Utility of T2-weighted short-tau inversion recovery (STIR) sequences in cardiac MRI: an overview of clinical applications in ischaemic and non-ischaemic heart disease

Role of Cardiac Magnetic Resonance in Inflammatory and Infiltrative Cardiomyopathies: A Narrative Review

Cardiac magnetic resonance (CMR) has acquired a pivotal role in modern cardiology. It represents the gold standard for biventricular volume and systolic function assessment. Moreover, CMR allows for non-invasive myocardial tissue evaluation, highlighting tissue edema, fibrosis, fibro-fatty infiltration and iron overload. This manuscript aims to review the impact of CMR in the main inflammatory and infiltrative cardiomyopathies, providing details on specific imaging patterns and insights regarding the most relevant trials in the setting.

Acute and Complicated Inflammatory Pericarditis: A Guide to Contemporary Practice

Inflammatory disease of the pericardium represents a relatively common presentation, especially among the young. For the most part, inflammatory pericardial disease can be expeditiously and effectively managed without significant sequelae. However, some individuals present with severe and recurrent illness, representing significant therapeutic challenges. During the past decade, there have been great strides made in developing an evidence-based approach to management of inflammatory pericardial disease, the result of which has been the development of (1) a systematic, protocoled approach to initial care; (2) targeted therapeutics; and (3) specialized, collaborative, and integrated care pathways. Herein we present a review of the current state of the art as it pertains to the diagnostic evaluation and therapeutic considerations in inflammatory pericardial disease with a focus on acute and complicated pericarditis.

Genetics of Dilated Cardiomyopathy

Dilated cardiomyopathy (DCM) is defined as dilation and/or reduced function of one or both ventricles and remains a common disease worldwide. An estimated 40% of cases of familial DCM have an identifiable genetic cause. Accordingly, there is a fast-growing interest in the field of molecular genetics as it pertains to DCM. Many gene mutations have been identified that contribute to phenotypically significant cardiomyopathy. DCM genes can affect a variety of cardiomyocyte functions, and particular genes whose function affects the cell-cell junction and cytoskeleton are associated with increased risk of arrhythmias and sudden cardiac death. Through advancements in next-generation sequencing and cardiac imaging, identification of genetic DCM has improved over the past couple decades, and precision medicine is now at the forefront of treatment for these patients and their families. In addition to standard treatment of heart failure and prevention of arrhythmias and sudden cardiac death, patients with genetic cardiomyopathy stand to benefit from gene mechanism-specific therapies.

Cardiovascular magnetic resonance findings in Danon disease: a case series of a family

Background

Cardiac involvement constitutes the primary cause of mortality in patients with Danon disease (DD). This study aimed to explore the cardiac magnetic resonance (CMR) features and progressions of DD cardiomyopathies in a family with long-term follow-up.

Methods

Seven patients (five females and two males), belonging to the same family and afflicted with DD, were enrolled in this study between 2017 and 2022. The cardiac structure, function, strain, tissue characteristics on CMR and their evolutions during follow-up were analyzed.

Results

Three young female patients (3/7, 42.86%) exhibited normal cardiac morphology. Four patients (4/7, 57.14%) displayed left ventricle hypertrophy (LVH), and mostly with septal thickening (3/4, 75%). A single male case (1/7, 14.3%) showed decreased LV ejection fraction (LVEF). Nonetheless, the global LV strain of the four adult patients decreased in different degree. The global strain of adolescent male patients was decreased compared to the age-appropriate female patients. Five patients (5/7, 71.43%) exhibited late gadolinium enhancement (LGE), with proportion ranging from 31.6% to 59.7% (median value 42.7%). The most common LGE location was the LV free wall (5/5, 100%), followed by right ventricle insertion points (4/5, 80%) and intraventricular septum (2/5, 40%). Segmental radial strain (rs = -0.586), circumferential strain (r = 0.589), and longitudinal strain (r = 0.514) were all moderately correlated with the LGE proportions of corresponding segments (P < 0.001). T2 hyperintense and perfusion defect foci were identified, overlapping with the LGE areas. During follow-up, both the young male patients exhibited notable deterioration of their cardiac symptoms and CMR. The LVEF and strain decreased, and the extent of LGE increased year by year. One patient underwent T1 mapping examination. The native T1 value was sensitively elevated even in regions without LGE.

Conclusions

Left ventricular hypertrophy, LGE with sparing or relatively less involved IVS, and LV dysfunction are prominent CMR features of Danon cardiomyopathy. Strain and T1 mapping may have advantages in detecting early-stage dysfunction and myocardial abnormalities in DD patients, respectively. Multi-parametric CMR can serve as an optimal instrument for detecting DD cardiomyopathies.

Remote ischemic preconditioning enhances aerobic performance by accelerating regional oxygenation and improving cardiac function during acute hypobaric hypoxia exposure

Remote ischemic preconditioning (RIPC) may improve exercise performance. However, the influence of RIPC on aerobic performance and underlying physiological mechanisms during hypobaric hypoxia (HH) exposure remains relatively uncertain. Here, we systematically evaluated the potential performance benefits and underlying mechanisms of RIPC during HH exposure. Seventy-nine healthy participants were randomly assigned to receive sham intervention or RIPC (4 × 5 min occlusion 180 mm Hg/reperfusion 0 mm Hg, bilaterally on the upper arms) for 8 consecutive days in phases 1 (24 participants) and phase 2 (55 participants). In the phases 1, we measured the change in maximal oxygen uptake capacity (VO₂max) and muscle oxygenation (SmO₂) on the leg during a graded exercise test. We also measured regional cerebral oxygenation (rSO₂) on the forehead. These measures and physiological variables, such as cardiovascular hemodynamic parameters and heart rate variability index, were used to evaluate the intervention effect of RIPC on the changes in bodily functions caused by HH exposure. In the phase 2, plasma protein mass spectrometry was then performed after RIPC intervention, and the results were further evaluated using ELISA tests to assess possible mechanisms. The results suggested that RIPC intervention improved VO₂max (11.29%) and accelerated both the maximum (18.13%) and minimum (53%) values of SmO₂ and rSO₂ (6.88%) compared to sham intervention in hypobaric hypoxia exposure. Cardiovascular hemodynamic parameters (SV, SVRI, PPV% and SpMet%) and the heart rate variability index (Mean RR, Mean HR, RMSSD, pNN50, Lfnu, Hfnu, SD1, SD2/SD1, ApEn, SampEn, DFA1and DFA2) were evaluated. Protein sequence analysis showed 42 unregulated and six downregulated proteins in the plasma of the RIPC group compared to the sham group after HH exposure. Three proteins, thymosin β4 (Tβ4), heat shock protein-70 (HSP70), and heat shock protein-90 (HSP90), were significantly altered in the plasma of the RIPC group before and after HH exposure. Our data demonstrated that in acute HH exposure, RIPC mitigates the decline in VO₂max and regional oxygenation, as well as physiological variables, such as cardiovascular hemodynamic parameters and the heart rate variability index, by influencing plasma Tβ4, HSP70, and HSP90. These data suggest that RIPC may be beneficial for acute HH exposure.

