognostic significance of diffuse/global HE in patients with suspected cardiac amyloid has been reported in 3 studies to date.
Cardiovascular magnetic resonance imaging (CMRI) is currently considered part of standard care at many academic centres for the evaluation of patients with ischemic or nonischemic cardiomyopathy. While CMRI provides unparalleled diagnostic versatility for the assessment of myocardial function, perfusion, and tissue health, evidence supporting its prognostic value for the prediction of important cardiovascular events is now emerging. Given the low specificity of currently available clinical markers in patients with cardiomyopathy, more-robust biomarkers aimed at identifying those at high risk of sudden cardiac death and other relevant outcomes are desirable. Late gadolinium enhancement (LGE) CMRI offers the novel capacity to quantify the burden of myocardial fibrosis, a common pathophysiological end point of most cardiomyopathy states. As such, it has the potential to be a robust and ubiquitous marker of cardiovascular events related to the presence of advanced tissue disease. This review paper focuses on the evidence to date supporting LGE imaging as a tool for the prediction of future cardiovascular events in patients with ischemic and nonischemic cardiomyopathy.
L’imagerie cardiovasculaire par résonance magnétique (ICRM) est actuellement considérée comme faisant partie des soins courants dans plusieurs centres d’enseignement lors de l’évaluation des patients ayant une cardiomyopathie ischémique ou non ischémique. Tandis que l’ICRM offre une polyvalence diagnostique inégalée pour l’évaluation du fonctionnement myocardique, de la perfusion et de la santé des tissus, il apparaît à présent que les données scientifiques soutiennent sa valeur pronostique dans la prédiction d’événements cardiovasculaires importants. Compte tenu de la faible spécificité des marqueurs cliniques actuellement disponibles chez les patients ayant une cardiomyopathie, des biomarqueurs plus fiables ayant pour but d’identifier ceux qui sont exposés à un risque élevé de mort cardiaque subite et d’autres résultats pertinents sont souhaitables. L’ICRM de rehaussement tardif après injection de gadolinium (RTG) offre la nouvelle possibilité de quantifier le fardeau de la fibrose myocardique, un critère de jugement physiopathologique commun à la plupart des états cardiomyopahtiques. À ce titre, il a le potentiel d’être un marqueur fiable et omniprésent d’événements cardiovasculaires liés à la présence de lésions tissulaires avancées. Cet article met l’accent sur les données scientifiques actuelles qui soutiennent que l’imagerie de RTG est un outil pour la prédiction d’événements cardiovasculaires futurs chez les patients ayant une cardiomyopathie ischémique et non ischémique.

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The Role of Cardiovascular MRI in Heart Failure and the Cardiomyopathies

Section snippets

The cardiovascular MRI toolbox

A stepwise approach to the undifferentiated heart failure patient using cardiovascular MRI

Supplemental information provided by cardiovascular MRI

Summary

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Lancet

J Card Fail

J Am Coll Cardiol

J Am Coll Cardiol

Chest

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

Magn Reson Imaging

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Chest

Am J Med

Chest

J Am Coll Cardiol

Genet Med

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Blood

Am J Cardiol

Int J Cardiol

J Am Coll Cardiol

Mayo Clin Proc

Circulation

Delayed enhancement cardiovascular magnetic resonance assessment of non-ischaemic cardiomyopathies

Eur Heart J

The wavefront phenomenon of ischemic cell death. 1. Myocardial infarct size vs duration of coronary occlusion in dogs

Circulation

Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy

N Engl J Med

Diagnostic performance of stress perfusion and delayed-enhancement MR imaging in patients with coronary artery disease

Radiology

Comparison of dobutamine stress magnetic resonance, adenosine stress magnetic resonance, and adenosine stress magnetic resonance perfusion

Circulation

Myocardial first-pass perfusion magnetic resonance imaging: a multicenter dose-ranging study

Circulation

Noninfarcted myocardium: correlation between dynamic first-pass contrast-enhanced myocardial MR imaging and quantitative coronary angiography

Radiology

Magnetic resonance perfusion imaging in patients with coronary artery disease: a qualitative approach

Int J Cardiovasc Imaging

Noninvasive detection of myocardial ischemia from perfusion reserve based on cardiovascular magnetic resonance

Circulation

Coronary artery anomalies: assessment with free-breathing three-dimensional coronary MR angiography

Radiology

Mixed echo train acquisition displacement encoding with stimulated echoes: an optimized DENSE method for in vivo functional imaging of the human heart

Magn Reson Med