Classic Images in Cardiac Magnetic Resonance Imaging A Case-based Atlas Highlighting Current Applications of ...

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Classic Images in Cardiac Magnetic
Resonance Imaging: A Case-based
Atlas Highlighting Current
Applications of Cardiac Magnetic
Resonance Imaging
Sanjeev A. Francis, MD, Otavio R. Coelho-Filho, MD,
Patrick T. O’Gara, MD, and
Raymond Y. Kwong, MD, MPH
Abstract: There have been tremendous technological
advances in noninvasive cardiovascular imaging, offer-
ing the clinician unparalleled information from a vari-
ety of modalities. Cardiovascular magnetic resonance
imaging (MRI) has the advantages of superior spatial
resolution, detailed tissue characterization, and accu-
rate quantitative assessment of cardiac structure and
function, without the need for radiation exposure. Recent
advances in image acquisition and postimage process-
ing have led to clinically validated protocols for myo-
cardial perfusion, late gadolinium enhancement, and
coronary angiography. The following collection of im-
ages was selected to demonstrate the typical appear-
ance of various cardiovascular conditions using MRI.
There is, of course, much heterogeneity in both the
phenotypic severity of a given condition as well as its
appearance on MRI. This article, while not intended to
be a comprehensive collection, aims to serve as an
introduction to the current applications of cardiac
MRI. (Curr Probl Cardiol 200
9;34:303-322.)
Dr. Patrick T. O’Gara receives modest funding from Lantheus Medical Imaging, as Chair DMC for
investigational PET.
All images shown were acquired from cases performed at Brigham and Women’s Hospital using a Siemens
3 T TIM Trio or a General Electric 1.5 T HDX MRI system.
Curr Probl Cardiol 2009;34:303-322.
0146-2806/$ – see front matter
doi:10.1016/j.cpcardiol.2009.03.002
Curr Probl Cardiol, July 2009
303
insufﬁciency was admitted with unstable angina. Given her inability
to perform exercise, adenosine stress cardiac magnetic resonance
imaging (MRI) was performed to evaluate for myocardial ischemia.
Fig
1
A and B are late gadolinium enhancement (LGE) images of the
short-axis location at mid and distal levels, respectively, indicating no
evidence of myocardial infarction.
Fig 1
C and D are perfusion images
during adenosine stress matching in location to the late gadolinium
images. These perfusion images demonstrated perfusion defects involving
the entire inferior wall, mid-inferoseptal, and mid-inferolateral walls
(white arrows;
Fig 1
C and D). There were no perfusion defects visualized
during resting ﬁrst-pass perfusion (not shown). These ﬁndings are
consistent with signiﬁcant reversible ischemia in the posterior descending
artery and the left circumﬂex territory. The patient was subsequently
referred for cardiac catheterization, which revealed a 95% thrombotic,
mid-RCA occlusion and severe left circumﬂex stenosis, which was
successfully treated with percutaneous intervention.
Case 2: Myocardial Infarction
A 49-year-old man with a history of myocardial infarction and prior
percutaneous interventions was admitted with a ST elevation myocardial
infarction. Cardiac MRI revealed signiﬁcant late gadolinium enhancement
in the anterolateral wall.
Fig 2
A indicates a postcontrast late gadolinium
enhancement image in the mid short-axis location, where the white arrow
points to the small anterolateral infarction.
Fig 2
B is a T2-weighted image
for myocardial edema. There was a corresponding increase in T2 intensity
(
Fig 2
B; white arrows) consistent with residual transmural myocardial
edema because of the recent ischemic event. In addition, there was
another region of subendocardial infarction involving the anteroseptal
wall that did not demonstrate increase in T2 signal, representing a chronic
myocardial infarction (black arrow).
Case 3: Right Ventricular Myocardial Infarction
A 49-year-old man with no signiﬁcant past medical history presented
with new onset congestive heart failure in the setting of a possible viral
syndrome. Echocardiography revealed signiﬁcant left ventricle (LV)
systolic dysfunction and his electrocardiogram was consistent with prior
inferior myocardial infarction. Cardiac MRI was performed to determine
the etiology of his cardiomyopathy and revealed severe systolic dysfunc-
304
Curr Probl Cardiol, July 2009
Case 1: Myocardial Ischemia
A
62-year-old woman with hypertension, diabetes, and chronic renal
FIG 1.
Myocardial ischemia is shown. (A) Short axis, mid-ventricle, LGE; demonstrating no
evidence of prior infarction. (B) Short axis, distal ventricle, LGE. (C,D) First pass gadolinium
perfusion during vasodilator stress demonstrating a perfusion defect involving the mid to distal
inferior, mid-inferoseptal, and mid-inferolateral walls (arrows).
FIG 2.
Myocardial infarction is shown. (A) Short axis, mid-ventricle, LGE; anterolateral infarction
(white arrow), subendocardial anteroseptal infarction (black arrow) (B) Short axis, mid-
ventricle, T2 weighted fast spin echo imaging with fat suppression; increased T2 intensity
consistent with myocardial edema (white arrow).
Curr Probl Cardiol, July 2009
305
FIG 3.
Right ventricular myocardial infarction is shown. (A) short axis, cine steady-state free
precession (SSFP); demonstrating an aneurysm of the inferior, inferoseptum and inferolateral
walls (black arrows). (B) short axis, LGE; demonstrating extensive late enhancement of the right
ventricle consistent with infarction (white arrows), asterisks represent a laminated thrombus.
FIG 4.
Left ventricular aneurysm is shown. (A) Short-axis, cine steady-state free precession (SSFP);
demonstrating large aneurysm neck. (B) Short-axis, LGE, demonstrating full-thickness myocardial
infarction with a small thrombus (arrow). (C) Two-chamber, cine SSFP; demonstrating basal inferior
aneurysm with a wide neck (asterisks). (D) Two-chamber, LGE; demonstrating a full-thickness
myocardial infarction with a rim of scar tissue appearing hyperintense, forming the wall of the
aneurysm sac (arrow).
306
Curr Probl Cardiol, July 2009
FIG 5.
Myocardial viability is shown. (A) 3 chamber, LGE; demonstrating extent of infarction
(white arrows). (B) 2 chamber, LGE; demonstrating apical LV thrombus (black arrow). (C) 4
chamber, LGE. (D) short axis, LGE.
tion (ejection fraction
23%) with a thin, aneurysmal inferior wall.
There was full-thickness late gadolinium enhancement of the entire
inferior wall, basal to mid-inferoseptal and inferolateral walls, and
right ventricle. These ﬁndings were consistent with a prior extensive
inferior and right ventricular infarction. There was also an area of
hypo-enhancement consistent with laminated thrombus involving the
basal to mid inferior wall aneurysm.
Fig 3
A demonstrates cine
function imaging (diastolic frame only). The inferior wall was thinned
and akinetic. The black arrows demonstrate an aneurysm of the
inferior, inferoseptal, and inferolateral walls.
Fig 3
B demonstrates the
late enhancement image of the matching short-axis location. The white
arrows illustrate extensive late enhancement of the right ventricle, consistent
with right ventricular infarction. In addition, there is a laminated thrombus
denoted by the asterisks.
Case 4: Left Ventricular Aneurysm
A 52-year-old man with a history of a large inferior ST elevation
myocardial infarction was noted to have a rapidly enlarging LV on
Curr Probl Cardiol, July 2009
307
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Classic Images in Cardiac Magnetic Resonance Imaging A Case-based Atlas Highlighting Current Applications of ...

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