T1 mapping is useful for staging deep venous thrombosis in the lower extremities

BACKGROUND

The discrimination of acute and chronic deep venous thrombosis (DVT) is of great importance. Quantitative imaging is an urgent requirement in reflecting intrinsic characteristics of thrombosis.

PURPOSE

To investigate the feasibility of T1 mapping in staging DVT in the lower extremities.

MATERIAL AND METHODS

A total of 57 patients with DVT in the lower extremities (26 men, 31 women; mean age = 53.3 years) underwent T1-weighted imaging and T1 mapping for obtaining T1 signal intensity (SI) and T1 time of thrombus. The relative SI (rSI) of DVT was obtained by calculating the ratio of thrombus SI to muscle SI. The Mann-Whitney U test was used to compare rSI and T1 time of DVT between acute group (patients with limb edema ≤ 2 weeks) and chronic group (patients with limb edema > 2 weeks). A receiver operator characteristic (ROC) curve was constructed for further evaluation.

RESULTS

DVT rSI was significantly higher in the acute group versus the chronic group (2.8 ± 1.2 vs. 1.4 ± 0.6; P<0.05). DVT T1 time was significantly lower in the acute group versus the chronic group (819.4 ± 223.7 ms vs. 1264.8 ± 270.7 ms; P<0.05). The area under the curve (AUC) was 0.93 for T1 time and 0.75 for rSI. When using 1015 ms as the cut-off, the sensitivity and specificity of T1 time were 91% (32/35) and 86% (19/22), respectively.

CONCLUSION

T1 mapping is a potential technique in discriminating acute from chronic DVT in the lower extremities and warrants further investigation.

The right ventricular involvement in dilated cardiomyopathy: prevalence and prognostic implications of the often-neglected child

Dilated cardiomyopathy (DCM) is a primary heart muscle disease characterized by left or biventricular systolic impairment. Historically, most of the clinical attention has been devoted to the evaluation of left ventricular function and morphology, while right ventricle (RV) has been for many years the forgotten chamber. Recently, progresses in cardiac imaging gave clinicians precious tools for the evaluation of RV, raising the awareness of the importance of biventricular assessment in DCM. Indeed, RV involvement is far from being uncommon in DCM, and the presence of right ventricular dysfunction (RVD) is one of the major negative prognostic determinants in DCM patients. However, some aspects such as the possible role of specific genetic mutations in determining the biventricular phenotype in DCM, or the lack of specific treatments able to primarily counteract RVD, still need research. In this review, we summarized the current knowledge on RV involvement in DCM, giving an overview on the epidemiology and pathogenetic mechanisms implicated in determining RVD. Furthermore, we discussed the imaging techniques to evaluate RV function and the role of RV failure in advanced heart failure.

Protective Value of Aspirin Loading Dose on Left Ventricular Remodeling After ST-Elevation Myocardial Infarction

Aims

Left ventricular (LV) remodeling after ST-elevation myocardial infarction (STEMI) is a complex process, defined as changes of LV volumes over time. CMR feature tracking analysis (CMR-FT) offers an accurate quantitative assessment of LV wall deformation and myocardial contractile function. This study aimed to evaluate the role of myocardial strain parameters in predicting LV remodeling and to investigate the effect of Aspirin (ASA) dose before primary coronary angioplasty (pPCI) on myocardial injury and early LV remodeling.

Methods and Results

Seventy-eight patients undergoing CMR, within 9 days from symptom onset and after 6 months, were enrolled in this cohort retrospective study. We divided the study population into three groups based on a revised Bullock's classification and we evaluated the role of baseline CMR features in predicting early LV remodeling. Regarding CMR strain analysis, worse global circumferential and longitudinal strain (GCS and GLS) values were associated with adverse LV remodeling. Patients were also divided based on pre-pPCI ASA dosage. Significant differences were detected in patients receiving ASA 500 mg dose before pPCI, which showed lower infarct size extent and better strain values compared to those treated with ASA 250 mg. The stepwise multivariate logistic regression analysis, adjusted for covariates, indicated that a 500 mg ASA dose remained an inverse independent predictor of early adverse LV remodeling.

Conclusion

GCS and GLS have high specificity to detect early LV adverse remodeling. We first reported a protective effect of ASA loading dose of 500 mg before pPCI on LV myocardial damage and in reducing early LV adverse remodeling.

Established and Emerging Techniques for Pericardial Imaging with Cardiac Magnetic Resonance

PURPOSE OF REVIEW

Pericardial diseases include a wide range of pathologies and their diagnosis can often be challenging. The goal of this review is to describe the established and emerging CMR imaging techniques used in the assessment of common pericardial diseases and explain the role of pericardial characterization in their diagnosis and management.

RECENT FINDINGS

CMR is indicated in cases of diagnostic uncertainty and for a comprehensive evaluation of the pericardium and its impact on the heart. This includes assessment of pericardial anatomy and associated cardiac hemodynamics, quantification and characterization of an effusion, disease staging, tissue characterization, guiding management, and even prognostication in some diseases of the pericardium. An emerging technique, pericardial characterization, utilizes various sequences to diagnose and stage pericardial inflammation, act as a biomarker in recurrent pericarditis, and guide management in inflammatory pericardial conditions. Beyond imaging, it has ushered in an era of tailored therapy for patients with pericardial diseases. Future directions should aim at exploring the role of tissue characterization in various pericardial diseases.

