CT Approaches for the Assessment of Myocardial Viability

  • Andreas H. MahnkenEmail author
Part of the Medical Radiology book series (MEDRAD)


Coronary artery disease is one of the most common causes of death. Treatment of coronary artery disease and its sequelae is costly and may pose an unnecessary risk to the patient if performed needlessly. Imaging of myocardial viability became well established for optimizing indication an resource allocation in patients suffering from myocardial infarction. While myocardial viability imaging is routinely performed using 18Fluorodeoxyglucose-positron emission tomography, single photon emission computed tomography or magnetic resonance imaging, multislice-spiral computed tomography (MSCT) techniques emerged as new tool for visualization of myocardial infarction. This chapter describes different concepts of MSCT viability imaging such as unenhanced CT for assessing calcifications and fatty infiltrations. The focus will be direct visualization of nonviable myocardium by depiction of delayed myocardial contrast enhancement. The clinical relevance of the different MSCT techniques is described. Basic concepts on how to perform late phase MSCT are introduced.


Single Photon Emission Compute Tomography Myocardial Viability Percutaneous Coronary Intervention Unenhanced Compute Tomography Arrhythmogenic Right Ventricular Dysplasia 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Adams DF, Hessel SJ, Judy PF, Stein JA, Abrams HL (1976) Computed tomography of the normal and infarcted myocardium. AJR Am J Roentgenol 126:786–791PubMedCrossRefGoogle Scholar
  2. Ahn SS, Kim YJ, Hur J, Lee HJ, Kim TH, Choe KO, Choi BW (2009) CT detection of subendocardial fat in myocardial infarction. AJR Am J Roentgenol 192:532–537PubMedCrossRefGoogle Scholar
  3. Baer FM, Voth E, Schneider CA, Theissen P, Schicha H, Sechtem U (1995) 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 myodardial viability. Circulation 91:1006–1015PubMedCrossRefGoogle Scholar
  4. Baks T, Cademartiri F, Moelker AD, Weustink AC, van Geuns RJ, Mollet NR, Krestin GP, Duncker DJ, de Feyter PJ (2006) Multislice computed tomography and magnetic resonance imaging for the assessment of reperfused acute myocardial infarction. J Am Coll Cardiol 48:144–152PubMedCrossRefGoogle Scholar
  5. Bax JJ, Visser FC, Poldermans D, Elhendy A, Cornel JH, Boersma E, van Lingen A, Fioretti PM, Visser CA (2001) Time course of functional recovery of stunned and hibernating segments after surgical revascularization. Circulation 104(12 Suppl 1):I314–I318PubMedGoogle Scholar
  6. Bolli R, Marban E (1999) Molecular and cellular mechanisms of myocardial stunning. Physiol Rev 79:609–634PubMedGoogle Scholar
  7. Braunwald E, Kloner RA (1982) The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation 66:1146–1149PubMedCrossRefGoogle Scholar
  8. Brodoefel H, Reimann A, Klumpp B, Fenchel M, Ohmer M, Miller S, Schroeder S, Claussen C, Scheule A, Kopp AF (2007) Assessment of myocardial viability in a reperfused porcine model: evaluation of different MSCT contrast protocols in acute and subacute infarct stages in comparison with MRI. J Comput Assist Tomogr 31:290–298PubMedCrossRefGoogle Scholar
  9. Buecker A, Katoh M, Krombach GA, Spuentrup E, Bruners P, Gunther RW, Niendorf T, Mahnken AH (2005) A feasibility study of contrast enhancement of acute myocardial infarction in multislice computed tomography: comparison with magnetic resonance imaging and gross morphology in pigs. Invest Radiol 40:700–704PubMedCrossRefGoogle Scholar
