Journal of Nuclear Cardiology

, Volume 18, Issue 6, pp 1095–1102

The cardiac magnetic resonance (CMR) approach to assessing myocardial viability

Review Article

Abstract

Cardiac magnetic resonance (CMR) is a noninvasive imaging method that can determine myocardial anatomy, function, perfusion, and viability in a relative short examination. In terms of viability assessment, CMR can determine viability in a non-contrast enhanced scan using dobutamine stress following protocols comparable to those developed for dobutamine echocardiography. CMR can also determine viability with late gadolinium enhancement (LGE) methods. The gadolinium-based contrast agents used for LGE differentiate viable myocardium from scar on the basis of differences in cell membrane integrity for acute myocardial infarction. In chronic myocardial infarction, the scarred tissue enhances much more than normal myocardium due to increases in extracellular volume. LGE is well validated in pre-clinical and clinical studies that now span from almost a cellular level in animals to human validations in a large international multicenter clinical trial. Beyond infarct size or infarct detection, LGE is a strong predictor of mortality and adverse cardiac events. CMR can also image microvascular obstruction and intracardiac thrombus. When combined with a measure of area at risk like T2-weighted images, CMR can determine infarct size, area at risk, and thus estimate myocardial salvage 1-7 days after acute myocardial infarction. Thus, CMR is a well validated technique that can assess viability by gadolinium-free dobutamine stress testing or late gadolinium enhancement.

