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Chong EYS, Wang H, Leung KHG, Kim P, Tada Y, Sin TH, Wong CK, Chan KYE, Tam CCF, Benovoy M, Arai AE, Goh V, Janich MA, Patel AR, Ng MY. Comparison of dual-bolus versus dual-sequence techniques for determining myocardial blood flow and myocardial perfusion reserve by cardiac magnetic resonance stress perfusion: From the Automated Quantitative analysis of myocardial perfusion cardiac Magnetic Resonance Consortium. J Cardiovasc Magn Reson 2024; 26:101085. [PMID: 39154806 PMCID: PMC11422560 DOI: 10.1016/j.jocmr.2024.101085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 08/20/2024] Open
Abstract
BACKGROUND Quantitative stress cardiac magnetic resonance (CMR) can be performed using the dual-sequence (DS) technique or dual-bolus (DB) method. It is unknown if DS and DB produce similar results for myocardial blood flow (MBF) and myocardial perfusion reserve (MPR). The study objective is to investigate if there are any differences between DB- and DS-derived MBF and MPR. METHODS Retrospective observational study with 168 patients who underwent stress CMR. DB and DS methods were simultaneously performed on each patient on the same day. Global and segmental stress MBF and rest MBF values were collected. RESULTS Using Bland-Altman analysis, segmental and global stress MBF values were higher in DB than DS (0.22 ± 0.60 mL/g/min, p < 0.001 and 0.20 ± 0.48 mL/g/min, p = 0.005, respectively) with strong correlation (r = 0.81, p < 0.001 for segmental and r = 0.82, p < 0.001 for global). In rest MBF, segmental and global DB values were higher than by DS (0.15 ± 0.51 mL/g/min, p < 0.001 and 0.14 ± 0.36 mL/g/min, p = 0.011, respectively) with strong correlation (r = 0.81, p < 0.001 and r = 0.77, p < 0.001). Mean difference between MPR by DB and DS was -0.02 ± 0.68 mL/g/min (p = 0.758) for segmental values and -0.01 ± 0.49 mL/g/min (p = 0.773) for global values. MPR values correlated strongly as well in both segmental and global, both (r = 0.74, p < 0.001) and (r = 0.75, p < 0.001), respectively. CONCLUSION There is a very good correlation between DB- and DS-derived MBF and MPR values. However, there are significant differences between DB- and DS-derived global stress and rest MBF. While MPR values did not show statistically significant differences between DB and DS methods.
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Affiliation(s)
- Emily Yin Sing Chong
- Department of Diagnostic Radiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | | | - Kwan Ho Gordon Leung
- Department of Diagnostic Radiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Paul Kim
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Yuko Tada
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Tsun Hei Sin
- Department of Diagnostic Radiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Chun Ka Wong
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong; Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong
| | - Kwong Yue Eric Chan
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, Hong Kong
| | | | | | - Andrew E Arai
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Victor Goh
- Hong Kong Sanatorium & Hospital, Hong Kong
| | | | - Amit R Patel
- Division of Cardiovascular Medicine, The University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ming-Yen Ng
- Department of Diagnostic Radiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong.
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Rafiee MJ, Friedrich MG. MRI of cardiac involvement in COVID-19. Br J Radiol 2024; 97:1367-1377. [PMID: 38656976 PMCID: PMC11256941 DOI: 10.1093/bjr/tqae086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/20/2024] [Accepted: 04/20/2024] [Indexed: 04/26/2024] Open
Abstract
The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has led to a diverse pattern of myocardial injuries, including myocarditis, which is linked to adverse outcomes in patients. Research indicates that myocardial injury is associated with higher mortality in hospitalized severe COVID-19 patients (75.8% vs 9.7%). Cardiovascular Magnetic Resonance (CMR) has emerged as a crucial tool in diagnosing both ischaemic and non-ischaemic myocardial injuries, providing detailed insights into the impact of COVID-19 on myocardial tissue and function. This review synthesizes existing studies on the histopathological findings and CMR imaging patterns of myocardial injuries in COVID-19 patients. CMR imaging has revealed a complex pattern of cardiac damage in these patients, including myocardial inflammation, oedema, fibrosis, and ischaemic injury, due to coronary microthrombi. This review also highlights the role of LLC criteria in diagnosis of COVID-related myocarditis and the importance of CMR in detecting cardiac complications of COVID-19 in specific groups, such as children, manifesting multisystem inflammatory syndrome in children (MIS-C) and athletes, as well as myocardial injuries post-COVID-19 infection or following COVID-19 vaccination. By summarizing existing studies on CMR in COVID-19 patients and highlighting ongoing research, this review contributes to a deeper understanding of the cardiac impacts of COVID-19. It emphasizes the effectiveness of CMR in assessing a broad spectrum of myocardial injuries, thereby enhancing the management and prognosis of patients with COVID-19 related cardiac complications.
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Affiliation(s)
- Moezedin Javad Rafiee
- Department of Medicine, McGill University Health Centre, Montreal, Quebec H4A3J1, Canada
- Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Quebec H4A3J1, Canada
| | - Matthias G Friedrich
- Department of Medicine, McGill University Health Centre, Montreal, Quebec H4A3J1, Canada
- Department of Diagnostic Radiology, McGill University Health Centre, Montreal, Quebec H4A3J1, Canada
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3
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Rasmussen LD, Murphy T, Milidonis X, Eftekhari A, Karim SR, Westra J, Dahl JN, Isaksen C, Brix L, Ejlersen JA, Nyegaard M, Johansen JK, Søndergaard HM, Mortensen J, Gormsen LC, Christiansen EH, Chiribiri A, Petersen SE, Bøttcher M, Winther S. Myocardial Blood Flow by Magnetic Resonance in Patients With Suspected Coronary Stenosis: Comparison to PET and Invasive Physiology. Circ Cardiovasc Imaging 2024; 17:e016635. [PMID: 38889213 DOI: 10.1161/circimaging.124.016635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Despite recent guideline recommendations, quantitative perfusion (QP) estimates of myocardial blood flow from cardiac magnetic resonance (CMR) have only been sparsely validated. Furthermore, the additional diagnostic value of utilizing QP in addition to the traditional visual expert interpretation of stress-perfusion CMR remains unknown. The aim was to investigate the correlation between myocardial blood flow measurements estimated by CMR, positron emission tomography, and invasive coronary thermodilution. The second aim is to investigate the diagnostic performance of CMR-QP to identify obstructive coronary artery disease (CAD). METHODS Prospectively enrolled symptomatic patients with >50% diameter stenosis on computed tomography angiography underwent dual-bolus CMR and positron emission tomography with rest and adenosine-stress myocardial blood flow measurements. Subsequently, an invasive coronary angiography (ICA) with fractional flow reserve and thermodilution-based coronary flow reserve was performed. Obstructive CAD was defined as both anatomically severe (>70% diameter stenosis on quantitative coronary angiography) or hemodynamically obstructive (ICA with fractional flow reserve ≤0.80). RESULTS About 359 patients completed all investigations. Myocardial blood flow and reserve measurements correlated weakly between estimates from CMR-QP, positron emission tomography, and ICA-coronary flow reserve (r<0.40 for all comparisons). In the diagnosis of anatomically severe CAD, the interpretation of CMR-QP by an expert reader improved the sensitivity in comparison to visual analysis alone (82% versus 88% [P=0.03]) without compromising specificity (77% versus 74% [P=0.28]). In the diagnosis of hemodynamically obstructive CAD, the accuracy was only moderate for a visual expert read and remained unchanged when additional CMR-QP measurements were interpreted. CONCLUSIONS CMR-QP correlates weakly to myocardial blood flow measurements by other modalities but improves diagnosis of anatomically severe CAD. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03481712.
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Affiliation(s)
- Laust Dupont Rasmussen
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
- Department of Cardiology, Aalborg University Hospital, Denmark (L.D.R.)
| | - Theodore Murphy
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (T.M., S.E.P.)
| | - Xenios Milidonis
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (X.M., A.C.)
| | - Ashkan Eftekhari
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
| | - Salma Raghad Karim
- Department of Cardiology (S.R.K., J.W., E.H.C.), Aarhus University Hospital, Denmark
| | - Jelmer Westra
- Department of Cardiology (S.R.K., J.W., E.H.C.), Aarhus University Hospital, Denmark
| | - Jonathan Nørtoft Dahl
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
| | - Christin Isaksen
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Denmark (C.I., L.B.)
| | - Lau Brix
- Department of Radiology, Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Denmark (C.I., L.B.)
| | | | - Mette Nyegaard
- Department of Health Science and Technology, Aalborg University, Denmark (M.N.)
| | - Jane Kirk Johansen
- Department of Cardiology, Regional Hospital Central Jutland, Silkeborg, Denmark (J.K.J.)
| | | | - Jesper Mortensen
- Department of Nuclear Medicine (J.M.), Gødstrup Hospital, Herning, Denmark
| | - Lars Christian Gormsen
- Department of Nuclear Medicine and PET Centre (L.C.G.), Aarhus University Hospital, Denmark
| | | | - Amedeo Chiribiri
- Department of Cardiovascular Imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, United Kingdom (X.M., A.C.)
| | - Steffen E Petersen
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, United Kingdom (T.M., S.E.P.)
- William Harvey Research Institute, NIHR Barts Biomedical Research Centre, Queen Mary University London, Charterhouse Square, United Kingdom (S.E.P.)
| | - Morten Bøttcher
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
| | - Simon Winther
- Department of Cardiology (L.D.R., A.E., J.N.D., M.B., S.W.), Gødstrup Hospital, Herning, Denmark
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4
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Huang Q, Le J, Joshi S, Mendes J, Adluru G, DiBella E. Arterial Input Function (AIF) Correction Using AIF Plus Tissue Inputs with a Bi-LSTM Network. Tomography 2024; 10:660-673. [PMID: 38787011 PMCID: PMC11126045 DOI: 10.3390/tomography10050051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
Background: The arterial input function (AIF) is vital for myocardial blood flow quantification in cardiac MRI to indicate the input time-concentration curve of a contrast agent. Inaccurate AIFs can significantly affect perfusion quantification. Purpose: When only saturated and biased AIFs are measured, this work investigates multiple ways of leveraging tissue curve information, including using AIF + tissue curves as inputs and optimizing the loss function for deep neural network training. Methods: Simulated data were generated using a 12-parameter AIF mathematical model for the AIF. Tissue curves were created from true AIFs combined with compartment-model parameters from a random distribution. Using Bloch simulations, a dictionary was constructed for a saturation-recovery 3D radial stack-of-stars sequence, accounting for deviations such as flip angle, T2* effects, and residual longitudinal magnetization after the saturation. A preliminary simulation study established the optimal tissue curve number using a bidirectional long short-term memory (Bi-LSTM) network with just AIF loss. Further optimization of the loss function involves comparing just AIF loss, AIF with compartment-model-based parameter loss, and AIF with compartment-model tissue loss. The optimized network was examined with both simulation and hybrid data, which included in vivo 3D stack-of-star datasets for testing. The AIF peak value accuracy and ktrans results were assessed. Results: Increasing the number of tissue curves can be beneficial when added tissue curves can provide extra information. Using just the AIF loss outperforms the other two proposed losses, including adding either a compartment-model-based tissue loss or a compartment-model parameter loss to the AIF loss. With the simulated data, the Bi-LSTM network reduced the AIF peak error from -23.6 ± 24.4% of the AIF using the dictionary method to 0.2 ± 7.2% (AIF input only) and 0.3 ± 2.5% (AIF + ten tissue curve inputs) of the network AIF. The corresponding ktrans error was reduced from -13.5 ± 8.8% to -0.6 ± 6.6% and 0.3 ± 2.1%. With the hybrid data (simulated data for training; in vivo data for testing), the AIF peak error was 15.0 ± 5.3% and the corresponding ktrans error was 20.7 ± 11.6% for the AIF using the dictionary method. The hybrid data revealed that using the AIF + tissue inputs reduced errors, with peak error (1.3 ± 11.1%) and ktrans error (-2.4 ± 6.7%). Conclusions: Integrating tissue curves with AIF curves into network inputs improves the precision of AI-driven AIF corrections. This result was seen both with simulated data and with applying the network trained only on simulated data to a limited in vivo test dataset.
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Affiliation(s)
- Qi Huang
- Utah Center for Advanced Imaging Research (UCAIR), Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT 84108, USA; (Q.H.); (J.L.); (J.M.); (G.A.)
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA;
| | - Johnathan Le
- Utah Center for Advanced Imaging Research (UCAIR), Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT 84108, USA; (Q.H.); (J.L.); (J.M.); (G.A.)
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA;
| | - Sarang Joshi
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA;
| | - Jason Mendes
- Utah Center for Advanced Imaging Research (UCAIR), Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT 84108, USA; (Q.H.); (J.L.); (J.M.); (G.A.)
| | - Ganesh Adluru
- Utah Center for Advanced Imaging Research (UCAIR), Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT 84108, USA; (Q.H.); (J.L.); (J.M.); (G.A.)
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA;
| | - Edward DiBella
- Utah Center for Advanced Imaging Research (UCAIR), Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT 84108, USA; (Q.H.); (J.L.); (J.M.); (G.A.)
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT 84112, USA;
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5
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Borodzicz-Jazdzyk S, Vink CEM, Demirkiran A, Hoek R, de Mooij GW, Hofman MBM, Wilgenhof A, Appelman Y, Benovoy M, Götte MJW. Clinical implementation of a fully automated quantitative perfusion cardiovascular magnetic resonance imaging workflow with a simplified dual-bolus contrast administration scheme. Sci Rep 2024; 14:9665. [PMID: 38671061 PMCID: PMC11053149 DOI: 10.1038/s41598-024-60503-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/23/2024] [Indexed: 04/28/2024] Open
Abstract
This study clinically implemented a ready-to-use quantitative perfusion (QP) cardiovascular magnetic resonance (QP CMR) workflow, encompassing a simplified dual-bolus gadolinium-based contrast agent (GBCA) administration scheme and fully automated QP image post-processing. Twenty-five patients with suspected obstructive coronary artery disease (CAD) underwent both adenosine stress perfusion CMR and an invasive coronary angiography or coronary computed tomography angiography. The dual-bolus protocol consisted of a pre-bolus (0.0075 mmol/kg GBCA at 0.5 mmol/ml concentration + 20 ml saline) and a main bolus (0.075 mmol/kg GBCA at 0.5 mmol/ml concentration + 20 ml saline) at an infusion rate of 3 ml/s. The arterial input function curves showed excellent quality. Stress MBF ≤ 1.84 ml/g/min accurately detected obstructive CAD (area under the curve 0.79; 95% Confidence Interval: 0.66 to 0.89). Combined visual assessment of color pixel QP maps and conventional perfusion images yielded a diagnostic accuracy of 84%, sensitivity of 70% and specificity of 93%. The proposed easy-to-use dual-bolus QP CMR workflow provides good image quality and holds promise for high accuracy in diagnosis of obstructive CAD. Implementation of this approach has the potential to serve as an alternative to current methods thus increasing the accessibility to offer high-quality QP CMR imaging by a wide range of CMR laboratories.
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Affiliation(s)
- S Borodzicz-Jazdzyk
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
- 1st Department of Cardiology, Medical University of Warsaw, Banacha 1a Str., 02-097, Warsaw, Poland
| | - C E M Vink
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - A Demirkiran
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - R Hoek
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - G W de Mooij
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - M B M Hofman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - A Wilgenhof
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - Y Appelman
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands
| | - M Benovoy
- Area19 Medical Inc., Montreal, H2V2X5, Canada
| | - M J W Götte
- Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1118, 1081 HV, Amsterdam, The Netherlands.
