Cardiac MRI: Clinical Application to Disease
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1 Cardiac MRI: Clinical Application to Disease Jessi Smith, MD Cardiothoracic imaging, Indiana University Slides courtesy of Stacy Rissing, MD
2 Outline Imaging planes Disease findings Pulse sequences used for each indication Pathophysiology being evaluated
3 Imaging planes
4 3 Plane localizer
5 Axial Haste
6 2 Chamber Planned from axial images- usually HASTE
7 2 Chamber Planned from axial images- usually HASTE
8 Pseudo short axis Planned from 2 chamber cine
9 Pseudo short axis BASE APEX
10 4 chamber Planned from Pseudo SA and 2 Chamber
11 4 chamber
12 True short axis
13 LVOT Left ventricular outflow tract Planned off of pseudo SA
14 LVOT1 and LVOT2
15 Trans-aortic valve view Planned off LVOT1 and LVOT2
16 Trans-aortic valve view
17 Trans-aortic valve view
18 What are we looking for?
19 CMR for Myocardial Disease Coronary artery disease Is there viable myocardium? Function and viability study Infiltrative myocardial disease Sarcoidosis and Amyloidosis Myocarditis Most idiopathic, some cases with viral etiology Cardiomyopathy Dilated CMO, Hypertrophic CMO, and ARVC
20 CMR for Myocardial Disease Coronary artery disease Is there viable myocardium? Function and viability study Infiltrative myocardial disease Sarcoidosis and Amyloidosis Myocarditis Most idiopathic, some cases with viral etiology Cardiomyopathy Dilated CMO, Hypertrophic CMO, and ARVC
21 Coronary Artery Disease The Function and Viability Study Usual clinical question: Would this patient benefit from CABG? Goal is to distinguish myocardium that has the ability to contract versus myocardium that is replaced by fibrosis or scar. Fibrosis and scar will not regain function after CABG David Letterman
22 Coronary Artery Disease The Function and Viability Study The Basic Protocol 3 plane localizer Axial haste Cine bright blood (SSFP) 2C, SA, 4C Delayed enhancement SA, 2C, 4C Key sequence, looking for scar Pattern is subendocardial
23 Function and viability Delayed enhancement = scar Scar!
24 CMR for Myocardial Disease Coronary artery disease Is there viable myocardium? Function and viability study Infiltrative myocardial disease Sarcoidosis and Amyloidosis Myocarditis Most idiopathic, some cases with viral etiology Cardiomyopathy Dilated CMO, Hypertrophic CMO, and ARVC
25 CMR for Myocardial Disease Coronary artery disease Is there viable myocardium? Function and viability study Infiltrative myocardial disease Sarcoidosis and Amyloidosis Myocarditis Most idiopathic, some cases with viral etiology Cardiomyopathy Dilated CMO, Hypertrophic CMO, and ARVC
26 Infiltrative myocardial disease Cardiac Sarcoidosis Presence of non-caseating granulomas in the pericardium, myocardium, or endocardium leading to clinical sequelae Myocardial granulomas have been associated with cardiac arrhythmia and even sudden death Reggie White
27 Sarcoidosis MR Protocol Function and viability study + T2WI 3-plane loc, axial haste Cine bright blood (SSFP) 2C, SA, and 4C Focal areas of myocardial thickening, wall motion abnormality, aneurysm formation T2-weighted images SA +/- 4C or 2C Myocardial edema and active inflammation Delayed enhancement in SA, 2C, and 4C Inflammation and/or granulomatous involvement Non-ischemic pattern (not confined to coronary distrib) Patchy or mid-myocardial in distribution
28 Cardiac Sarcoidosis Delayed enhancement, short axis images Courtesy Ricardo Cury
29 Cardiac Sarcoidosis Sparrow P J et al. Radiographics 2009;29: by Radiological Society of North America
30 CMR for Myocardial Disease Coronary artery disease Is there viable myocardium? Function and viability study Infiltrative myocardial disease Sarcoidosis and Amyloidosis Myocarditis Most idiopathic, some cases with viral etiology Cardiomyopathy Dilated CMO, Hypertrophic CMO, and ARVC
31 Cardiac Amyloidosis Amyloid proteins are abnormally deposited within heart, especially myocardium Nobody famous Imaging findings: LV wall thickening, atrial enlargement, pericardial effusion, patchy or diffuse LV delayed enhancement
32 Cardiac Amyloidosis MR protocol Essentially function and viability study 3-plane loc, axial haste Cine SSFP 2C, SA, 4C views Cardiac function often reduced Myocardial wall thickness and mass Delayed enhancement SA, 2C, 4C views Eval for infiltrative myocardial process
33 Infiltrative disease Figure 3a. Cardiac amyloidosis in a 75-year-old man with multiple myeloma. Amyloidosis Really thick myocardium Cummings K W et al. Radiographics 2009;29: by Radiological Society of North America
34 Cardiac Amyloidosis delayed enhancement More typical, patchy Classic, diffuse subendocardial
35 CMR for Myocardial Disease Coronary artery disease Is there viable myocardium? Function and viability study Infiltrative myocardial disease Sarcoidosis and Amyloidosis Myocarditis Most idiopathic, some cases with viral etiology Cardiomyopathy Dilated CMO, Hypertrophic CMO, and ARVC
36 Myocarditis Inflammation of the myocardium with necrosis of the adjacent myocytes; usually infectious Classic diagnostic picture: Suddenly decreased systolic function Big dilated heart Otherwise healthy person Shortly after viral illness Rachel Hunter
