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Lim SP, Mc Ardle BA, Beanlands RS, Hessian RC. Myocardial Viability: It is Still Alive. Semin Nucl Med 2014; 44:358-74. [DOI: 10.1053/j.semnuclmed.2014.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Ligabue G, Fiocchi F, Ferraresi S, Barbieri A, Romagnoli R, Torricelli P. How to quantify infarct size on delayed-enhancement MR images: a comparison between visual and quantitative approach. Radiol Med 2007; 112:959-68. [DOI: 10.1007/s11547-007-0196-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2006] [Accepted: 12/29/2006] [Indexed: 11/28/2022]
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Abstract
Patients with ischemic heart disease may have left ventricular (LV) dysfunction due to reversible or irreversible causes. The ability to distinguish viable myocardium with dysfunction due to a reversible etiology (hibernation, stunning) from nonviable scar is critical for determining proper management of the patient. Cardiovascular magnetic resonance (CMR) is a technique that has been established to be useful for the detection of myocardial viability and advancements in the field promise to further increase its utility. In this review we describe the features of CMR that make it suited for this purpose and outline promising developments that may soon make CMR the reference standard for viability assessment.
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Affiliation(s)
- Steven G Lloyd
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 35294, USA.
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Teraoka K, Hirano M, Ookubo H, Sasaki K, Katsuyama H, Amino M, Abe Y, Yamashina A. Delayed contrast enhancement of MRI in hypertrophic cardiomyopathy. Magn Reson Imaging 2004; 22:155-61. [PMID: 15010107 DOI: 10.1016/j.mri.2003.08.009] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2003] [Revised: 08/17/2003] [Accepted: 08/18/2003] [Indexed: 12/12/2022]
Abstract
Fibrotic lesions in the myocardium exhibit delayed contrast enhancement (DCE) on MR images. On the other hand, plexiform fibrosis is observed in hypertrophic cardiomyopathy (HCM), indicating an association of this condition with the pathogenesis of heart failure and arrhythmia. To examine the occurrence and extent of DCE and its relation to cardiac function and arrhythmia in HCM, we studied 59 patients with HCM who had undergone MRI. The relationship of DCE to cardiac function and arrhythmia was further investigated. DCE occurred in 45 (76.3%) of the 59 patients with HCM, with a high frequency of localization in regions, where the right ventricle is attached. As for the relationship of DCE to cardiac function, a significant decrease (P=0.007) in cardiac function was observed in the group in which 4 or more segments exhibited DCE, compared with the group in which DCE was observed in 3 or less segments. Regarding the relationship of DCE to arrhythmia, both the occurrence of DCE and the extent of DCE were significantly larger (p<0.05, p=0.026, respectively) in the group with VT. These results indicate that DCE may save to identify severe cases of HCM on the basis of cardiac function, arrhythmia, and pathophysiological aspects.
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Affiliation(s)
- Kunihiko Teraoka
- Second Department of Internal Medicine, Tokyo Medical University, Tokyo, Japan.
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Thomson LEJ, Kim RJ, Judd RM. Magnetic resonance imaging for the assessment of myocardial viability. J Magn Reson Imaging 2004; 19:771-88. [PMID: 15170783 DOI: 10.1002/jmri.20075] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The identification of myocardial viability in the setting of left ventricular (LV) dysfunction is crucial for the prediction of functional recovery following revascularization. Although echocardiography, positron emission tomography (PET), and nuclear imaging have validated roles, recent advances in cardiac magnetic resonance (CMR) technology and availability have led to increased experience in CMR for identification of myocardial viability. CMR has unique advantages in the ability of magnetic resonance spectroscopy (MRS) to measure subcellular components of myocardium, and in the image resolution of magnetic resonance proton imaging. As a result of excellent image resolution and advances in pulse sequences and coil technology, magnetic resonance imaging (MRI) can be used to identify the transmural extent of myocardial infarction (MI) in vivo for the first time. This review of the role of CMR in myocardial viability imaging describes the acute and chronic settings of ventricular dysfunction and concepts regarding the underlying pathophysiology. Recent advances in MRS and MRI are discussed, including the potential for dobutamine MRI to identify viable myocardium and a detailed review of the technique of delayed gadolinium (Gd) contrast hyperenhancement for visualization of viable and nonviable myocardium.
