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Over the past years considerable progress has been made in the field of CMR, which provides accurate evaluation of left ventricular function particularly in patients with ischemic heart disease and various manifestations of cardiomyopathy [1–11]. Stress first-pass contrast-enhanced myocardial perfusion CMR can be used to detect subendocardial ischemia and recent studies have demonstrated the high diagnostic accuracy of stress myocardial perfusion CMR for detecting significant coronary artery disease [12–17]. Magnetic resonance angiography (MRA) has been introduced as a method that can provide visualization of all three major coronary arteries, coronary anomalies, coronary bypasses and the aorta within a single three-dimensional acquisition [18–21]. CMR has become the first choice imaging modality in complex congenital heart disease [22–26] and imaging great vessels [27–30].
Contrast-enhanced CMR has been used to visualize the transmural extent of myocardial infarction with high spatial resolution [31–35]. Infarcted myocardium appears hyperenhanced compared with normal myocardium when imaged by late enhancement CMR. The transmural extent of delayed gadolinium enhancement predicts functional outcome after interventional procedures performed in patients with acute myocardial infarction and chronic ischemic heart disease [36–42]. In this way, tissue characterization of the myocardium has become a major asset of CMR, providing unique information of the structure of the myocardium both in normal and abnormal conditions. In particular, late gadolinium enhancement techniques make use of T1-weighted images for tissue characterization and these techniques are used regularly both in experimental research and clinical cardiology.
For over 25 years it is known that in the acutely infarcted heart the signal intensity in T2-weighted images correlates well with myocardial edema [43–49]. This “edema imaging” on T2-weighted images has been shown to be dependent of infarct age: edema-associated hyper-intense zones in T2-weighted images resolve over time and the area of T2 abnormality delineates the area at risk rather than the infarcted area. An advantage of the clinical use of T2-weighted images is the fact that T2-weighted imaging detects acutely infarcted myocardium better than chronic infarction, the latter being assessed best with late gadolinium enhancement imaging.
In the current issue of the International Journal of Cardiovascular Imaging, Joshi et al. [50] studied 8 patients, all female, with typical chest pain and elevated troponin levels. At coronary angiography all patients showed normal coronary arteries but clear signs of left ventricular ballooning consistent with the syndrome of Takotsubo cardiomyopathy. Four patients had apical ballooning and 4 patients had midwall- or basal ballooning. CMR was performed at hospital admission and the images were analyzed with commercially available software (QMASS MR Version 6.2.1, Medis, Leiden, the Netherlands). The authors used a T2-weighted imaging technique and the T2 signal was assessed both in normal and dysfunctional myocardial regions. Interestingly, it was found that T2-signal intensity was highest in the dysfunctional segments, potentially indicating the presence of myocardial edema in the affected areas of patients with Takotsubo cardiomyopathy. Interestingly, in the 5 patients who had a 2–3 week follow-up CMR scan, there was normalization of the wall motion abnormalities associated with a significant reduction in T2 signal intensity.
Takotsubo cardiomyopathy has recently been recognized in patients with typical signs of acute myocardial infarction mostly due to emotional stress. In these patients the coronary arteries appear normal but they show reversible wall motion abnormalities [51–54]. As a result, it might be of great interest to know the pathophysiological condition of the affected myocardial tissue in the acute phase. Therefore, several indications exist to use CMR-employed T2-weighted images in the setting of the acute myocardial infarction in these patients [55–57]. Whereas decreased T2-weighted contrast ratios significantly correlate with the extent of persistent microvascular obstruction and intra-myocardial hemorrhage, this way of tissue characterization may contribute to early detection of myocardial injury due to myocardial infarction. In addition, CMR derived parameters may be of great significance in the follow-up of these patients as they may show spontaneous recovery of the cardiac abnormalities As a result, the article by Yoshi et al. [50] clearly shows that the T2-weigthed imaging technique may be a valuable approach in patients who are suspected for Takotsubo cardiomyopathy, both in the acute and subacute phase.