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6
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Demirel OB, Yaman B, Shenoy C, Moeller S, Weingärtner S, Akçakaya M. Signal intensity informed multi-coil encoding operator for physics-guided deep learning reconstruction of highly accelerated myocardial perfusion CMR. Magn Reson Med 2023; 89:308-321. [PMID: 36128896 PMCID: PMC9617789 DOI: 10.1002/mrm.29453] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/21/2022] [Accepted: 08/21/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE To develop a physics-guided deep learning (PG-DL) reconstruction strategy based on a signal intensity informed multi-coil (SIIM) encoding operator for highly-accelerated simultaneous multislice (SMS) myocardial perfusion cardiac MRI (CMR). METHODS First-pass perfusion CMR acquires highly-accelerated images with dynamically varying signal intensity/SNR following the administration of a gadolinium-based contrast agent. Thus, using PG-DL reconstruction with a conventional multi-coil encoding operator leads to analogous signal intensity variations across different time-frames at the network output, creating difficulties in generalization for varying SNR levels. We propose to use a SIIM encoding operator to capture the signal intensity/SNR variations across time-frames in a reformulated encoding operator. This leads to a more uniform/flat contrast at the output of the PG-DL network, facilitating generalizability across time-frames. PG-DL reconstruction with the proposed SIIM encoding operator is compared to PG-DL with conventional encoding operator, split slice-GRAPPA, locally low-rank (LLR) regularized reconstruction, low-rank plus sparse (L + S) reconstruction, and regularized ROCK-SPIRiT. RESULTS Results on highly accelerated free-breathing first pass myocardial perfusion CMR at three-fold SMS and four-fold in-plane acceleration show that the proposed method improves upon the reconstruction methods use for comparison. Substantial noise reduction is achieved compared to split slice-GRAPPA, and aliasing artifacts reduction compared to LLR regularized reconstruction, L + S reconstruction and PG-DL with conventional encoding. Furthermore, a qualitative reader study indicated that proposed method outperformed all methods. CONCLUSION PG-DL reconstruction with the proposed SIIM encoding operator improves generalization across different time-frames /SNRs in highly accelerated perfusion CMR.
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Affiliation(s)
- Omer Burak Demirel
- Department of Electrical and Computer EngineeringUniversity of MinnesotaMinneapolisMinnesotaUSA,Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Burhaneddin Yaman
- Department of Electrical and Computer EngineeringUniversity of MinnesotaMinneapolisMinnesotaUSA,Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Chetan Shenoy
- Department of Medicine (Cardiology)University of MinnesotaMinneapolisMinnesotaUSA
| | - Steen Moeller
- Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
| | | | - Mehmet Akçakaya
- Department of Electrical and Computer EngineeringUniversity of MinnesotaMinneapolisMinnesotaUSA,Center for Magnetic Resonance ResearchUniversity of MinnesotaMinneapolisMinnesotaUSA
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7
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McElroy S, Kunze KP, Nazir MS, Speier P, Stäb D, Villa ADM, Yazdani M, Vergani V, Roujol S, Neji R, Chiribiri A. Simultaneous multi-slice steady-state free precession myocardial perfusion with iterative reconstruction and integrated motion compensation. Eur J Radiol 2022; 151:110286. [PMID: 35452953 PMCID: PMC9941714 DOI: 10.1016/j.ejrad.2022.110286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022]
Abstract
PURPOSE Simultaneous multi-slice (SMS) balanced steady-state free precession (bSSFP) acquisition and iterative reconstruction can provide high spatial resolution and coverage for cardiac magnetic resonance (CMR) perfusion. However, respiratory motion remains a challenge for iterative reconstruction techniques employing temporal regularisation. The aim of this study is to evaluate an iterative reconstruction with integrated motion compensation for SMS-bSSFP first-pass myocardial stress perfusion in the presence of respiratory motion. METHODS Thirty-one patients with suspected coronary artery disease were prospectively recruited and imaged at 1.5 T. A SMS-bSSFP prototype myocardial perfusion sequence was acquired at stress in all patients. All datasets were reconstructed using an iterative reconstruction with temporal regularisation, once with and once without motion compensation (MC and NMC, respectively). Three readers scored each dataset in terms of: image quality (1:poor; 4:excellent), motion/blurring (1:severe motion/blurring; 3:no motion/blurring), and diagnostic confidence (1:poor confidence; 3:high confidence). Quantitative assessment of sharpness was performed. The number of uncorrupted first-pass dynamics was measured on the NMC datasets to classify patients into 'suboptimal breath-hold (BH)' and 'good BH' groups. RESULTS Compared across all cases, MC performed better than NMC in terms of image quality (3.5 ± 0.5 vs. 3.0 ± 0.8, P = 0.002), motion/blurring (2.9 ± 0.1 vs. 2.2 ± 0.8, P < 0.001), diagnostic confidence (2.9 ± 0.1 vs. 2.3 ± 0.7, P < 0.001) and sharpness index (0.34 ± 0.05 vs. 0.31 ± 0.06, P < 0.001). Fourteen patients with a suboptimal BH were identified. For the suboptimal BH group, MC performed better than NMC in terms of image quality (3.8 ± 0.4 vs. 2.6 ± 0.8, P < 0.001), motion/blurring (3.0 ± 0.1 vs. 1.6 ± 0.7, P < 0.001), diagnostic confidence (3.0 ± 0.1 vs. 1.9 ± 0.7, P < 0.001) and sharpness index (0.34 ± 0.05 vs. 0.30 ± 0.06, P = 0.004). For the good BH group, sharpness index was higher for MC than NMC (0.34 ± 0.06 vs 0.31 ± 0.07, P = 0.03), while there were no significant differences observed for the other three metrics assessed (P > 0.11). There were no significant differences between suboptimal BH MC and good BH MC for any of the reported metrics (P > 0.06). CONCLUSIONS Integrated motion compensation significantly reduces motion/blurring and improves image quality, diagnostic confidence and sharpness index of SMS-bSSFP perfusion with iterative reconstruction in the presence of motion.
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Affiliation(s)
- Sarah McElroy
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom.
| | - Karl P Kunze
- MR Research Collaborations, Siemens Healthcare Limited, Frimley, United Kingdom
| | - Muhummad Sohaib Nazir
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Peter Speier
- Cardiovascular Predevelopment, Siemens Healthcare GmbH, Erlangen, Germany
| | - Daniel Stäb
- MR Research Collaborations, Siemens Healthcare Limited, Melbourne, Australia
| | - Adriana D M Villa
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Momina Yazdani
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Vittoria Vergani
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Radhouene Neji
- MR Research Collaborations, Siemens Healthcare Limited, Frimley, United Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom.
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8
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McElroy S, Ferrazzi G, Nazir MS, Evans C, Ferreira J, Bosio F, Mughal N, Kunze KP, Neji R, Speier P, Stäb D, Ismail TF, Masci PG, Villa ADM, Razavi R, Chiribiri A, Roujol S. Simultaneous multislice steady-state free precession myocardial perfusion with full left ventricular coverage and high resolution at 1.5 T. Magn Reson Med 2022; 88:663-675. [PMID: 35344593 PMCID: PMC9310832 DOI: 10.1002/mrm.29229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 12/27/2022]
Abstract
Purpose To implement and evaluate a simultaneous multi‐slice balanced SSFP (SMS‐bSSFP) perfusion sequence and compressed sensing reconstruction for cardiac MR perfusion imaging with full left ventricular (LV) coverage (nine slices/heartbeat) and high spatial resolution (1.4 × 1.4 mm2) at 1.5T. Methods A preliminary study was performed to evaluate the performance of blipped controlled aliasing in parallel imaging (CAIPI) and RF‐CAIPI with gradient‐controlled local Larmor adjustment (GC‐LOLA) in the presence of fat. A nine‐slice SMS‐bSSFP sequence using RF‐CAIPI with GC‐LOLA with high spatial resolution (1.4 × 1.4 mm2) and a conventional three‐slice sequence with conventional spatial resolution (1.9 × 1.9 mm2) were then acquired in 10 patients under rest conditions. Qualitative assessment was performed to assess image quality and perceived signal‐to‐noise ratio (SNR) on a 4‐point scale (0: poor image quality/low SNR; 3: excellent image quality/high SNR), and the number of myocardial segments with diagnostic image quality was recorded. Quantitative measurements of myocardial sharpness and upslope index were performed. Results Fat signal leakage was significantly higher for blipped CAIPI than for RF‐CAIPI with GC‐LOLA (7.9% vs. 1.2%, p = 0.010). All 10 SMS‐bSSFP perfusion datasets resulted in 16/16 diagnostic myocardial segments. There were no significant differences between the SMS and conventional acquisitions in terms of image quality (2.6 ± 0.6 vs. 2.7 ± 0.2, p = 0.8) or perceived SNR (2.8 ± 0.3 vs. 2.7 ± 0.3, p = 0.3). Inter‐reader variability was good for both image quality (ICC = 0.84) and perceived SNR (ICC = 0.70). Myocardial sharpness was improved using the SMS sequence compared to the conventional sequence (0.37 ± 0.08 vs 0.32 ± 0.05, p < 0.001). There was no significant difference between measurements of upslope index for the SMS and conventional sequences (0.11 ± 0.04 vs. 0.11 ± 0.03, p = 0.84). Conclusion SMS‐bSSFP with multiband factor 3 and compressed sensing reconstruction enables cardiac MR perfusion imaging with three‐fold increased spatial coverage and improved myocardial sharpness compared to a conventional sequence, without compromising perceived SNR, image quality, upslope index or number of diagnostic segments.
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Affiliation(s)
- Sarah McElroy
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Muhummad Sohaib Nazir
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Carl Evans
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Joana Ferreira
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Filippo Bosio
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Nabila Mughal
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Karl P Kunze
- MR Research Collaborations, Siemens Healthcare Limited, Frimley, England, UK
| | - Radhouene Neji
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,MR Research Collaborations, Siemens Healthcare Limited, Frimley, England, UK
| | - Peter Speier
- Magnetic Resonance, Siemens Healthcare GmbH, Erlangen, Germany
| | - Daniel Stäb
- MR Research Collaborations, Siemens Healthcare Limited, Melbourne, Australia
| | - Tevfik F Ismail
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Pier Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Adriana D M Villa
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Sébastien Roujol
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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9
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Sakuma H, Ishida M. Advances in Myocardial Perfusion MR Imaging: Physiological Implications, the Importance of Quantitative Analysis, and Impact on Patient Care in Coronary Artery Disease. Magn Reson Med Sci 2022; 21:195-211. [PMID: 34108304 PMCID: PMC9199984 DOI: 10.2463/mrms.rev.2021-0033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/27/2021] [Indexed: 11/09/2022] Open
Abstract
Stress myocardial perfusion imaging (MPI) is the preferred test in patients with intermediate-to-high clinical likelihood of coronary artery disease (CAD) and can be used as a gatekeeper to avoid unnecessary revascularization. Cardiac magnetic resonance (CMR) has a number of favorable characteristics, including: (1) high spatial resolution that can delineate subendocardial ischemia; (2) comprehensive assessment of morphology, global and regional cardiac functions, tissue characterization, and coronary artery stenosis; and (3) no radiation exposure to patients. According to meta-analysis studies, the diagnostic accuracy of perfusion CMR is comparable to positron emission tomography (PET) and perfusion CT, and is better than single-photon emission CT (SPECT) when fractional flow reserve (FFR) is used as a reference standard. In addition, stress CMR has an excellent prognostic value. One meta-analysis study demonstrated the annual event rate of cardiovascular death or non-fatal myocardial infarction was 4.9% and 0.8%, respectively, in patients with positive and negative stress CMR. Quantitative assessment of perfusion CMR not only allows the objective evaluation of regional ischemia but also provides insights into the pathophysiology of microvascular disease and diffuse subclinical atherosclerosis. For accurate quantification of myocardial perfusion, saturation correction of arterial input function is important. There are two major approaches for saturation correction, one is a dual-bolus method and the other is a dual-sequence method. Absolute quantitative mapping with myocardial perfusion CMR has good accuracy in detecting coronary microvascular dysfunction. Flow measurement in the coronary sinus (CS) with phase contrast cine CMR is an alternative approach to quantify global coronary flow reserve (CFR). The measurement of global CFR by quantitative analysis of perfusion CMR or flow measurement in the CS permits assessment of microvascular disease and diffuse subclinical atherosclerosis, which may provide improved prediction of future event risk in patients with suspected or known CAD. Multi-institutional studies to validate the diagnostic and prognostic values of quantitative perfusion CMR approaches are required.
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Affiliation(s)
- Hajime Sakuma
- Department of Radiology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masaki Ishida
- Department of Radiology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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10
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Franks R, Plein S, Chiribiri A. Clinical Application of Dynamic Contrast Enhanced Perfusion Imaging by Cardiovascular Magnetic Resonance. Front Cardiovasc Med 2021; 8:768563. [PMID: 34778420 PMCID: PMC8585782 DOI: 10.3389/fcvm.2021.768563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/27/2021] [Indexed: 12/12/2022] Open
Abstract
Functionally significant coronary artery disease impairs myocardial blood flow and can be detected non-invasively by myocardial perfusion imaging. While multiple myocardial perfusion imaging modalities exist, the high spatial and temporal resolution of cardiovascular magnetic resonance (CMR), combined with its freedom from ionising radiation make it an attractive option. Dynamic contrast enhanced CMR perfusion imaging has become a well-validated non-invasive tool for the assessment and risk stratification of patients with coronary artery disease and is recommended by international guidelines. This article presents an overview of CMR perfusion imaging and its clinical application, with a focus on chronic coronary syndromes, highlighting its strengths and challenges, and discusses recent advances, including the emerging role of quantitative perfusion analysis.
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Affiliation(s)
- Russell Franks
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Sven Plein
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Amedeo Chiribiri
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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11
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Paddock S, Tsampasian V, Assadi H, Mota BC, Swift AJ, Chowdhary A, Swoboda P, Levelt E, Sammut E, Dastidar A, Broncano Cabrero J, Del Val JR, Malcolm P, Sun J, Ryding A, Sawh C, Greenwood R, Hewson D, Vassiliou V, Garg P. Clinical Translation of Three-Dimensional Scar, Diffusion Tensor Imaging, Four-Dimensional Flow, and Quantitative Perfusion in Cardiac MRI: A Comprehensive Review. Front Cardiovasc Med 2021; 8:682027. [PMID: 34307496 PMCID: PMC8292630 DOI: 10.3389/fcvm.2021.682027] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/04/2021] [Indexed: 01/05/2023] Open
Abstract
Cardiovascular magnetic resonance (CMR) imaging is a versatile tool that has established itself as the reference method for functional assessment and tissue characterisation. CMR helps to diagnose, monitor disease course and sub-phenotype disease states. Several emerging CMR methods have the potential to offer a personalised medicine approach to treatment. CMR tissue characterisation is used to assess myocardial oedema, inflammation or thrombus in various disease conditions. CMR derived scar maps have the potential to inform ablation therapy—both in atrial and ventricular arrhythmias. Quantitative CMR is pushing boundaries with motion corrections in tissue characterisation and first-pass perfusion. Advanced tissue characterisation by imaging the myocardial fibre orientation using diffusion tensor imaging (DTI), has also demonstrated novel insights in patients with cardiomyopathies. Enhanced flow assessment using four-dimensional flow (4D flow) CMR, where time is the fourth dimension, allows quantification of transvalvular flow to a high degree of accuracy for all four-valves within the same cardiac cycle. This review discusses these emerging methods and others in detail and gives the reader a foresight of how CMR will evolve into a powerful clinical tool in offering a precision medicine approach to treatment, diagnosis, and detection of disease.