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Affiliation(s)
- Louise E J Thomson
- Duke Cardiovascular Magnetic Resonance Center, Duke University, Durham, North Carolina 27710, USA
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Wagner A, Mahrholdt H, Sechtem U, Kim RJ, Judd RM. MR imaging of myocardial perfusion and viability. Magn Reson Imaging Clin N Am 2003; 11:49-66. [PMID: 12797510 DOI: 10.1016/s1064-9689(02)00048-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
CMR is a rapidly developing new modality with applications in clinical cardiology for detection and assessment of myocardial ischemia and viability. CMR perfusion results for the detection of ischemia in comparison with stress echocardiography and scintigraphic techniques are reasonable, but all the studies reported to date have been conduced in selected patients. Larger studies in patient populations reflecting a broader spectrum of disease are necessary before perfusion CMR can be envisaged as a clinically reliable and robust diagnostic tool. Other CMR techniques provide a variety of novel methods of obtaining information on postischemic viability. Signs of viability that can be observed by CMR are the absence of late gadolinium-based contrast enhancement in a myocardial region involved in a recent infarct, any sign of wall thickening at rest (which is detectable with high accuracy by CMR), wall thickening after stimulation by low-dose dobutamine, and preserved wall thickness. Conversely, myocardial necrosis is characterized by signal enhancement of the infarct area after injection of Gd-DTPA, reduced wall thickness in chronic infarcts, and absence of a contractile reserve during dobutamine stimulation. Dobutamine CMR and late enhancement contrast-enhanced CMR predict contractile improvement after revascularization.
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Affiliation(s)
- Anja Wagner
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Box 3934, Durham, NC, USA.
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Rehwald WG, Fieno DS, Chen EL, Kim RJ, Judd RM. Myocardial magnetic resonance imaging contrast agent concentrations after reversible and irreversible ischemic injury. Circulation 2002; 105:224-9. [PMID: 11790705 DOI: 10.1161/hc0202.102016] [Citation(s) in RCA: 243] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Discrepant reports have been published recently regarding the relationship of contrast-enhanced magnetic resonance image intensities to reversible and irreversible ischemic injury. Unlike image intensities, contrast agent concentrations provide data independent of the MRI technique. We used electron probe x-ray microanalysis (EPXMA) to simultaneously examine concentrations of Gd, Na, P, S, Cl, K, and Ca over a range of myocardial injuries. Methods and Results- Reversible and irreversible injury were studied in 38 rabbits divided into 4 groups defined by occlusion and reperfusion time, as well as time the animals were euthanized. Gd-DTPA was administered, and the hearts were excised and rapidly frozen, cryosectioned, freeze-dried, and examined by EPXMA in up to 3 regions: remote, infarcted, and at risk but not infarcted. Infarcted regions were defined by anti-myoglobin antibody or triphenyltetrazolium chloride staining. Regions at risk were defined by fluorescent microparticles administered during occlusion. Compared with remote regions, in acutely infarcted regions, Gd was increased (235+/-24%, P<0.005) in the same 50 x 100-microm areas in which Na was increased (154+/-5%, P<0.001) and K was decreased (52+/-8%, P<0.001). Similarly, in chronically infarcted regions, Gd was increased (472+/-78%, P<0.001) in areas in which Na was increased (332+/-28%, P<0.001) and K was decreased (47+/-5%, P<0.001). Also compared with remote regions, however, concentrations of Gd, Na, and K were not elevated after reperfusion in regions that were at risk but not infarcted (P=NS). CONCLUSIONS Regional elevations in myocardial MRI contrast agent concentrations are exclusively associated with irreversible ischemic injury defined histologically and by regional electrolyte concentrations.