References

  1. 1.
    Helfant RH, Pine R, Meister SG, Feldman MS, Trout RG, Banka VS. Nitroglycerin to unmask reversible asynergy. Correlation with post coronary bypass ventriculography. Circulation 1974;50:108-13.PubMedGoogle Scholar
  2. 2.
    Horn HR, Teichholz LE, Cohn PF, Herman MV, Gorlin R. Augmentation of left ventricular contraction pattern in coronary artery disease by an inotropic catecholamine. The epinephrine ventriculogram. Circulation 1974;49:1063-71.PubMedGoogle Scholar
  3. 3.
    Rahimtoola SH. A perspective on the three large multicenter randomized clinical trials of coronary bypass surgery for chronic stable angina. Circulation 1985;72:V123-35.PubMedCrossRefGoogle Scholar
  4. 4.
    Braunwald E, Rutherford JD. Reversible ischemic left ventricular dysfunction: Evidence for the “hibernating myocardium”. J Am Coll Cardiol 1986;8:1467-70.PubMedCrossRefGoogle Scholar
  5. 5.
    Heusch G, Schulz R, Baumgart D. Dobutamine induces a biphasic response in dysfunctional left ventricular regions. Circulation 1996;93:1258-60.PubMedGoogle Scholar
  6. 6.
    Afridi I, Kleiman NS, Raizner AE, Zoghbi WA. Dobutamine echocardiography in myocardial hibernation. Optimal dose and accuracy in predicting recovery of ventricular function after coronary angioplasty. Circulation 1995;91:663-70.PubMedGoogle Scholar
  7. 7.
    Pennell DJ, Underwood SR, Manzara CC, Swanton RH, Walker JM, Ell PJ, et al. Magnetic resonance imaging during dobutamine stress in coronary artery disease. Am J Cardiol 1992;70:34-40.PubMedCrossRefGoogle Scholar
  8. 8.
    Hundley WG, Hamilton CA, Thomas MS, Herrington DM, Salido TB, Kitzman DW, et al. Utility of fast cine magnetic resonance imaging and display for the detection of myocardial ischemia in patients not well suited for second harmonic stress echocardiography. Circulation 1999;100:1697-702.PubMedGoogle Scholar
  9. 9.
    Nagel E, Lehmkuhl HB, Bocksch W, Klein C, Vogel U, Frantz E, et al. Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: Comparison with dobutamine stress echocardiography. Circulation 1999;99:763-70.PubMedGoogle Scholar
  10. 10.
    Baer FM, Voth E, Schneider CA, Theissen P, Schicha H, Sechtem U. Comparison of low-dose dobutamine-gradient-echo magnetic resonance imaging and positron emission tomography with [18F]fluorodeoxyglucose in patients with chronic coronary artery disease. A functional and morphological approach to the detection of residual myocardial viability. Circulation 1995;91:1006-15.PubMedGoogle Scholar
  11. 11.
    Baer FM, Voth E, LaRosee K, Schneider CA, Theissen P, Deutsch HJ, et al. Comparison of dobutamine transesophageal echocardiography and dobutamine magnetic resonance imaging for detection of residual myocardial viability. Am J Cardiol 1996;78:415-9.PubMedCrossRefGoogle Scholar
  12. 12.
    Baer FM, Theissen P, Schneider CA, Voth E, Sechtem U, Schicha H, et al. Dobutamine magnetic resonance imaging predicts contractile recovery of chronically dysfunctional myocardium after successful revascularization. J Am Coll Cardiol 1998;31:1040-8.PubMedCrossRefGoogle Scholar
  13. 13.
    Baer FM, Theissen P, Crnac J, Schmidt M, Deutsch HJ, Sechtem U, et al. Head to head comparison of dobutamine-transoesophageal echocardiography and dobutamine-magnetic resonance imaging for the prediction of left ventricular functional recovery in patients with chronic coronary artery disease. Eur Heart J 2000;21:981-91.PubMedCrossRefGoogle Scholar
  14. 14.
    Wellnhofer E, Olariu A, Klein C, Grafe M, Wahl A, Fleck E, et al. Magnetic resonance low-dose dobutamine test is superior to SCAR quantification for the prediction of functional recovery. Circulation 2004;109:2172-4.PubMedCrossRefGoogle Scholar
  15. 15.
    Arrighi JA, Dilsizian V. Assessment of myocardial viability by radionuclide and echocardiographic techniques: is it simply a sensitivity and specificity issue? Curr Opin Cardiol 2006;21(5):450-6.PubMedCrossRefGoogle Scholar
  16. 16.
    Wesbey GE, Higgins CB, McNamara MT, Engelstad BL, Lipton MJ, Sievers R, et al. Effect of gadolinium–DTPA on the magnetic relaxation times of normal and infarcted myocardium. Radiology 1984;153:165-9.PubMedGoogle Scholar
  17. 17.
    Simonetti OP, Kim RJ, Fieno DS, Hillenbrand HB, Wu E, Bundy JM, et al. An improved MR imaging technique for the visualization of myocardial infarction. Radiology 2001;218:215-23.PubMedGoogle Scholar
  18. 18.
    Christian TF, Rettmann DW, Aletras AH, Liao SL, Taylor JL, Balaban RS, et al. Absolute myocardial perfusion in canines measured by using dual-bolus first-pass MR imaging. Radiology 2004;232:677-84.PubMedCrossRefGoogle Scholar
  19. 19.
    Kim RJ, Fieno DS, Parrish TB, Harris K, Chen EL, Simonetti O, et al. Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function. Circulation 1999;100:1992-2002.PubMedGoogle Scholar
  20. 20.
    Rehwald WG, Fieno DS, Chen EL, Kim RJ, Judd RM. Myocardial magnetic resonance imaging contrast agent concentrations after reversible and irreversible ischemic injury. Circulation 2002;105:224-9.PubMedCrossRefGoogle Scholar
  21. 21.