  10. Carlsson E, Lipton MJ, Berninger WH, Doherty P, Redington RW (1977) Selective left coronary myocardiography by computed tomography in living dogs. Invest Radiol 12:559–562PubMedCrossRefGoogle Scholar
  11. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, Pennell DJ, Rumberger JA, Ryan T (2002) American Heart Association writing group on myocardial segmentation and registration for cardiac imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart: a statement for healthcare professionals from the cardiac imaging committee of the council on clinical cardiology of the American Heart Association. Circulation 105:539–542PubMedCrossRefGoogle Scholar
  12. Choi KM, Kim RJ, Gubernikoff G, Vargas JD, Parker M, Judd RM (2001) Transmural extent of acute myocardial infarction predicts long-term improvement in contractile function. Circulation 104:1101–1107PubMedCrossRefGoogle Scholar
  13. Cohn JN, Ferrari R, Sharpe N (2000) Cardiac remodeling-concepts and clinical implications: a consensus paper from an international forum on cardiac remodeling. Behalf of an international forum on cardiac remodeling. J Am Coll Cardiol 35:569–582PubMedCrossRefGoogle Scholar
  14. Dambrin G, Laissy JP, Serfaty JM, Caussin C, Lancelin B, Paul JF (2007) Diagnostic value of ECG-gated multidetector computed tomography in the early phase of suspected acute myocarditis. A preliminary comparative study with cardiac MRI. Eur Radiol 17:331–338PubMedCrossRefGoogle Scholar
  15. Diamond GA, Forrester JS, deLuz PL, Wyatt HL, Swan HJ (1978) Post-extrasystolic potentiation of ischemic myocardium by atrial stimulation. Am Heart J 95:204–209PubMedCrossRefGoogle Scholar
  16. Gerber BL, Belge B, Legros GJ, Lim P, Poncelet A, Pasquet A, Gisellu G, Coche E, Vanoverschelde JLJ (2006) Characterization of acute and chronic myocardial infarcts by multidetector computed tomography: comparison with contrast-enhanced magnetic resonance. Circulation 113:823–833PubMedCrossRefGoogle Scholar
  17. Gersh BJ, Anderson JL (1993) Thrombolysis and myocardial salvage. Results of clinical trials and the animal paradigm-paradoxic or predictable? Circulation 88:296–306PubMedCrossRefGoogle Scholar
  18. Gupta M, Kadakia J, Hacioglu Y, Ahmadi N, Patel A, Choi T, Yamada G, Budoff M (2011) Non-contrast cardiac computed tomography can accurately detect chronic myocardial infarction: validation study. J Nucl Cardiol 18:96–103PubMedCrossRefGoogle Scholar
  19. Habis M, Capderou A, Ghostine S, Daoud B, Caussin C, Riou JY, Brenot P, Angel CY, Lancelin B, Paul JF (2007) Acute myocardial infarction early viability assessment by 64-slice computed tomography immediately after coronary angiography: comparison with low-dose dobutamine echocardiography. J Am Coll Cardiol 49:1178–1185PubMedCrossRefGoogle Scholar
  20. Habis M, Capderou A, Sigal-Cinqualbre A, Ghostine S, Rahal S, Riou JY, Brenot P, Angel CY, Paul JF (2009) Comparison of delayed enhancement patterns on multislice computed tomography immediately after coronary angiography and cardiac magnetic resonance imaging in acute myocardial infarction. Heart 95:624–629PubMedCrossRefGoogle Scholar
  21. Hamada S, Naito H, Takamiya M (1992) Evaluation of myocardium in ischemic heart disease by ultrafast computed tomography. Jpn Circ J 56:627–631PubMedCrossRefGoogle Scholar
  22. Higgins CB, Sovak M, Schmidt W, Siemers PT (1978) Uptake of contrast materials by experimental acute myocardial infarctions: a preliminary report. Invest Radiol 13:337–339PubMedCrossRefGoogle Scholar