37 Myocarditis 3-plane loc, axial haste Cine bright blood (SSFP) 2C, SA, 4C Evaluate cardiac function usually reduced T2-weighted images SA and 4C Myocardial edema and inflammation Relative to skeletal muscle Want plenty of skeletal muscle in the FOV get that arm! Pre and post contrast T1-weighted images SA and 4C Ratio myocardial enhance to skeletal muscle enhance RE-RUN if possible!! Hyperemia and inflammation Delayed enhancement images SA, 4C, 2C Inflammation and scar
38 Myocarditis Sneak in that arm! Post contrast Pre contrast We do a similar measurement for T2-weighted images
39 Myocarditis Patchy mid myocardial delayed enhancement
40 CMR for Myocardial Disease Coronary artery disease Is there viable myocardium? Function and viability study Infiltrative myocardial disease Sarcoidosis and Amyloidosis Myocarditis Most idiopathic, some cases with viral etiology Cardiomyopathy (CMO) Dilated CMO, Hypertrophic CMO, and ARVC
41 Cardiomyopathy Dilated Cardiomyopathy Disease of the myocardium LV becomes enlarged (dilated) and cannot pump blood as effectively to the body (heart failure) Can have no symptoms end stage heart failure Usually idiopathic need to r/o other causes Viral infxn, genetic, CAD, metabolic, lots more
42
43 Dilated Cardiomyopathy MR protocol Basic function and viability 3-plane loc, axial haste Cine SSFP 2C, SA, 4C Evaluate function and chamber sizes Delayed enhancement SA, 2c, 4C Evaluate for infarct
44 Dilated Cardiomyopathy LV too big LV too big Poor LV function
45 Hypertrophic Cardiomyopathy Disease of the myocardium Myocardial thickening, hypertrophy Leading cause sudden cardiac death in young athletes
46 Hypertrophic Cardiomyopathy MR Protocol 3-plane loc, axial haste SSFP 2C, SA, 4C LV wall thickness, chamber size, function LVOT1, LVOT2 LV outflow tract obstruction (important) +/- cine AV and FQ aortic valve Aortic valve appearance and function Delayed enhancement SA, 2C, 4C Myocardial scarring, fibrosis - prognosis
47 60-year-old woman with symmetric hypertrophic cardiomyopathy who underwent cardiac MRI before surgical intervention for mitral valve regurgitation and left ventricle (LV) outflow tract obliteration. Hypertrophic Cardiomyopathy Muscle too thick!! 2008 by American Roentgen Ray Society Belloni E et al. AJR 2008;191:
48 Hypertrophic Cardiomyopathy Patchy delayed enhancement = scar Can be source of arrhythmia
49 Arrhythmogenic Right Ventricular Cardiomyopathy ARVC Fibrofatty infiltration of the right ventricle Arrhythmia and possible sudden cardiac death
50 ARVC MR Protocol Much shorter protocol now! 3 plane loc, axial haste Cine SSFP 2C, SA, 4C RV size and wall thickness, function Coronal single shot TRUFI set up sequence HTR cine RV-axial and RV-sagittal High attention to RV aneurysm, dyskinesia
51 ARVC
52 Valve disease Looking for stenosis or regurgitation Aortic Mitral Tricuspid Pulmonic Barbara Walters
53 Aortic valve Stenosis or regurgitation Morphology- cusps? Helpful sequences to obtain: Cine SSFP LVOT and trans-aortic valve Look for the jet of aortic regurgitation Phase contrast (Flow quant)
54 Aortic valve- regurgitation
55 Aortic valve- regurgitation
56 Aortic valve- stenosis often seen with bicuspid aortic valve
57 Mitral valve Stenosis or regurgitation Cine bright blood (SSFP/SPGR) SA, 2C, 4C, and LVOT Phase contrast not as helpful for MV
58 Mitral valve- regurgitation
59 Pericardial disease Pericarditis Pericardial constriction Pericardial effusion Simple, blood, or malignant
60 Pericarditis Pericardial inflammation Usually due to infection Double IR images 4C and SA views Evaluate for pericardial thickening Early and delayed enhancement Evaluate for pericardial inflammation Bob Dylan
61 Pericarditis Way too thick! Way to bright! Double IR Delayed Enhancement
62 Pericarditis
63 Pericardial Constriction Thickened, fibrotic pericardium forms a non-compliant shell around the heart, which prevents heart from expanding when blood enters Most common in US = radiation therapy and surgery Most common worldwide = infection (TB) Key sequences: Double IR Pericardial thickening High temporal resolution SA cine Septal bounce Delayed enhancement - Pericardial inflammation TAG LINES!! Tethering of pericardial layers
64 Pericardium- normal
65 Pericardial constriction
66 Pericardial constriction
67 Pericardial fluid
68 Take home points Practice your cardiac imaging planes Help build MR protocol for specific diseases Cine SSFP is your workhorse Delayed enhancement for inflammation, infiltration, or infarction Phase contrast for flow quantification (valves) T1, T2, and contrast images for tissue characterization
69 Thank You
70 How many people do cardiac MRI at place Radiologist or cardiologist present for the study Do they give you a tailored protocol or run same protocol for all hearts?
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Index. K Knobology, TTE artifact, image resolution, ultrasound, 14
A Acute aortic regurgitation (AR), 124 128 Acute aortic syndrome (AAS) classic aortic dissection diagnosis, 251 263 evolutive patterns, 253 255 pathology, 250 251 classifications, 247 248 incomplete aortic