References
van der Wall EE, Vliegen HW, de Roos A, Bruschke AV (1995) Magnetic resonance imaging in coronary artery disease. Circulation 92:2723–2739
Bavelaar-Croon CD, Kayser HW, van der Wall EE et al (2000) Left ventricular function: correlation of quantitative gated SPECT and MR imaging over a wide range of values. Radiology 217:572–575
Bax JJ, Lamb H, Dibbets P et al (2000) Comparison of gated single-photon emission computed tomography with magnetic resonance imaging for evaluation of left ventricular function in ischemic cardiomyopathy. Am J Cardiol 86:1299–1305
Posma JL, Blanksma PK, van der Wall EE, Hamer HP, Mooyaart EL, Lie KI (1996) Assessment of quantitative hypertrophy scores in hypertrophic cardiomyopathy: magnetic resonance imaging versus echocardiography. Am Heart J 132:1020–1027
Pluim BM, Beyerbacht HP, Chin JC et al (1997) Comparison of echocardiography with magnetic resonance imaging in the assessment of the athlete’s heart. Eur Heart J 18:1505–1513
Pluim BM, Chin JC, De Roos A et al (1996) Cardiac anatomy, function and metabolism in elite cyclists assessed by magnetic resonance imaging and spectroscopy. Eur Heart J 17:1271–1278
van der Wall EE, den Hollander W, Heidendal GA, Westera G, Majid PA, Roos JP (1981) Dynamic myocardial scintigraphy with 123I-labeled free fatty acids in patients with myocardial infarction. Eur J Nucl Med 6:383–389
Braun S, van der Wall EE, Emanuelsson S, Kobrin I (1996) Effects of a new calcium antagonist, mibefradil (Ro 40–5967), on silent ischemia in patients with stable chronic angina pectoris: a multicenter placebo-controlled study. The mibefradil international study group. J Am Coll Cardiol 27:317–322
Holman ER, Buller VG, de Roos A et al (1997) Detection and quantification of dysfunctional myocardium by magnetic resonance imaging. A new three-dimensional method for quantitative wall-thickening analysis. Circulation 95:924–931
Schuijf JD, Bax JJ, Shaw LJ et al (2006) Meta-analysis of comparative diagnostic performance of magnetic resonance imaging and multislice computed tomography for noninvasive coronary angiography. Am Heart J 151:404–411
Ypenburg C, van der Wall EE, Schalij MJ, Bax JJ (2008) Imaging in cardiac resynchronisation therapy. Neth Heart J 16:S36–S40
van Rugge FP, van der Wall EE, Bruschke AV (1992) New developments in pharmacologic stress imaging. Am Heart J 124:468–485
van Rugge FP, Holman ER, van der Wall EE et al (1993) Quantitation of global and regional left ventricular function by cine magnetic resonance imaging during dobutamine stress in normal human subjects. Eur Heart J 14:456–463
Pluim BM, Lamb HJ, Kayser HW, Leujes F et al (1998) Functional and metabolic evaluation of the athlete’s heart by magnetic resonance imaging and dobutamine stress magnetic resonance spectroscopy. Circulation 97:666–672
van Rugge FP, van der Wall EE, Spanjersberg SJ et al (1994) Magnetic resonance imaging during dobutamine stress for detection and localization of coronary artery disease. Quantitative wall motion analysis using a modification of the centerline method. Circulation 90:127–138
Nemes A, Geleijnse ML, van Geuns RJ et al (2008) Dobutamine stress MRI versus threedimensional contrast echocardiography: it’s all black and white. Neth Heart J 16:217–218
Bleeker GB, Bax JJ, Fung JW et al (2006) Clinical versus echocardiographic parameters to assess response to cardiac resynchronization therapy. Am J Cardiol 97:260–263
Schuijf JD, Bax JJ, van der Wall EE (2007) Anatomical and functional imaging techniques: basically similar or fundamentally different? Neth Heart J 15:43–44
Vliegen HW, Doornbos J, de Roos A, Jukema JW, Bekedam MA, van der Wall EE (1997) Value of fast gradient echo magnetic resonance angiography as an adjunct to coronary arteriography in detecting and confirming the course of clinically significant coronary artery anomalies. Am J Cardiol 79:773–776