Machine learning and network medicine: a novel approach for precision medicine and personalized therapy in cardiomyopathies

The early identification of pathogenic mechanisms is essential to predict the incidence and progression of cardiomyopathies and to plan appropriate preventive interventions. Noninvasive cardiac imaging such as cardiac computed tomography, cardiac magnetic resonance, and nuclear imaging plays an important role in diagnosis and management of cardiomyopathies and provides useful prognostic information. Most molecular factors exert their functions by interacting with other cellular components, thus many diseases reflect perturbations of intracellular networks. Indeed, complex diseases and traits such as cardiomyopathies are caused by perturbations of biological networks. The network medicine approach, by integrating systems biology, aims to identify pathological interacting genes and proteins, revolutionizing the way to know cardiomyopathies and shifting the understanding of their pathogenic phenomena from a reductionist to a holistic approach. In addition, artificial intelligence tools, applied to morphological and functional imaging, could allow imaging scans to be automatically analyzed to extract new parameters and features for cardiomyopathy evaluation. The aim of this review is to discuss the tools of network medicine in cardiomyopathies that could reveal new candidate genes and artificial intelligence imaging-based features with the aim to translate into clinical practice as diagnostic, prognostic, and predictive biomarkers and shed new light on the clinical setting of cardiomyopathies. The integration and elaboration of clinical habits, molecular big data, and imaging into machine learning models could provide better disease phenotyping, outcome prediction, and novel drug targets, thus opening a new scenario for the implementation of precision medicine for cardiomyopathies.

Appropriate use criteria for cardiovascular magnetic resonance imaging (CMR): SIC-SIRM position paper part 1 (ischemic and congenital heart diseases, cardio-oncology, cardiac masses and heart transplant)

Cardiac magnetic resonance (CMR) has emerged as new mainstream technique for the evaluation of patients with cardiac diseases, providing unique information to support clinical decision-making. This document has been developed by a joined group of experts of the Italian Society of Cardiology and Italian society of Radiology and aims to produce an updated consensus statement about the current state of technology and clinical applications of CMR. The writing committee consisted of members and experts of both societies who worked jointly to develop a more integrated approach in the field of cardiac radiology. Part 1 of the document will cover ischemic heart disease, congenital heart disease, cardio-oncology, cardiac masses and heart transplant.

Use of the new Lake Louise Criteria improves CMR detection of atypical forms of acute myocarditis

The purpose of our study was to compare diagnostic performance of old and new Lake Louise Criteria (oLLC and nLLC) among different clinical presentations: infarct-like (IL), cardiomyopathic (CM) and arrhythmic (AR). 102 patients with clinical suspicion of acute myocarditis underwent cardiac magnetic resonance (CMR) on a 1.5 T scanner. Protocol included cine-SSFP, T2-weighted STIR, T2 mapping, early and late gadolinium enhancement and T1 mapping acquired before and after gadolinium administration. The degree of agreement has been calculated with Cohen's K test. 42 patients also underwent endomyocardial biopsy (EMB). IL onset was present in 54/102 patients, CM in 28/102 and AR in 20/102. nLLC were positive in 58.3% of the patients, while oLLC in 37.9%, k = 0.57 (IC: 0.428-0.713). The degree of agreement between nLLC and oLLC was 0.49 (IC: 0.111-0.876) for AR onset (nLLC positive in 35% vs oLLC in 15%), 0.25 (IC: 0.035-0.459) for CM pattern (nLLC positive in 60.7% vs oLLC 17.9%) and 0.73 (IC: 0.543-0.912) for IL presentation (nLLC positive in 66.7% vs oLLC in 57.4%). Diagnostic accuracy was 75% for both nLLC and oLLC among IL onset, and 41.6% for oLLC vs 66.7% for nLLC, as regards CM clinical presentation. nLLC have improved diagnostic performance of CMR for the diagnosis of acute myocarditis, in particular for atypical clinical presentation.

The current landscape of imaging recommendations in cardiovascular clinical guidelines: toward an imaging-guided precision medicine

The purpose of this article is to provide an overview on the role of CT scan and MRI according to selected guidelines by the European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association (ACC/AHA). ESC and ACC/AHA guidelines were systematically reviewed for recommendations to CT and MRI use in specific cardiovascular (CV) clinical categories. All recommendations were collected in a dataset, including the class of recommendation, the level of evidence (LOE), the specific imaging technique, the clinical purpose of the recommendation and the recommending Society. Among the 43 included guidelines (ESC: n = 18, ACC/AHA: n = 25), 26 (60.4%) contained recommendations for CT scan or MRI (146 recommendations: 62 for CT and 84 for MRI). Class of recommendation IIa (32.9%) was the most represented, followed by I (28.1%), IIb (24%) and III (11.9%). MRI recommendations more frequently being of higher class (I: 36.9%, IIa: 29.8%, IIb: 21.4%, III: 11.9%) as compared to CT (I: 16.1%, IIa: 37.1%, IIb: 27.4%, III: 19.4%). Most of recommendation (55.5%) were based on expert opinion (LOE C). The use of cardiac CT and cardiac MR in the risk assessment, diagnosis, therapeutic and procedural planning is in continuous development, driven by an increasing need to evolve toward an imaging-guided precision medicine, combined with cost-effectiveness and healthcare sustainability. These developments must be accompanied by an increased availability of high-performance scanners in healthcare facilities and should emphasize the need of increasing the number of radiologists fully trained in cardiac imaging.

Myocarditis: imaging up to date

Myocarditis is an inflammatory disease of the heart muscle, diagnosed by histological, immunological, and immunohistochemical criteria. Endomyocardial biopsy represents the diagnostic gold standard for its diagnosis but is infrequently used. Due to its noninvasive ability to detect the presence of myocardial edema, hyperemia and necrosis/fibrosis, Cardiac MR imaging is routinely used in the clinical practice for the diagnosis of acute myocarditis. Recently pixel-wise mapping of T1 and T2 relaxation time have been introduced into the clinical Cardiac MR protocol increasing its accuracy. Our paper will review the role of MR imaging in the diagnosis of acute myocarditis.