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Affiliation(s)
- Sophie Paddock
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Vasiliki Tsampasian
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Hosamadin Assadi
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Bruno Calife Mota
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Amrit Chowdhary
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Peter Swoboda
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Eylem Levelt
- Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Eva Sammut
- Bristol Heart Institute and Translational Biomedical Research Centre, Faculty of Health Science, University of Bristol, Bristol, United Kingdom
| | - Amardeep Dastidar
- Bristol Heart Institute and Translational Biomedical Research Centre, Faculty of Health Science, University of Bristol, Bristol, United Kingdom
| | - Jordi Broncano Cabrero
- Cardiothoracic Imaging Unit, Hospital San Juan De Dios, Ressalta, HT Medica, Córdoba, Spain
| | - Javier Royuela Del Val
- Cardiothoracic Imaging Unit, Hospital San Juan De Dios, Ressalta, HT Medica, Córdoba, Spain
| | - Paul Malcolm
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Julia Sun
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Alisdair Ryding
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Chris Sawh
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Richard Greenwood
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - David Hewson
- Department of Cardiology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Vassilios Vassiliou
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Pankaj Garg
- Department of Cardiovascular and Metabolic Health, Norwich Medical School, University of East Anglia, Norwich, United Kingdom.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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12
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Sirajuddin A, Mirmomen SM, Kligerman SJ, Groves DW, Burke AP, Kureshi F, White CS, Arai AE. Ischemic Heart Disease: Noninvasive Imaging Techniques and Findings. Radiographics 2021; 41:990-1021. [PMID: 34019437 PMCID: PMC8262179 DOI: 10.1148/rg.2021200125] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Ischemic heart disease is a leading cause of death worldwide and comprises a large proportion of annual health care expenditure. Management of ischemic heart disease is now best guided by the physiologic significance of coronary artery stenosis. Invasive coronary angiography is the standard for diagnosing coronary artery stenosis. However, it is expensive and has risks including vascular access site complications and contrast material–induced nephropathy. Invasive coronary angiography requires fractional flow reserve (FFR) measurement to determine the physiologic significance of a coronary artery stenosis. Multiple noninvasive cardiac imaging modalities can also anatomically delineate or functionally assess for significant coronary artery stenosis, as well as detect the presence of myocardial infarction (MI). While coronary CT angiography can help assess the degree of anatomic stenosis, its inability to assess the physiologic significance of lesions limits its specificity. Physiologic significance of coronary artery stenosis can be determined by cardiac MR vasodilator or dobutamine stress imaging, CT stress perfusion imaging, FFR CT, PET myocardial perfusion imaging (MPI), SPECT MPI, and stress echocardiography. Clinically unrecognized MI, another clear indicator of physiologically significant coronary artery disease, is relatively common and is best evaluated with cardiac MRI. The authors illustrate the spectrum of imaging findings of ischemic heart disease (coronary artery disease, myocardial ischemia, and MI); highlight the advantages and disadvantages of the various noninvasive imaging methods used to assess ischemic heart disease, as illustrated by recent clinical trials; and summarize current indications and contraindications for noninvasive imaging techniques for detection of ischemic heart disease. Online supplemental material is available for this article. Published under a CC BY 4.0 license.
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Affiliation(s)
- Arlene Sirajuddin
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - S Mojdeh Mirmomen
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Seth J Kligerman
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Daniel W Groves
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Allen P Burke
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Faraz Kureshi
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Charles S White
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
| | - Andrew E Arai
- From the Cardiovascular and Pulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, 10 Center Dr, Building 10, Room B1D416, Bethesda, MD 20814 (A.S., S.M.M., A.E.A.); Department of Radiology, University of California San Diego, San Diego, Calif (S.J.K.); Departments of Medicine and Radiology, Divisions of Cardiology and Cardiothoracic Imaging, University of Colorado Anschutz Medical Campus, Aurora, Colo (D.W.G.); Department of Pathology (A.P.B.) and Department of Radiology and Nuclear Medicine (C.S.W.), School of Medicine, University of Maryland, Baltimore, Md; and St David's Healthcare and Austin Heart, Austin, Tex (F.K.)
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13
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Daviller C, Boutelier T, Giri S, Ratiney H, Jolly MP, Vallée JP, Croisille P, Viallon M. Direct Comparison of Bayesian and Fermi Deconvolution Approaches for Myocardial Blood Flow Quantification: In silico and Clinical Validations. Front Physiol 2021; 12:483714. [PMID: 33912066 PMCID: PMC8072361 DOI: 10.3389/fphys.2021.483714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Cardiac magnetic resonance myocardial perfusion imaging can detect coronary artery disease and is an alternative to single-photon emission computed tomography or positron emission tomography. However, the complex, non-linear MR signal and the lack of robust quantification of myocardial blood flow have hindered its widespread clinical application thus far. Recently, a new Bayesian approach was developed for brain imaging and evaluation of perfusion indexes (Kudo et al., 2014). In addition to providing accurate perfusion measurements, this probabilistic approach appears more robust than previous approaches, particularly due to its insensitivity to bolus arrival delays. We assessed the performance of this approach against a well-known and commonly deployed model-independent method based on the Fermi function for cardiac magnetic resonance myocardial perfusion imaging. The methods were first evaluated for accuracy and precision using a digital phantom to test them against the ground truth; next, they were applied in a group of coronary artery disease patients. The Bayesian method can be considered an appropriate model-independent method with which to estimate myocardial blood flow and delays. The digital phantom comprised a set of synthetic time-concentration curve combinations generated with a 2-compartment exchange model and a realistic combination of perfusion indexes, arterial input dynamics, noise and delays collected from the clinical dataset. The myocardial blood flow values estimated with the two methods showed an excellent correlation coefficient (r2 > 0.9) under all noise and delay conditions. The Bayesian approach showed excellent robustness to bolus arrival delays, with a similar performance to Fermi modeling when delays were considered. Delays were better estimated with the Bayesian approach than with Fermi modeling. An in vivo analysis of coronary artery disease patients revealed that the Bayesian approach had an excellent ability to distinguish between abnormal and normal myocardium. The Bayesian approach was able to discriminate not only flows but also delays with increased sensitivity by offering a clearly enlarged range of distribution for the physiologic parameters.
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Affiliation(s)
- Clément Daviller
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS, UMR 5220, U1294, Lyon, France
| | - Timothé Boutelier
- Department of Research and Innovation, Olea Medical, La Ciotat, France
| | - Shivraman Giri
- Siemens Medical Solutions USA, Inc., Boston, MA, United States
| | - Hélène Ratiney
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS, UMR 5220, U1294, Lyon, France
| | | | - Jean-Paul Vallée
- Division of Radiology, Faculty of Medicine, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Pierre Croisille
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS, UMR 5220, U1294, Lyon, France.,Department of Radiology, CHU de Saint-Etienne, University of Lyon, UJM-Saint-Etienne, Saint-Étienne, France
| | - Magalie Viallon
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, CNRS, Inserm, CREATIS, UMR 5220, U1294, Lyon, France.,Department of Radiology, CHU de Saint-Etienne, University of Lyon, UJM-Saint-Etienne, Saint-Étienne, France
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14
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Milidonis X, Franks R, Schneider T, Sánchez-González J, Sammut EC, Plein S, Chiribiri A. Influence of the arterial input sampling location on the diagnostic accuracy of cardiovascular magnetic resonance stress myocardial perfusion quantification. J Cardiovasc Magn Reson 2021; 23:35. [PMID: 33775247 PMCID: PMC8006361 DOI: 10.1186/s12968-021-00733-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/12/2021] [Accepted: 02/09/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Quantification of myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) by cardiovascular magnetic resonance (CMR) perfusion requires sampling of the arterial input function (AIF). While variation in the AIF sampling location is known to impact quantification by CMR and positron emission tomography (PET) perfusion, there is no evidence to support the use of a specific location based on their diagnostic accuracy in the detection of coronary artery disease (CAD). This study aimed to evaluate the accuracy of stress MBF and MPR for different AIF sampling locations for the detection of abnormal myocardial perfusion with expert visual assessment as the reference. METHODS Twenty-five patients with suspected or known CAD underwent vasodilator stress-rest perfusion with a dual-sequence technique at 3T. A low-resolution slice was acquired in 3-chamber view to allow AIF sampling at five different locations: left atrium (LA), basal left ventricle (bLV), mid left ventricle (mLV), apical left ventricle (aLV) and aortic root (AoR). MBF and MPR were estimated at the segmental level using Fermi function-constrained deconvolution. Segments were scored as having normal or abnormal perfusion by visual assessment and the diagnostic accuracy of stress MBF and MPR for each location was evaluated using receiver operating characteristic curve analysis. RESULTS In both normal (300 out of 400, 75 %) and abnormal segments, rest MBF, stress MBF and MPR were significantly different across AIF sampling locations (p < 0.001). Stress MBF for the AoR (normal: 2.42 (2.15-2.84) mL/g/min; abnormal: 1.71 (1.28-1.98) mL/g/min) had the highest diagnostic accuracy (sensitivity 80 %, specificity 85 %, area under the curve 0.90; p < 0.001 versus stress MBF for all other locations including bLV: normal: 2.78 (2.39-3.14) mL/g/min; abnormal: 2.22 (1.83-2.48) mL/g/min; sensitivity 91 %, specificity 63 %, area under the curve 0.81) and performed better than MPR for the LV locations (p < 0.01). MPR for the AoR (normal: 2.43 (1.95-3.14); abnormal: 1.58 (1.34-1.90)) was not superior to MPR for the bLV (normal: 2.59 (2.04-3.20); abnormal: 1.69 (1.36-2.14); p = 0.717). CONCLUSIONS The AIF sampling location has a significant impact on MBF and MPR estimates by CMR perfusion, with AoR-based stress MBF comparing favorably to that for the current clinical reference bLV.
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Affiliation(s)
- Xenios Milidonis
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.
| | - Russell Franks
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Torben Schneider
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
- Philips Healthcare, Guilford, UK
| | | | - Eva C Sammut
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
- Bristol Heart Institute and Translational Biomedical Research Centre, Faculty of Health Science, University of Bristol, Bristol, UK
| | - Sven Plein
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Amedeo Chiribiri
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
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15
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Jacobs M, Benovoy M, Chang LC, Corcoran D, Berry C, Arai AE, Hsu LY. Automated Segmental Analysis of Fully Quantitative Myocardial Blood Flow Maps by First-Pass Perfusion Cardiovascular Magnetic Resonance. IEEE ACCESS : PRACTICAL INNOVATIONS, OPEN SOLUTIONS 2021; 9:52796-52811. [PMID: 33996344 PMCID: PMC8117952 DOI: 10.1109/access.2021.3070320] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
First pass gadolinium-enhanced cardiovascular magnetic resonance (CMR) perfusion imaging allows fully quantitative pixel-wise myocardial blood flow (MBF) assessment, with proven diagnostic value for coronary artery disease. Segmental analysis requires manual segmentation of the myocardium. This work presents a fully automatic method of segmenting the left ventricular myocardium from MBF pixel maps, validated on a retrospective dataset of 247 clinical CMR perfusion studies, each including rest and stress images of three slice locations, performed on a 1.5T scanner. Pixel-wise MBF maps were segmented using an automated pipeline including region growing, edge detection, principal component analysis, and active contours to segment the myocardium, detect key landmarks, and divide the myocardium into sectors appropriate for analysis. Automated segmentation results were compared against a manually defined reference standard using three quantitative metrics: Dice coefficient, Cohen Kappa and myocardial border distance. Sector-wise average MBF and myocardial perfusion reserve (MPR) were compared using Pearson's correlation coefficient and Bland-Altman Plots. The proposed method segmented stress and rest MBF maps of 243 studies automatically. Automated and manual myocardial segmentation had an average (± standard deviation) Dice coefficient of 0.86 ± 0.06, Cohen Kappa of 0.86 ± 0.06, and Euclidian distances of 1.47 ± 0.73 mm and 1.02 ± 0.51 mm for the epicardial and endocardial border, respectively. Automated and manual sector-wise MBF and MPR values correlated with Pearson's coefficient of 0.97 and 0.92, respectively, while Bland-Altman analysis showed bias of 0.01 and 0.07 ml/g/min. The validated method has been integrated with our fully automated MBF pixel mapping pipeline to aid quantitative assessment of myocardial perfusion CMR.
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Affiliation(s)
- Matthew Jacobs
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Electrical Engineering and Computer Science, The Catholic University of America, Washington, DC 20064, USA
| | - Mitchel Benovoy
- Circle Cardiovascular Imaging Inc., Calgary, AB T2P 3T6, Canada
| | - Lin-Ching Chang
- Department of Electrical Engineering and Computer Science, The Catholic University of America, Washington, DC 20064, USA
| | - David Corcoran
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8QQ, U.K
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow G81 4DY, U.K
| | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8QQ, U.K
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Glasgow G81 4DY, U.K
| | - Andrew E Arai
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Li-Yueh Hsu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
- Radiology and Imaging Sciences, Clinical Center, National Institutes of Health, Bethesda, MD 20892, USA
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Ong P, Seitz A. Advances in Risk Stratification of Patients With Coronary Microvascular Dysfunction: Usefulness of Stress Perfusion CMR. JACC Cardiovasc Imaging 2020; 14:612-614. [PMID: 33248964 DOI: 10.1016/j.jcmg.2020.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Peter Ong
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
| | - Andreas Seitz
- Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany
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17
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Louis JS, Odille F, Mandry D, De Chillou C, Huttin O, Felblinger J, Venner C, Beaumont M. Design and evaluation of an abbreviated pixelwise dynamic contrast enhancement analysis protocol for early extracellular volume fraction estimation. Magn Reson Imaging 2020; 76:61-68. [PMID: 33227403 DOI: 10.1016/j.mri.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 11/15/2020] [Accepted: 11/15/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION T1-based method is considered as the gold standard for extracellular volume fraction (ECV) mapping. This technique requires at least a 10 min delay after injection to acquire the post injection T1 map. Quantitative analysis of Dynamic Contrast Enhancement (DCE) images could lead to an earlier estimation of an ECV like parameter (2 min). The purpose of this study was to design a quantitative pixel-wise DCE analysis workflow to assess the feasibility of an early estimation of ECV. METHODS Fourteen patients with mitral valve prolapse were included in this study. The MR protocol, performed on a 3 T MR scanner, included MOLLI sequences for T1 maps acquisition and a standard SR-turboFlash sequence for dynamic acquisition. DCE data were acquired for at least 120 s. We implemented a full DCE analysis pipeline with a pre-processing step using an innovative motion correction algorithm (RC-REG algorithm) and a post-processing step using the extended Tofts Model (ECVETM). Estimated ECVETM maps were compared to standard T1-based ECV maps (ECVT1) with both a Pearson correlation analysis and a group-wise analysis. RESULTS Image and map quality assessment showed systematic improvements using the proposed workflow. Strong correlation was found between ECVETM, and ECVT1 values (r-square = 0.87). CONCLUSION A DCE analysis workflow based on RC-REG algorithm and ETM analysis can provide good quality parametric maps. Therefore, it is possible to extract ECV values from a 2 min-long DCE acquisition that are strongly correlated with ECV values from the T1 based method.
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Affiliation(s)
- J S Louis
- IADI, INSERM U1254, Université de Lorraine, Nancy, France.
| | - F Odille
- IADI, INSERM U1254, Université de Lorraine, Nancy, France; CIC-IT, INSERM 1433, Université de Lorraine and CHRU Nancy, Nancy, France.
| | - D Mandry
- IADI, INSERM U1254, Université de Lorraine, Nancy, France; Pôle Imagerie, CHRU Nancy, Nancy, France.
| | - C De Chillou
- IADI, INSERM U1254, Université de Lorraine, Nancy, France; Pôle Cardiologie, CHRU Nancy, Nancy, France.
| | - O Huttin
- Pôle Cardiologie, CHRU Nancy, Nancy, France.
| | - J Felblinger
- IADI, INSERM U1254, Université de Lorraine, Nancy, France; CIC-IT, INSERM 1433, Université de Lorraine and CHRU Nancy, Nancy, France; Pôle Imagerie, CHRU Nancy, Nancy, France.
| | - C Venner
- Pôle Cardiologie, CHRU Nancy, Nancy, France
| | - M Beaumont
- IADI, INSERM U1254, Université de Lorraine, Nancy, France; CIC-IT, INSERM 1433, Université de Lorraine and CHRU Nancy, Nancy, France.