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Affiliation(s)
- Wolfgang G Rehwald
- Northwestern University Medical School Feinberg Cardiovascular Research Institute, Biomedical Engineering, Chicago, IL, USA
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Klein C, Nekolla SG, Bengel FM, Momose M, Sammer A, Haas F, Schnackenburg B, Delius W, Mudra H, Wolfram D, Schwaiger M. Assessment of myocardial viability with contrast-enhanced magnetic resonance imaging: comparison with positron emission tomography. Circulation 2002; 105:162-7. [PMID: 11790695 DOI: 10.1161/hc0202.102123] [Citation(s) in RCA: 377] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Recent studies indicate that MRI, after administration of gadolinium-diethylenetriamine pentaacetic acid, can identify nonviable areas in dysfunctional myocardium. We compared MRI hyperenhancement with PET as a gold standard for detection and quantification of myocardial scar tissue. METHODS AND RESULTS Thirty-one patients with ischemic heart failure (ejection fraction, 28+/-9%) were imaged with PET and MRI. Scar was defined as regionally increased MRI signal intensity 20 minutes after injection of 0.2 mmol/kg gadolinium-diethylenetriamine pentaacetic acid and as concordantly reduced perfusion and glucose metabolism as defined by PET. Sensitivity and specificity of MRI in identifying patients and segments (n=1023) with matched flow/metabolism defects was 0.96 of 1.0 and 0.86 of 0.94, respectively. Eleven percent of segments defined as viable by PET showed some degree of MRI hyperenhancement. Defect severity score based on visual analysis was 44.3+/-9.1 for PET and 47.6+/-11.1 for MRI (r=0.91, P<0.0001). Quantitatively assessed relative MRI infarct mass correlated well with PET infarct size (r=0.81, P<0.0001). Furthermore, MRI hyperenhancement was a better predictor of scar tissue than end-diastolic and end-systolic wall thickness or thickening. CONCLUSIONS In severe ischemic heart failure, MRI hyperenhancement as a marker of myocardial scar closely agrees with PET data. Although hyperenhancement correlated with areas of decreased flow and metabolism, it seems to identify scar tissue more frequently than PET, reflecting the higher spatial resolution. Additional functional studies after revascularization are required to define the significance of small islands of scar detected by MRI.
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Affiliation(s)
- Christoph Klein
- Nuklearmedizinische Klinik und Poliklinik der Technischen Universität München, Germany
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Flacke SJ, Fischer SE, Lorenz CH. Measurement of the gadopentetate dimeglumine partition coefficient in human myocardium in vivo: normal distribution and elevation in acute and chronic infarction. Radiology 2001; 218:703-10. [PMID: 11230643 DOI: 10.1148/radiology.218.3.r01fe18703] [Citation(s) in RCA: 163] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE To establish a method for measuring the partition coefficient (lambda) of gadopentetate dimeglumine in humans in vivo, evaluate the spatial and intersubject variation in the lambda of normal myocardium, and compare these values on a regional basis with lambda values of acute and chronic infarcted myocardium. MATERIALS AND METHODS Twelve healthy subjects and patients with acute (n = 5) or chronic (n = 5) myocardial infarction underwent magnetic resonance imaging at 1.5 T. Look-Locker images were acquired at four short-axis levels to measure myocardial and blood longitudinal relaxation time at baseline and after a 30-40-minute infusion of gadopentetate dimeglumine. lambda was calculated as DeltaR1(M)/DeltaR1(B, )where M = myocardium, and B = blood. RESULTS The magnitude of the estimated lambda in normal myocardium was uniform over the entire myocardium at 0.56 mL/g +/- 0.10 (SD). The lambda values in patients with acute (0.91 mL/g +/- 0.11, P <.001) or chronic (lambda = 0.78 mL/g +/- 0.09, P <.001) infarction were significantly elevated, as compared with those in healthy subjects. A 20% elevation in lambda, as compared with the mean value of a corresponding normal circumferential segment, allowed identification of chronically (sensitivity, 88%; specificity, 96%) or acutely (sensitivity, 100%; specificity, 98%) infarcted segments. CONCLUSION Quantification of the lambda in vivo allows differentiation between normal and acutely or chronically infarcted myocardium, with high sensitivity and specificity.
