Reduced global myocardial perfusion reserve in DCM and HCM patients assessed by CMR-based velocity-encoded coronary sinus flow measurements and first-pass perfusion imaging
Coronary microvascular dysfunction (CMD) is an independent predictor of poor prognosis in patients suffering from dilative or hypertrophic cardiomyopathy (DCM/HCM). To assess CMD, quantitative myocardial first-pass perfusion (1P) cardiovascular magnetic resonance (CMR) can be performed. Coronary sinus flow (CSF) measurements at rest and during maximal vasodilatation are an alternative and well-validated approach for the quantification of global myocardial blood flow (MBF) in CMR.
Global myocardial perfusion reserve (MPR) was used to compare both methods, 1P and CSF. This measure reflects the ratio of myocardial blood flow during maximal coronary vasodilatation over rest. 1P-MPR and CSF-MPR were calculated in 17 HCM patients, 14 DCM patients and 16 controls, who underwent a stress CMR study to rule out obstructive coronary artery disease. All patients were examined on a 1.5-T system and the study protocol comprised both, first-pass myocardial perfusion imaging (MPI) and velocity-encoded (VENC) phase-contrast imaging of CSF during rest and adenosine stress.
1P-MPR was significantly decreased only in HCM patients compared to controls (1.14 vs. 1.43, p = 0.045) whereas CSF-MPR was significantly reduced in both patient groups, HCM and DCM, compared to controls (2.38 and 2.07 vs. 3.18, p = 0.041 and p = 0.032). CSF-MBF at maximal stress was significantly lower in HCM and DCM patients compared to the control group (0.11 and 1.23 vs. 1.58 ml/min/g, p = 0.008 and p = 0.040). A moderate but significant correlation between CSF-MPR and 1P-MPR was observed (r = 0.39, p = 0.011). A negative correlation between LV wall thickness and CSF-MBF at rest and stress was found in the DCM group using VENC-based CSF measurements (r = − 0.64, p = 0.013 and r = − 0.69, p = 0.006)—but not using 1P-MPI. Post-proceeding analysis regarding 1P-MPR and CSF-MPR measurements required 20.1 and 6.5 min, respectively (p < 0.001).
The presence of microvascular disease can be non-invasively and quickly detected by VENC-based CSF-MPR measurements during routine stress perfusion CMR in both HCM and DCM patients. Compared to conventional 1P-MPI, VENC-based CSF-MPR is particularly useful in DCM patients with thinned ventricular walls.
KeywordsMyocardial perfusion CMR Coronary sinus flow HCM DCM
Cardiovascular magnetic resonance
Left ventricular end-diastolic volume
Left ventricular ejection fraction
Coronary artery disease
Myocardial perfusion imaging
Region of interest
Rate pressure product
Major cardiac events
Myocardial perfusion reserve
Coronary sinus flow
Myocardial blood flow
MB participated in the CMR exams, carried out the data and statistical analysis, and wrote the initial draft version of the manuscript. AF participated in the CMR exams and in the analysis of the CMR data. CM and ZS critically reviewed the manuscript. AY supervised the study, critically reviewed the manuscript and drafted the manuscript. All authors read and approved the final manuscript.
Compliance with ethical standards
Conflict of interest
The author declares that there is no competing interest.