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18
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Thomas MA, Hazany S, Ellingson BM, Hu P, Nguyen KL. Pathophysiology, classification, and MRI parallels in microvascular disease of the heart and brain. Microcirculation 2020; 27:e12648. [PMID: 32640064 DOI: 10.1111/micc.12648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/12/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022]
Abstract
Diagnostic imaging technology in vascular disease has long focused on large vessels and the pathologic processes that impact them. With improved diagnostic techniques, investigators are now able to uncover many underlying mechanisms and prognostic factors for microvascular disease. In the heart and brain, these pathologic entities include coronary microvascular disease and cerebral small vessel disease, both of which have significant impact on patients, causing angina, myocardial infarction, heart failure, stroke, and dementia. In the current paper, we will discuss parallels in pathophysiology, classification, and diagnostic modalities, with a focus on the role of magnetic resonance imaging in microvascular disease of the heart and brain. Novel approaches for streamlined imaging of the cardiac and central nervous systems including the use of intravascular contrast agents such as ferumoxytol are presented, and unmet research gaps in diagnostics are summarized.
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Affiliation(s)
- Michael A Thomas
- Division of Cardiology, David Geffen School of Medicine at, UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Saman Hazany
- Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Benjamin M Ellingson
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Peng Hu
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kim-Lien Nguyen
- Division of Cardiology, David Geffen School of Medicine at, UCLA and VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Sampath S, Parimal AS, Huang W, Manigbas E, Gsell W, Chang MML, Qiu A, Jacobsen K, Evelhoch JL, Chin CL. Quantification of regional myocardial mean intracellular water lifetime: A nonhuman primate study in myocardial stress. NMR IN BIOMEDICINE 2020; 33:e4248. [PMID: 31977123 DOI: 10.1002/nbm.4248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 06/10/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is typically associated with early metabolic remodeling. Noninvasive imaging biomarkers that reflect these changes will be crucial in determining responses to early drug interventions in these patients. Mean intracellular water lifetime (τi ) has been shown to be partially inversely related to Na, K-ATPase transporter activity and may thus provide insight into the metabolic status in HFpEF patients. Here, we aim to perform regional quantification of τi using dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) in the nonhuman primate (NHP) heart and evaluate its region-specific variations under conditions of myocardial stress in the context of perturbed myocardial function. Cardiac stress was induced in seven naïve cynomolgus macaques using a dobutamine stepwise infusion protocol. All animals underwent 3 T cardiac dual-bolus DCE and tagging MRI experiments. The shutter-speed model was employed to quantify regional τi from the DCE-MR images. Additionally, τi values were correlated with myocardial strains. During cardiac stress, there was a significant decrease in global τi (192.9 ± 76.3 ms vs 321.6 ± 70 ms at rest, P < 0.05) in the left ventricle, together with an increase in global peak circumferential strain (-15.4% ± 2.7% vs -10.1% ± 2.9% at rest, P < 0.05). Specifically, slice-level analysis further revealed that a greater significant decrease in mean τi was observed in the apical region (ΔτI = 182.4 ms) compared with the basal (Δτi = 113.2 ms) and midventricular regions (Δτi = 108.4 ms). Regional analysis revealed that there was a greater significant decrease in mean τi in the anterior (Δτi = 243.9 ms) and antero-lateral (Δτi = 177.2 ms) regions. In the inferior and infero-septal regions, although a decrease in τi was observed, it was not significant. Whole heart regional quantification of τi is feasible using DCE-MRI. τi is sensitive to regional changes in metabolic state during cardiac stress, and its value correlates with strain.
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Affiliation(s)
| | | | - Wei Huang
- Advanced Imaging Research Center, Oregon Health and Science University, Portland, Oregon, United States
| | - Elaine Manigbas
- Imaging, Maccine Pte. Ltd., Singapore
- Comparative Medicine Imaging Facility, National University of Singapore, Singapore
| | - Willy Gsell
- Imaging, Maccine Pte. Ltd., Singapore
- Biomedical MRI, Department of Imaging and Pathology, Molecular Small Imaging Center, Leuven, Belgium
| | | | - Anqi Qiu
- Department of Biomedical Engineering, National University of Singapore, Singapore
| | | | - Jeffrey L Evelhoch
- Translational Biomarkers, MRL, Merck & Co., Inc, West Point, Pennsylvania
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20
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Xue H, Brown LA, Nielles-Vallespin S, Plein S, Kellman P. Automatic in-line quantitative myocardial perfusion mapping: Processing algorithm and implementation. Magn Reson Med 2020; 83:712-730. [PMID: 31441550 PMCID: PMC8400845 DOI: 10.1002/mrm.27954] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 06/27/2019] [Accepted: 07/27/2019] [Indexed: 02/03/2023]
Abstract
PURPOSE Quantitative myocardial perfusion mapping has advantages over qualitative assessment, including the ability to detect global flow reduction. However, it is not clinically available and remains a research tool. Building upon the previously described imaging sequence, this study presents algorithm and implementation of an automated solution for inline perfusion flow mapping with step by step performance characterization. METHODS Proposed workflow consists of motion correction (MOCO), arterial input function blood detection, intensity to gadolinium concentration conversion, and pixel-wise mapping. A distributed kinetics model, blood-tissue exchange model, is implemented, computing pixel-wise maps of myocardial blood flow (mL/min/g), permeability-surface-area product (mL/min/g), blood volume (mL/g), and interstitial volume (mL/g). RESULTS Thirty healthy subjects (11 men; 26.4 ± 10.4 years) were recruited and underwent adenosine stress perfusion cardiovascular MR. Mean MOCO quality score was 3.6 ± 0.4 for stress and 3.7 ± 0.4 for rest. Myocardial Dice similarity coefficients after MOCO were significantly improved (P < 1e-6), 0.87 ± 0.05 for stress and 0.86 ± 0.06 for rest. Arterial input function peak gadolinium concentration was 4.4 ± 1.3 mmol/L at stress and 5.2 ± 1.5 mmol/L at rest. Mean myocardial blood flow at stress and rest were 2.82 ± 0.47 mL/min/g and 0.68 ± 0.16 mL/min/g, respectively. The permeability-surface-area product was 1.32 ± 0.26 mL/min/g at stress and 1.09 ± 0.21 mL/min/g at rest (P < 1e-3). Blood volume was 12.0 ± 0.8 mL/100 g at stress and 9.7 ± 1.0 mL/100 g at rest (P < 1e-9), indicating good adenosine vasodilation response. Interstitial volume was 20.8 ± 2.5 mL/100 g at stress and 20.3 ± 2.9 mL/100 g at rest (P = 0.50). CONCLUSIONS An inline perfusion flow mapping workflow is proposed and demonstrated on normal volunteers. Initial evaluation demonstrates this fully automated solution for the respiratory MOCO, arterial input function left ventricle mask detection, and pixel-wise mapping, from free-breathing myocardial perfusion imaging.
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Affiliation(s)
- Hui Xue
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Louise A.E. Brown
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | | | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre (MCRC) & Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Peter Kellman
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
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21
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Impact of baseline calibration on semiquantitative assessment of myocardial perfusion reserve by adenosine stress MRI. Int J Cardiovasc Imaging 2019; 36:521-532. [PMID: 31728679 DOI: 10.1007/s10554-019-01729-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/03/2019] [Indexed: 12/31/2022]
Abstract
In this study, we sought to investigate the impact of baseline calibration, which is used in quantitative cardiac MRI perfusion analysis to correct for surface coil inhomogeneity and noise, on myocardial perfusion reserve index (MPRI) and its contribution to previously reported paradoxical low MPRI < 1.0 in patients with unobstructed coronary arteries. Semiquantitative perfusion analysis was performed in 20 patients with unobstructed coronary arteries undergoing stress/rest perfusion CMR and in ten patients undergoing paired rest perfusion CMR. The following baseline calibration settings were compared: (1) baseline division, (2) baseline subtraction and (3) no baseline calibration. In uncalibrated analysis, we observed ~ 20% segmental dispersion of signal intensity (SI)-over-time curves. Both baseline subtraction and baseline division reduced relative dispersion of t0-SI (p < 0.001), but only baseline division corrected for dispersion of peak-SI and maximum upslope also (p < 0.001). In the assessment of perfusion indices, however, baseline division resulted in paradoxical low MPRI (1.01 ± 0.23 vs. 1.63 ± 0.38, p < 0.001) and rest perfusion index (RPI 0.54 ± 0.07 vs. 0.94 ± 0.12, p < 0.001), respectively. This was due to a reversed ratio of blood-pool and myocardial baseline-SI before the second perfusion study caused by circulating contrast agent from the first injection. In conclusion, baseline division reliably corrects for inhomogeneity of the surface coil sensitivity profile facilitating comparisons of regional myocardial perfusion during hyperemia or at rest. However, in the assessment of MPRI, baseline division can lead to paradoxical low results (even MPRI < 1.0 in patients with unobstructed coronary arteries) potentially mimicking severely impaired perfusion reserve. Thus, in the assessment of MPRI we propose to waive baseline calibration.
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22
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Rasmussen LD, Winther S, Westra J, Isaksen C, Ejlersen JA, Brix L, Kirk J, Urbonaviciene G, Søndergaard HM, Hammid O, Schmidt SE, Knudsen LL, Madsen LH, Frost L, Petersen SE, Gormsen LC, Christiansen EH, Eftekhari A, Holm NR, Nyegaard M, Chiribiri A, Bøtker HE, Böttcher M. Danish study of Non-Invasive testing in Coronary Artery Disease 2 (Dan-NICAD 2): Study design for a controlled study of diagnostic accuracy. Am Heart J 2019; 215:114-128. [PMID: 31323454 DOI: 10.1016/j.ahj.2019.03.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 03/27/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coronary computed tomography angiography (CTA) is the preferred primary diagnostic modality when examining patients with low to intermediate pre-test probability of coronary artery disease (CAD). Only 20-30% of these have potentially obstructive CAD. Because of the relatively poor positive predictive value of coronary CTA, unnecessary invasive coronary angiographies (ICAs) are conducted with the costs and risks associated with the procedure. Hence, an optimized diagnostic CAD algorithm may reduce the numbers of ICAs not followed by revascularization. The Dan-NICAD 2 study has 3 equivalent main aims: (1) To examine the diagnostic precision of a sound-based diagnostic algorithm, The CADScor®System (Acarix A/S, Denmark), in patients with a low to intermediate pre-test risk of CAD referred to a primary examination by coronary CTA. We hypothesize that the CADScor®System provides better stratification prior to coronary CTA than clinical risk stratification scores alone. (2) To compare the diagnostic accuracy of 3T cardiac magnetic resonance imaging (3T CMRI), 82rubidium positron emission tomography (82Rb-PET), and CT-derived fractional flow reserve (FFRCT) in patients where obstructive CAD cannot be ruled out by coronary CTA using ICA fractional flow reserve (FFR) as reference standard. (3) To compare the diagnostic performance of quantitative flow ratio (QFR) and ICA-FFR in patients with low to intermediate pre-test probability of CAD using 82Rb-PET as reference standard. METHODS Dan-NICAD 2 is a prospective, multicenter, cross-sectional study including approximately 2,000 patients with low to intermediate pre-test probability of CAD and without previous history of CAD. Patients are referred to coronary CTA because of symptoms suggestive of CAD, as evaluated by a cardiologist. Patient interviews, sound recordings, and blood samples are obtained in connection with the coronary CTA. If coronary CTA does not rule out obstructive CAD, patients will be examined by 3T CMRI 82Rb-PET, FFRCT, ICA, and FFR. Reference standard is ICA-FFR. Obstructive CAD is defined as an FFR ≤0.80 or as high-grade stenosis (>90% diameter stenosis) by visual assessment. Diagnostic performance will be evaluated as sensitivity, specificity, predictive values, likelihood ratios, calibration, and discrimination. Enrolment started January 2018 and is expected to be completed by June 2020. Patients are followed for 10 years after inclusion. DISCUSSION The results of the Dan-NICAD 2 study are expected to contribute to the improvement of diagnostic strategies for patients suspected of CAD in 3 different steps: risk stratification prior to coronary CTA, diagnostic strategy after coronary CTA, and invasive wireless QFR analysis as an alternative to ICA-FFR.
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23
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Alves JR, de Queiroz RAB, Bär M, Dos Santos RW. Simulation of the Perfusion of Contrast Agent Used in Cardiac Magnetic Resonance: A Step Toward Non-invasive Cardiac Perfusion Quantification. Front Physiol 2019; 10:177. [PMID: 30949059 PMCID: PMC6436070 DOI: 10.3389/fphys.2019.00177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 02/12/2019] [Indexed: 01/02/2023] Open
Abstract
This work presents a new mathematical model to describe cardiac perfusion in the myocardium as acquired by cardiac magnetic resonance (CMR) perfusion exams. The combination of first pass (or contrast-enhanced CMR) and late enhancement CMR is a widely used non-invasive exam that can identify abnormal perfused regions of the heart via the use of a contrast agent (CA). The exam provides important information to the diagnosis, management, and prognosis of ischemia and infarct: perfusion on different regions, the status of microvascular structures, the presence of fibrosis, and the relative volume of extracellular space. This information is obtained by inferring the spatiotemporal dynamics of the contrast in the myocardial tissue from the acquired images. The evaluation of these physiological parameters plays an important role in the assessment of myocardial viability. However, the nature of cardiac physiology poses great challenges in the estimation of these parameters. Briefly, these are currently estimated qualitatively via visual inspection of images and comparison of relative brightness between different regions of the heart. Therefore, there is a great urge for techniques that can help to quantify cardiac perfusion. In this work, we propose a new mathematical model based on multidomain flow in porous media. The model is based on a system of partial differential equations. Darcy's law is used to obtain the pressure and velocity distribution. CA dynamics is described by reaction-diffusion-advection equations in the intravascular space and in the interstitial space. The interaction of fibrosis and the CA is also considered. The new model treats the domains as anisotropic media and imposes a closed loop of intravascular flow, which is necessary to reproduce the recirculation of the CA. The model parameters were adjusted to reproduce clinical data. In addition, the model was used to simulate different scenarios: normal perfusion; endocardial ischemia due to stenosis in a coronary artery in the epicardium; and myocardial infarct. Therefore, the computational model was able to correlate anatomical features, stenosis and the presence of fibrosis, with functional ones, cardiac perfusion. Altogether, the results suggest that the model can support the process of non-invasive cardiac perfusion quantification.
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Affiliation(s)
- João R Alves
- Graduate Program in Computational Modeling, Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
| | - Rafael A B de Queiroz
- Graduate Program in Computational Modeling, Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
| | - Markus Bär
- Department of Mathematical Modeling and Data Analysis, Physikalisch-Technische Bundesanstalt, Berlin, Germany
| | - Rodrigo W Dos Santos
- Graduate Program in Computational Modeling, Universidade Federal de Juiz de Fora, Juiz de Fora, Brazil
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24
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Ta AD, Hsu LY, Conn HM, Winkler S, Greve AM, Shanbhag SM, Chen MY, Patricia Bandettini W, Arai AE. Fully quantitative pixel-wise analysis of cardiovascular magnetic resonance perfusion improves discrimination of dark rim artifact from perfusion defects associated with epicardial coronary stenosis. J Cardiovasc Magn Reson 2018; 20:16. [PMID: 29514708 PMCID: PMC5842542 DOI: 10.1186/s12968-018-0436-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 02/07/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dark rim artifacts in first-pass cardiovascular magnetic resonance (CMR) perfusion images can mimic perfusion defects and affect diagnostic accuracy for coronary artery disease (CAD). We evaluated whether quantitative myocardial blood flow (MBF) can differentiate dark rim artifacts from true perfusion defects in CMR perfusion. METHODS Regadenoson perfusion CMR was performed at 1.5 T in 76 patients. Significant CAD was defined by quantitative invasive coronary angiography (QCA) ≥ 50% diameter stenosis. Non-significant CAD (NonCAD) was defined as stenosis by QCA < 50% diameter stenosis or computed tomographic coronary angiography (CTA) < 30% in all major epicardial arteries. Dark rim artifacts had study specific and guideline-based definitions for comparison purposes. MBF was quantified at the pixel-level and sector-level. RESULTS In a NonCAD subgroup with dark rim artifacts, stress MBF was lower in the subendocardial than midmyocardial and epicardial layers (2.17 ± 0.61 vs. 3.06 ± 0.75 vs. 3.24 ± 0.80 mL/min/g, both p < 0.001) and was also 30% lower than in remote regions (2.17 ± 0.61 vs. 2.83 ± 0.67 mL/min/g, p < 0.001). However, subendocardial stress MBF in dark rim artifacts was 37-56% higher than in true perfusion defects (2.17 ± 0.61 vs. 0.95 ± 0.43 mL/min/g, p < 0.001). Absolute stress MBF differentiated CAD from NonCAD with an accuracy ranging from 86 to 89% (all p < 0.001) using pixel-level analyses. Similar results were seen at a sector level. CONCLUSION Quantitative stress MBF is lower in dark rim artifacts than remote myocardium but significantly higher than in true perfusion defects. If confirmed in larger series, this approach may aid the interpretation of clinical stress perfusion exams. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00027170 ; first posted 11/28/2001; updated 11/27/2017.