  23. Ho KT, Chua KC, Klotz E, Panknin C (2010) Stress and rest dynamic myocardial perfusion imaging by evaluation of complete time-attenuation curves with dual-source CT. JACC Cardiovasc Imaging 3:811–820PubMedCrossRefGoogle Scholar
  24. Ichikawa Y, Kitagawa K, Chino S, Ishida M, Matsuoka K, Tanigawa T, Nakamura T, Hirano T, Takeda K, Sakuma H (2009) Adipose tissue detected by multislice computed tomography in patients after myocardial infarction. JACC Cardiovasc Imaging 2:548–555PubMedCrossRefGoogle Scholar
  25. Kaminaga T, Naito H, Takamiya M, Hamada S, Nishimura T (1994) Myocardial damage in patients with dilated cardiomyopathy: CT evaluation. J Comput Assist Tomogr 18:393–397PubMedCrossRefGoogle Scholar
  26. Kato M, Dote K, Sasaki S, Ueda K, Goto K, Takemoto H, Habara S, Hasegawa D, Matsuda O, Nakano Y, Naganuma T (2006) Plain computed tomography for assessment of early coronary microcirculatory damage after revascularization therapy in acute myocardial infarction. Circ J 70:1475–1480PubMedCrossRefGoogle Scholar
  27. Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, Simonetti O, Klocke FJ, Bonow RO, Judd RM (2000) The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 343:1445–1453PubMedCrossRefGoogle Scholar
  28. Kim T, Choi BJ, Kang DK, Sun JS (2012) Assessment of myocardial viability using multidetector computed tomography in patients with reperfused acute myocardial infarction. Clin Radiol 67:754–765PubMedCrossRefGoogle Scholar
  29. Kloner RA, Bolli R, Marban E, Reinlib L, Braunwald E (1998) Medical and cellular implications of stunning, hibernation, and preconditioning: an NHLBI workshop. Circulation 97:1848–1867PubMedCrossRefGoogle Scholar
  30. Ko SM, Kim YW, Han SW, Seo JB (2007) Early and delayed myocardial enhancement in myocardial infarction using two-phase contrast-enhanced multidetector-row CT. Korean J Radiol 8:94–102PubMedCrossRefGoogle Scholar
  31. Koyama Y, Matsuoka H, Mochizuki T, Higashino H, Kawakami H, Nakata S, Aono J, Ito T, Naka M, Ohashi Y, Higaki J (2005) Assessment of reperfused acute myocardial infarction with two-phase contrast-enhanced helical CT: prediction of left ventricular function and wall thickness. Radiology 235:804–811PubMedCrossRefGoogle Scholar
  32. Lessick J, Dragu R, Mutlak D, Rispler S, Beyar R, Litmanovich D, Engel A, Agmon Y, Kapeliovich M, Hammerman H, Ghersin E (2007) Is functional improvement after myocardial infarction predicted with myocardial enhancement patterns at multidetector CT? Radiology 244:736–744PubMedCrossRefGoogle Scholar
  33. Mahnken AH, Koos R, Katoh M, Wildberger JE, Spuentrup E, Buecker A, Günther RW, Kühl HP (2005) Assessment of myocardial viability in reperfused acute myocardial infarction using 16-slice computed tomography in comparison to magnetic resonance imaging. J Am Coll Cardiol 45:2042–2047PubMedCrossRefGoogle Scholar
  34. Mahnken AH, Bruners P, Mühlenbruch G, Emmerich M, Hohl C, Günther RW, Wildberger JE (2007) Low tube voltage improves computed tomography imaging of delayed myocardial contrast enhancement in an experimental acute myocardial infarction model. Invest Radiol 42:123–129PubMedCrossRefGoogle Scholar
  35. Mahnken AH, Jost G, Bruners P, Sieber M, Seidensticker PR, Günther RW, Pietsch H (2009) Multidetector computed tomography (MDCT) evaluation of myocardial viability: intraindividual comparison of monomeric vs. dimeric contrast media in a rabbit model. Eur Radiol 19:290–297PubMedCrossRefGoogle Scholar
  36. Mahnken AH, Bruners P, Friman O, Hennemuth A (2010) The culprit lesion and its consequences: combined visualization of the coronary arteries and delayed myocardial enhancement in dual-source CT: a pilot study. Eur Radiol 20:2834–2843PubMedCrossRefGoogle Scholar
