Why Cardiac MRI? Presented by:
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1 Why Cardiac MRI? Presented by: Lisa G. Carkner, MD, FACC 1
2 Disclosures I have no financial disclosures
3 Objectives Review basic principles of Cardiac MRI. What patient characteristics do I need to consider before ordering a cardiac MRI? Review key MRI findings identified in ischemic and non-ischemic cardiomyopathies. Review other cardiac MRI applications. Review the appropriate use criteria.
4 Cardiac MRI is the non-invasive tool of choice for the evaluation of myocardial tissue characteristics Myocardial structure Myocardial function It can also be used for myocardial viability but does not give tissue metabolic activity which can be obtained from PET Myocardial viability studies
5 Principle: Nuclear magnetic resonance In the presence of a strong magnetic field hydrogen ions are stimulated to emit radio waves Radio waves are detected by a coil put over or around the the body part of interest. Images of the structure are reconstructed based on radio waves emitted. Magnetic gradients (banging sounds) are introduced to capture data and reconstruct images.
6 MRI allows accurate image reconstruction because studies are gated and a small amount of data is collected while the heart is continually moving. Data is collected at the same point in several cardiac cycles allowing for image reconstruction limiting distortion from cardiac motion.
7 Inherent magnetic relaxation times are used to characterize tissue structure T1 Longitudinal Relaxation Time T2 Transverse Relaxation Time Alteration of the time and strength of the gradient fields along with the addition of contrast allows for evaluation of tissue characteristics such as edema, infarct, storage disease or tumors.
8 Contrast Gadolinium contrast diffuses from the capillary to the extracellular space. Initially appears bright as it is perfused into the cardiac chambers and myocardium. Different relaxation times than blood or myocardium. Delayed images retain gadolinium in scarred, infarcted, injured or infiltrated myocardium.
9 Gadolinium Contrast
10 What do I need to consider? Can the patient lay still and almost flat for an hour? Is the patient claustrophobic? Is the patient able to follow instructions? Is the patient able to perform breath holds? Does the patient have an MRI compatible pacer or AICD? Can the patient receive gadolinium contrast GFR>30?
11 Typical MRI Protocol
12 Ischemia/Infarct evaluation
13 Viability
14 Viability
15 45 F with CP negative cardiac catheterization and prior viral illness Myocarditis
16 Hypertrophic cardiomyopathy
17 Sarcoidosis patchy to band like
18 Noncompaction cardiomyopathy Noncompacted:Compacted 2.3 to 1
19 Normal liver Hemochromatosis T2 weighted imaging Normal =40ms Abnormal <20 ms Iron deposition in liver
20 ARVD Arrhythmogenic Right Ventricular Dysplasia T1 Fat Saturation
21 Other Infiltrative Diseases Amyloidosis Metabolic storage diseases Anderson-Fabry Pompe Gaucher Neimann-Pick
22
23 Cardiac Masses
24
25 Structural Heart disease Cortriatriatum VSD
26 Appropriate Evaluation of Chest Pain Syndrome with ECG un-interpretable or unable to exercise (CMR stress) Evaluation of Intra-cardiac Structures Cardiac Risk assessment with known disease Evaluation of complex congenital heart disease Evaluation of LV function post MI with technically limited images from echocardiogram
27 Appropriate Evaluation of specific cardiomyopathies Characterization of native and prosthetic cardiac valves in patients with limited echo or TEE Evaluation of arrhythmogenic right ventricular cardiomyopathy Evaluation of myocarditis or MI with normal coronary arteries
28 Appropriate Evaluation of cardiac mass Evaluation of pericardial conditions Evaluation for aortic dissection Evaluation of left atrium and pulmonary venous anatomy prior to ablation
29 Appropriate Location and extent of myocardial necrosis including no-flow regions Determine post PCI necrosis Determine viability prior to revascularization 29
30 References Radiologic-Pathologic Correlation of Primary and Secondary Cardiomyopathies: MR Imaging and Histopathologic Findings in Heart from Autopsy and Transplantation. Radiographics 37: May-June ACCF/ACR/SCMR/ASNC/NASCI/SIR Appropriateness criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging, Journal of the American College of Cardiology Volume 48, No (focused update in 2010)
31 References Cardiac MRI: A preferred method for assessing myocardial ischemia and infarct burden. Applied Radiology, November 2017 MR Imaging in Hypertrophic Cardiomyopathy: From Magnet to Bedside. Radiology: Volume 273: Number 2 November 2014
32 References Acute Myocarditis: Multiparametric Cardiac MR Imaging. Radiology: Volume 272: Number 2, November 2014 Detection of Myocardial with Low-b-value Diffusion-weighted Echo-planar Imaging Sequence in Patients with Acute Myocarditis. Radiology:Volume 269: Number 2, November
33 References Fibrofatty Changes: Incidence at Cardiac MR Imaging in Patients with Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. Radiology: Volume 280: Number 2, August 2016 Amyloidosis: Modern Cross-sectional Imaging. Radiographics:Volume 35, September-October 2015
34 References American College of Radiology Special Thanks to Dr. John Biese
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