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Affiliation(s)
- Allison D. Ta
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
- Duke University School of Medicine, Durham, North Carolina USA
| | - Li-Yueh Hsu
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
| | - Hannah M. Conn
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
| | - Susanne Winkler
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
- Medical University of Vienna, Vienna, Austria
| | - Anders M. Greve
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
| | - Sujata M. Shanbhag
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
| | - Marcus Y. Chen
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
| | - W. Patricia Bandettini
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
| | - Andrew E. Arai
- National Heart, Lung and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bldg 10, Rm B1D416, MSC 1061, 10 Center Drive, Bethesda, MD 20892-1061 USA
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25
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Hsu LY, Jacobs M, Benovoy M, Ta AD, Conn HM, Winkler S, Greve AM, Chen MY, Shanbhag SM, Bandettini WP, Arai AE. Diagnostic Performance of Fully Automated Pixel-Wise Quantitative Myocardial Perfusion Imaging by Cardiovascular Magnetic Resonance. JACC Cardiovasc Imaging 2018; 11:697-707. [PMID: 29454767 PMCID: PMC8760891 DOI: 10.1016/j.jcmg.2018.01.005] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The authors developed a fully automated framework to quantify myocardial blood flow (MBF) from contrast-enhanced cardiac magnetic resonance (CMR) perfusion imaging and evaluated its diagnostic performance in patients. BACKGROUND Fully quantitative CMR perfusion pixel maps were previously validated with microsphere MBF measurements and showed potential in clinical applications, but the methods required laborious manual processes and were excessively time-consuming. METHODS CMR perfusion imaging was performed on 80 patients with known or suspected coronary artery disease (CAD) and 17 healthy volunteers. Significant CAD was defined by quantitative coronary angiography (QCA) as ≥70% stenosis. Nonsignificant CAD was defined by: 1) QCA as <70% stenosis; or 2) coronary computed tomography angiography as <30% stenosis and a calcium score of 0 in all vessels. Automatically generated MBF maps were compared with manual quantification on healthy volunteers. Diagnostic performance of the automated MBF pixel maps was analyzed on patients using absolute MBF, myocardial perfusion reserve (MPR), and relative measurements of MBF and MPR. RESULTS The correlation between automated and manual quantification was excellent (r = 0.96). Stress MBF and MPR in the ischemic zone were lower than those in the remote myocardium in patients with significant CAD (both p < 0.001). Stress MBF and MPR in the remote zone of the patients were lower than those in the normal volunteers (both p < 0.001). All quantitative metrics had good area under the curve (0.864 to 0.926), sensitivity (82.9% to 91.4%), and specificity (75.6% to 91.1%) on per-patient analysis. On a per-vessel analysis of the quantitative metrics, area under the curve (0.837 to 0.864), sensitivity (75.0% to 82.7%), and specificity (71.8% to 80.9%) were good. CONCLUSIONS Fully quantitative CMR MBF pixel maps can be generated automatically, and the results agree well with manual quantification. These methods can discriminate regional perfusion variations and have high diagnostic performance for detecting significant CAD. (Technical Development of Cardiovascular Magnetic Resonance Imaging; NCT00027170)
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Affiliation(s)
- Li-Yueh Hsu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Matthew Jacobs
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Mitchel Benovoy
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Allison D Ta
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Hannah M Conn
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Susanne Winkler
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Anders M Greve
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Marcus Y Chen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Sujata M Shanbhag
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - W Patricia Bandettini
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Andrew E Arai
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
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26
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Ning J, Schubert T, Johnson KM, Roldán-Alzate A, Chen H, Yuan C, Reeder SB. Vascular input function correction of inflow enhancement for improved pharmacokinetic modeling of liver DCE-MRI. Magn Reson Med 2017; 79:3093-3102. [PMID: 29124781 DOI: 10.1002/mrm.26988] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 10/08/2017] [Accepted: 10/09/2017] [Indexed: 01/09/2023]
Abstract
PURPOSE To propose a simple method to correct vascular input function (VIF) due to inflow effects and to test whether the proposed method can provide more accurate VIFs for improved pharmacokinetic modeling. METHODS A spoiled gradient echo sequence-based inflow quantification and contrast agent concentration correction method was proposed. Simulations were conducted to illustrate improvement in the accuracy of VIF estimation and pharmacokinetic fitting. Animal studies with dynamic contrast-enhanced MR scans were conducted before, 1 week after, and 2 weeks after portal vein embolization (PVE) was performed in the left portal circulation of pigs. The proposed method was applied to correct the VIFs for model fitting. Pharmacokinetic parameters fitted using corrected and uncorrected VIFs were compared between different lobes and visits. RESULTS Simulation results demonstrated that the proposed method can improve accuracy of VIF estimation and pharmacokinetic fitting. In animal study results, pharmacokinetic fitting using corrected VIFs demonstrated changes in perfusion consistent with changes expected after PVE, whereas the perfusion estimates derived by uncorrected VIFs showed no significant changes. CONCLUSION The proposed correction method improves accuracy of VIFs and therefore provides more precise pharmacokinetic fitting. This method may be promising in improving the reliability of perfusion quantification. Magn Reson Med 79:3093-3102, 2018. © 2017 International Society for Magnetic Resonance in Medicine.
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Affiliation(s)
- Jia Ning
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, People's Republic of China.,Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Tilman Schubert
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Clinic for Radiology and Nuclear Medicine, Basel University Hospital, Basel, Switzerland
| | - Kevin M Johnson
- Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | | | - Huijun Chen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Chun Yuan
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, People's Republic of China.,Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Scott B Reeder
- Department of Radiology, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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27
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Jao TR, Nayak KS. Demonstration of velocity selective myocardial arterial spin labeling perfusion imaging in humans. Magn Reson Med 2017; 80:272-278. [PMID: 29106745 DOI: 10.1002/mrm.26994] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 09/19/2017] [Accepted: 10/13/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE Transit delay is a potential source of error in cardiac arterial spin-labeled (ASL) in heart failure or with collateral circulation. This study demonstrates the feasibility of using transit delay insensitive velocity selective ASL and compares its performance with flow-sensitive alternating inversion recovery (FAIR) ASL. METHODS Velocity selective labeling was achieved using an adiabatic BIR8 preparation. FAIR and velocity-selective ASL (VSASL) with various velocity cutoffs (VC = 10-40 cm/s) and labeling directions (anterior-posterior X, lateral-septal Y, and apical-basal Z) were carried out in 10 healthy volunteers (1F/9M age 23-30 y). Myocardial blood flow (MBF) and temporal signal-to-noise (TSNR) were measured. RESULTS VSASL sensitivity to perfusion decreased with increasing VC . At low VC (<5 cm/s), spurious labeling of myocardium occurs and overestimates MBF. MBF measured with FAIR (1.12 ± 0.26 ml/g/min) and VASL (1.26 ± 0.27 ml/g/min) at VC of 10 cm/s in Z were comparable (TOST with difference of 0.30 ml/g/min, P = 0.049). TSNR was 2.8 times larger using FAIR (13.62 ± 5.25) than in VSASL (4.87 ± 1.58). VSASL was insensitive to perfusion in the Y direction. X and Z performed similarly with TSNR of 4.17 ± 2.32 and 3.97 ± 0.56, respectively. CONCLUSION VSASL is a promising alternative to FAIR ASL in the heart and is well suited for scenarios when transit delays are long. Magn Reson Med 80:272-278, 2018. © 2017 International Society for Magnetic Resonance in Medicine.
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Affiliation(s)
- Terrence R Jao
- Department of Biomedical Engineering, University of Southern California, Los Angeles, California, USA
| | - Krishna S Nayak
- Ming Hsieh Department of Electrical Engineering, University of Southern California, Los Angeles, California, USA
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28
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Kellman P, Hansen MS, Nielles-Vallespin S, Nickander J, Themudo R, Ugander M, Xue H. Myocardial perfusion cardiovascular magnetic resonance: optimized dual sequence and reconstruction for quantification. J Cardiovasc Magn Reson 2017; 19:43. [PMID: 28385161 PMCID: PMC5383963 DOI: 10.1186/s12968-017-0355-5] [Citation(s) in RCA: 175] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/23/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Quantification of myocardial blood flow requires knowledge of the amount of contrast agent in the myocardial tissue and the arterial input function (AIF) driving the delivery of this contrast agent. Accurate quantification is challenged by the lack of linearity between the measured signal and contrast agent concentration. This work characterizes sources of non-linearity and presents a systematic approach to accurate measurements of contrast agent concentration in both blood and myocardium. METHODS A dual sequence approach with separate pulse sequences for AIF and myocardial tissue allowed separate optimization of parameters for blood and myocardium. A systems approach to the overall design was taken to achieve linearity between signal and contrast agent concentration. Conversion of signal intensity values to contrast agent concentration was achieved through a combination of surface coil sensitivity correction, Bloch simulation based look-up table correction, and in the case of the AIF measurement, correction of T2* losses. Validation of signal correction was performed in phantoms, and values for peak AIF concentration and myocardial flow are provided for 29 normal subjects for rest and adenosine stress. RESULTS For phantoms, the measured fits were within 5% for both AIF and myocardium. In healthy volunteers the peak [Gd] was 3.5 ± 1.2 for stress and 4.4 ± 1.2 mmol/L for rest. The T2* in the left ventricle blood pool at peak AIF was approximately 10 ms. The peak-to-valley ratio was 5.6 for the raw signal intensities without correction, and was 8.3 for the look-up-table (LUT) corrected AIF which represents approximately 48% correction. Without T2* correction the myocardial blood flow estimates are overestimated by approximately 10%. The signal-to-noise ratio of the myocardial signal at peak enhancement (1.5 T) was 17.7 ± 6.6 at stress and the peak [Gd] was 0.49 ± 0.15 mmol/L. The estimated perfusion flow was 3.9 ± 0.38 and 1.03 ± 0.19 ml/min/g using the BTEX model and 3.4 ± 0.39 and 0.95 ± 0.16 using a Fermi model, for stress and rest, respectively. CONCLUSIONS A dual sequence for myocardial perfusion cardiovascular magnetic resonance and AIF measurement has been optimized for quantification of myocardial blood flow. A validation in phantoms was performed to confirm that the signal conversion to gadolinium concentration was linear. The proposed sequence was integrated with a fully automatic in-line solution for pixel-wise mapping of myocardial blood flow and evaluated in adenosine stress and rest studies on N = 29 normal healthy subjects. Reliable perfusion mapping was demonstrated and produced estimates with low variability.
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Affiliation(s)
- Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, 10 Center Drive MSC-1061, Bethesda, MD 20892 USA
| | - Michael S. Hansen
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, 10 Center Drive MSC-1061, Bethesda, MD 20892 USA
| | - Sonia Nielles-Vallespin
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, 10 Center Drive MSC-1061, Bethesda, MD 20892 USA
| | - Jannike Nickander
- Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Raquel Themudo
- Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Martin Ugander
- Department of Clinical Physiology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Hui Xue
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, 10 Center Drive MSC-1061, Bethesda, MD 20892 USA
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29
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Keith GA, Rodgers CT, Chappell MA, Robson MD. A look-locker acquisition scheme for quantitative myocardial perfusion imaging with FAIR arterial spin labeling in humans at 3 tesla. Magn Reson Med 2016; 78:541-549. [PMID: 27604183 PMCID: PMC5516148 DOI: 10.1002/mrm.26388] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/28/2016] [Accepted: 07/28/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE A novel method for quantitative measurement of myocardial blood flow (MBF) using arterial spin labeling (ASL) in a single breath-hold is presented, evaluated by simulations, phantom studies and in vivo studies and tested for reproducibility and variability. METHODS A flow-sensitive alternating inversion recovery (FAIR) ASL method with Look-Locker readout (LL-FAIR-ASL) was implemented at 3 tesla. Scans were performed on 10 healthy volunteers and MBF measured in three slices. The method was investigated for reproducibility by Bland-Altman analysis and statistical measures, the coefficients of reproducibility (CR) and variation (CV) are reported. RESULTS The MBF values for the basal, mid, and apical slices were 1.04 ± 0.40, 1.06 ± 0.46, and 1.06 ± 0.38 ml/g/min, respectively (mean ± SD), which compare well with literature values. The CV across all scans, 43%, was greater than the between-session and within-session values, at 16 and 13%, respectively, for the mid-ventricular slice. The change in MBF required for detection, from the CR, was 61% between-session and 53% within-session for the mid-ventricle. CONCLUSION This study shows the feasibility of the LL-FAIR-ASL method for the quantification of MBF. The statistical measures reported will allow the planning of future clinical research studies involving rest and stress measurements. Magn Reson Med 78:541-549, 2017. © 2016 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
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Affiliation(s)
- Graeme A. Keith
- Oxford Centre for Clinical Magnetic Resonance ResearchUniversity of Oxford, John Radcliffe HospitalOxfordUnited Kingdom
| | - Christopher T. Rodgers
- Oxford Centre for Clinical Magnetic Resonance ResearchUniversity of Oxford, John Radcliffe HospitalOxfordUnited Kingdom
| | - Michael A. Chappell
- Institute of Biomedical EngineeringUniversity of Oxford, Old Road CampusOxfordUnited Kingdom
| | - Matthew D. Robson
- Oxford Centre for Clinical Magnetic Resonance ResearchUniversity of Oxford, John Radcliffe HospitalOxfordUnited Kingdom
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30
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Sampath S, Parimal AS, Feng D, Chang MML, Baumgartner R, Klimas M, Jacobsen K, Manigbas E, Gsell W, Evelhoch JL, Chin CL. Quantitative MRI biomarkers to characterize regional left ventricular perfusion and function in nonhuman primates during dobutamine-induced stress: A reproducibility and reliability study. J Magn Reson Imaging 2016; 45:556-569. [PMID: 27384520 DOI: 10.1002/jmri.25379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 06/22/2016] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To identify reproducible and reliable noninvasive regional imaging biomarkers of cardiac function and perfusion at rest and under stress in healthy nonhuman primates (NHPs) that may be used in the future for the early characterization of preclinical heart failure models, to evaluate therapy, and for clinical translation. MATERIALS AND METHODS Seven naive cynomolgus macaques underwent test-retest 3T cardiac MRI tagging and dual-bolus perfusion experiments. Regional cardiac function biomarkers, such as peak circumferential strain (CS), average diastolic strain-rate (DSR), contractile reserve (CR), diastolic reserve, peak torsion, and torsion reserve were quantified. Further, regional myocardial blood flow (MBF), myocardial perfusion reserve (MPR), and myocardial perfusion reserve-to-contractile reserve (MPR/CR) were also derived. Inter- and intraobserver reproducibility and test-retest reliability analyses were conducted using the reliability and generalizability coefficients including correlation coefficient (CC) and intraclass correlation coefficient (ICC). RESULTS Overall, peak CS, DSR, and MBF are robust biomarkers at both rest and stress with moderate-good inter- and intraobserver reproducibility and test-retest reliability. At rest: intra-/interobserver reproducibility (CC): peak CS (0.81/0.81), DSR (0.81/0.81), MBF (0.72/0.57), peak torsion (0.79/0.79); test-retest reliability: (CC/ICC): peak CS (0.62/0.75), DSR (0.24/0.55), MBF (0.66/0.62), and peak torsion (0.79/0.78). Under stress: intra-/interobserver reproducibility (CC): peak CS (0.61/0.60), DSR (0.50/0.50), MBF (0.63/0.61), MPR (0.43/0.43), and peak torsion (0.38/0.38); test-retest reliability: (CC/ICC): peak CS (0.58/0.58), DSR (0.24/0.43), MBF (0.58/0.58), MPR (0.43/0.38), and peak torsion (0.38/0.38). CONCLUSION We demonstrated the feasibility of using cardiac MRI to characterize left ventricular functional and perfusion responses to stress in an NHP species, and specific robust biomarkers such as peak CS, DSR, MBF, diastolic reserve, and MPR have been identified for clinical translation and drug research. LEVEL OF EVIDENCE 1 J. Magn. Reson. Imaging 2017;45:556-569.