Cardiovascular Magnetic Resonance of Myocardial Fibrosis, Edema, and Infiltrates in Heart Failure

Cardiac magnetic resonance (CMR) imaging is a unique imaging modality, which provides accurate noninvasive tissue characterization. Various CMR sequences can be utilized to identify and quantify patterns of myocardial edema, fibrosis, and infiltrates, which are important determinants for diagnosis and prognostication of heart failure. This article describes available methods of tissue characterization imaging applied in CMR. The presence and patterns of abnormal tissue characterization are related to common etiologies of heart failure and the techniques employed to demonstrate this. CMR provides the opportunity to identify the etiology of heart failure based on the recognition of different patterns of myocardial abnormalities.

Cardiac magnetic resonance in arrhythmogenic cardiomyopathies

Over the past few years, the approach to the 'arrhythmic patient' has profoundly changed. An early clinical presentation of arrhythmia is often accompanied by non-specific symptoms and followed by inconclusive electrocardiographic findings. In this scenario, cardiac magnetic resonance (CMR) has been established as a clinical tool of fundamental importance for a correct prognostic stratification of the arrhythmic patient. This technique provides a high-spatial-resolution tomographic evaluation of the heart, which allows studying accurately the ventricular volumes, identifying even segmental kinetic anomalies and properly detecting diffuse or focal tissue alterations through an excellent tissue characterization, while depicting different patterns of fibrosis distribution, myocardial edema or fatty substitution. Through these capabilities, CMR has a pivotal role for the adequate management of the arrhythmic patient, allowing the identification of those phenotypic manifestations characteristic of structural heart diseases. Therefore, CMR provides valuable information to reclassify the patient within the wide spectrum of potentially arrhythmogenic heart diseases, the definition of which remains the major determinants for both an adequate treatment and a poor prognosis. The purpose of this review study was to focus on the role of CMR in the evaluation of the main cardiac clinical entities associated with arrhythmogenic phenomena and to present a brief debate on the main pathophysiological mechanisms involved in the arrhythmogenesis process.

Noninvasive imaging of congenital cardiovascular defects

Advances in the treatment have drastically increased the survival rate of congenital heart disease (CHD) patients. Therefore, the prevalence of these patients is growing. Imaging plays a crucial role in the diagnosis and management of this population as a key component of patient care at all stages, especially in those patients who survived into adulthood. Over the last decades, noninvasive imaging techniques, such as cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT), progressively increased their clinical relevance, reaching stronger levels of accuracy and indications in the clinical surveillance of CHD. The current review highlights the main technical aspects and clinical applications of CMR and CCT in the setting of congenital cardiovascular abnormalities, aiming to address a state-of-the-art guidance to every physician and cardiac imager not routinely involved in the field.

Cardiac MRI: technical basis

Cardiac magnetic resonance (CMR) imaging is an effective method for noninvasively imaging the heart which in the last two decades impressively enhanced spatial and temporal resolution and imaging speed, broadening its spectrum of applications in cardiovascular disease. CMR imaging techniques are designed to noninvasively assess cardiovascular morphology, ventricular function, myocardial perfusion, tissue characterization, flow quantification and coronary artery disease. These intrinsic features yield CMR suitable for diagnosis, follow-up and longitudinal monitoring after treatment of cardiovascular diseases. The aim of this paper is to review the technical basis of CMR, from cardiac imaging planes to cardiac imaging sequences.

Artificial intelligence in cardiac radiology

Artificial intelligence (AI) is entering the clinical arena, and in the early stage, its implementation will be focused on the automatization tasks, improving diagnostic accuracy and reducing reading time. Many studies investigate the potential role of AI to support cardiac radiologist in their day-to-day tasks, assisting in segmentation, quantification, and reporting tasks. In addition, AI algorithms can be also utilized to optimize image reconstruction and image quality. Since these algorithms will play an important role in the field of cardiac radiology, it is increasingly important for radiologists to be familiar with the potential applications of AI. The main focus of this article is to provide an overview of cardiac-related AI applications for CT and MRI studies, as well as non-imaging-based applications for reporting and image optimization.

Pericarditis and Post-cardiac Injury Syndrome as a Sequelae of Acute Myocardial Infarction

PURPOSE OF REVIEW

Pericarditis secondary to acute myocardial infarction (AMI) is known to develop either immediately or after a latent period of few months. Due to varied presentation and timing, its diagnosis and treatment can be challenging. This article reviews underlying mechanisms and the role of cardiac imaging in investigating and managing this condition.

RECENT FINDINGS

Timely diagnosis of pericarditis after AMI is important to prevent potential progression to complicated pericarditis. Clinical suspicion warrants initial investigation with serum inflammatory levels, electrocardiogram, and echocardiography. When findings are inconclusive, cardiac magnetic resonance imaging and computerized tomography can provide additional diagnostic information. Pericarditis after AMI is a treatable condition. Clinicians should maintain a high suspicion in this era of revascularization and develop a strategic plan for timely diagnosis and management.

Utility of FDG PET and Cardiac MRI in Diagnosis and Monitoring of Immunosuppressive Treatment in Cardiac Sarcoidosis

PURPOSE

To compare the contributions of cardiac MRI and PET in the diagnosis and management of cardiac sarcoidosis (CS), with particular reference to quantitative measures.

MATERIALS AND METHODS

This is a retrospective, observational study of 31 patients (mean age, 45.7 years) with proven extracardiac sarcoidosis and possible CS who were investigated with fluorine 18 fluorodeoxyglucose (FDG) PET/CT and cardiac MRI. Patients were treated at physicians' discretion with repeat combined imaging after an interval of 102-770 days (median, 228 days).

RESULTS

Significant myocardial FDG uptake was shown on visit 1 (myocardial maximum standardized uptake value [SUVmax] > 3.6) in 17 of 22 patients who were subsequently treated. Myocardial SUVmax decreased at follow-up (6.5 to 4.0; P < .01) and was matched by significant decreases in FDG-avid lung and mediastinal node disease. A volumetric measure of myocardium above a threshold SUV (cardiac metabolic volume) decreased from a mean of 42.5 to a mean of 4.1 (P < .001). This was associated with significant improvement in the left ventricular ejection fraction (LVEF) (45.8 increasing to 50.9; P < .031). There was no change in volume of late gadolinium enhancement at treatment. Patients who were untreated showed no change in any FDG PET or cardiac MRI parameter.

