Role of cardiovascular magnetic resonance in the guidelines of the European Society of Cardiology

BACKGROUND: Despite common enthusiasm for cardiovascular magnetic resonance (CMR), its application in Europe is quite diverse. Restrictions are attributed to a number of factors, like limited access, deficits in training, and incomplete reimbursement. Aim of this study is to perform a systematic summary of the representation of CMR in the guidelines of the European Society of Cardiology (ESC). METHODS: Twenty-nine ESC guidelines were screened for the terms "magnetic", "MRI", "CMR", "MR" and "imaging". As 3 topics were published twice (endocarditis, pulmonary hypertension, NSTEMI), 26 guidelines were finally included. MRI in the context of non-cardiovascular examinations was not recognized. The main CMR-related conclusions and, if available, the level of evidence and the class of recommendation were extracted. RESULTS: Fourteen of the 26 guidelines (53.8 %) contain specific recommendations regarding the use of CMR. Nine guidelines (34.6 %) mention CMR in the text, and 3 (11.5 %) do not mention CMR. The 14 guidelines with recommendations regarding the use of CMR contain 39 class-I recommendations, 12 class-IIa recommendations, 10 class-IIb recommendations and 2 class-III recommendations. Most of the recommendations have evidence level C (41/63; 65.1 %), followed by level B (16/63; 25.4 %) and level A (6/63; 9.5 %). The four guidelines, which absolutely contained most recommendations for CMR, were stable coronary artery disease (n = 14), aortic diseases (n = 9), HCM (n = 7) and myocardial revascularization (n = 7). CONCLUSIONS: CMR is represented in the majority of the ESC guidelines. They contain many recommendations in favour of the use of CMR in specific scenarios. Issues regarding access, training and reimbursement have to be solved to offer CMR to patients in accordance with the ESC guidelines

In vivo myocardial tissue characterization of all four chambers using high-resolution quantitative MRI

Quantitative native T(1) Mapping of the myocardium without the application of contrast agents can be used to detect fibrosis in the left ventricle. Spatial resolution of standard native T(1) mapping is limited by cardiac motion and hence is not sufficient to resolve small myocardial structures, such as the right ventricle and the atria. Here, we present a novel MR approach which provides cardiac motion information and native T(1) maps from the same data. Motion information is utilized to optimize data selection for T(1) mapping and a model-based iterative reconstruction scheme ensures high-resolution T(1) maps for the entire heart. Feasibility of the approach was demonstrated in three healthy volunteers. In the T(1) maps, the myocardium of all four chambers can be visualized and T(1) values of the left atrium and right chambers were comparable to left ventricular T(1) values

High spatial resolution and temporally resolved t(2) (*) mapping of normal human myocardium at 7.0 tesla: an ultrahigh field magnetic resonance feasibility study

Myocardial tissue characterization using T(2) (*) relaxation mapping techniques is an emerging application of (pre)clinical cardiovascular magnetic resonance imaging. The increase in microscopic susceptibility at higher magnetic field strengths renders myocardial T(2) (*) mapping at ultrahigh magnetic fields conceptually appealing. This work demonstrates the feasibility of myocardial T(2) (*) imaging at 7.0 T and examines the applicability of temporally-resolved and high spatial resolution myocardial T(2) (*) mapping. In phantom experiments single cardiac phase and dynamic (CINE) gradient echo imaging techniques provided similar T(2) (*) maps. In vivo studies showed that the peak-to-peak B(0) difference following volume selective shimming was reduced to approximately 80 Hz for the four chamber view and mid-ventricular short axis view of the heart and to 65 Hz for the left ventricle. No severe susceptibility artifacts were detected in the septum and in the lateral wall for T(2) (*) weighting ranging from TE = 2.04 ms to TE = 10.2 ms. For TE >7 ms, a susceptibility weighting induced signal void was observed within the anterior and inferior myocardial segments. The longest T(2) (*) values were found for anterior (T(2) (*) = 14.0 ms), anteroseptal (T(2) (*) = 17.2 ms) and inferoseptal (T(2) (*) = 16.5 ms) myocardial segments. Shorter T(2) (*) values were observed for inferior (T(2) (*) = 10.6 ms) and inferolateral (T(2) (*) = 11.4 ms) segments. A significant difference (p = 0.002) in T(2) (*) values was observed between end-diastole and end-systole with T(2) (*) changes of up to approximately 27% over the cardiac cycle which were pronounced in the septum. To conclude, these results underscore the challenges of myocardial T(2) (*) mapping at 7.0 T but demonstrate that these issues can be offset by using tailored shimming techniques and dedicated acquisition schemes