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Affiliation(s)
- Smita Sampath
- Translational Biomarkers, Merck Research Laboratories, MSD, Singapore
| | | | - Dai Feng
- Biometric Research, Biostatistics and Research Decision Sciences, Merck Research Laboratories, Merck & Co. Inc., Rahway, New Jersey, USA
| | | | - Richard Baumgartner
- Biometric Research, Biostatistics and Research Decision Sciences, Merck Research Laboratories, Merck & Co. Inc., Rahway, New Jersey, USA
| | - Michael Klimas
- Translational Biomarkers, Merck Research Laboratories, Merck & Co. Inc., West Point, Pennsylvania, USA
| | - Kirsten Jacobsen
- In Vivo Pharmacology, Merck Research Laboratories, MSD, Singapore
| | | | | | - Jeffrey L Evelhoch
- Translational Biomarkers, Merck Research Laboratories, Merck & Co. Inc., West Point, Pennsylvania, USA
| | - Chih-Liang Chin
- Translational Biomarkers, Merck Research Laboratories, MSD, Singapore
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31
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Kober F, Jao T, Troalen T, Nayak KS. Myocardial arterial spin labeling. J Cardiovasc Magn Reson 2016; 18:22. [PMID: 27071861 PMCID: PMC4830031 DOI: 10.1186/s12968-016-0235-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/22/2016] [Indexed: 11/10/2022] Open
Abstract
Arterial spin labeling (ASL) is a cardiovascular magnetic resonance (CMR) technique for mapping regional myocardial blood flow. It does not require any contrast agents, is compatible with stress testing, and can be performed repeatedly or even continuously. ASL-CMR has been performed with great success in small-animals, but sensitivity to date has been poor in large animals and humans and remains an active area of research. This review paper summarizes the development of ASL-CMR techniques, current state-of-the-art imaging methods, the latest findings from pre-clinical and clinical studies, and future directions. We also explain how successful developments in brain ASL and small-animal ASL-CMR have helped to inform developments in large animal and human ASL-CMR.
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Affiliation(s)
- Frank Kober
- />Aix-Marseille Université, CNRS CRMBM UMR 7339, Centre de Résonance Magnétique Biologique et Médicale, Marseille, France
| | - Terrence Jao
- />Department of Biomedical Engineering, University of Southern California, Los Angeles, California USA
| | - Thomas Troalen
- />Aix-Marseille Université, CNRS CRMBM UMR 7339, Centre de Résonance Magnétique Biologique et Médicale, Marseille, France
| | - Krishna S. Nayak
- />Department of Biomedical Engineering, University of Southern California, Los Angeles, California USA
- />Ming Hsieh Department of Electrical Engineering, University of Southern California, Los Angeles, California USA
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32
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Wissmann L, Niemann M, Gotschy A, Manka R, Kozerke S. Quantitative three-dimensional myocardial perfusion cardiovascular magnetic resonance with accurate two-dimensional arterial input function assessment. J Cardiovasc Magn Reson 2015; 17:108. [PMID: 26637221 PMCID: PMC4669617 DOI: 10.1186/s12968-015-0212-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 11/24/2015] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Quantification of myocardial perfusion from first-pass cardiovascular magnetic resonance (CMR) images at high contrast agent (CA) dose requires separate acquisition of blood pool and myocardial tissue enhancement. In this study, a dual-sequence approach interleaving 2D imaging of the arterial input function with high-resolution 3D imaging for myocardial perfusion assessment is presented and validated for low and high CA dose. METHODS A dual-sequence approach interleaving 2D imaging of the aortic root and 3D imaging of the whole left ventricle using highly accelerated k-t PCA was implemented. Rest perfusion imaging was performed in ten healthy volunteers after administration of a Gadolinium-based CA at low (0.025 mmol/kg b.w.) and high dose (0.1 mmol/kg b.w.). Arterial input functions extracted from the 2D and 3D images were analysed for both doses. Myocardial contrast-to-noise ratios (CNR) were compared across volunteers and doses. Variations of myocardial perfusion estimates between volunteers and across myocardial territories were studied. RESULTS High CA dose imaging resulted in strong non-linearity of the arterial input function in the 3D images at peak CA concentration, which was avoided when the input function was derived from the 2D images. Myocardial CNR was significantly increased at high dose compared to low dose, with a 2.6-fold mean CNR gain. Most robust myocardial blood flow estimation was achieved using the arterial input function extracted from the 2D image at high CA dose. In this case, myocardial blood flow estimates varied by 24% between volunteers and by 20% between myocardial territories when analysed on a per-volunteer basis. CONCLUSION Interleaving 2D imaging for arterial input function assessment enables robust quantitative 3D myocardial perfusion imaging at high CA dose.
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Affiliation(s)
- Lukas Wissmann
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092, Zurich, Switzerland.
| | - Markus Niemann
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092, Zurich, Switzerland.
- Clinic of Cardiology, University Hospital Zurich, Zurich, Switzerland.
- Furtwangen University, Faculty Mechanical and Medical Engineering, Villingen-Schwenningen, Germany.
| | - Alexander Gotschy
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092, Zurich, Switzerland.
- Clinic of Cardiology, University Hospital Zurich, Zurich, Switzerland.
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland.
| | - Robert Manka
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092, Zurich, Switzerland.
- Clinic of Cardiology, University Hospital Zurich, Zurich, Switzerland.
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland.
| | - Sebastian Kozerke
- Institute for Biomedical Engineering, University and ETH Zurich, Gloriastrasse 35, 8092, Zurich, Switzerland.
- Imaging Sciences and Biomedical Engineering, King's College London, London, UK.
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33
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Tran-Gia J, Lohr D, Weng AM, Ritter CO, Stäb D, Bley TA, Köstler H. A model-based reconstruction technique for quantitative myocardial perfusion imaging. Magn Reson Med 2015; 76:880-7. [PMID: 26414857 DOI: 10.1002/mrm.25921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/19/2015] [Accepted: 08/14/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE To reduce saturation effects in the arterial input function (AIF) estimation of quantitative myocardial first-pass saturation recovery perfusion imaging by employing a model-based reconstruction. THEORY AND METHODS Imaging was performed with a saturation recovery prepared radial FLASH sequence. A model-based reconstruction was applied for reconstruction. By exploiting prior knowledge about the relaxation process, an image series with different saturation recovery times was reconstructed. By evaluating images with an effective saturation time of approximately 3 ms, saturation effects in the AIF determination were reduced. In a volunteer study, this approach was compared with a standard prebolus technique. RESULTS In comparison to the low-dose injection of a prebolus acquisition, saturation effects were further reduced in the AIFs determined using the model-based approach. These effects, which were clearly visible for all six volunteers, were reflected in a statistically significant difference of up to 20% in the absolute perfusion values. CONCLUSION The application of model-based reconstruction algorithms in quantitative myocardial perfusion imaging promises a significant improvement of the AIF determination. In addition to greatly reducing saturation effects that occur even for the prebolus methods, only a single bolus has to be applied. Magn Reson Med 76:880-887, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Johannes Tran-Gia
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Germany.,Department of Nuclear Medicine, University of Würzburg, Germany
| | - David Lohr
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Germany.,Comprehensive Heart Failure Center Würzburg, University of Würzburg, Germany
| | - Andreas Max Weng
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Germany
| | - Christian Oliver Ritter
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Germany.,Department of Diagnostic and Interventional Radiology, University Medical Center Göttingen, Germany
| | - Daniel Stäb
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Germany.,Centre for Advanced Imaging, University of Queensland, Brisbane, Australia
| | | | - Herbert Köstler
- Department of Diagnostic and Interventional Radiology, University of Würzburg, Germany.,Comprehensive Heart Failure Center Würzburg, University of Würzburg, Germany
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Sommer K, Bernat D, Schmidt R, Breit HC, Schreiber LM. Resting myocardial blood flow quantification using contrast-enhanced magnetic resonance imaging in the presence of stenosis: A computational fluid dynamics study. Med Phys 2015; 42:4375-84. [PMID: 26133634 DOI: 10.1118/1.4922708] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE The extent to which atherosclerotic plaques affect contrast agent (CA) transport in the coronary arteries and, hence, quantification of myocardial blood flow (MBF) using magnetic resonance imaging (MRI) is unclear. The purpose of this work was to evaluate the influence of plaque induced stenosis both on CA transport and on the accuracy of MBF quantification. METHODS Computational fluid dynamics simulations in a high-detailed realistic vascular model were employed to investigate CA bolus transport in the coronary arteries. The impact of atherosclerosis was analyzed by inserting various medium- to high-grade stenoses in the vascular model. The influence of stenosis morphology was examined by varying the stenosis shapes but keeping the area reduction constant. Errors due to CA bolus transport were analyzed using the tracer-kinetic model MMID4. RESULTS Dispersion of the CA bolus was found in all models and for all outlets, but with a varying magnitude. The impact of stenosis was complex: while high-grade stenoses amplified dispersion, mild stenoses reduced the effect. Morphology was found to have a marked influence on dispersion for a small number of outlets in the post-stenotic region. Despite this marked influence on the concentration-time curves, MBF errors were less affected by stenosis. In total, MBF was underestimated by -7.9% to -44.9%. CONCLUSIONS The presented results reveal that local hemodynamics in the coronary vasculature appears to have a direct impact on CA bolus dispersion. Inclusion of atherosclerotic plaques resulted in a complex alteration of this effect, with both degree of area reduction and stenosis morphology affecting the amount of dispersion. This strong influence of vascular transport effects impairs the accuracy of MRI-based MBF quantification techniques and, potentially, other bolus-based perfusion measurement techniques like computed tomography perfusion imaging.
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Affiliation(s)
- Karsten Sommer
- Section of Medical Physics, Department of Radiology, Johannes Gutenberg University Medical Center, Mainz 55131, Germany and Max Planck Graduate Center with the Johannes Gutenberg University Mainz, Mainz 55128, Germany
| | - Dominik Bernat
- Section of Medical Physics, Department of Radiology, Johannes Gutenberg University Medical Center, Mainz 55131, Germany
| | - Regine Schmidt
- Section of Medical Physics, Department of Radiology, Johannes Gutenberg University Medical Center, Mainz 55131, Germany
| | - Hanns-Christian Breit
- Section of Medical Physics, Department of Radiology, Johannes Gutenberg University Medical Center, Mainz 55131, Germany
| | - Laura M Schreiber
- Comprehensive Heart Failure Center, Department of Cardiovascular Imaging, Würzburg University Hospital, Würzburg 97078, Germany
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35
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Chen D, Sharif B, Bi X, Wei J, Thomson LEJ, Bairey Merz CN, Berman DS, Li D. Quantification of myocardial blood flow using non-electrocardiogram-triggered MRI with three-slice coverage. Magn Reson Med 2015; 75:2112-20. [PMID: 26059326 DOI: 10.1002/mrm.25787] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 05/06/2015] [Accepted: 05/06/2015] [Indexed: 11/11/2022]
Abstract
PURPOSE Accurate quantification of myocardial perfusion is dependent on reliable electrocardiogram (ECG) triggering. Measuring myocardial blood flow (MBF) in patients with arrhythmias or poor ECGs is currently infeasible with MR. The purpose of this study was to demonstrate the feasibility of a non-ECG-triggered method with clinically useful three-slice ventricular coverage for measurement of MBF in healthy volunteers. METHODS A saturation recovery magnetization-prepared gradient recalled echo acquisition was continuously repeated during first-pass imaging. A slice-interleaved radial trajectory was employed to enable image-based retrospective triggering. The arterial input function was generated using a beat-by-beat T1 estimation method. The proposed technique was validated against a conventional ECG-triggered dual-bolus technique in 10 healthy volunteers. The technique was further demonstrated under adenosine stress in 12 healthy volunteers. RESULTS The proposed method produced MBF with no significant difference compared with the ECG-triggered technique. The proposed method yielded mean myocardial perfusion reserve comparable to published literature. CONCLUSION We have developed a non-ECG-triggered quantitative perfusion imaging method. In this preliminary study, our results demonstrate that our method yields comparable MBF compared with the conventional ECG-triggered method and that it is feasible for stress imaging.
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Affiliation(s)
- David Chen
- Department of Biomedical Engineering, Northwestern University, Chicago, Illinois, USA.,Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Behzad Sharif
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xiaoming Bi
- MR R&D, Siemens Healthcare, Los Angeles, California, USA
| | - Janet Wei
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Louise E J Thomson
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California, USA.,Barbara Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - C Noel Bairey Merz
- Barbara Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Daniel S Berman
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Debiao Li
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, California, USA
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36
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Broadbent DA, Biglands JD, Ripley DP, Higgins DM, Greenwood JP, Plein S, Buckley DL. Sensitivity of quantitative myocardial dynamic contrast-enhanced MRI to saturation pulse efficiency, noise and t1 measurement error: Comparison of nonlinearity correction methods. Magn Reson Med 2015; 75:1290-300. [PMID: 25946025 DOI: 10.1002/mrm.25726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/19/2015] [Accepted: 03/20/2015] [Indexed: 12/12/2022]
Abstract
PURPOSE To compare methods designed to minimize or correct signal nonlinearity in quantitative myocardial dynamic contrast-enhanced (DCE) MRI. METHODS DCE-MRI studies were simulated and data acquired in eight volunteers. Signal nonlinearity was corrected using either a dual-bolus approach or model-based correction using proton-density weighted imaging (conventional or dual-sequence acquisition) or T1 data (native or bookend). Scanning of healthy and infarcted myocardium at 3 T was simulated, including noise, saturation imperfection and T1 measurement error. Data were analyzed using model-based deconvolution with a one-compartment (mono-exponential) model. RESULTS Substantial variation between methods was demonstrated in volunteers. In simulations the dual-bolus method proved stable for realistic levels of saturation efficiency but demonstrated bias due to residual nonlinearity. Model-based methods performed ideally in the absence of confounding error sources and were generally robust to noise or saturation imperfection, except for native T1 based correction which was highly sensitive to the latter. All methods demonstrated large variation in accuracy above an over-saturation level where baseline signal was nulled. For the dual-sequence approach this caused substantial bias at the saturation efficiencies observed in volunteers. CONCLUSION The choice of nonlinearity correction method in myocardial DCE-MRI impacts on accuracy and precision of estimated parameters, particularly in the presence of nonideal saturation.