CONCLUSION

Myocardial FDG uptake in patients suspected of having CS is presumed to represent active inflammation. When treated with corticosteroids, this resolved or regressed at follow-up, with an improvement in LVEF and FDG-avid thoracic disease. Patients who were untreated showed no change in any parameter. Quantification of FDG-avid myocardium using cardiac metabolic volume is proposed as a useful objective measure for assessing response to therapy.© RSNA, 2020See also commentary by Gutberlet in this issue.

Multimodality imaging in chronic heart failure

The prevalence of heart failure (HF) is approximately 1-2% of the adult population in developed countries, rising to  ≥ 10% among people over 70. The common symptoms of HF include shortness of breath, ankle swelling and fatigue, determined by a reduced cardiac output. Multimodality imaging is crucial to define HF etiology, determine prognosis and guiding tailored treatments. Echocardiography is the most widely used imaging modality and maintains a pivotal role in the initial diagnostic work-up and in the follow-up of HF patients. Cardiac magnetic resonance (CMR) may support the morpho-functional assessment provided by echocardiography when the acoustic window is limited or a gold standard evaluation is required. Furthermore, CMR is frequently used due to the unmatched capability to characterize myocardial structure. Coronary computed tomography angiography has become the non-invasive imaging of choice to diagnose or rule-out coronary artery disease, acquiring remarkable importance in the management of HF patients. Moreover, emerging capabilities of CT-based tissue characterization may be useful, especially when CMR is contraindicated. Finally, chest CT may contribute to precisely define the framework of HF patients, revealing new insight about cardiopulmonary pathophysiological interactions with potential high prognostic value.

Aortic valvular imaging with cardiovascular magnetic resonance: seeking for comprehensiveness

Cardiovascular magnetic resonance (CMR) has an emerging role in aortic valve disease evaluation, becoming an all-in-one technique. CMR evaluation of the anatomy and flow through the aortic valve has a higher reproducibility than echocardiography. Its unique ability of in vivo myocardial tissue characterization, significantly improves the risk stratification and management of patients. In addition, CMR is equivalent to cardiac CT angiography for trans-aortic valvular implantation and surgical aortic valve replacement planning; on the other hand, its role in the evaluation of ventricular function improving and post-treatment complications is undisputed. This review encompasses the existing literature regarding the role of CMR in aortic valve disease, exploring all the aspects of the disease, from diagnosis to prognosis.

Cocaine Abuse: An Attack to the Cardiovascular System-Insights from Cardiovascular MRI

Cocaine is the most commonly used illicit drug in the European Union. Its cardiac effects are numerous and diverse, both in acute and chronic abuse, and include myocardial infarction, myocarditis, catecholamine-induced cardiomyopathy, and chronic cardiomyopathy (subclinical, hypertrophic, and dilated phases). Their clinical manifestations are vastly overlapping, and differential diagnosis should be performed using a thorough diagnostic workup featuring clinical history, laboratory tests, electrocardiography, stress test, noninvasive imaging modalities, and coronary angiography. Cardiac MRI has the unique ability of in vivo tissue characterization. This unique feature can play a pivotal role in the differential diagnosis through proper characterization of the myocardial tissue. Especially in acute settings, cardiac MRI makes it possible to distinguish between cocaine-induced myocardial infarction, cocaine-induced myocarditis, and catecholamine-induced cardiomyopathy. Conversely, in chronic cardiomyopathy, cardiac MRI permits evaluation of ventricular function and myocardial tissue, allowing the investigation of the underlying cause. On the one hand, assessing the ventricular function permits differentiation among subclinical, hypertrophic, and dilated phases of chronic cardiomyopathy; on the other hand, cardiac MRI could classify the causes underlying remodeling, including chronic ischemic injury, chronic myocarditis, and cardiac motion impairment. This review analyzes the relationship between pathophysiology, histology, and disease using the existing literature on cardiac MRI cocaine abuse evaluation. © RSNA, 2019.

Microvascular obstruction extent predicts major adverse cardiovascular events in patients with acute myocardial infarction and preserved ejection fraction

OBJECTIVES

To investigate the prognostic role of early post-infarction cardiac magnetic resonance (CMR) on long-term risk stratification of ST segment elevation myocardial infarction (STEMI) patients with preserved left ventricular ejection fraction (LVEF).

METHODS

Seventy-seven STEMI patients treated by primary percutaneous coronary intervention (PCI) and LVEF > 50% at CMR were included. The median time between STEMI and CMR was 5 days (IQR 2-8). LV volumes and function, area at risk (on T2 weighted images), infarcted myocardium (on late enhanced images), intramyocardial hemorrhage, and early and late microvascular obstruction (MVO) were detected and measured. CMR tissue determinants were correlated with the incidence of major adverse cardiovascular events (MACEs) over a 5-year follow-up.

RESULTS

During median follow-up of 4 years (range 3 to 5 years), eight (10%) patients experienced MACE, yielding an annualized event rate of 2.1%. All CMR tissue markers were not significantly different between MACE and no-MACE patients, except for the presence of late MVO (50% vs. 16%, respectively; p = 0.044) and its extent (2.30 ± 1.64 g vs. 0.18 ± 0.12 g, respectively; p = 0.000). From receiver-operating characteristic (ROC) curve (area under the curve 0.89; 95% confidence interval, 0.75-1.0; p = 0.000), late MVO extent > 0.385 g was a strong independent predictor of MACE at long-term follow-up (sensitivity = 87%, specificity = 90%; hazard ratio = 2.24; 95% confidence interval, 1.51-3.33; p = 0.000).

CONCLUSIONS

Late MVO extent after primary PCI on CMR seems to be a strong predictor of MACE at 5-year follow-up in patients with LVEF > 50%. Noticeably, late MVO extent > 0.385 g provided relevant prognostic insights leading to improved long-term risk stratification.

KEY POINTS

• Tissue markers provided by cardiac magnetic resonance aid in prognostic stratification after myocardial infarction • The occurrence of late microvascular obstruction after acute myocardial infarction increases risk of major adverse events at 5-year follow-up. • The greater microvascular obstruction extent on late gadolinium enhanced images is related to an increased risk of adverse events in patients with myocardial infarction and preserved left ventricular function.