  37. Masuda Y, Yoshida H, Morooka N, Watanabe S, Inagaki Y (1984) The usefulness of X-ray computed tomography for the diagnosis of myocardial infarction. Circulation 70:217–225PubMedCrossRefGoogle Scholar
  38. Myers JH, Stirling MC, Choy M, Buda AJ, Gallagher KP (1986) Direct measurement of inner and outer wall thickening dynamics with epicardial echocardiography. Circulation 74:164–172PubMedCrossRefGoogle Scholar
  39. Naito H, Saito H, Ohta M, Takamiya M (1990) Significance of ultrafast computed tomography in cardiac imaging: usefulness in assessment of myocardial characteristics and cardiac function. Jpn Circ J 54:322–327PubMedCrossRefGoogle Scholar
  40. Newell JD, Higgins CB, Abraham JL (1982) Uptake of iodinated contrast material by the ischemically damaged myocardial cell. Invest Radiol 17:61–65PubMedCrossRefGoogle Scholar
  41. Nieman K, Cury RC, Ferencik M, Nomura CH, Abbara S, Hoffmann U, Gold HK, Jang IK, Brady TJ (2006) Differentiation of recent and chronic myocardial infarction by cardiac computed tomography. Am J Cardiol 98:303–308PubMedCrossRefGoogle Scholar
  42. Rahimtoola SH (1985) A perspective on the three large multicenter randomized clinical trials of coronary bypass surgery for chronic stable angina. Circulation 72:V123–V135PubMedCrossRefGoogle Scholar
  43. Rees G, Bristow JD, Kremkau EL, Green GS, Herr RH, Griswold HE, Starr A (1971) Influence of aortocoronary bypass surgery on left ventricular performance. N Engl J Med 284:1116–1120PubMedCrossRefGoogle Scholar
  44. Reimer KA, Lowe JE, Rasmussen MM, Jennings RB (1977) The wavefront phenomenon of ischemic cell death. 1. Myocardial infarct size vs duration of coronary occlusion in dogs. Circulation 56:786–794PubMedCrossRefGoogle Scholar
  45. Roger VL, Go AS, Lloyd-Jones DM, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Soliman EZ, Sorlie PD, Sotoodehnia N, Turan TN, Virani SS, Wong ND, Woo D (2012) American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation 125:e2–e220PubMedCrossRefGoogle Scholar
  46. Sandstede J, Bertsch G, Beer M, Kenn W, Werner E, Pabst T, Lipke C, Kretschmer S, Neubauer S, Hahn D (1999) Detection of myocardial viability by low-dose dobutamine cine MR imaging. Magn Reson Imaging 17:1437–1443PubMedCrossRefGoogle Scholar
  47. Sarwar A, Shapiro MD, Nasir K, Nieman K, Nomura CH, Brady TJ, Cury RC (2009) Evaluating global and regional left ventricular function in patients with reperfused acute myocardial infarction by 64-slice multidetector CT: a comparison to magnetic resonance imaging. J Cardiovasc Comput Tomogr 3:170–177PubMedCrossRefGoogle Scholar
  48. Sato A, Hiroe M, Nozato T, Hikita H, Ito Y, Ohigashi H, Tamura M, Takahashi A, Isobe M, Aonuma K (2008) Early validation study of 64-slice multidetector computed tomography for the assessment of myocardial viability and the prediction of left ventricular remodeling after acute myocardial infarction. Eur Heart J 29:490–498PubMedCrossRefGoogle Scholar
  49. Sato A, Nozato T, Hikita H, Akiyama D, Nishina H, Hoshi T, Aihara H, Kakefuda Y, Watabe H, Hiroe M, Aonuma K (2012) Prognostic value of myocardial contrast delayed enhancement with 64-slice multidetector computed tomography after acute myocardial infarction. J Am Coll Cardiol 59:730–738PubMedCrossRefGoogle Scholar
  50. Scanlan JG, Gustafson DE, Chevalier PA, Robb RA, Ritman EL (1980) Evaluation of ischemic heart disease with a prototype volume imaging computed tomographic (CT) scanner: preliminary experiments. Am J Cardiol 46:1263–1268PubMedCrossRefGoogle Scholar