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Affiliation(s)
- David A Broadbent
- Division of Biomedical Imaging, University of Leeds, Leeds, United Kingdom.,Department of Medical Physics and Engineering, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - John D Biglands
- Division of Biomedical Imaging, University of Leeds, Leeds, United Kingdom.,Department of Medical Physics and Engineering, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - David P Ripley
- Division of Biomedical Imaging, University of Leeds, Leeds, United Kingdom.,Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | | | - John P Greenwood
- Division of Biomedical Imaging, University of Leeds, Leeds, United Kingdom.,Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Sven Plein
- Division of Biomedical Imaging, University of Leeds, Leeds, United Kingdom.,Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - David L Buckley
- Division of Biomedical Imaging, University of Leeds, Leeds, United Kingdom.,Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
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Zarinabad N, Hautvast GLTF, Sammut E, Arujuna A, Breeuwer M, Nagel E, Chiribiri A. Effects of tracer arrival time on the accuracy of high-resolution (voxel-wise) myocardial perfusion maps from contrast-enhanced first-pass perfusion magnetic resonance. IEEE Trans Biomed Eng 2015; 61:2499-2506. [PMID: 24833413 DOI: 10.1109/tbme.2014.2322937] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
First-pass perfusion cardiac magnetic resonance(CMR) allows the quantitative assessment of myocardial blood flow(MBF). However, flow estimates are sensitive to the delay between the arterial and myocardial tissue tracer arrival time (tOnset) and the accurate estimation of MBF relies on the precise identification of tOnset . The aim of this study is to assess the sensitivity of the quantification process to tOnset at voxel level. Perfusion data were obtained from series of simulated data, a hardware perfusion phantom, and patients. Fermi deconvolution has been used for analysis. A novel algorithm, based on sequential deconvolution,which minimizes the error between myocardial curves and fitted curves obtained after deconvolution, has been used to identify the optimal tOnset for each region. Voxel-wise analysis showed to be more sensitive to tOnset compared to segmental analysis. The automated detection of the tOnset allowed a net improvement of the accuracy of MBF quantification and in patients the identification of perfusion abnormalities in territories that were missed when a constant user-selected tOnset was used. Our results indicate that high-resolution MBF quantification should be performed with optimized tOnset values at voxel level.
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Affiliation(s)
- Niloufar Zarinabad
- Division of Imaging Sciences and Biomedical Engineering, The Rayne Institute, St. Thomas¿ Hospital, London, U.K
| | - Gilion L T F Hautvast
- Philips Group Innovation¿Healthcare Incubators, Philips Research High Tech Campus, Eindhoven, AE, The Netherlands
| | - Eva Sammut
- Division of Imaging Sciences and Biomedical Engineering, The Rayne Institute, St. Thomas¿ Hospital, London, U.K
| | - Aruna Arujuna
- Division of Imaging Sciences and Biomedical Engineering, The Rayne Institute, St. Thomas¿ Hospital, London, U.K
| | - Marcel Breeuwer
- Philips Healthcare, Imaging Systems¿MR, Best, DA, The Netherlands
| | - Eike Nagel
- Division of Imaging Sciences and Biomedical Engineering, The Rayne Institute, St. Thomas¿ Hospital, London, U.K
| | - Amedeo Chiribiri
- Division of Imaging Sciences and Biomedical Engineering, The Rayne Institute, St. Thomas¿ Hospital, London, U.K
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Cyclosporine A reduces microvascular obstruction and preserves left ventricular function deterioration following myocardial ischemia and reperfusion. Basic Res Cardiol 2015; 110:18. [PMID: 25720581 PMCID: PMC4342514 DOI: 10.1007/s00395-015-0475-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 01/31/2015] [Accepted: 02/18/2015] [Indexed: 12/13/2022]
Abstract
Postconditioning and cyclosporine A prevent mitochondrial permeability transition pore opening providing cardioprotection during ischemia/reperfusion. Whether microvascular obstruction is affected by these interventions is largely unknown. Pigs subjected to coronary occlusion for 1 h followed by 3 h of reperfusion were assigned to control (n = 8), postconditioning (n = 9) or cyclosporine A intravenous infusion 10–15 min before the end of ischemia (n = 8). Postconditioning was induced by 8 cycles of repeated 30-s balloon inflation and deflation. After 3 h of reperfusion magnetic resonance imaging, triphenyltetrazolium chloride/Evans blue staining and histopathology were performed. Microvascular obstruction (MVO, percentage of gadolinium-hyperenhanced area) was measured early (3 min) and late (12 min) after contrast injection. Infarct size with double staining was smaller in cyclosporine (46.2 ± 3.1 %, P = 0.016) and postconditioning pigs (47.6 ± 3.9 %, P = 0.008) versus controls (53.8 ± 4.1 %). Late MVO was significantly reduced by cyclosporine (13.9 ± 9.6 %, P = 0.047) but not postconditioning (23.6 ± 11.7 %, P = 0.66) when compared with controls (32.0 ± 16.9 %). Myocardial blood flow in the late MVO was improved with cyclosporine versus controls (0.30 ± 0.06 vs 0.21 ± 0.03 ml/g/min, P = 0.002) and was inversely correlated with late-MVO extent (R2 = 0.93, P < 0.0001). Deterioration of left ventricular ejection fraction (LVEF) between baseline and 3 h of reperfusion was smaller with cyclosporine (−7.9 ± 2.4 %, P = 0.008) but not postconditioning (−12.0 ± 5.5 %, P = 0.22) when compared with controls (−16.4 ± 5.5 %). In the three groups, infarct size (β = −0.69, P < 0.001) and late MVO (β = −0.33, P = 0.02) were independent predictors of LVEF deterioration following ischemia/reperfusion (R2 = 0.73, P < 0.001). Despite both cyclosporine A and postconditioning reduce infarct size, only cyclosporine A infusion had a beneficial effect on microvascular damage and was associated with better preserved LV function when compared with controls.
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Sánchez-González J, Fernandez-Jiménez R, Nothnagel ND, López-Martín G, Fuster V, Ibañez B. Optimization of dual-saturation single bolus acquisition for quantitative cardiac perfusion and myocardial blood flow maps. J Cardiovasc Magn Reson 2015; 17:21. [PMID: 25880970 PMCID: PMC4332925 DOI: 10.1186/s12968-015-0116-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 01/08/2015] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND In-vivo quantification of cardiac perfusion is of great research and clinical value. The dual-bolus strategy is universally used in clinical protocols but has known limitations. The dual-saturation acquisition strategy has been proposed as a more accurate alternative, but has not been validated across the wide range of perfusion rates encountered clinically. Dual-saturation acquisition also lacks a clinically-applicable procedure for optimizing parameter selection. Here we present a comprehensive validation study of dual-saturation strategy in vitro and in vivo. METHODS The impact of saturation time and profile ordering in acquisitions was systematically analyzed in a phantom consisting of 15 tubes containing different concentrations of contrast agent. In-vivo experiments in healthy pigs were conducted to evaluate the effect of R2* on the definition of the arterial input function (AIF) and to evaluate the relationship between R2* and R1 variations during first-pass of the contrast agent. Quantification by dual-saturation perfusion was compared with the reference-standard dual-bolus strategy in 11 pigs with different grades of myocardial perfusion. RESULTS Adequate flow estimation by the dual-saturation strategy is achieved with myocardial tissue saturation times around 100 ms (always <30 ms of AIF), with the lowest echo time, and following a signal model for contrast conversion that takes into account the residual R2* effect and profile ordering. There was a good correlation and agreement between myocardial perfusion quantitation by dual-saturation and dual-bolus techniques (R(2) = 0.92, mean difference of 0.1 ml/min/g; myocardial perfusion ranges between 0.18 and 3.93 ml/min/g). CONCLUSIONS The dual-saturation acquisition strategy produces accurate estimates of absolute myocardial perfusion in vivo. The procedure presented here can be applied with minimal interference in standard clinical procedures.
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Affiliation(s)
| | - Rodrigo Fernandez-Jiménez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernandez Almagro 3. 28029, Madrid, Spain.
- Hospital Universitario Clínico San Carlos, Madrid, Spain.
| | - Nils D Nothnagel
- Philips Healthcare Iberia, Maria de Portugal 1. 28050, Madrid, Spain.
| | - Gonzalo López-Martín
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernandez Almagro 3. 28029, Madrid, Spain.
| | - Valentin Fuster
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernandez Almagro 3. 28029, Madrid, Spain.
- The Zena and Michael A. Wiener CVI, Mount Sinai School of Medicine, New York, NY, USA.
| | - Borja Ibañez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Melchor Fernandez Almagro 3. 28029, Madrid, Spain.
- Hospital Universitario Clínico San Carlos, Madrid, Spain.
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Nielles-Vallespin S, Kellman P, Hsu LY, Arai AE. FLASH proton density imaging for improved surface coil intensity correction in quantitative and semi-quantitative SSFP perfusion cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2015; 17:16. [PMID: 25827180 PMCID: PMC4331176 DOI: 10.1186/s12968-015-0120-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 01/21/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND A low excitation flip angle (α < 10°) steady-state free precession (SSFP) proton-density (PD) reference scan is often used to estimate the B1-field inhomogeneity for surface coil intensity correction (SCIC) of the saturation-recovery (SR) prepared high flip angle (α = 40-50°) SSFP myocardial perfusion images. The different SSFP off-resonance response for these two flip angles might lead to suboptimal SCIC when there is a spatial variation in the background B0-field. The low flip angle SSFP-PD frames are more prone to parallel imaging banding artifacts in the presence of off-resonance. The use of FLASH-PD frames would eliminate both the banding artifacts and the uneven frequency response in the presence of off-resonance in the surface coil inhomogeneity estimate and improve homogeneity of semi-quantitative and quantitative perfusion measurements. METHODS B0-field maps, SSFP and FLASH-PD frames were acquired in 10 healthy volunteers to analyze the SSFP off-resonance response. Furthermore, perfusion scans preceded by both FLASH and SSFP-PD frames from 10 patients with no myocardial infarction were analyzed semi-quantitatively and quantitatively (rest n = 10 and stress n = 1). Intra-subject myocardial blood flow (MBF) coefficient of variation (CoV) over the whole left ventricle (LV), as well as intra-subject peak contrast (CE) and upslope (SLP) standard deviation (SD) over 6 LV sectors were investigated. RESULTS In the 6 out of 10 cases where artifacts were apparent in the LV ROI of the SSFP-PD images, all three variability metrics were statistically significantly lower when using the FLASH-PD frames as input for the SCIC (CoVMBF-FLASH = 0.3 ± 0.1, CoVMBF-SSFP = 0.4 ± 0.1, p = 0.03; SDCE-FLASH = 10 ± 2, SDCE-SSFP = 32 ± 7, p = 0.01; SDSLP-FLASH = 0.02 ± 0.01, SDSLP-SSFP = 0.06 ± 0.02, p = 0.03). Example rest and stress data sets from the patient pool demonstrate that the low flip angle SSFP protocol can exhibit severe ghosting artifacts originating from off-resonance banding artifacts at the edges of the field of view that parallel imaging is not able to unfold. These artifacts lead to errors in the quantitative perfusion maps and the semi-quantitative perfusion indexes, such as false positives. It is shown that this can be avoided by using FLASH-PD frames as input for the SCIC. CONCLUSIONS FLASH-PD images are recommended as input for SCIC of SSFP perfusion images instead of low flip angle SSFP-PD images.
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Affiliation(s)
- Sonia Nielles-Vallespin
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), DHHS Bethesda, MD, USA
| | - Peter Kellman
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), DHHS Bethesda, MD, USA
| | - Li-Yueh Hsu
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), DHHS Bethesda, MD, USA
| | - Andrew E Arai
- National Heart Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), DHHS Bethesda, MD, USA
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Papanastasiou G, Williams MC, Kershaw LE, Dweck MR, Alam S, Mirsadraee S, Connell M, Gray C, MacGillivray T, Newby DE, Semple SI. Measurement of myocardial blood flow by cardiovascular magnetic resonance perfusion: comparison of distributed parameter and Fermi models with single and dual bolus. J Cardiovasc Magn Reson 2015; 17:17. [PMID: 25885056 PMCID: PMC4331385 DOI: 10.1186/s12968-015-0125-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 01/22/2015] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Mathematical modeling of cardiovascular magnetic resonance perfusion data allows absolute quantification of myocardial blood flow. Saturation of left ventricle signal during standard contrast administration can compromise the input function used when applying these models. This saturation effect is evident during application of standard Fermi models in single bolus perfusion data. Dual bolus injection protocols have been suggested to eliminate saturation but are much less practical in the clinical setting. The distributed parameter model can also be used for absolute quantification but has not been applied in patients with coronary artery disease. We assessed whether distributed parameter modeling might be less dependent on arterial input function saturation than Fermi modeling in healthy volunteers. We validated the accuracy of each model in detecting reduced myocardial blood flow in stenotic vessels versus gold-standard invasive methods. METHODS Eight healthy subjects were scanned using a dual bolus cardiac perfusion protocol at 3T. We performed both single and dual bolus analysis of these data using the distributed parameter and Fermi models. For the dual bolus analysis, a scaled pre-bolus arterial input function was used. In single bolus analysis, the arterial input function was extracted from the main bolus. We also performed analysis using both models of single bolus data obtained from five patients with coronary artery disease and findings were compared against independent invasive coronary angiography and fractional flow reserve. Statistical significance was defined as two-sided P value < 0.05. RESULTS Fermi models overestimated myocardial blood flow in healthy volunteers due to arterial input function saturation in single bolus analysis compared to dual bolus analysis (P < 0.05). No difference was observed in these volunteers when applying distributed parameter-myocardial blood flow between single and dual bolus analysis. In patients, distributed parameter modeling was able to detect reduced myocardial blood flow at stress (<2.5 mL/min/mL of tissue) in all 12 stenotic vessels compared to only 9 for Fermi modeling. CONCLUSIONS Comparison of single bolus versus dual bolus values suggests that distributed parameter modeling is less dependent on arterial input function saturation than Fermi modeling. Distributed parameter modeling showed excellent accuracy in detecting reduced myocardial blood flow in all stenotic vessels.
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Affiliation(s)
- Giorgos Papanastasiou
- Clinical Research Imaging Centre, University of Edinburgh,, Edinburgh, UK.
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
| | | | - Lucy E Kershaw
- Christie Medical Physics and Engineering, The Christie NHS FT, Manchester, UK.
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
| | - Shirjel Alam
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
| | - Saeed Mirsadraee
- Clinical Research Imaging Centre, University of Edinburgh,, Edinburgh, UK.
| | - Martin Connell
- Clinical Research Imaging Centre, University of Edinburgh,, Edinburgh, UK.
| | - Calum Gray
- Clinical Research Imaging Centre, University of Edinburgh,, Edinburgh, UK.
| | - Tom MacGillivray
- Clinical Research Imaging Centre, University of Edinburgh,, Edinburgh, UK.
| | - David E Newby
- Clinical Research Imaging Centre, University of Edinburgh,, Edinburgh, UK.
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
| | - Scott Ik Semple
- Clinical Research Imaging Centre, University of Edinburgh,, Edinburgh, UK.
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.
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Likhite D, Adluru G, Hu N, McGann C, DiBella E. Quantification of myocardial perfusion with self-gated cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2015; 17:14. [PMID: 25827080 PMCID: PMC4325943 DOI: 10.1186/s12968-015-0109-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/31/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Current myocardial perfusion measurements make use of an ECG-gated pulse sequence to track the uptake and washout of a gadolinium-based contrast agent. The use of a gated acquisition is a problem in situations with a poor ECG signal. Recently, an ungated perfusion acquisition was proposed but it is not known how accurately quantitative perfusion estimates can be made from such datasets that are acquired without any triggering signal. METHODS An undersampled saturation recovery radial turboFLASH pulse sequence was used in 7 subjects to acquire dynamic contrast-enhanced images during free-breathing. A single saturation pulse was followed by acquisition of 4-5 slices after a delay of ~40 msec. This was repeated without pause and without any type of gating. The same pulse sequence, with ECG-gating, was used to acquire gated data as a ground truth. An iterative spatio-temporal constrained reconstruction was used to reconstruct the undersampled images. After reconstruction, the ungated images were retrospectively binned ("self-gated") into two cardiac phases using a region of interest based technique and deformably registered into near-systole and near-diastole. The gated and the self-gated datasets were then quantified with standard methods. RESULTS Regional myocardial blood flow estimates (MBFs) obtained using self-gated systole (0.64 ± 0.26 ml/min/g), self-gated diastole (0.64 ± 0.26 ml/min/g), and ECG-gated scans (0.65 ± 0.28 ml/min/g) were similar. Based on the criteria for interchangeable methods listed in the statistical analysis section, the MBF values estimated from self-gated and gated methods were not significantly different. CONCLUSION The self-gated technique for quantification of regional myocardial perfusion matched ECG-gated perfusion measurements well in normal subjects at rest. Self-gated systolic perfusion values matched ECG-gated perfusion values better than did diastolic values.