Role of CMR imaging in diagnostics and evaluation of cardiac involvement in muscle dystrophies

PURPOSE OF REVIEW: This review aims to outline the utility of cardiac magnetic resonance (CMR) in patients with different types of muscular dystrophies for the assessment of myocardial involvement, risk stratification and in guiding therapeutic decisions. RECENT FINDINGS: In patients suffering from muscular dystrophies (MD), even mild initial dysfunction may lead to severe heart failure over a time course of years. CMR plays an increasing role in the diagnosis and clinical care of these patients, mostly due to its unique capability to precisely characterize subclinical and progressive changes in cardiac geometry, function in order to differentiate myocardial injury it allows the identification of inflammation, focal and diffuse fibrosis as well as fatty infiltration. CMR may provide additional information in addition to the physical examination, laboratory tests, ECG, and echocardiography. SUMMARY: Further trials are needed to investigate the potential impact of CMR on the therapeutic decision-making as well as the assessment of long-term prognosis in different forms of muscular dystrophies. In addition to the basic cardiovascular evaluation, CMR can provide a robust, non-invasive technique for the evaluation of subclinical myocardial tissue injury like fat infiltration and focal and diffuse fibrosis. Furthermore, CMR has a unique capability to detect the progression of myocardial tissue damage in patients with a preserved systolic function

Cardiovascular magnetic resonance in the guidelines of the European Society of Cardiology: a comprehensive summary and update

BACKGROUND: Cardiovascular magnetic resonance (CMR) has been established as a valuable tool in clinical and scientific cardiology. This study summarizes the current evidence and role of CMR in the guidelines of the European Society of Cardiology (ESC) and is an update of a former guideline analysis. METHODS: Since the last guideline analysis performed in 2015, 28 new ESC guideline documents have been published. Twenty-seven ESC practice guidelines are currently in use. They were screened regarding CMR in the text, tables and figures. The main CMR-related sentences and recommendations were extracted. RESULTS: Nineteen of the 27 guidelines (70.4%) contain relevant text passages regarding CMR in the text and include 92 specific recommendations regarding the use of CMR. Seven guidelines (25.9%) mention CMR in the text, and 1 (3.7%, dyslipidemia) does not mention CMR. The 19 guidelines with recommendations regarding the use of CMR contain 40 class-I recommendations (43.5%), 28 class-IIa recommendations (30.4%), 19 class-IIb recommendations (20.7%) and 5 class-III recommendations (5.4%). Most of the recommendations have evidence level C (56/92; 60.9%), followed by level B (34/92; 37.0%) and level A (2/92; 2.2%). Twenty-one recommendations refer to the field of cardiomyopathies, 21 recommendations to stress perfusion imaging, 20 recommendations to vascular assessment, 12 to myocardial tissue characterization in general, 8 to left and right ventricular function assessment, 5 to the pericardium and 5 to myocarditis. CONCLUSIONS: CMR is integral part of the majority of the ESC guidelines. Its representation in the guidelines has increased since the last analysis from 2015, now comprising 92 instead of formerly 63 specific recommendations. To enable patient management in accordance to the ESC guidelines, CMR must become more widely available

Prospective, randomized comparison of gadopentetate and gadobutrol to assess chronic myocardial infarction applying cardiovascular magnetic resonance

BACKGROUND: We hypothesized that the contrast medium gadobutrol is not inferior compared to Gd-DTPA in identifying and quantifying ischemic late gadolinium enhancement (LGE), even by using a lower dose. METHODS: We prospectively enrolled 30 patients with chronic myocardial infarction as visualized by LGE during clinical routine scan at 1.5 T with 0.20 mmol/kg Gd-DTPA. Participants were randomized to either 0.15 mmol/kg gadobutrol (group A) or 0.10 mmol/kg gadobutrol (group B). CMR protocol was identical in both exams. LGE was quantified using a semiautomatic approach. Signal intensities of scar, remote myocardium, blood and air were measured. Signal to noise (SNR) and contrast to noise ratios (CNR) were calculated. RESULTS: Signal intensities were not different between Gd-DTPA and gadobutrol in group A, whereas significant differences were detected in group B. SNR of injured myocardium (53.5+/-21.4 vs. 30.1+/-10.4, p = 0.0001) and CNR between injured and remote myocardium (50.3+/-20.3 vs. 27.3+/-9.3, p < 0.0001) were lower in gadobutrol. Infarct size was lower in both gadobutrol groups compared to Gd-DTPA (group A: 16.8+/-10.2 g vs. 12.8+/-6.8 g, p = 0.03; group B: 18.6+/-12.0 g vs. 14.0+/-9.9 g, p = 0.0016). CONCLUSIONS: Taking application of 0.2 mmol/kg Gd-DTPA as the reference, the delineation of infarct scar was similar with 0.15 mmol/kg gadobutrol, whereas the use 0.10 mmol/kg gadobutrol led to reduced tissue contrast. TRIAL REGISTRATION: The study had been registered under EudraCT Number: 2010-020775-22 . Registration date: 2010.08.10