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Affiliation(s)
- S J Flacke
- Cardiovascular Division, Barnes-Jewish Hospital at Washington University Medical Center, St Louis, MO, USA
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Wu E, Judd RM, Vargas JD, Klocke FJ, Bonow RO, Kim RJ. Visualisation of presence, location, and transmural extent of healed Q-wave and non-Q-wave myocardial infarction. Lancet 2001; 357:21-8. [PMID: 11197356 DOI: 10.1016/s0140-6736(00)03567-4] [Citation(s) in RCA: 514] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND A technical advance in contrast-enhanced magnetic resonance imaging (MRI) has significantly improved image quality. We investigated whether healed myocardial infarction can be visualised as hyperenhanced regions with this new technique, and whether assessment of the transmural extent of infarction yields new physiological data. METHODS 82 MRI examinations were carried out in three groups: patients with healed myocardial infarction; patients with non-ischaemic cardiomyopathy; and healthy volunteers. Patients with healed myocardial infarction were prospectively enrolled after enyzmatically proven necrosis and imaged 3 months (SD 1) or 14 months (7) later. The MRI procedure used a segmented inversion-recovery gradient-echo sequence after gadolinium administration. Findings were compared with those of coronary angiography, electrocardiography, cine MRI, and creatine kinase measurements. FINDINGS 29 (91%) of 32 patients with infarcts imaged at 3 months (13 non-Q-wave) and all of 19 imaged at 14 months (eight non-Q-wave) showed hyperenhancement. In patients in whom the infarct-related-artery was identified by angiography, 24 of 25 imaged at 3 months and all of 14 imaged at 14 months had hyperenhancement in the appropriate territory. None of the 20 patients with non-ischaemic cardiomyopathy or the 11 healthy volunteers showed hyperenhancement. Irrespective of the presence or absence of Q waves, the majority of patients with hyperenhancement had only non-transmural involvement. Normal left-ventricular contraction was shown in seven patients examined at 3 months and three examined at 14 months, but in these cases hyperenhancement was limited to the subendocardium. INTERPRETATION The presence, location, and transmural extent of healed Q-wave and non-Q-wave myocardial infarction can be accurately determined by contrast-enhanced MRI.
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Affiliation(s)
- E Wu
- Department of Medicine, Feinberg Cardiovascular Research Institute, Northwestern University Medical School, Chicago, IL 60611-3008, USA
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Simonetti OP, Kim RJ, Fieno DS, Hillenbrand HB, Wu E, Bundy JM, Finn JP, Judd RM. An improved MR imaging technique for the visualization of myocardial infarction. Radiology 2001; 218:215-23. [PMID: 11152805 DOI: 10.1148/radiology.218.1.r01ja50215] [Citation(s) in RCA: 976] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE To design a segmented inversion-recovery turbo fast low-angle shot (turboFLASH) magnetic resonance (MR) imaging pulse sequence for the visualization of myocardial infarction, compare this technique with other MR imaging approaches in a canine model of ischemic injury, and evaluate its utility in patients with coronary artery disease. MATERIALS AND METHODS Six dogs and 18 patients were examined. In dogs, infarction was produced and images were acquired by using 10 different pulse sequences. In patients, the segmented turboFLASH technique was used to acquire contrast material-enhanced images 19 days +/- 7 (SD) after myocardial infarction. RESULTS Myocardial regions of increased signal intensity were observed in all animals and patients at imaging. With the postcontrast segmented turboFLASH sequence, the signal intensity of the infarcted myocardium was 1,080% +/- 214 higher than that of the normal myocardium in dogs-nearly twice that of the next best sequence tested and approximately 10-fold greater than that in previous reports. All 18 patients with myocardial infarction demonstrated high signal intensity at imaging. On average, the signal intensity of the high-signal-intensity regions in patients was 485% +/- 43 higher than that of the normal myocardium. CONCLUSION The segmented inversion-recovery turboFLASH sequence produced the greatest differences in regional myocardial signal intensity in animals. Application of this technique in patients with infarction substantially improved differentiation between injured and normal regions.
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Affiliation(s)
- O P Simonetti
- Siemens Medical Systems, 448 E Ontario St, Chicago, IL 60611, USA.
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Abstract
Magnetic resonance imaging offers the unique opportunity to directly visualize the size and location of myocardial infarcts (MIs) with excellent spatial resolution. Because infarct size is the most important determinant of postinfarct outcome, precise determination of infarct size may be valuable to risk stratify patients after acute MI. In addition, infarct imaging may provide direct information on the amount of irreversibly injured myocardium and thus can be used to identify myocardial viability in dysfunctional regions. Acute infarcts can be recognized as hyperintense signal on T2-weighted spin-echo images. This technique, however, does not identify chronic infarcts and may overestimate infarct size by including area at risk. Also, T2-weighted images often have a low signal-to-noise ratio. Contrast-enhanced perfusion imaging provides better-quality images. Extravascular contrast agents such as (Gd-DTPA) gadolinium diethyletriamine-pentaacetic acid identify infarcts as hyperenhanced regions on images acquired late after contrast injection. In addition, these tracers can examine the integrity and permeability of infarct microvasculature on first-pass perfusion images. Necrosis avid tracers and 23Na imaging are other new exciting approaches to identify infarcted myocardium acutely after MI. These techniques, are still investigational, and their value for clinical imaging remains to be established.