Clinical Utility of Cardiac Magnetic Resonance Imaging in Pericardial Diseases

Background:

Pericardial diseases are relatively common in clinical practice and encountered in various clinical settings with consequent significant morbidity and mortality. However, the diagnosis as well as management can be complex and challenging, as the clinical presentation is usually non-specific. Therefore, there is an increasing role for Cardiac Magnetic Resonance Imaging (CMR) as an imaging tool to facilitate the diagnosis of pericardial diseases.

Conclusion:

Herein we describe conventional and unique CMR approaches to provide an increased non-invasive understanding of the pericardium in health and disease including a novel method to diagnose constrictive pericarditis via radio-frequency tissue tagging by defining unique visceral-parietal adherence patterns easily learned by the cardiologist and radiologist.

State of the art review: Chemotherapy-induced cardiotoxicity in children

Chemotherapy-induced cardiotoxicity in adults and children is a topic with a growing interest in the cardiology literature. The ability to detect cardiac dysfunction in a timely manner is essential in order to begin adequate treatment and prevent further deterioration. This article aims to provide a review on the myocardial injury process, chemotherapeutic agents that lead to cardiotoxicity, the definition of cardiotoxicity, and the methods of timely detection and treatment.

Oedema-fibrosis in Duchenne Muscular Dystrophy: Role of cardiovascular magnetic resonance imaging

Duchenne muscular dystrophy (DMD) is an X-linked muscle disorder characterized by progressive, irreversible loss of cardiac and skeletal muscular function. Muscular enlargement in DMD is attributed to oedema, due to the increased cytoplasmic Na+ concentration. The aim of this review was to present the current experience and emphasize the role of cardiovascular magnetic resonance (CMR) in the diagnosis of this condition. DMD patients' survival depends on ventilatory assistance, as respiratory muscle dysfunction was the most common cause of death in the past. Currently, due to improved ventilatory assistance, cardiomyopathy has become the main cause of death, even though clinically overt heart failure may be absent. CMR is the technique of choice to assess the pathophysiologic phenomena taking place in DMD, such as myocardial oedema and subepicardial fibrosis. The classic index to assess oedema is the T2-weighted short-tau inversion recovery (T2w-STIR), as it suppresses the signal from flowing blood and resident fat and enhances sensitivity to tissue fluid. Furthermore, CMR is the most reliable technique to detect and quantify fibrosis in DMD. Recently, the new indices T2, T1 mapping (native and postcontrast) and the extracellular volume (ECV) allow a more accurate approach of myocardial oedema and fibrosis. To conclude, the assessment of cardiac oedema and subepicardial fibrosis in the inferolateral wall of the left heart ventricle are the most important early finding in DMD with preserved ventricular function, and CMR, using both the classic and the new indices, is the best technique to detect and monitor these lesions.

The Prognostic Role of Tissue Characterisation using Cardiovascular Magnetic Resonance in Heart Failure

Despite significant advances in heart failure diagnostics and therapy, the prognosis remains poor, with one in three dying within a year of hospital admission. This is at least in part due to the difficulties in risk stratification and personalisation of therapy. The use of left ventricular systolic function as the main arbiter for entrance into clinical trials for drugs and advanced therapy, such as implantable defibrillators, grossly simplifies the complex heterogeneous nature of the syndrome. Cardiovascular magnetic resonance offers a wealth of data to aid in diagnosis and prognostication. The advent of novel cardiovascular magnetic resonance mapping techniques allows us to glimpse some of the pathophysiological mechanisms underpinning heart failure. We review the growing prognostic evidence base using these techniques.

Lights and shadows of cardiac magnetic resonance imaging in acute myocarditis

Abstract

Cardiac magnetic resonance (CMR) is considered a primary tool for the diagnosis of acute myocarditis, due to its unique potential for non-invasive identification of the various hallmarks of the inflammatory response, with relevant impact on patient management and prognosis. Nonetheless, a marked variation in sensitivity and negative predictive value has been reported in the literature, reflecting the intrinsic drawbacks of current diagnostic criteria, which are based mainly on the use of conventional CMR pulse sequences. As a consequence, a negative exam cannot reliably exclude the diagnosis, especially in patients who do not present an infarct-like onset of disease. The introduction of new-generation mapping techniques further widened CMR potentials, allowing quantification of tissue changes and opening new avenues for non-invasive workup of patients with inflammatory myocardial disease.

Main messages

• CMR sensitivity varies in AM, reflecting its clinical polymorphism and the intrinsic drawbacks of LLc.

• Semiquantitative approaches such as EGEr or T2 ratio have limited accuracy in diffuse disease forms.

• T1 mapping allows objective quantification of inflammation, with no need to normalize measurements.

• A revised protocol including T2-STIR, T1 mapping and LGE could be hypothesized to improve sensitivity.

Myocardial tissue characterization with magnetic resonance imaging

The availability of an accurate, noninvasive method using cardiac magnetic resonance imaging (MRI) to distinguish microscopic myocardial tissue changes at a macroscopic scale is well established. High-resolution in vivo monitoring of different pathologic tissue changes in the heart is a useful clinical tool for assessing the nature and extent of cardiac pathology. Cardiac MRI utilizes myocardial signal characteristics based on relaxation parameters such as T1, T2, and T2 star values. Identifying changes in relaxation time enables the detection of distinctive myocardial diseases such as cardiomyopathies and ischemic myocardial injury. The presented state-of-the-art review paper serves the purpose of introducing and summarizing MRI capability of tissue characterization in present clinical practice.

Imaging of reperfused intramyocardial hemorrhage with cardiovascular magnetic resonance susceptibility weighted imaging (SWI)

Purpose

To report initial experience with TE-averaged susceptibility weighted imaging (SWI) in normal subjects and acute myocardial infarction (AMI) patients for the detection of intramyocardial hemorrhage (IMH).

Materials and Methods

15 healthy control and 11 AMI subjects were studied at 1.5T before contrast agent administration with a dark blood double inversion recovery multiple spoiled gradient-echo sequence. Magnitude, susceptibility weighted and TE-averaged images were reconstructed from raw data. Contrast and signal-difference-to-noise were measured and compared between methods for IMH detection.