    Fieno DS, Kim RJ, Chen EL, Lomasney JW, Klocke FJ, Judd RM. Contrast-enhanced magnetic resonance imaging of myocardium at risk: Distinction between reversible and irreversible injury throughout infarct healing. J Am Coll Cardiol 2000;36:1985-91.PubMedCrossRefGoogle Scholar
  22. 22.
    Schelbert EB, Hsu LY, Anderson SA, Mohanty BD, Karim SM, Kellman P, et al. Late gadolinium-enhancement cardiac magnetic resonance identifies postinfarction myocardial fibrosis and the border zone at the near cellular level in ex vivo rat heart. Circ Cardiovasc Imaging 2010;3:743-52.PubMedCrossRefGoogle Scholar
  23. 23.
    Ricciardi MJ, Wu E, Davidson CJ, Choi KM, Klocke FJ, Bonow RO, et al. Visualization of discrete microinfarction after percutaneous coronary intervention associated with mild creatine kinase-MB elevation. Circulation 2001;103:2780-3.PubMedCrossRefGoogle Scholar
  24. 24.
    Selvanayagam JB, Porto I, Channon K, Petersen SE, Francis JM, Neubauer S, et al. Troponin elevation after percutaneous coronary intervention directly represents the extent of irreversible myocardial injury: Insights from cardiovascular magnetic resonance imaging. Circulation 2005;111:1027-32.PubMedCrossRefGoogle Scholar
  25. 25.
    Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M, Parker M, et al. Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: An imaging study. Lancet 2003;361:374-9.PubMedCrossRefGoogle Scholar
  26. 26.
    Lund GK, Stork A, Saeed M, Bansmann MP, Gerken JH, Muller V, et al. Acute myocardial infarction: Evaluation with first-pass enhancement and delayed enhancement MR imaging compared with 201Tl SPECT imaging. Radiology 2004;232:49-57.PubMedCrossRefGoogle Scholar
  27. 27.
    Ibrahim T, Bulow HP, Hackl T, Hornke M, Nekolla SG, Breuer M, et al. Diagnostic value of contrast-enhanced magnetic resonance imaging and single-photon emission computed tomography for detection of myocardial necrosis early after acute myocardial infarction. J Am Coll Cardiol 2007;49:208-16.PubMedCrossRefGoogle Scholar
  28. 28.
    Kumar A, Abdel-Aty H, Kriedemann I, Schulz-Menger J, Gross CM, Dietz R, et al. Contrast-enhanced cardiovascular magnetic resonance imaging of right ventricular infarction. J Am Coll Cardiol 2006;48:1969-76.PubMedCrossRefGoogle Scholar
  29. 29.
    Kim RJ, Albert TS, Wible JH, Elliott MD, Allen JC, Lee JC, et al. Performance of delayed-enhancement magnetic resonance imaging with gadoversetamide contrast for the detection and assessment of myocardial infarction: An international, multicenter, double-blinded, randomized trial. Circulation 2008;117:629-37.PubMedCrossRefGoogle Scholar
  30. 30.
    Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, Simonetti O, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 2000;343:1445-53.PubMedCrossRefGoogle Scholar
  31. 31.
    Selvanayagam JB, Kardos A, Francis JM, Wiesmann F, Petersen SE, Taggart DP, et al. Value of delayed-enhancement cardiovascular magnetic resonance imaging in predicting myocardial viability after surgical revascularization. Circulation 2004;110:1535-41.PubMedCrossRefGoogle Scholar
  32. 32.
    Baks T, van Geuns RJ, Biagini E, Wielopolski P, Mollet NR, Cademartiri F, et al. Effects of primary angioplasty for acute myocardial infarction on early and late infarct size and left ventricular wall characteristics. J Am Coll Cardiol 2006;47:40-4.PubMedCrossRefGoogle Scholar
  33. 33.
    Selvanayagam JB, Jerosch-Herold M, Porto I, Sheridan D, Cheng AS, Petersen SE, et al. Resting myocardial blood flow is impaired in hibernating myocardium: A magnetic resonance study of quantitative perfusion assessment. Circulation 2005;112:3289-96.PubMedCrossRefGoogle Scholar
  34. 34.
    Beek AM, Kuhl HP, Bondarenko O, Twisk JW, Hofman MB, van Dockum WG, et al. Delayed contrast-enhanced magnetic resonance imaging for the prediction of regional functional improvement after acute myocardial infarction. J Am Coll Cardiol 2003;42:895-901.PubMedCrossRefGoogle Scholar
  35. 35.
    Choi KM, Kim RJ, Gubernikoff G, Vargas JD, Parker M, Judd RM. Transmural extent of acute myocardial infarction predicts long-term improvement in contractile function. Circulation 2001;104:1101-7.PubMedCrossRefGoogle Scholar
  36. 36.
    Gerber BL, Garot J, Bluemke DA, Wu KC, Lima JA. Accuracy of contrast-enhanced magnetic resonance imaging in predicting improvement of regional myocardial function in patients after acute myocardial infarction. Circulation 2002;106:1083-9.PubMedCrossRefGoogle Scholar
  37. 37.
    Ingkanisorn WP, Rhoads KL, Aletras AH, Kellman P, Arai AE. Gadolinium delayed enhancement cardiovascular magnetic resonance correlates with clinical measures of myocardial infarction. J Am Coll Cardiol 2004;43:2253-9.PubMedCrossRefGoogle Scholar
  38. 38.
    Baks T, van Geuns RJ, Biagini E, Wielopolski P, Mollet NR, Cademartiri F, et al. Recovery of left ventricular function after primary angioplasty for acute myocardial infarction. Eur Heart J 2005;26:1070-7.PubMedCrossRefGoogle Scholar
  39. 39.