Fast myocardial T(1) mapping using cardiac motion correction

PURPOSE: To improve the efficiency of native and postcontrast high-resolution cardiac T(1) mapping by utilizing cardiac motion correction. METHODS: Common cardiac T(1) mapping techniques only acquire data in a small part of the cardiac cycle, leading to inefficient data sampling. Here, we present an approach in which 80% of each cardiac cycle is used for T(1) mapping by integration of cardiac motion correction. Golden angle radial data was acquired continuously for 8 s with in-plane resolution of 1.3 × 1.3 mm(2). Cine images were reconstructed for nonrigid cardiac motion estimation. Images at different TIs were reconstructed from the same data, and motion correction was performed prior to T(1) mapping. Native T(1) mapping was evaluated in healthy subjects. Furthermore, the technique was applied for postcontrast T(1) mapping in 5 patients with suspected fibrosis. RESULTS: Cine images with high contrast were obtained, leading to robust cardiac motion estimation. Motion-corrected T(1) maps showed myocardial T(1) times similar to cardiac-triggered T(1) maps obtained from the same data (1288 ± 49 ms and 1259 ± 55 ms, respectively) but with a 34% improved precision (spatial variation: 57.0 ± 12.5 ms and 94.8 ± 15.4 ms, respectively, P < 0.0001) due to the increased amount of data. In postcontrast T(1) maps, focal fibrosis could be confirmed with late contrast-enhancement images. CONCLUSION: The proposed approach provides high-resolution T(1) maps within 8 s. Data acquisition efficiency for T(1) mapping was improved by a factor of 5 by integration of cardiac motion correction, resulting in precise T(1) maps

Motion-corrected model-based reconstruction for 2D myocardial T1 mapping

PURPOSE: To allow for T1 mapping of the myocardium within 2.3 s for a 2D slice utilizing cardiac motion-corrected, model-based image reconstruction. METHODS: Golden radial data acquisition is continuously carried out for 2.3 s after an inversion pulse. In a first step, dynamic images are reconstructed which show both contrast changes due to T1 recovery and anatomical changes due to the heartbeat. An image registration algorithm with a signal model for T1 recovery is applied to estimate non-rigid cardiac motion. In a second step, estimated motion fields are applied during an iterative model-based T1 reconstruction. The approach was evaluated in numerical simulations, phantom experiments and in in-vivo scans in healthy volunteers. RESULTS: The accuracy of cardiac motion estimation was shown in numerical simulations with an average motion field error of 0.7 ± 0.6 mm for a motion amplitude of 5.1 mm. The accuracy of T1 estimation was demonstrated in phantom experiments, with no significant difference (p = 0.13) in T1 estimated by the proposed approach compared to an inversion-recovery reference method. In vivo, the proposed approach yielded 1.3 × 1.3 mm T1 maps with no significant difference (p = 0.77) in T1 and SDs in comparison to a cardiac-gated approach requiring 16 s scan time (i.e., seven times longer than the proposed approach). Cardiac motion correction improved the precision of T1 maps, shown by a 40% reduced SD. CONCLUSION: We have presented an approach that provides T1 maps of the myocardium in 2.3 s by utilizing both cardiac motion correction and model-based T1 reconstruction

Left ventricular remodelling post-myocardial infarction: pathophysiology, imaging, and novel therapies

Most patients survive acute myocardial infarction (MI). Yet this encouraging development has certain drawbacks: heart failure (HF) prevalence is increasing and patients affected tend to have more comorbidities worsening economic strain on healthcare systems and impeding effective medical management. The heart's pathological changes in structure and/or function, termed myocardial remodelling, significantly impact on patient outcomes. Risk factors like diabetes, chronic obstructive pulmonary disease, female sex, and others distinctly shape disease progression on the 'road to HF'. Despite the availability of HF drugs that interact with general pathways involved in myocardial remodelling, targeted drugs remain absent, and patient risk stratification is poor. Hence, in this review, we highlight the pathophysiological basis, current diagnostic methods and available treatments for cardiac remodelling following MI. We further aim to provide a roadmap for developing improved risk stratification and novel medical and interventional therapies