  51. Schwarz ER, Schoendube FA, Kostin S, Schmiedtke N, Schulz G, Buell U, Messmer BJ, Morrison J, Hanrath P, vom Dahl J (1998) Prolonged myocardial hibernation exacerbates cardiomyocyte degeneration and impairs recovery of function after revascularization. J Am Coll Cardiol 31:1018–1026PubMedCrossRefGoogle Scholar
  52. Shen YT, Vatner SF (1995) Mechanism of impaired myocardial function during progressive coronary stenosis in conscious pigs. Hibernation versus stunning? Circ Res 76:479–488PubMedCrossRefGoogle Scholar
  53. Shivalkar B, Flameng W, Szilard M, Pislaru S, Borgers M, Vanhaecke J (1999) Repeated stunning precedes myocardial hibernation in progressive multiple coronary artery obstruction. J Am Coll Cardiol 34:2126–2136PubMedCrossRefGoogle Scholar
  54. Smedema JP, Truter R, de Klerk PA, Zaaiman L, White L, Doubell AF (2006) Cardiac sarcoidosis evaluated with gadolinium-enhanced magnetic resonance and contrast-enhanced 64-slice computed tomography. Int J Cardiol 112:261–263PubMedCrossRefGoogle Scholar
  55. Su L, Siegel JE, Fishbein MC (2004) Adipose tissue in myocardial infarction. Cardiovasc Pathol 13:98–102PubMedCrossRefGoogle Scholar
  56. Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P (2010) American College of Cardiology Foundation Appropriate Use Criteria Task Force; Society of Cardiovascular Computed Tomography; American College of Radiology; American Heart Association; American Society of Echocardiography; American Society of Nuclear Cardiology; North American Society for Cardiovascular Imaging; Society for Cardiovascular Angiography and Interventions; Society for Cardiovascular Magnetic Resonance. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. Circulation 122:e525–e555PubMedCrossRefGoogle Scholar
  57. Thompson BH, Stanford W (1994) Evaluation of cardiac function with ultrafast computed tomography. Radiol Clin North Am 32:537–551PubMedGoogle Scholar
  58. Tillisch J, Brunken R, Marshall R, Schwaiger M, Mandelkern M, Phelps M, Schelbert H (1986) Reversibility of cardiac wall motion abnormalities predicted by positron emission tomography. N Engl J Med 314:884–888PubMedCrossRefGoogle Scholar
  59. Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M, Parker M, Klocke FJ, Bonow RO, Kim RJ, Judd RM (2003) Contrast-enhanced MRI and routine single photon emission computed tomography (SPECT) perfusion imaging for detection of subendocardial myocardial infarcts: an imaging study. Lancet 361:374–379PubMedCrossRefGoogle Scholar
  60. Wang R, Zhang Z, Xu L, Ma Q, He Y, Lu D, Yu W, Fan Z (2011) Low dose prospective ECG-gated delayed enhanced dual-source computed tomography in reperfused acute myocardial infarction comparison with cardiac magnetic resonance. Eur J Radiol 80:326–330PubMedCrossRefGoogle Scholar
  61. Wu KC, Zerhouni EA, Judd RM, Lugo-Olivieri CH, Barouch LA, Schulman SP, Blumenthal RS, Lima JA (1998) Prognostic significance of microvascular obstruction by magnetic resonance imaging in patients with acute myocardial infarction. Circulation 97:765–772PubMedCrossRefGoogle Scholar
  62. Zafar HM, Litt HI, Torigian DA (2008) CT imaging features and frequency of left ventricular myocardial fat in patients with CT findings of chronic left ventricular myocardial infarction. Clin Radiol 63:256–262PubMedCrossRefGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Department of RadiologyMarburg University Hospital, Philipps UniversityMarburgGermany

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