Results

There were six patients with microvascular obstruction (MVO) and four patients with IMH detected by TE-averaged SWI imaging. All patients with IMH on SWI scans had MVO on late gadolinium-enhanced (LGE) imaging. There was a three-fold increase in IMH contrast with SWI compared to magnitude images. IMH contrast decreased and signal-to-noise increased with increased TE averages.

Conclusions

TE-averaged SWI imaging is a promising method for myocardial tissue characterization in the setting of AMI for the detection of IMH. Along with gray-scale colormap inversion, it combines not only magnitude and phase information, but also images across TEs to provide a single image sensitive to IMH with characteristics similar to LGE imaging.

Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

CMR sensitivity varies with clinical presentation and extent of cell necrosis in biopsy-proven acute myocarditis

OBJECTIVES

The aim of this study was to determine whether clinical presentation and type of cell death in acute myocarditis might contribute to cardiac magnetic resonance (CMR) sensitivity.

BACKGROUND

Growing evidence indicates CMR is the reference noninvasive tool for the diagnosis of acute myocarditis. However, factors affecting CMR sensitivity are still unclear.

METHODS

We retrospectively evaluated 57 consecutive patients with a diagnosis of acute myocarditis made on the basis of clinical history (≤3 months) and endomyocardial biopsy evidence of lymphocytic infiltrates (≥14 infiltrating leukocytes/mm(2) at immunohistochemistry) in association with damage of the adjacent myocytes and absence or minimal evidence of myocardial fibrosis. CMR acquisition protocol included T2-weighted (edema), early (hyperemia), and late (fibrosis/necrosis) gadolinium enhancement sequences. Presence of ≥2 CMR criteria denoted myocarditis. Type of cell death was evaluated by using in situ ligation with hairpin probes.

RESULTS

Three clinical myocarditis patterns were recognized: infarct-like (pattern 1, n = 21), cardiomyopathic (pattern 2, n = 21), and arrhythmic (pattern 3, n = 15). Tissue edema was observed in 81% of pattern 1, 28% of pattern 2, and 27% of pattern 3. Early enhancement was evident in 71% of pattern 1, 67% of pattern 2, and 40% of pattern 3. Late gadolinium enhancement was documented in 71% of pattern 1, 57% of pattern 2, and 47% of pattern 3. CMR sensitivity was significantly higher in pattern 1 (80%) compared with pattern 2 (57%) and pattern 3 (40%) (p < 0.05). Cell necrosis was the prevalent mechanism of death in pattern 1 compared with pattern 2 (p < 0.001) and pattern 3 (p < 0.05), whereas apoptosis prevailed in pattern 2 (p < 0.001 vs. pattern 1 and p < 0.05 vs. pattern 3).

CONCLUSIONS

In acute myocarditis, CMR sensitivity is high for infarct-like, low for cardiomyopathic, and very low for arrhythmic clinical presentation; it correlates with the extent of cell necrosis-promoting expansion of interstitial space.

Role of cardiac magnetic resonance in the evaluation of dilated cardiomyopathy: diagnostic contribution and prognostic significance

Dilated cardiomyopathy (DCM) represents the final common morphofunctional pathway of various pathological conditions in which a combination of myocyte injury and necrosis associated with tissue fibrosis results in impaired mechanical function. Recognition of the underlying aetiology of disease and accurate disease monitoring may be crucial to individually optimize therapeutic strategies and stratify patient's prognosis. In this regard, CMR has emerged as a new reference gold standard providing important information for differential diagnosis and new insight about individual risk stratification. The present review article will focus on the role of CMR in the evaluation of present condition, analysing respective strengths and limitations in the light of current literature and technological developments.

Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography

Cardiac toxicity is one of the most concerning side effects of anti-cancer therapy. The gain in life expectancy obtained with anti-cancer therapy can be compromised by increased morbidity and mortality associated with its cardiac complications. While radiosensitivity of the heart was initially recognized only in the early 1970s, the heart is regarded in the current era as one of the most critical dose-limiting organs in radiotherapy. Several clinical studies have identified adverse clinical consequences of radiation-induced heart disease (RIHD) on the outcome of long-term cancer survivors. A comprehensive review of potential cardiac complications related to radiotherapy is warranted. An evidence-based review of several imaging approaches used to detect, evaluate, and monitor RIHD is discussed. Recommendations for the early identification and monitoring of cardiovascular complications of radiotherapy by cardiac imaging are also proposed.

Utility of cardiac magnetic resonance (CMR) in the evaluation of right ventricular (RV) involvement in patients with myocardial infarction (MI)

PURPOSE

The aim of this work was to compare the prevalence of right ventricle involvement in a population of patients with myocardial infarction as detected by cardiac magnetic resonance (CMR), clinical presentation, electrocardiographic (ECG) and echocardiographic criteria.

MATERIALS AND METHODS

A total of 97 consecutive patients, admitted to our institution for acute myocardial infarction, underwent a standard CMR examination within 5 days after the event. The presence of myocardial oedema and late enhancement of the right ventricle were compared to infarct location (anterior vs. inferior), clinical data, ECG, echocardiography results and other CMR findings. The results were analysed statistically using the Student's t test for independent samples and the K statistic.

RESULTS

Among the 97 patients included in the study, a diagnosis of right ventricular infarction was established in 12, 14 and 24 cases on the basis of the clinical data, the ECG and echocardiography, respectively. CMR demonstrated myocardial oedema and late enhancement of the right ventricle in 48 and 32 cases, respectively. The right ventricle was involved in 46 % of patients with inferior myocardial infarction (15/32) and in 30 % with anterior myocardial infarction (17/56), correlating to a worsening of both right and left ventricular performance (p = 0.001-0.05).

CONCLUSIONS

The right ventricle is frequently involved in myocardial infarction, correlating to a worse functional impairment of both ventricles and a worse prognosis. This finding, which is often underestimated by traditional cardiological tests, is well revealed by CMR, with potential clinical and therapeutic impact.

Noncardiac findings in clinical cardiac magnetic resonance: prevalence in 300 examinations after blind reassessment

PURPOSE

To assess the prevalence of noncardiac findings (NCFs) in a consecutive series of 300 cardiac magnetic resonance (CMR) studies.

