CME Topic

The Many Facets of Cardiovascular Magnetic

Resonance Imaging: Review of Background,
Clinical Utility, and Increasing Use in the
Community Hospital
Thomas B. Gore, MD, Robert C. Rollings, MD, and Andrew W. Gore, MS III
Abstract: Cardiovascular magnetic resonance imaging (CMR or
cardiac MRI) has advanced dramatically in the last ten years and has
been proven a reliable and flexible method for cardiac diagnosis.
Stress perfusion MRI is a new technique that accurately detects
coronary heart disease with high sensitivity and specificity. The role
of CMR is also increasing for the evaluation of congestive heart
failure and cardiomyopathy. Late gadolinium enhancement high-
lights areas of myocardial scar and helps predict prognosis. CMR
usually complements, but does not fully replace, other diagnostic
modalities. Careful patient selection is required to ensure safety in
the presence of this powerful magnetic field. MRI gives unique
tissue characterization without ionizing radiation. No longer used
just for esoteric conditions, CMR is becoming common in the com-
munity hospital.
Key Words: cardiac MRI, cardiomyopathy, coronary heart disease,
delayed hyperenhancement, gadolinium
F
or many years, cardiovascular magnetic resonance (CMR)
imaging was available only at academic medical centers
and its use was not practical for routine patient evaluation. In
the past, the main indications were rare congenital anomalies
or cardiac masses (Fig. 1). Use of magnetic resonance imag-
ing (MRI) has been limited by the expense of the equipment
and site-specific requirements for locating the radiofrequency
magnet, as well as maintenance of its cryogen materials, rig-
orous training of technical staff and physicians, long scanning
times, and safety restrictions.
Cardiac MRI has entered a new era. MRI scanning has
become more patient-friendly and image quality has vastly
improved. Awareness of the ionizing radiation of other radi-
ology exams has to some degree spurred interest in MRI.
Many of the patient conditions previously excluded can now
be safely scanned. MR angiography has been well established
for many years in radiology, but cardiac diagnosis by MRI is
now making a real difference in the everyday clinical man-
agement of patients.
A new generation in radiology and cardiology is being
trained in this technology as a routine part of their residency
and fellowship programs. The training requirements have also
been standardized, allowing a physician in practice to attend
off-site supervised study sessions with mentors who have
preset case volumes to achieve certification. Most insurers
are requiring such Level 2 or Level 3 training for reimburse-
ment of the professional fees for reading cardiac studies.
Granting of credentials and privileges, however, remains a
responsibility of the local medical community. While CMR
had previously been offered only in metropolitan areas, it
now has a presence in many community hospitals.
Basics of Magnetic Resonance Imaging
A complete explanation of the physics behind MRI is
beyond the scope of this article. More in-depth basic science
information is available in radiology or cardiology texts. A
brief summary is presented here.
From the Southern CardioPulmonary Associates and West Georgia Health
System, LaGrange, GA; Savannah Cardiology, Savannah, GA; and
Vanderbilt University School of Medicine, Nashville, TN.
Reprint requests to Thomas Bowden Gore, MD, Department of Cardiovas-
cular Medicine, West Georgia Health System, 1514 Vernon Road,
LaGrange, GA 30240. Email: smtg@charter.net
The authors do not have any financial disclosures to declare or conflicts of
interest to report.
Accepted February 24, 2009.
Copyright 2009 by The Southern Medical Association
0038-4348/02000/10200-0719
Key Points
Cardiovascular magnetic resonance (CMR) imaging
has advanced greatly within the last ten years.
CMR has proven a reliable and flexible method for
cardiac diagnosis.
While CMR had previously been offered only in met-
ropolitan areas, it is now available in many commu-
nity hospitals.
Southern Medical Journal Volume 102, Number 7, July 2009
719
The external magnetic field strength of the MRI scanner
is typically 1.5 Tesla which is about 30,000 times the earths
magnetic field. This has been compared to the force of a city
bus traveling at 60 miles per hour. This leads to obvious
safety concerns which are well outlined in other publications.
