Role of Cardiac Imaging: Cardiac Magnetic Resonance and Cardiac Computed Tomography
Cardiovascular imaging is key for the assessment of patients with heart failure. Today, both cardiac magnetic resonance and cardiac computed tomography play an established role in the assessment of patients with suspected and confirmed heart failure syndromes. In particular, cardiac magnetic resonance is of paramount importance in identifying etiology of left ventricular dysfunction. It has an increasing role in prognostic stratification and in clinical decision-making around therapy. Key strengths include its ability to characterize myocardial tissue, unrestricted field of view, lack of radiation, as well as accuracy and reproducibility.
Cardiac computed tomography has become an important tool in the management of patients with congestive heart failure. Advances in scanner technology have increased its spatial and temporal resolution to unprecedented levels while resulting in decreasing radiation doses. The primary diagnostic application is in differentiation of ischemic from nonischemic etiology of left ventricular dysfunction. Its role in tissue characterization shows promise and is increasingly being studied.
KeywordsDilated cardiomyopathy Magnetic resonance imaging Computed tomography Delayed contrast enhancement Myocardial fibrosis T1 mapping T2 mapping Myocardial systolic strain Prognosis
Abbreviations and Acronyms
Coronary artery disease
Cardiac computed tomography
Cardiac magnetic resonance
Cardiac resynchronization therapy
Computed tomography coronary angiography
Fractional flow reserve
Global relative enhancement
Left atrial volume
Late gadolinium enhancement
Late iodine enhancement
Lake Louise criteria
Left ventricular ejection fraction
Left ventricular reverse remodeling
Modified look-locker inversion recovery
Right ventricular ejection fraction
Saturation pulse prepared heart rate-independent inversion recovery
Saturation recovery single-shot acquisition
Sudden cardiac death
Shortened modified look-locker inversion recovery
Steady-state free precession
Short tau inversion recovery
8.1 Cardiac Magnetic Resonance
Cardiac magnetic resonance (CMR) has become an extensively validated noninvasive diagnostic imaging tool. Through its ability to assess cardiac morphology and function, and to characterize myocardial tissue in a reliable and reproducible fashion, it plays a pivotal role in the management of patients with dilated cardiomyopathy (DCM). In particular, it increases diagnostic accuracy and it aids in determining the etiology of left ventricular (LV) dysfunction and in prognostic stratification.
8.2 Diagnostic Accuracy
8.3 Differential Diagnosis
8.4 Myocarditis Presenting as Left Ventricular Dysfunction
As native T1 values increase with increasing myocardial water content, native T1 mapping may serve as a complementary technique to T2-weighted imaging for assessing myocardial edema in myocarditis presenting as infarct-like syndrome [22, 27] or where gadolinium is contraindicated. However, since native T1 values increase both with water content and with diffuse fibrosis, it is not able to discriminate between inflammatory and noninflammatory cardiomyopathies in patients presenting with heart failure .
8.5 Other Secondary Forms of DCM
CMR may help in diagnosing Chagas cardiomyopathy, caused by Trypanosoma cruzi infection, which results in LV dysfunction, HF, and ventricular arrhythmias. Its typical pattern is characterized by DCM with aneurysm formation with preferential sites at the apex and infero-lateral walls, which can be easily detected with SSFP cine imaging. The pattern of LGE is variable and may involve any or all layers of the myocardial wall [29, 30]. CMR was also found to identify the early stages of the disease .
Cardiac involvement of sarcoidosis may manifest itself as LV dilatation and dysfunction. Patients with sarcoidosis develop large areas of LGE with variable distribution, which can precede the occurrence of LV dilatation, frequently involving the mid-wall of the basal septum, basal and lateral segments of the LV, and papillary muscles, unrelated to vascular territories .
8.6 Prognostic Stratification
Risk stratification is of foremost importance in DCM, particularly regarding the risk of sudden arrhythmic cardiac death (SCD). LV ejection fraction (LVEF) is the strongest predictor of progression to HF , while LV volume and mass are independently correlated with mortality and morbidity. Therefore, accurate quantification of all these parameters is essential to adequately evaluate patients and to monitor progression of disease and response to different therapeutic agents . LVEF is the main criterion to select patients for primary prevention of SCD with implantable cardioverter-defibrillator (ICD) [34, 35, 36]. However, LVEF has low sensitivity and low specificity for the prediction of SCD [34, 37]. The use of low LVEF alone as an indicator for ICD placement is associated with both a low event rate of SCD in the control and treatment groups and a significant number of inappropriate ICD shocks . Risk stratification for SCD among patients with nonischemic cardiomyopathy remains inadequate, causing ongoing clinical challenges in the appropriate identification of candidates for primary prevention ICDs .
In DCM, the remodeling process is characterized by changes in the extracellular matrix and interstitial fibrosis. The fibrous tissue constitutes a substrate for ventricular arrhythmias by inducing slow and heterogeneous conduction, favoring reentrant circuits, and producing vulnerability to life-threatening ventricular tachyarrhythmias . Areas of LGE detected by CMR correlate well with histologically detected regional myocardial fibrosis in animal models and human explanted hearts [41, 42].