Hoogendoorn LI, Pattynama PM, Buis B, van der Geest RJ, van der Wall EE, de Roos A (1995) Noninvasive evaluation of aortocoronary bypass grafts with magnetic resonance flow mapping. Am J Cardiol 75:845–848
Langerak SE, Vliegen HW, de Roos A et al (2002) Detection of vein graft disease using high-resolution magnetic resonance angiography. Circulation 105:328–333
Rebergen SA, Ottenkamp J, Doornbos J, van der Wall EE, Chin JG, de Roos A (1993) Postoperative pulmonary flow dynamics after Fontan surgery: assessment with nuclear magnetic resonance velocity mapping. J Am Coll Cardiol 21:123–131
Groenink M, Lohuis TA, Tijssen JG et al (1999) Survival and complication free survival in Marfan’s syndrome: implications of current guidelines. Heart 82:499–504
Tulevski II, Hirsch A, Sanson BJ et al (2001) Increased brain natriuretic peptide as a marker for right ventricular dysfunction in acute pulmonary embolism. Thromb Haemost 86:1193–1196
Niezen RA, Helbing WA, van der Wall EE, van der Geest RJ, Rebergen SA, de Roos A (1996) Biventricular systolic function and mass studied with MR imaging in children with pulmonary regurgitation after repair for tetralogy of Fallot. Radiology 201:135–140
Vliegen HW, van Straten A, de Roos A et al (2002) Magnetic resonance imaging to assess the hemodynamic effects of pulmonary valve replacement in adults late after repair of tetralogy of Fallot. Circulation 106:1703–1707
Oosterhof T, van Straten A, Vliegen HW et al (2007) Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance. Circulation 116:545–551
van der Geest RJ, de Roos A, van der Wall EE, Reiber JH (1997) Quantitative analysis of cardiovascular MR images. Int J Card Imaging 13:247–258
van der Geest RJ, Niezen RA, van der Wall EE, de Roos A, Reiber JH (1998) Automated measurement of volume flow in the ascending aorta using MR velocity maps: evaluation of inter- and intraobserver variability in healthy volunteers. J Comput Assist Tomogr 22:904–911
van der Laarse A, Kerkhof PL, Vermeer F et al (1988) Relation between infarct size and left ventricular performance assessed in patients with first acute myocardial infarction randomized to intracoronary thrombolytic therapy or to conventional treatment. Am J Cardiol 61:1–7
de Roos A, Matheijssen NA, Doornbos J et al (1990) Myocardial infarct size after reperfusion therapy: assessment with Gd-DTPA-enhanced MR imaging. Radiology 176:517–521
de Roos A, Matheijssen NA, Doornbos J, van Dijkman PR, van Rugge PR, van der Wall EE (1991) Myocardial infarct sizing and assessment of reperfusion by magnetic resonance imaging: a review. Int J Card Imaging 7:133–138
van Rugge FP, Boreel JJ, van der Wall EE et al (1991) Cardiac first-pass and myocardial perfusion in normal subjects assessed by sub-second Gd-DTPA enhanced MR imaging. J Comput Assist Tomogr 15:959–965
van Rugge FP, van der Wall EE, van Dijkman PR, Louwerenburg HW, de Roos A, Bruschke AV (1992) Usefulness of ultrafast magnetic resonance imaging in healed myocardial infarction. Am J Cardiol 70:1233–1237
Holman ER, van Jonbergen HP, van Dijkman PR, van der Laarse A, de Roos A, van der Wall EE (1993) Comparison of magnetic resonance imaging studies with enzymatic indexes of myocardial necrosis for quantification of myocardial infarct size. Am J Cardiol 71:1036–1040
Buller VG, van der Geest RJ, Kool MD, van der Wall EE, de Roos A, Reiber JH (1997) Assessment of regional left ventricular wall parameters from short axis magnetic resonance imaging using a three-dimensional extension to the improved centerline method. Invest Radiol 32:529–539
Holman ER, van Rossum AC, Doesburg T, van der Wall EE, de Roos A, Visser CA (1996) Assessment of acute myocardial infarction in man with magnetic resonance imaging and the use of a new paramagnetic contrast agent gadolinium-BOPTA. Magn Reson Imaging 14:21–29
Krauss XH, Van der Wall EE, Doornbos J et al (1989) Value of magnetic resonance imaging in patients with a recent myocardial infarction: comparison with planar thallium-201 scintigraphy. Cardiovasc Intervent Radiol 12:119–124