One should be aware that the magnet is always on and
always take appropriate precautions for the patient and staff,
including after-hours personnel.
The basic MRI principle involves the excitement of pro-
tons in the imaging slice by external radiofrequency (RF)
pulses, temporarily changing their axis of precession. The
MRI signal is received during relaxation back to the base-
line as the RF pulse is turned off. The transverse axis signal
decay determines the T1 properties. The return of signal in
the longitudinal axis gives the T2 properties of the tissue.
These properties are specific for different tissues, giving in-
formation about the characteristics of the material in the im-
aging slice. Water, fat, and muscle all have typical T1 and T2
properties, so that one can identify pericardial effusion, blood
pool, epicardial fat, cardiac muscle and myocardial scar with
remarkable clarity (Figs. 25). The RF field varies within the
imaging slice, giving rise to a gradient which helps locate
the signal and produce an image. The gradient strength and its
slew rate are features that distinguish scanners and certain
tolerances that are necessary for cardiac imaging. The in-
creased electrical conductivity of the RF coil is aided by a
surrounding bath of cryogen, liquid helium or liquid nitrogen.
Vibration of the coils during electrical gradient switching
determines the loud noise of the scanner and can be in the
range of 65120 decibels.
Advances in MR Cardiac Exams
Historically, the most difficult obstacles to cardiac im-
aging were cardiac motion and respiratory movement. Faster
scanning largely overcomes these limitations. Rapid se-
quences available within the past 10 years (turbo imaging)
have improved speed and made cardiac MRI practical. The
early pulse sequences of MRI were spin echo images which
are intrinsically black blood techniques. In these images,
the heart is a lighter shade of gray and the blood pool is dark.
Although spin echo is still used in some situations, the work-
horses of cardiac imaging have become the gradient echo
image (T1-weighted) and steady state free precession
(SSFP, a T2/T1 weighting) sequences which are bright blood
techniques with remarkable image definition (Figs. 25). In these
images, the blood pool is bright and the heart muscle is darker.
Administration of the paramagnetic contrast agent gadolinium
exaggerates the T1 weighting and increases signal-to-noise ratio
(SNR). T1 properties dominate the T2 effect in most sequences.
Common protocols now have high SNR, high contrast-to-noise
ratio (CNR) and high temporal and spatial resolution.
Scans have gradually become more patient friendly. Ear
plugs and ear phones have provided improved patient comfort.
Faster scanning has resulted in much shorter breath-hold times.
Fig. 1 Intracardiac mass: This 4-chamber image shows a large
right atrial mass which was an angiosarcoma that was not de-
tected by echocardiography. The tumor was successfully re-
moved. (Double-inversion recovery T1-weighted sequence with
black-blood appearance prior to intravenous contrast).
Fig. 2 Circumflex infarction: Large inferolateral, nearly trans-
mural myocardial infarction (MI) on 3-chamber view. Angio-
gram showed a severe circumflex stenosis. Due to full thickness
of the infarct, angioplasty was not recommended, as it was un-
likely to improve function. The inferolateral wall is very thin in
comparison to the normal septum. Due to the large amount of
myocardial scar (28% of the left ventricle) and low ejection
fraction (20%), a defibrillator was placed. This is a delayed
hyperenhancement inversion-recovery image taken 12 min-
utes following intravenous gadolinium 0.2 mmoles/kilogram
body weight, inversion time of 300 msec. The myocardium ap-
pears black and the scar is white.
Gore et al The Many Facets of Cardiovascular Magnetic Resonance Imaging
720
2009 Southern Medical Association
Information obtained from CMR is categorized as (a)
morphology and function, (b) viability, (c) perfusion and (d)
flow. A complete cardiac study includes all of these. Myo-
cardial viability assessment and perfusion imaging require the
use of gadolinium, but much information can be obtained
even without its use. More limited exams, even in more se-
riously ill patients, are sometimes warranted and can be done
in a shorter period of time with a variety of techniques to
adjust for heart rate or diminished cooperative capacity.
There are many misperceptions regarding exclusions with
metallic devices because the recommendations have changed
over the years. Patients with stents and most cardiac valves
can be examined safely.