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Affiliation(s)
- B L Gerber
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Fieno DS, Kim RJ, Chen EL, Lomasney JW, Klocke FJ, Judd RM. Contrast-enhanced magnetic resonance imaging of myocardium at risk: distinction between reversible and irreversible injury throughout infarct healing. J Am Coll Cardiol 2000; 36:1985-91. [PMID: 11092675 DOI: 10.1016/s0735-1097(00)00958-x] [Citation(s) in RCA: 425] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We sought to determine the relationship of delayed hyperenhancement by contrast magnetic resonance imaging (MRI) to viable and nonviable myocardium within the region at risk throughout infarct healing. BACKGROUND The relationship of delayed MRI contrast enhancement patterns to injured but viable myocardium within the ischemic bed at risk has not been established. METHODS We compared in vivo and ex vivo MRI contrast enhancement to histopathologic tissue sections encompassing the entire left ventricle in dogs (n = 24) subjected to infarction with (n = 12) and without (n = 12) reperfusion at 4 h, 1 day, 3 days, 10 days, 4 weeks and 8 weeks. In vivo MR imaging was performed 30 min after contrast injection. RESULTS The sizes and shapes of in vivo myocardial regions of elevated image intensity (828+/-132% of remote) were the same as those observed ex vivo (241 slices, r = 0.99, bias = 0.05+/-1.6% of left ventricle [LV]). Comparison of ex vivo MRI to triphenyltetrazolim chloride-stained sections demonstrated that the spatial extent of hyperenhancement was the same as the spatial extent ofinfarction at every stage of healing (510 slices, lowest r = 0.95, largest bias = 1.7+/-2.9% of LV). Conversely, hyperenhanced regions were smaller than the ischemic bed at risk defined by fluorescent microparticles at every stage of healing (239 slices, 35+/-24% of risk region, p<0.001). Image intensities of viable myocardium within the risk region were the same as those of remote, normal myocardium (102+/-9% of remote, p = NS). CONCLUSIONS Delayed contrast enhancement by MRI distinguishes between viable and nonviable regions within the myocardium at risk throughout infarct healing.
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Affiliation(s)
- D S Fieno
- Northwestern University Medical School Feinberg Cardiovascular Research Institute, Department of Biomedical Engineering, Chicago, Illinois 60611-3008, USA
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Sandstede JJ, Lipke C, Beer M, Harre K, Pabst T, Kenn W, Neubauer S, Hahn D. Analysis of first-pass and delayed contrast-enhancement patterns of dysfunctional myocardium on MR imaging: use in the prediction of myocardial viability. AJR Am J Roentgenol 2000; 174:1737-40. [PMID: 10845515 DOI: 10.2214/ajr.174.6.1741737] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of the study was to analyze first-pass and delayed contrast-enhancement patterns of dysfunctional myocardial regions on MR imaging after injection of gadopentetate dimeglumine to predict myocardial viability in patients with coronary artery disease. SUBJECTS AND METHODS Twelve patients with wall motion abnormalities and related coronary artery disease revealed by conventional coronary angiography underwent MR imaging at 1.5-T before and 3 months after revascularization therapy. Short-axis images were acquired using a cine gradient-echo sequence. Each slice was divided into eight segments. Overall, 73 segments with impaired contractility were imaged during the first-pass and 14 +/- 2 min after injection of 0.05-mmol/kg gadopentetate dimeglumine at a flow of 3 ml/sec using a T1-weighted turbo fast low-angle shot sequence. Improved systolic wall thickening 3 months after revascularization served as the criterion of viability. RESULTS At study entry, 26 dysfunctional segments showed delayed hyperenhancement compared with the adjacent functional segments within the same slice, and 47 did not reveal hyperenhancement. After revascularization, 25 (96%) of the 26 hyperenhanced segments did not recover function, whereas 39 (83%) of the 47 segments without hyperenhancement showed mechanical improvement. Segment-related sensitivity and specificity for the correlation of lack of delayed hyperenhancement with myocardial viability were 39 (98%) of 40 and 25 (76%) of 33, respectively. Hypoenhancement during first-pass did not serve as a reliable criterion of viability. CONCLUSION Evidence of delayed hyperenhancement of dysfunctional myocardium may be used to predict lack of mechanical improvement or nonviability, whereas the lack of hyperenhancement can be correlated with improvement of regional contractility or viability after revascularization.