METHODS

We retrospectively evaluated CMRs of 192 males and 108 females (42 ± 22 years), comparing findings included in reports to those detected after focused reassessment of CMR images. Noncardiac findings were classified as relevant if additional workup was required.

RESULTS

We found 19 NCFs, 14 (4.7%) tagged as nonrelevant and 5 (1.7%) as relevant. Images' reassessment presented 45 NCFs, 26 (8.7%) nonrelevant and 16 (5.3%) relevant (P < 0.003).

CONCLUSIONS

Cardiac magnetic resonance involves the study of areas larger than the heart alone, and NCFs are found in 1 of 7 patients; more than a half of them are not included in the initial CMR report. A small part is relevant, but detection can be unnecessarily stressful and harmful for patients and could increase costs. Risks of overdiagnosis or underreporting are to be taken into account.

Pericardial disease: value of CT and MR imaging

The pericardium represents an important focus of morbidity and mortality in patients with cardiovascular disease. Fortunately, in recent years knowledge regarding this enigmatic part of the heart and the diagnosis of related diseases has substantially advanced. To a large extent, this can be attributed to the availability of several noninvasive cardiac imaging modalities. Transthoracic echocardiography, which combines structural and physiologic assessment, is the first-line technique for examination of patients suspected of having or known to have pericardial disease; however, cardiac computed tomography (CT) and magnetic resonance (MR) imaging are becoming increasingly popular for the study of this part of the heart. Modern multidetector CT scanners merge acquisition speed and high spatial and contrast resolution, with volumetric scanning to provide excellent anatomic detail of the pericardium. Multidetector CT is by far the modality of choice for depiction of pericardial calcifications. MR imaging is probably the best imaging modality for the acquisition of a comprehensive view of the pericardial abnormalities. MR imaging combines cardiac and pericardial anatomic assessment with tissue characterization and appraisal of the effects of pericardial abnormalities on cardiac performance. This review aims to elucidate the role of the pericardium and its interaction with the remainder of the heart in normal and pathologic conditions. It focuses on the rapidly evolving insights regarding pericardial disease provided by modern imaging modalities, not infrequently necessitating reconsideration of evidence that has thus far been taken for granted.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13121059/-/DC1.

Imaging of early modification in cardiomyopathy: the doxorubicin-induced model

Doxorubicin chemotherapy is effective and widely used to treat acute lymphoblastic leukemia. However, its effectiveness is hampered by a wide spectrum of dose-dependent cardiotoxicity including both morphological and functional changes, affecting primarily the myocardium. Non-invasive imaging techniques are used for the diagnosis and monitoring of these cardiotoxic effects. The purpose of this review is to summarize and compare the most common imaging techniques used in early detection and therapeutic monitoring of doxorubicin-induced cardiotoxicity and the suggested mechanisms of such side effects. Imaging techniques using echocardiography including conventional 2D and 3D echocardiography along with MRI sequences including Tagging, Cine, and quantitative MRI in detecting early myocardial damage are also reviewed. As there is a multitude of reported indices and imaging methods to assess particular functional alterations, we limit this review to the most relevant techniques based on their clinical application and their potential to early detection of doxorubicin-induced cardiotoxic effects.

Myocardial oedema as the sole marker of acute injury in Takotsubo cardiomyopathy: a cardiovascular magnetic resonance (CMR) study

PURPOSE

The main hallmark of Takotsubo cardiomyopathy (TT-CMP) is transient ischaemia, with completely reversible regional contractile dysfunction, which involves the mid-apical segments and shows no angiographic signs of coronary artery disease (CAD). The acute and reversible myocardial injury suggests that tissue oedema may be an important marker of disease.

MATERIALS AND METHODS

Seventeen patients with a clinical and angiographic diagnosis of TT-CMP underwent cardiovascular magnetic resonance (CMR) imaging in the acute phase and at follow-up after 4 months. A standard acquisition protocol including turbo spin echo (TSE) T2-weighted short-tau inversion-recovery (T2 STIR), steady-state free-precession cine (SSFP cine) and lateenhancement (LE) imaging after gadolinium benzyloxypropionic tetraacetic acid (Gd-BOPTA) administration was performed. All images were analysed, and data on oedema and LE were correlated with regional dysfunction and histological findings from endomyocardial biopsy (EMB) where available.

RESULTS

In all patients, T2 STIR images showed a diffuse homogeneous hyperintensity that extended to all mid-apical segments and perfectly matched the area of regional dysfunction, reflecting tissue oedema. In the five patients who underwent EMB, histology confirmed the massive interstitial oedema associated with typical contraction-band necrosis. No cases of LE were observed. At follow-up, complete regression of oedema was observed in all cases, with significant recovery of regional and global left ventricular (LV) function (ejection fraction from 48.7% to 59.8%).

CONCLUSIONS

Myocardial oedema on CMR is a characteristic feature of acute TT-CMP, which reflects acute inflammation and acute myocardial injury. It could therefore be used as a specific marker of disease severity.

[Clinical indications for the use of cardiac MRI. By the SIRM Study Group on Cardiac Imaging]

Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected.

Myocardial edema imaging by cardiovascular magnetic resonance: current status and future potential

Cardiovascular magnetic resonance (CMR) imaging is widely established, free of radioactive material or ionizing radiation, and the accepted noninvasive gold standard for numerous noninvasive cardiac markers. Using a technique called T2-weighted imaging, CMR can be used to assess myocardial edema as a reliable marker for acute, potentially reversible myocardial injury. Contrast agents are not required as the myocardial free water content affects the magnetic properties of the tissue, thus providing inherent image contrast. In this review, we illustrate the utility of T2-weighted techniques in the assessment of myocardial edema in a range of clinical scenarios. The detection of myocardial edema is clinically relevant in many acute settings and may be further helpful to better understand the pathophysiology of many non-acute clinical diseases. Currently, T2-weighted CMR represents the only imaging modality that can accurately depict and quantify the presence of myocardial edema in a noninvasive fashion. Thus, T2-weighted imaging should be included in a comprehensive CMR imaging protocol, especially if an acute injury is suspected.