1,2
Orthopaedic joint replacements
and sternotomy wires may produce artifacts that can occa-
sionally reduce evaluability, but these are not contraindica-
tions. Patients with pacemakers and implantable cardiac de-
fibrillator (ICD) units are rarely imaged outside of regional
academic centers. However, active research suggests that
many pacemaker patients may be able to undergo noncardiac
MRI scans with careful patient selection and follow-up, so
this standard may change in the future.
3,4
When this has been
done in a research setting, it was offered to non-pacemaker-
dependent patients. The pacemaker was preprogrammed to min-
imal functions and thresholds were checked before and after the
MRI examination, then the device was reprogrammed. The US
Government Food and Drug Administration continues to urge
extreme caution even with this approach.
5
NewMRI-compatible
pacemaker generators and leads are under development and may
provide better options for pacemaker patients who need MRI
scans. Ferrous aneurysm clips and certain otologic implants are
still absolutely contraindicated.
Clinical Issues
The Table lists many indications for the use of CMR.
The MR examination can, in some cases, replace other tests
and can provide almost the same information as echocardi-
ography or nuclear stress testing. However, it is usually a
targeted study to clarify or extend the results of other studies,
sometimes obviating the need for more invasive procedures.
Appropriateness criteria for CMR have been published.
6,7
Cardiac MRI is now a valid option for assessment and
risk stratification of acute and chronic heart failure patients
with resting function and viability studies. Cardiac stress
testing has also been shown to have high sensitivity (84%)
Fig. 3 Pericardial effusion: Moderate-sized pericardial effu-
sion surrounding the heart. This sequence is a diastolic frame
from SSFP (steady-state free precession) cine-image showing all
four cardiac chambers and the aortic outflow. Note the bright-
white pericardial fluid and the less-bright subcutaneous fat. This
is a bright-blood image showing a brighter gray blood pool
and darker gray myocardium. Epicardial fat anterior to the
right ventricle is also distinguished from fluid.
Fig. 4 Lateral MI: Small lateral subendocardial myocardial
infarction, about 50% of the wall thickness. Total scar was only
5% of the myocardium. This patient had an adenosine stress
magnetic resonance study which showed a matching perfusion
defect and no additional ischemia. The patient was continued on
medical management without angiography. This is a standard,
delayed hyperenhancement inversion-recovery image with the
scar appearing white and the normal myocardium appearing
black.
CME Topic
Southern Medical Journal Volume 102, Number 7, July 2009
721
and specificity (87%), so it can be reasonably used to screen
patients for a new diagnosis of ischemic heart disease.
8,9
Stress-perfusion MRI combines the established method of
intravenous adenosine infusion for inducing myocardial hy-
peremia, with the use of first-pass myocardial perfusion after
a bolus of intravenous gadolinium (usual dose 0.1 mmole/kg
of body weight, sometimes referred to as single dose) and
rapid perfusion imaging sequences. The MR-IMPACT trial
10
has shown the superiority of perfusion cardiac MRI to nuclear
stress imaging, with greater sensitivity and accuracy for small
subendocardial perfusion defects. Accuracy was best for the
dose of 0.1 mmole/kg than for lower doses. In comparison,
nuclear imaging is often limited by breast or diaphragmatic
attenuation. MRI has its own peculiar artifacts such as wrap
or breathing motion artifacts, but these generally do not pre-
vent accurate image interpretation. Despite the growing data
supporting its use, stress perfusion MRI has not been widely
adopted, perhaps because it is time-intensive and requires a
very high level of local expertise and greater staff require-
ments than the basic function or viability studies.
The truly unique feature of cardiac MRI is the direct
visualization of myocardial scar through the late enhance-
ment properties of gadolinium administration (delayed hyper-
enhancement [DHE] or late gadolinium enhancement [LGE]).