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Affiliation(s)
- J J Sandstede
- Department of Radiology, Universität Würzburg, Germany
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Affiliation(s)
- A J Duerinckx
- Radiology Service, VA North Texas Healthcare System, Dallas 75216, USA
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Kim RJ, Fieno DS, Parrish TB, Harris K, Chen EL, Simonetti O, Bundy J, Finn JP, Klocke FJ, Judd RM. Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age, and contractile function. Circulation 1999; 100:1992-2002. [PMID: 10556226 DOI: 10.1161/01.cir.100.19.1992] [Citation(s) in RCA: 1706] [Impact Index Per Article: 68.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Contrast MRI enhancement patterns in several pathophysiologies resulting from ischemic myocardial injury are controversial or have not been investigated. We compared contrast enhancement in acute infarction (AI), after severe but reversible ischemic injury (RII), and in chronic infarction. METHODS AND RESULTS In dogs, a large coronary artery was occluded to study AI and/or chronic infarction (n = 18), and a second coronary artery was chronically instrumented with a reversible hydraulic occluder and Doppler flowmeter to study RII (n = 8). At 3 days after surgery, cine MRI revealed reduced wall thickening in AI (5+/-6% versus 33+/-6% in normal, P<0.001). In RII, wall thickening before, during, and after inflation of the occluder for 15 minutes was 35+/-5%, 1+/-8%, and 21+/-10% and Doppler flow was 19.8+/-5.3, 0.2+/-0.5, and 56.3+/-17.7 (peak hyperemia) cm/s, respectively, confirming occlusion, transient ischemia, and reperfusion. Gd-DTPA-enhanced MR images acquired 30 minutes after contrast revealed hyperenhancement of AI (294+/-96% of normal, P<0.001) but not of RII (98+/-6% of normal, P = NS). Eight weeks later, the chronically infarcted region again hyperenhanced (253+/-54% of normal, n = 8, P<0.001). High-resolution (0.5 x 0.5 x 0.5 mm) ex vivo MRI demonstrated that the spatial extent of hyperenhancement was the same as the spatial extent of myocyte necrosis with and without reperfusion at 1 day (R = 0.99, P<0.001) and 3 days (R = 0.99, P<0.001) and collagenous scar at 8 weeks (R = 0.97, P<0.001). CONCLUSIONS In the pathophysiologies investigated, contrast MRI distinguishes between reversible and irreversible ischemic injury independent of wall motion and infarct age.
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Affiliation(s)
- R J Kim
- Northwestern University Medical School, Feinberg Cardiovascular Research Institute, Department of Medicine, Chicago, IL 60611-3008, USA
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Carreras F, Borrás X, Pons-Lladó G, Llauger J, Palmer J. [Acute myocardial infarct studied by magnetic resonance with gadolinium-DTPA contrast compared to echocardiography]. Rev Esp Cardiol 1999; 52:885-91. [PMID: 10611802 DOI: 10.1016/s0300-8932(99)75019-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION AND OBJECTIVES Gadolinium-DTPA used as a contrast agent in magnetic resonance imaging allows the detection and quantification of the necrotic area in acute myocardial infarction. The aim of the present study is to assess the value of this method for the diagnosis of myocardial infarction in comparison with clinical and echocardiographic data. METHODS Contrast magnetic resonance imaging and echocardiographic studies were performed on 16 patients during the first week after admission for acute myocardial infarction. Necrotic and total myocardial mass were calculated from magnetic resonance images and this was compared to the extension of the myocardial infarction assessed by electrocardiography and the peak level of total creatinine-phosphokinase serum enzyme. The number and localization of myocardial segments showing contrast uptake was related to segments with contractile abnormalities at the echocardiographic exam. RESULTS The mean value of the mass of myocardial necrosis calculated from the total area of gadolinium-DTPA uptake in each patient was 25 g (range: 2-67 g), corresponding to 17% of the total myocardial mass (range: 1-45%). This value correlated with the peak serum level of total creatinine-phosphokinase enzyme (r = 0.714; p < 0.003) and with the number of Q waves present at the electrocardiogram (r = 0.69; p < 0.005). A very good agreement between the location of the myocardial infarction by ECG, echocardiography and magnetic resonance was evidenced, and a satisfactory correlation existed between myocardial segments with gadolinium-DTPA uptake and akinetic echocardiographic segments (kappa = 0.65). CONCLUSIONS The detection and quantitation of the necrotic area in the acute myocardial infarction with gadolinium-DTPA contrast magnetic resonance shows a good correlation with clinical and echocardiographic data.