    Kwong RY, Chan AK, Brown KA, Chan CW, Reynolds HG, Tsang S, et al. Impact of unrecognized myocardial scar detected by cardiac magnetic resonance imaging on event-free survival in patients presenting with signs or symptoms of coronary artery disease. Circulation 2006;113:2733-43.PubMedCrossRefGoogle Scholar
  40. 40.
    Roes SD, Kelle S, Kaandorp TA, Kokocinski T, Poldermans D, Lamb HJ, et al. Comparison of myocardial infarct size assessed with contrast-enhanced magnetic resonance imaging and left ventricular function and volumes to predict mortality in patients with healed myocardial infarction. Am J Cardiol 2007;100:930-6.PubMedCrossRefGoogle Scholar
  41. 41.
    Kwong RY, Sattar H, Wu H, Vorobiof G, Gandla V, Steel K, et al. Incidence and prognostic implication of unrecognized myocardial scar characterized by cardiac magnetic resonance in diabetic patients without clinical evidence of myocardial infarction. Circulation 2008;118:1011-20.PubMedCrossRefGoogle Scholar
  42. 42.
    Srichai MB, Junor C, Rodriguez LL, Stillman AE, Grimm RA, Lieber ML, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: A comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J 2006;152:75-84.PubMedCrossRefGoogle Scholar
  43. 43.
    Weinsaft JW, Kim RJ, Ross M, Krauser D, Manoushagian S, LaBounty TM, et al. Contrast-enhanced anatomic imaging as compared to contrast-enhanced tissue characterization for detection of left ventricular thrombus. JACC Cardiovasc Imaging 2009;2:969-79.PubMedCrossRefGoogle Scholar
  44. 44.
    Wu KC, Zerhouni EA, Judd RM, Lugo-Olivieri CH, Barouch LA, Schulman SP, et al. Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation 1998;97:765-72.PubMedGoogle Scholar
  45. 45.
    Hombach V, Grebe O, Merkle N, Waldenmaier S, Hoher M, Kochs M, et al. Sequelae of acute myocardial infarction regarding cardiac structure and function and their prognostic significance as assessed by magnetic resonance imaging. Eur Heart J 2005;26:549-57.PubMedCrossRefGoogle Scholar
  46. 46.
    Tarantini G, Cacciavillani L, Corbetti F, Ramondo A, Marra MP, Bacchiega E, et al. Duration of ischemia is a major determinant of transmurality and severe microvascular obstruction after primary angioplasty: A study performed with contrast-enhanced magnetic resonance. J Am Coll Cardiol 2005;46:1229-35.PubMedCrossRefGoogle Scholar
  47. 47.
    Aletras AH, Tilak GS, Natanzon A, Hsu LY, Gonzalez FM, Hoyt RF Jr, et al. Retrospective determination of the area at risk for reperfused acute myocardial infarction with T2-weighted cardiac magnetic resonance imaging: Histopathological and displacement encoding with stimulated echoes (DENSE) functional validations. Circulation 2006;113:1865-70.PubMedCrossRefGoogle Scholar
  48. 48.
    Abdel-Aty H, Cocker M, Meek C, Tyberg JV, Friedrich MG. Edema as a very early marker for acute myocardial ischemia: A cardiovascular magnetic resonance study. J Am Coll Cardiol 2009;53:1194-201.PubMedCrossRefGoogle Scholar
  49. 49.
    Tilak GS, Hsu LY, Hoyt RF, Arai AE, Aletras AH. In vivo T2-weighted magnetic resonance imaging can accurately determine the ischemic area at risk for 2-day-old nonreperfused myocardial infarction. Invest Radiol 2008;43:7-15.PubMedCrossRefGoogle Scholar
  50. 50.
    Abdel-Aty H, Zagrosek A, Schulz-Menger J, Taylor AJ, Messroghli D, Kumar A, et al. Delayed enhancement and T2-weighted cardiovascular magnetic resonance imaging differentiate acute from chronic myocardial infarction. Circulation 2004;109:2411-6.PubMedCrossRefGoogle Scholar
  51. 51.
    Friedrich MG, Abdel-Aty H, Taylor A, Schulz-Menger J, Messroghli D, Dietz R. The salvaged area at risk in reperfused acute myocardial infarction as visualized by cardiovascular magnetic resonance. J Am Coll Cardiol 2008;51:1581-7.PubMedCrossRefGoogle Scholar
  52. 52.
    Carlsson M, Ubachs JF, Hedstrom E, Heiberg E, Jovinge S, Arheden H. Myocardium at risk after acute infarction in humans on cardiac magnetic resonance: Quantitative assessment during follow-up and validation with single-photon emission computed tomography. JACC Cardiovasc Imaging 2009;2:569-76.PubMedCrossRefGoogle Scholar
  53. 53.
    Berry C, Kellman P, Mancini C, Chen MY, Bandettini WP, Lowrey T, et al. Magnetic resonance imaging delineates the ischemic area at risk and myocardial salvage in patients with acute myocardial infarction. Circ Cardiovasc Imaging 2010;3:527-35.PubMedCrossRefGoogle Scholar
  54. 54.
    Yan AT, Shayne AJ, Brown KA, Gupta SN, Chan CW, Luu TM, et al. Characterization of the peri-infarct zone by contrast-enhanced cardiac magnetic resonance imaging is a powerful predictor of post-myocardial infarction mortality. Circulation 2006;114:32-9.PubMedCrossRefGoogle Scholar
  55. 55.
    Bello D, Fieno DS, Kim RJ, Pereles FS, Passman R, Song G, et al. Infarct morphology identifies patients with substrate for sustained ventricular tachycardia. J Am Coll Cardiol 2005;45:1104-8.PubMedCrossRefGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2011

Authors and Affiliations

  1. 1.Cardiovascular and Pulmonary Branch, National Heart, Lung and Blood InstituteNational Institutes of Health, Department of Health and Human ServicesBethesdaUSA

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