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Affiliation(s)
- Devavrat Likhite
- />Department of Radiology, Utah Center for Advanced Imaging Research, University of Utah, Salt Lake City, UT USA
| | - Ganesh Adluru
- />Department of Radiology, Utah Center for Advanced Imaging Research, University of Utah, Salt Lake City, UT USA
| | - Nan Hu
- />Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Chris McGann
- />Division of Cardiology, University of Utah, Salt Lake City, UT USA
| | - Edward DiBella
- />Department of Radiology, Utah Center for Advanced Imaging Research, University of Utah, Salt Lake City, UT USA
- />Department of Bioengineering, University of Utah, Salt Lake City, UT USA
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Miller CA, Hsu LY, Ta A, Conn H, Winkler S, Arai AE. Quantitative pixel-wise measurement of myocardial blood flow: the impact of surface coil-related field inhomogeneity and a comparison of methods for its correction. J Cardiovasc Magn Reson 2015; 17:11. [PMID: 25827156 PMCID: PMC4323126 DOI: 10.1186/s12968-015-0117-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 01/08/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Surface coil-related field inhomogeneity potentially confounds pixel-wise quantitative analysis of perfusion CMR images. This study assessed the effect of surface coil-related field inhomogeneity on the spatial variation of pixel-wise myocardial blood flow (MBF), and assessed its impact on the ability of MBF quantification to differentiate ischaemic from remote coronary territories. Two surface coil intensity correction (SCIC) techniques were evaluated: 1) a proton density-based technique (PD-SCIC) and; 2) a saturation recovery steady-state free precession-based technique (SSFP-SCIC). METHODS 26 subjects (18 with significant CAD and 8 healthy volunteers) underwent stress perfusion CMR using a motion-corrected, saturation recovery SSFP dual-sequence protocol. A proton density (PD)-weighted image was acquired at the beginning of the sequence. Surface coil-related field inhomogeneity was approximated using a third-order surface fit to the PD image or a pre-contrast saturation prepared SSFP image. The estimated intensity bias field was subsequently applied to the image series. Pixel-wise MBF was measured from mid-ventricular stress images using the two SCIC approaches and compared to measurements made without SCIC. RESULTS MBF heterogeneity in healthy volunteers was higher using SSFP-SCIC (24.8 ± 4.1%) compared to PD-SCIC (20.8 ± 3.0%; p = 0.009), however heterogeneity was significantly lower using either SCIC technique compared to analysis performed without SCIC (36.2 ± 6.3%). In CAD patients, the difference in MBF between remote and ischaemic territories was minimal when analysis was performed without SCIC (0.06 ± 0.91 mL/min/kg), and was substantially lower than with either PD-SCIC (0.50 ± 0.63 mL/min/kg; p = 0.013) or with SSFP-SCIC (0.63 ± 0.89 mL/min/kg; p = 0.005). In 6 patients, MBF quantified without SCIC was artifactually higher in the stenosed coronary territory compared to the remote territory. PD-SCIC and SSFP-SCIC had similar differences in MBF between remote and ischaemic territories (p = 0.145). CONCLUSIONS This study demonstrates that surface coil-related field inhomogeneity can confound pixel-wise MBF quantification. Whilst a PD-based SCIC led to a more homogenous correction than a saturation recovery SSFP-based technique, this did not result in an appreciable difference in the differentiation of ischaemic from remote coronary territories and thus either method could be applied.
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Affiliation(s)
- Christopher A Miller
- Department of Health and Human Services, Advanced Cardiovascular Imaging Laboratory, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1061 USA
| | - Li-Yueh Hsu
- Department of Health and Human Services, Advanced Cardiovascular Imaging Laboratory, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1061 USA
| | - Allison Ta
- Department of Health and Human Services, Advanced Cardiovascular Imaging Laboratory, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1061 USA
| | - Hannah Conn
- Department of Health and Human Services, Advanced Cardiovascular Imaging Laboratory, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1061 USA
| | - Susanne Winkler
- Department of Health and Human Services, Advanced Cardiovascular Imaging Laboratory, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1061 USA
| | - Andrew E Arai
- Department of Health and Human Services, Advanced Cardiovascular Imaging Laboratory, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1061 USA
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Mordini FE, Haddad T, Hsu LY, Kellman P, Lowrey TB, Aletras AH, Bandettini WP, Arai AE. Diagnostic accuracy of stress perfusion CMR in comparison with quantitative coronary angiography: fully quantitative, semiquantitative, and qualitative assessment. JACC Cardiovasc Imaging 2015; 7:14-22. [PMID: 24433707 DOI: 10.1016/j.jcmg.2013.08.014] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study's primary objective was to determine the sensitivity, specificity, and accuracy of fully quantitative stress perfusion cardiac magnetic resonance (CMR) versus a reference standard of quantitative coronary angiography. We hypothesized that fully quantitative analysis of stress perfusion CMR would have high diagnostic accuracy for identifying significant coronary artery stenosis and exceed the accuracy of semiquantitative measures of perfusion and qualitative interpretation. BACKGROUND Relatively few studies apply fully quantitative CMR perfusion measures to patients with coronary disease and comparisons to semiquantitative and qualitative methods are limited. METHODS Dual bolus dipyridamole stress perfusion CMR exams were performed in 67 patients with clinical indications for assessment of myocardial ischemia. Stress perfusion images alone were analyzed with a fully quantitative perfusion (QP) method and 3 semiquantitative methods including contrast enhancement ratio, upslope index, and upslope integral. Comprehensive exams (cine imaging, stress/rest perfusion, late gadolinium enhancement) were analyzed qualitatively with 2 methods including the Duke algorithm and standard clinical interpretation. A 70% or greater stenosis by quantitative coronary angiography was considered abnormal. RESULTS The optimum diagnostic threshold for QP determined by receiver-operating characteristic curve occurred when endocardial flow decreased to <50% of mean epicardial flow, which yielded a sensitivity of 87% and specificity of 93%. The area under the curve for QP was 92%, which was superior to semiquantitative methods: contrast enhancement ratio: 78%; upslope index: 82%; and upslope integral: 75% (p = 0.011, p = 0.019, p = 0.004 vs. QP, respectively). Area under the curve for QP was also superior to qualitative methods: Duke algorithm: 70%; and clinical interpretation: 78% (p < 0.001 and p < 0.001 vs. QP, respectively). CONCLUSIONS Fully quantitative stress perfusion CMR has high diagnostic accuracy for detecting obstructive coronary artery disease. QP outperforms semiquantitative measures of perfusion and qualitative methods that incorporate a combination of cine, perfusion, and late gadolinium enhancement imaging. These findings suggest a potential clinical role for quantitative stress perfusion CMR.
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Affiliation(s)
- Federico E Mordini
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland; Department of Cardiology, Veterans Affairs Medical Center, Washington, DC
| | - Tariq Haddad
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Li-Yueh Hsu
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Peter Kellman
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Tracy B Lowrey
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Anthony H Aletras
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland; Department of Biomedical Informatics, University of Central Greece, Lamia, Greece
| | - W Patricia Bandettini
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland
| | - Andrew E Arai
- Cardiovascular and Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland.
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Tomiyama Y, Manabe O, Oyama-Manabe N, Naya M, Sugimori H, Hirata K, Mori Y, Tsutsui H, Kudo K, Tamaki N, Katoh C. Quantification of myocardial blood flow with dynamic perfusion 3.0 Tesla MRI: Validation with15o-water PET. J Magn Reson Imaging 2014; 42:754-62. [DOI: 10.1002/jmri.24834] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 12/10/2014] [Indexed: 01/11/2023] Open
Affiliation(s)
- Yuuki Tomiyama
- Department of Nuclear Medicine; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Osamu Manabe
- Department of Nuclear Medicine; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Noriko Oyama-Manabe
- Department of Diagnostic and Interventional Radiology; Hokkaido University Hospital; Sapporo Japan
| | - Masanao Naya
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Hiroyuki Sugimori
- Department of Diagnostic and Interventional Radiology; Hokkaido University Hospital; Sapporo Japan
| | - Kenji Hirata
- Department of Nuclear Medicine; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Yuki Mori
- Faculty of Health Sciences, Hokkaido University Graduate School of Health Sciences; Sapporo Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Kohsuke Kudo
- Department of Diagnostic and Interventional Radiology; Hokkaido University Hospital; Sapporo Japan
| | - Nagara Tamaki
- Department of Nuclear Medicine; Hokkaido University Graduate School of Medicine; Sapporo Japan
| | - Chietsugu Katoh
- Faculty of Health Sciences, Hokkaido University Graduate School of Health Sciences; Sapporo Japan
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DCE-MRI of the liver: reconstruction of the arterial input function using a low dose pre-bolus contrast injection. PLoS One 2014; 9:e115667. [PMID: 25546176 PMCID: PMC4278725 DOI: 10.1371/journal.pone.0115667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 11/26/2014] [Indexed: 11/26/2022] Open
Abstract
Purpose To assess the quality of the arterial input function (AIF) reconstructed using a dedicated pre-bolus low-dose contrast material injection imaged with a high temporal resolution and the resulting estimated liver perfusion parameters. Materials and Methods In this IRB–approved prospective study, 24 DCE-MRI examinations were performed in 21 patients with liver disease (M/F 17/4, mean age 56 y). The examination consisted of 1.3 mL and 0.05 mmol/kg of gadobenate dimeglumine for pre-bolus and main bolus acquisitions, respectively. The concentration-curve of the abdominal aorta in the pre-bolus acquisition was used to reconstruct the AIF. AIF quality and shape parameters obtained with pre-bolus and main bolus acquisitions and the resulting estimated hepatic perfusion parameters obtained with a dual-input single compartment model were compared between the 2 methods. Test–retest reproducibility of perfusion parameters were assessed in three patients. Results The quality of the pre-bolus AIF curve was significantly better than that of main bolus AIF. Shape parameters peak concentration, area under the time activity curve of gadolinium contrast at 60 s and upslope of pre-bolus AIF were all significantly higher, while full width at half maximum was significantly lower than shape parameters of main bolus AIF. Improved liver perfusion parameter reproducibility was observed using pre-bolus acquisition [coefficient of variation (CV) of 4.2%–38.7% for pre-bolus vs. 12.1–71.4% for main bolus] with the exception of distribution volume (CV of 23.6% for pre-bolus vs. 15.8% for main bolus). The CVs between pre-bolus and main bolus for the perfusion parameters were lower than 14%. Conclusion The AIF reconstructed with pre-bolus low dose contrast injection displays better quality and shape parameters and enables improved liver perfusion parameter reproducibility, although the resulting liver perfusion parameters demonstrated no clinically significant differences between pre-bolus and main bolus acquisitions.
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Biglands JD, Magee DR, Sourbron SP, Plein S, Greenwood JP, Radjenovic A. Comparison of the Diagnostic Performance of Four Quantitative Myocardial Perfusion Estimation Methods Used in Cardiac MR Imaging: CE-MARC Substudy. Radiology 2014; 275:393-402. [PMID: 25521666 DOI: 10.1148/radiol.14140433] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare the diagnostic performance of four tracer kinetic analysis methods to quantify myocardial perfusion from magnetic resonance (MR) imaging cardiac perfusion data sets in terms of their ability to lead to the diagnosis of myocardial ischemia. MATERIALS AND METHODS The study was approved by the regional ethics committee, and all patients gave written consent. A representative sample of 50 patients with suspected ischemic heart disease was retrospectively selected from the Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease trial data set. Quantitative myocardial blood flow (MBF) was estimated from rest and adenosine stress MR imaging perfusion data sets by using four established methods. A matching diagnosis of both an inducible defect as assessed with single photon emission computed tomography and a luminal stenosis of 70% or more as assessed with quantitative x-ray angiography was used as the reference standard for the presence of myocardial ischemia. Diagnostic performance was evaluated with receiver operating characteristic (ROC) curve analysis for each method, with stress MBF and myocardial perfusion reserve (MPR) serving as continuous measures. RESULTS Area under the ROC curve with stress MBF and MPR as the outcome measures, respectively, was 0.86 and 0.92 for the Fermi model, 0.85 and 0.87 for the uptake model, 0.85 and 0.80 for the one-compartment model, and 0.87 and 0.87 for model-independent deconvolution. There was no significant difference between any of the models or between MBF and MPR, except that the Fermi model outperformed the one-compartment model if MPR was used as the outcome measure (P = .02). CONCLUSION Diagnostic performance of quantitative myocardial perfusion estimates is not affected by the tracer kinetic analysis method used.
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Affiliation(s)
- John D Biglands
- From the Division of Medical Physics (J.D.B., S.P.S.) and Division of Cardiovascular and Diabetes Research (S.P. J.P.G.), Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Worsley Building, Leeds LS2 9JT, England; Department of Medical Physics and Engineering, Leeds Teaching Hospitals NHS Trust, Leeds, England (J.D.B.); School of Computing, University of Leeds, Leeds, England (D.R.M.); and Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland (A.R.)
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Camici PG, d'Amati G, Rimoldi O. Coronary microvascular dysfunction: mechanisms and functional assessment. Nat Rev Cardiol 2014; 12:48-62. [DOI: 10.1038/nrcardio.2014.160] [Citation(s) in RCA: 290] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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49
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Shehata ML, Basha TA, Hayeri MR, Hartung D, Teytelboym OM, Vogel-Claussen J. MR Myocardial Perfusion Imaging: Insights on Techniques, Analysis, Interpretation, and Findings. Radiographics 2014; 34:1636-57. [DOI: 10.1148/rg.346140074] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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50
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Chen D, Sharif B, Dharmakumar R, Thomson LEJ, Bairey Merz CN, Berman DS, Li D. Quantification of myocardial blood flow using non-ECG-triggered MR imaging. Magn Reson Med 2014; 74:765-71. [PMID: 25227935 DOI: 10.1002/mrm.25451] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 08/19/2014] [Accepted: 08/22/2014] [Indexed: 12/11/2022]
Abstract
PURPOSE MR myocardial perfusion imaging is dependent on reliable electrocardiogram (ECG) triggering for accurate measurement of myocardial blood flow (MBF). A non-ECG-triggered method for quantitative first-pass imaging may improve clinical feasibility in patients with poor ECG signal. The purpose of this study is to evaluate the feasibility of a non-ECG-triggered method for myocardial perfusion imaging in a single slice. METHODS The proposed non-ECG-triggered technique uses a saturation-recovery magnetization preparation and golden-angle radial acquisition for integrated arterial input function (AIF) measurement. Image based self-gating with a temporal resolution of 42.6 ms is used to generate a first-pass image series with consistent cardiac phase. The AIF is measured using beat-by-beat T1 estimation of the ventricular blood pool. The proposed technique was performed on 14 healthy volunteers and compared against a conventional ECG-triggered dual-bolus acquisition. RESULTS The proposed method produced MBF with no significant difference compared with ECG-triggered technique (mean of 0.63 ± 0.22 mL/min/g to 0.73 ± 0.21 mL/min/g). CONCLUSION We have developed a non-ECG-triggered perfusion imaging method with T1 based measurement of the AIF in a single slice. In this preliminary study, our results demonstrate that MBF measured using the proposed method is comparable to the conventional ECG-triggered method.
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Affiliation(s)
- David Chen
- Department of Biomedical Engineering, Northwestern University, Chicago, Illinois, USA.,Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Behzad Sharif
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Rohan Dharmakumar
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Louise E J Thomson
- S. Mark Taper Foundation Imaging Center, Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Barbara Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - C Noel Bairey Merz
- Barbara Streisand Women's Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Daniel S Berman
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,S. Mark Taper Foundation Imaging Center, Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Debiao Li
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA.,David Geffen School of Medicine, University of California, Los Angeles, California, USA
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