Ethics approval and consent to participate
The study protocol complies with the Declaration of Helsinki. Written informed consent was obtained from every patient.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
- 6.Vermeltfoort IAC, Bondarenko O, Raijmakers PGHM., Odekerken DAM, Kuijper AFM, Zwijnenburg A et al (2007) Is subendocardial ischaemia present in patients with chest pain and normal coronary angiograms? A cardiovascular MR study. Eur Heart J 28:1554–1558. https://doi.org/10.1093/eurheartj/ehm088 CrossRefPubMedGoogle Scholar
- 9.Mordini FE, Haddad T, Hsu L-Y, Kellman P, Lowrey TB, Aletras AH et al (2014) Diagnostic accuracy of stress perfusion CMR in comparison with quantitative coronary angiography: fully quantitative, semiquantitative, and qualitative assessment. JACC Cardiovasc Imaging 7:14–22. https://doi.org/10.1016/J.JCMG.2013.08.014 CrossRefPubMedPubMedCentralGoogle Scholar
- 12.Shomanova Z, Florian A, Bietenbeck M, Waltenberger J, Sechtem U, Yilmaz A (2017) Diagnostic value of global myocardial perfusion reserve assessment based on coronary sinus flow measurements using cardiovascular magnetic resonance in addition to myocardial stress perfusion imaging. Eur Hear J Cardiovasc Imaging 18:851–859. https://doi.org/10.1093/ehjci/jew315 CrossRefGoogle Scholar
- 13.Schwitter J, DeMarco T, Kneifel S, von Schulthess GK, Jorg MC, Arheden H et al (2000) Magnetic resonance-based assessment of global coronary flow and flow reserve and its relation to left ventricular functional parameters: a comparison with positron emission tomography. Circulation 101:2696–2702. https://doi.org/10.1161/01.CIR.101.23.2696 CrossRefPubMedGoogle Scholar
- 14.van Rossum AC, Visser FC, Hofman MB, Galjee MA, Westerhof N, Valk J (1992) Global left ventricular perfusion: noninvasive measurement with cine MR imaging and phase velocity mapping of coronary venous outflow. Radiology 182:685–691. https://doi.org/10.1148/radiology.182.3.1535881 CrossRefPubMedGoogle Scholar
- 17.Kato S, Saito N, Kirigaya H, Gyotoku D, Iinuma N, Kusakawa Y et al (2016) Impairment of coronary flow reserve evaluated by phase contrast cine-magnetic resonance imaging in patients with heart failure with preserved ejection fraction. J Am Heart Assoc. https://doi.org/10.1161/JAHA.115.002649 CrossRefPubMedPubMedCentralGoogle Scholar
- 20.Kellman P, Hansen MS, Nielles-Vallespin S, Nickander J, Themudo R, Ugander M et al (2017) Myocardial perfusion cardiovascular magnetic resonance: optimized dual sequence and reconstruction for quantification. J Cardiovasc Magn Reson. https://doi.org/10.1186/s12968-017-0355-5 CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Kawada N, Sakuma H, Yamakado T, Takeda K, Isaka N, Nakano T et al (1999) Hypertrophic cardiomyopathy: MR measurement of coronary blood flow and vasodilator flow reserve in patients and healthy subjects. Radiology 211:129–135. https://doi.org/10.1148/radiology.211.1.r99ap36129 CrossRefPubMedGoogle Scholar
- 23.Karamitsos TD, Dass S, Suttie J, Sever E, Birks J, Holloway CJ et al (2013) Blunted myocardial oxygenation response during vasodilator stress in patients with hypertrophic cardiomyopathy. J Am Coll Cardiol 61:1169–1176. https://doi.org/10.1016/j.jacc.2012.12.024 CrossRefPubMedPubMedCentralGoogle Scholar
- 24.Watzinger N, Lund GK, Saeed M, Reddy GP, Araoz PA, Yang M et al (2005) Myocardial blood flow in patients with dilated cardiomyopathy: Quantitative assessment with velocity-encoded cine magnetic resonance imaging of the coronary sinus. J Magn Reson Imaging 21:347–353. https://doi.org/10.1002/jmri.20274 CrossRefPubMedGoogle Scholar
- 25.Dass S, Holloway CJ, Cochlin LE, Rider OJ, Mahmod M, Robson M et al (2015) No evidence of myocardial oxygen deprivation in nonischemic heart failure. Circ Hear Fail 8:1088–1093. https://doi.org/10.1161/CIRCHEARTFAILURE.114.002169 CrossRefGoogle Scholar
- 28.Stolen KQ, Kemppainen J, Kalliokoski KK, Karanko H, Toikka J, Janatuinen T et al (2004) Myocardial perfusion reserve and peripheral endothelial function in patients with idiopathic dilated cardiomyopathy. Am J Cardiol 93:64–68. https://doi.org/10.1016/j.amjcard.2003.08.074 CrossRefPubMedGoogle Scholar
- 31.Abraham D, Hofbauer R, Schäfer R, Blumer R, Paulus P, Miksovsky A et al (2000) Selective downregulation of VEGF-A(165), VEGF-R(1), and decreased capillary density in patients with dilative but not ischemic cardiomyopathy. Circ Res 87:644–647. https://doi.org/10.1161/01.RES.87.8.644 CrossRefPubMedGoogle Scholar
- 35.Merkle N, Wöhrle J, Nusser T, Grebe O, Spiess J, Torzewski J et al (2010) Diagnostic performance of magnetic resonance first pass perfusion imaging is equally potent in female compared to male patients with coronary artery disease. Clin Res Cardiol 99:21–28. https://doi.org/10.1007/s00392-009-0071-8 CrossRefPubMedGoogle Scholar