Several studies demonstrated that LGE is associated with an increased risk of adverse remodeling, hospitalization for HF, ventricular arrhythmia induction, and SCD in patients with DCM [43, 44, 45, 46, 47, 48, 49, 50, 51, 52]. A recent meta-analysis showed that LGE was present in a considerable proportion of patients with DCM (44%), and it had a strong and significant association with the risk for ventricular arrhythmias and SCD. This association was consistently observed in patients at different stages of their cardiomyopathy and was independent of LVEF . In DCM patients undergoing ICD placement for primary prevention of SCD, the presence of myocardial fibrosis is also predictive of appropriate device therapy [46, 54] regardless of LVEF. Mid-wall LGE may also identify a subgroup at high risk of SCD despite mild or moderate LV systolic impairment, not meeting conventional criteria for ICD implantation [55, 56]. Moreover, LGE extent is also associated with adverse outcomes . However, LGE extent is variably described in studies, and there is no current consensus on the best method of LGE quantification . A relationship between patterns of myocardial scar and arrhythmogenesis was also suggested: a scar with a transmurality of 26–75% is predictive of inducible ventricular tachycardia . The detailed characterization of the heterogeneous boundary zone surrounding the LGE-CMR base scar has been linked to all-cause mortality and the most frequent ventricular arrhythmias although its role in DCM patients is still controversial . Despite the abovementioned strong evidences, however, current guidelines from European Society of Cardiology  and more recently from American College of Cardiology/American Heart Association/Heart Rhythm Society  do not mention arrhythmic risk stratification with LGE-CMR.
The presence and extent of LGE in patients with DCM also predicts a lack of improvement in LV function despite optimal medical treatment compared to a significant improvement in patients without LGE [48, 58, 59, 60, 61]. Furthermore, LGE detected at CMR correlates with LV diastolic function evaluated by Doppler echocardiography. Patients with DCM and positive LGE have indices of higher diastolic filling pressure [62, 63, 64]. The presence and extent of LGE also correlates with echocardiographic measures of LV systolic dyssynchrony, an indicator of poor clinical outcome .
Scar burden was also found to be predictive of poor response to cardiac resynchronization therapy (CRT) . Specifically, pacing over scar was associated with a higher risk of cardiac mortality or HF hospitalizations compared with pacing viable myocardium [67, 68]. Moreover, pacing a transmural scar was associated with a worse outcome than pacing a subendocardial scar . Scar in the vicinity of right ventricular (RV) lead during CRT may also be associated with suboptimal left ventricular reverse remodeling (LVRR) . However, the strategy avoiding myocardial scar in lead implantation has not been evaluated by multicenter, randomized, controlled trials.
8.7 Macroscopic vs. Diffuse Fibrosis
8.8 Strain Analysis
Cardiac dyssynchrony assessed by CMR strain analysis, associated with LGE imaging, was also suggested to better predict improvement in functional class after CRT implantation , compared to currently recommended parameters for patient selection .
8.9 Other Prognostic Indicators
Biventricular involvement in DCM identifies a subset of patients with poor outcome [107, 108]. CMR is considered the gold standard for noninvasive assessment of RV function [7, 8]. RV ejection fraction (RVEF) ≤45% was shown to be independently associated with adverse outcome in nonischemic DCM patients . Furthermore, RV longitudinal strain is also an independent predictor of outcome and offers additional prognostic information over RVEF .
Left atrial enlargement is associated with adverse outcome in patients with DCM [111, 112]. Left atrial volume (LAV) provides the most accurate estimate of left atrial size compared to linear dimension in M-mode and area in 2D echocardiography . Echocardiographic measures systematically underestimate LAV compared to CMR , even though both methods are reproducible and have limited intra- or interobserver variability. A LAV index >72 mL/m2, measured with the biplane area-length method, was found to be an independent predictor of adverse events in DCM . Conversely, LAV index<38 mL/m2 is predictive of LVRR .
8.10 Computed Tomography
Cardiac computed tomography (CCT) is a noninvasive cardiac imaging technique that is increasingly gaining importance in DCM patients. It is mainly used to test for the presence of CAD but may also play a role in the evaluation of cardiac volumes and function, characterization of the type of cardiomyopathy, and treatment planning.
Prospective ECG triggering is the preferred CTCA mode to minimize radiation dose, although this is possible only if the heart rate is slow and regular. Retrospective ECG gating must be used if the heart rate is high or irregular. This mode is also used for the evaluation of cardiac function and volumes, wall motion, and valvular abnormalities, with good correlation with CMR and contrast-enhanced echocardiography [2, 126, 127, 128, 129]. Latest technologies such as CT perfusion and CT-FFR may give additional important information on the hemodynamic significance of coronary artery disease [130, 131, 132, 133, 134, 135].
There is increasing evidence supporting the usefulness of CCT for the detection of myocardial fibrosis in patients with hypertrophic cardiomyopathy  and after myocardial infarction [137, 138] through late iodine enhancement (LIE), although CMR remains more sensitive. However, data in DCM patients are still limited. Initial data suggest that LIE-CCT correlates well with LGE-CMR and electro-anatomic mapping [139, 140]. LIE may also be used for ECV assessment . It has good correlation with T1-mapping methods and is associated with increased LV volume and reduced EF and circumferential strain . Dual-energy CT reduces imaging artifacts and increases contrast to noise ratio and thus may improve LIE images compared to conventional CT [143, 144].
A number of challenges still remain, relating to the required contrast dose, image quality, and radiation exposure. CTCA has been given a high appropriateness rating for the evaluation of ischemic etiology in patients presenting with HF [145, 146]. However, for all other indications, CCT should still be reserved for patients with contraindications or suboptimal results of other imaging tests.
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