The first detailed explanation of this technique was pub-
lished by Kim et al
11
in 1999. After intravenous infusion in
humans, gadolinium (0.10.2 mmole/kg) rapidly diffuses
into the interstitial areas of damaged or fibrotic myocar-
dium and the scar appears white at 10 to 12 minutes
following infusion, compared with the black myocar-
dium on this type of inversion recovery T1-weighted im-
age (Figs. 2, 4, and 5).
As gadolinium accumulates in the fibrotic extracellular
space of infarcts, it shortens T1 more in the infarct than in the
surrounding normal myocardium, which has much less ex-
tracellular matrix. The inversion time of the scanner is
manually set for each patient (usually in the range of 175250
milliseconds) to null the normal myocardium as it recovers
from proton inversion to its baseline state, making it appear
black.
12
The infarct or scar recovers earlier with its shorter
T1 and has a bright or white signal at the set inversion
time. This maximizes the contrast between infarct (shorter T1
and brighter recovery signal) and normal myocardium (longer
T1, selected to be nulled or black at the inversion time).
Setting the inversion time may even require constant adjust-
ment during the scan due to gadolinium pharmacokinetics
and patient factors. This requires considerable skill and ex-
perience on the part of the scanner operator.
Delayed enhancement imaging demonstrates subendo-
cardial or transmural fibrosis and scar, as evidence of viable
or nonviable myocardium for decisions on revascularization
Fig. 5 Thrombus: Left ventricular apical mural thrombus
1 cm 2.5 cm on this inversion recovery image, requested
because of an equivocal echocardiographic study. A band of
transmural apical infarction is also visible. The scar is white,
blood pool is bright, normal myocardium black and thrombus
dark. This patient was placed on Coumadin therapy. There is a
variation of gray-scale signal intensity within the thrombus, due
to variable amounts of proton signal recovery at 300 msec fol-
lowing the inversion pulse. A 600 msec inversion time showed
uniform black density.
Table. Sample indications for cardiovascular MRI
a
Equivocal results or suboptimal images from echocardiography
Equivocal results from nuclear imaging
More exact ejection fraction (prelude to ICD)
Left and right ventricular volumes or regurgitant fractions
Serial study of ischemic cardiomyopathy (viability and perfusion)
Viability assessment of myocardium before PCI or CABG
Assess salvage of myocardium after PCI or CABG
Evaluate cause of nonischemic cardiomyopathy
Suspected cardiac amyloidosis or sarcoidosis
Serial evaluation of aortic root enlargement or aortic aneurysm
Suspected thrombus in left ventricle or left atrium
Pericardial constriction
Congenital heart disease or shunt
Cardiac mass evaluation
Suspected ARVD
Peripheral vascular disease imaging
Stress testing
Risk stratification of acute coronary syndrome
a
ICD, implantable cardioverter defibrillator; PCI, percutaneous coronary
intervention; CABG, coronary artery bypass graft; ARVD, arrhythmogenic
right ventricular dysplasia.
Gore et al The Many Facets of Cardiovascular Magnetic Resonance Imaging
722
2009 Southern Medical Association
with angioplasty, stenting or coronary bypass surgery.
13
Re-
cent literature also proposes that this may be helpful in the
decision for use of implantable defibrillators, as a higher
amount of scar (15% or more of the left ventricle) appears to
correlate with increased risk of inducible ventricular tachy-
cardia at electrophysiologic study.
14
Myocardial scar quanti-
fication also appears to risk-stratify subgroups of nonisch-
emic cardiomyopathy, with a worse prognosis in those having
a higher scar burden.
15
The pattern of scar is more patchy
or midwall or epicardial with cardiomyopathies, unlike the
subendocardial or transmural pattern seen in coronary heart
disease. Thrombi in the left ventricle and left atrium can be
seen clearly and perhaps more reliably with MRI than with
echocardiography.
16,17
Recently, studies have demonstrated that T2-weighting can
be useful to visualize edema surrounding recent myocardial in-
farction and may represent the most effective way to determine
infarct size after reperfusion, as reported in the Effect of FXO6
on Ischemia Reperfusion Injury (FIRE) trial.