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Affiliation(s)
- F Carreras
- Departamento de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona.
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Ramani K, Judd RM, Holly TA, Parrish TB, Rigolin VH, Parker MA, Callahan C, Fitzgerald SW, Bonow RO, Klocke FJ. Contrast magnetic resonance imaging in the assessment of myocardial viability in patients with stable coronary artery disease and left ventricular dysfunction. Circulation 1998; 98:2687-94. [PMID: 9851954 DOI: 10.1161/01.cir.98.24.2687] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The utility of contrast MRI for assessing myocardial viability in stable coronary artery disease (CAD) with left ventricular dysfunction is uncertain. We therefore performed cine and contrast MRI in 24 stable patients with CAD and regional contractile abnormalities and compared MRI findings with rest-redistribution 201Tl imaging and dobutamine echocardiography. METHODS AND RESULTS Delayed MRI contrast enhancement patterns were examined from 3 to 15 minutes after injection of 0.1 mmol/kg IV gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA). Comparable MRI and 201Tl basal and midventricular short-axis images were subdivided into 6 segments. Segments judged nonviable by quantitative and qualitative assessment of 201Tl scans showed persistent, systematically greater MRI contrast signal intensity than segments judged viable (P</=0.002). Delayed contrast hyperenhancement also occurred in segments judged nonviable by dobutamine echocardiography (P</=0.03). The presence or absence of hyperenhancement correlated most closely with nonviability and viability, respectively, in segments that were akinetic or dyskinetic under resting conditions (83% concordance with 201Tl in both cases). In segments with resting hypokinesis, 58% of segments showing hyperenhancement were judged viable by 201Tl and may have represented an admixture of scar tissue and viable myocardium. CONCLUSIONS Delayed (by 3 to 15 minutes) hyperenhancement of Gd-DTPA contrast-enhanced MRI images occurs frequently in dysfunctional areas of the left ventricle in patients with stable CAD. Hyperenhancement is associated with nonviability by rest-redistribution 201Tl scintigraphy and dobutamine echocardiography, particularly in regions exhibiting resting akinesis/dyskinesis. The absence of hyperenhancement correlates with radionuclide and echocardiographic determinations of viability, regardless of resting contractile function.
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Affiliation(s)
- K Ramani
- Departments of Medicine, Radiology, and Biomedical Engineering and the Feinberg Cardiovascular Research Institute, Northwestern University Medical School, Chicago, IL, USA
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Pereira RS, Prato FS, Wisenberg G, Sykes J. The determination of myocardial viability using Gd-DTPA in a canine model of acute myocardial ischemia and reperfusion. Magn Reson Med 1996; 36:684-93. [PMID: 8916018 DOI: 10.1002/mrm.1910360506] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The partition coefficient of Gd-DTPA was thought to vary with the amount of cellular membrane damage after an acute myocardial infarction. The relationship between the partition coefficient of Gd-DTPA (lambda) and the uptake of 201Tl (as a marker of tissue viability) was studied 2 h to 3 weeks after reperfusion of a 2-h occlusion to the left anterior descending coronary artery in a canine model. Gd-DTPA was infused as a bolus followed by a prolonged constant infusion, and this infusion protocol was optimized such that the concentration of Gd-DTPA was directly related to lambda. After this infusion, MR images of excised hearts showed regions of increased signal intensity corresponding to increased Gd-DTPA concentration. At all time points, lambda and 201Tl uptake were strongly negatively correlated indicating that lambda is an accurate indicator of myocardial viability. Furthermore, lambda in the infarcted regions was increased relative to normal regions after 2 h of reperfusion and stayed elevated up to 3 weeks. At all time points, lambda in the infarcted and normal regions were significantly different. As well, this data showed a trend that lambda in infarcted regions decreased monotonically from 1 day to 3 weeks. This trend was confirmed with MR imaging by examining the change in signal intensity of in vivo images from 4 days to 3 weeks in two animals. These results suggest that MRI with Gd-DTPA could be used to measure the extent of myocardial damage after an acute myocardial infarction.
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Affiliation(s)
- R S Pereira
- Department of Nuclear Medicine and Magnetic Resonance, Lawson Research Institute, St. Joseph's Health Centre, Ontario, London, Canada
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