van der Wall EE, Bax JJ (2008) Late contrast enhancement by CMR: more than scar? Int J Cardiovasc Imaging 24:609–611
Nijveldt R, Beek AM, Hirsch A et al (2008) ‘No-reflow’ after acute myocardial infarction: direct visualisation of microvascular obstruction by gadolinium-enhanced CMR. Neth Heart J 16:179–181
van der Hoeven BL, Pires NM, Warda HM et al (2005) Drug-eluting stents: results, promises and problems. Int J Cardiol 99:9–17
van der Laan A, Hirsch A, Nijveldt R et al (2008) Bone marrow cell therapy after acute myocardial infarction: the HEBE trial in perspective, first results. Neth Heart J 16:436–439
Higgins CB, Herfkens R, Lipton MJ et al (1983) Nuclear magnetic resonance imaging of acute myocardial infarction in dogs: Alterations in magnetic resonance times. Am J Cardiol 52:184–188
Matheijssen NA, de Roos A, van der Wall EE et al (1991) Acute myocardial infarction: comparison of T2-weighted and T1-weighted gadolinium-DTPA enhanced MR imaging. Magn Reson Med 17:460–469
Krauss XH, van der Wall EE, van der Laarse A et al (1990) Follow-up of regional myocardial T2 relaxation times in patients with myocardial infarction evaluated with magnetic resonance imaging. Eur J Radiol 11:110–119
Choi SH, Kang J-W, Kim S-T et al (2009) Investigation of T2-weighted signal intensity of infarcted myocardium and its correlation with delayed enhancement magnetic resonance imaging in a porcine model with reperfused acute myocardial infarction. Int J Cardiovasc Imaging 25(Suppl 1):111–119
Abdel-Aty H, Zagrosek A, Schulze-Menger J et al (2004) Delayed enhancement and T2-weighted cardiovascular magnetic resonance imaging differentiate acute from chronic myocardial infarction. Circulation 109:2411–2416
Aletras AH, Tilak GS, Natanzon A et al (2006) Retrospective determination of the area at risk for reperfused acute myocardial infarction with T2-weighted cardiac magnetic resonance imaging. Circulation 113:1865–1870
Stork A, Lund GK, Muellerleile K et al (2006) Characterization of the peri-infarction zone using T2-weighted MRI and delayed-enhancement MRI in patients with acute myocardial infarction. Eur Radiol 16:2350–2357
Joshi SB, Chow T, Herzka DA et al. (2009). Cardiovascular magnetic resonance T2 signal abnormalities in left ventricular ballooning syndrome. Int J Cardiovasc Imaging (Epub ahead of print)
Scholte AJ, Bax JJ, Stokkel MP et al (2006) Multimodality imaging to diagnose takotsubo cardiomyopathy. J Nucl Cardiol 13:123–126
Alizadeh Dehnavi R, van der Wall EE (2005) Transient left ventricular apical ballooning. Ann Intern Med 142:678
Alizadeh Dehnavi R, van der Wall EE, Smits PC (2006) Left ventricular apical ballooning. Int J Cardiovasc Imaging 22:327–331
Gurlek C, van Es J, van der Burgh PH, Galjee MA, van Birgelen C (2007) Full pattern of transient apical ballooning of the left ventricle triggered by minor myocardial infarction. Neth Heart J 15:310–311
Singh V, Mayer T, Salanitri J, Salinger MH (2007) Cardiac MRI documented left ventricular thrombus complicating acute Takotsubo syndrome: an uncommon dilemma. Int J Cardiovasc Imaging 23:591–593
Syed IS, Prasad A, Oh JK et al (2008) Apical ballooning syndrome or aborted acute myocardial infarction? Insights from cardiovascular magnetic resonance imaging. Int J Cardiovasc Imaging 24:875–882
Patrignani A, Di Cesare E, Cicogna S (2009) Echocardiography and cardiovascular magnetic resonance diagnostic role in Takotsubo cardiomyopathy. Int J Cardiovasc Imaging 25:109–112
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van der Wall, E.E. Tissue characterization in Takotsubo cardiomyopathy; a valuable approach?. Int J Cardiovasc Imaging 26, 233–236 (2010). https://doi.org/10.1007/s10554-009-9534-2
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DOI: https://doi.org/10.1007/s10554-009-9534-2