18
These sequences
may also show details of blood vessel walls and give insight into
the pathophysiology of plaque development and rupture. Future
applications of techniques recently developed include whole
heart imaging with 3D coronary imaging using infusions of
newer contrast agents and protocols, higher field strength mag-
nets (3T) as well as an increase in the number of elements in the
phased array coils (now up to 32) and the development of sur-
face coils which both receive and transmit.
Coronary artery imaging by MRI is possible and is mainly
used to assess congenital anomalies at this time, showing the
course of the arteries relative to the aorta and main pulmonary
artery. However, it is not the routine first choice since CT
coronary angiography has greater spatial resolution and better
delineation of calcium plaque.
Vascular MRA with or without contrast is a commonly
used and robust imaging technique, and is an ideal study for
follow-up of diseases such as aortic root enlargement, aneu-
rysm measurement, and serial studies of chronic aortic dis-
sections without ionizing radiation. It is widely used for aor-
tic, renal, carotid and lower extremity vascular assessment.
Some of these studies can be added to cardiac images in the
same session, or at a separate time dedicated to vascular
imaging. Pulmonary veins can be assessed before and after
electrophysiologic ablation procedures to evaluate the venous
anatomy or iatrogenic occlusions.
Limitations for Facilities and Patients
Many times the cardiac study is performed in a shared
MRI unit at hospital facilities used jointly by cardiologists
and radiologists. Often a longer exam for cardiac evaluation
competes for scanner time and staff schedules with more
frequent and shorter radiologic exams such as brain or spinal
MRI. Efficiency for cardiac studies may be greater in the
dedicated outpatient center.
Individual patients may be limited by claustrophobia, but
medication can avert this anxiety in most situations. Severe
obesity can rule out some patient examinations, but there is
not a specific weight limit. It is generally stated that if a
patient can fit in the magnet, a good quality study can be
obtained. It should be considered that acutely ill patients may
not be able to cooperate fully with being supine or with the
multiple breath-holding sequences required in cardiac MRI.
Open MRI units do not have sufficient magnet or gradient
strength to perform cardiac studies.
Nephrogenic Systemic Fibrosis
Renal insufficiency (with glomerular filtration rate less
than 30 cc per minute) appears to increase the risk of the rare
disorder called nephrogenic systemic fibrosis (NSF) after use
of gadolinium.
19
Since most studies indicate the highest risk
of NSF in severe renal failure or dialysis patients, recent
reviews and editorials
20,21
suggest that below a GFR of 30 cc/
min, gadolinium should be avoided. A noncontrast exam is
preferred if possible. If ever performed in individuals with
lower renal function (less than 15 cc/min GFR), gadolinium-
enhanced MR imaging should be followed shortly by dialy-
sis. Some authors suggest a maximum dose of 0.1 mmole/kg
(single dose) for all patients. Newer imaging sequences for
vascular studies may allow certain areas examined without
contrast or with newer contrast agents having a higher SNR,
or by half-dose (0.05 mmole/kg) and time-resolved im-
ages for visualization of flow with minimal contrast, but this
may not be useful for cardiac studies. Additional risk factors
for NSF that bear consideration are a high lifetime total dose
of gadolinium (multiple previous scans with gadolinium) and
inflammatory factors such as recent surgery, recent sepsis, or
recent vascular injury. Gadolinium should be avoided in the
individuals with these risk factors to eliminate the risk of NSF
in such patients.
Summary
Cardiac MRI provides certain unique advantages for de-
tailed examination in select patients. This modality is not
useful for all patients and for all diagnoses. The astute clini-
cian must always consider the best imaging modality to help
answer the clinical question at hand. CMR is not always the
best choice. Clear-cut goals in test ordering may lead to en-
hanced patient care without the use of ionizing radiation.
Most physicians who train in this field see it as a major
advance for cardiac diagnosis that is now available at the
community level and it can be reasonably anticipated that
hospital-based facilities will be duplicated in the outpatient
setting. Careful consideration in ordering practices can lead
to cost-effective care overall. This exciting and expanding
field is gradually changing our methods of cardiovascular
evaluation and management.
CME Topic
Southern Medical Journal Volume 102, Number 7, July 2009
723
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