Intracoronary injection of contrast media maps the territory of the coronary artery: an MRI technique for assessing the effects of locally delivered angiogenic therapies

Interventional cardiac magnetic resonance imaging: current applications, technology readiness level, and future perspectives

BACKGROUND

Cardiac magnetic resonance (CMR) provides excellent temporal and spatial resolution, tissue characterization, and flow measurements. This enables major advantages when guiding cardiac invasive procedures compared with X-ray fluoroscopy or ultrasound guidance. However, clinical implementation is limited due to limited availability of technological advancements in magnetic resonance imaging (MRI) compatible equipment. A systematic review of the available literature on past and present applications of interventional MR and its technology readiness level (TRL) was performed, also suggesting future applications.

METHODS

A structured literature search was performed using PubMed. Search terms were focused on interventional CMR, cardiac catheterization, and other cardiac invasive procedures. All search results were screened for relevance by language, title, and abstract. TRL was adjusted for use in this article, level 1 being in a hypothetical stage and level 9 being widespread clinical translation. The papers were categorized by the type of procedure and the TRL was estimated.

RESULTS

Of 466 papers, 117 papers met the inclusion criteria. TRL was most frequently estimated at level 5 meaning only applicable to in vivo animal studies. Diagnostic right heart catheterization and cavotricuspid isthmus ablation had the highest TRL of 8, meaning proven feasibility and efficacy in a series of humans.

CONCLUSION

This article shows that interventional CMR has a potential widespread application although clinical translation is at a modest level with TRL usually at 5. Future development should be directed toward availability of MR-compatible equipment and further improvement of the CMR techniques. This could lead to increased TRL of interventional CMR providing better treatment.

T2-based area-at-risk and edema are influenced by ischemic duration in acute myocardial infarction

The purpose of our study was to assess whether T2 MRI identifies the infarcted myocardium or the true area-at-risk (AAR) and whether edema is present in the salvageable region following acute myocardial infarction (MI). The study involved a porcine model of MI with a coronary occlusion model of either 60 min or 90 min. Imaging was performed on a 3T MRI pre-occlusion and at day 3 post-MI. Prior-MI, myocardial perfusion territory (MPT) maps were obtained under MRI via direct intracoronary injection of contrast agent. Post-MI, edema extent was quantified by T2 mapping while infarction and microvascular obstruction (MVO) were assessed by late gadolinium enhancement (LGE). Anatomically registered short-axis slices were analyzed for MPT, T2-AAR and infarct areas and T2 relaxation values. Animals were divided into groups with (MVO+) and without MVO (MVO-). T2-AAR area was significantly greater than infarct area in both groups. In the MVO+ group, T2-AAR and MPT were comparable and highly correlated, whereas, in the MVO- group, T2-AAR significantly underestimated MPT without any trend. T2 values in the salvageable myocardium were found to be significantly higher than those in remote myocardium. Our methodology offers the advantage that all images are acquired within the same MRI reference as opposed to complex co-registration with gross pathology. Our study suggests that edema may expand beyond the infarct zone over the entire ischemic bed. T2-AAR may be more clinically relevant than true AAR by perfusion territory since it identifies the "salvageable" myocardium.

Vessel-specific coronary perfusion territories using a CT angiogram with a minimum cost path technique and its direct comparison to the American Heart Association 17-segment model

OBJECTIVES

This study compared the accuracy of an automated, vessel-specific minimum cost path (MCP) myocardial perfusion territory assignment technique as compared with the standard American Heart Association 17-segment (AHA) model.

METHODS

Six swine (42 ± 9 kg) were used to evaluate the accuracy of the MCP technique and the AHA method. In each swine, a dynamic acquisition, comprised of twenty consecutive whole heart volume scans, was acquired with a computed tomography scanner, following peripheral injection of contrast material. From this acquisition, MCP and AHA perfusion territories were determined, for the left (LCA) and right (RCA) coronary arteries. Each animal underwent additional dynamic acquisitions, consisting of twenty consecutive volume scans, following direct intracoronary contrast injection into the LCA or RCA. These images were used as the reference standard (REF) LCA and RCA perfusion territories. The MCP and AHA techniques' perfusion territories were then quantitatively compared with the REF perfusion territories.

RESULTS

The myocardial mass of MCP perfusion territories (M_MCP) was related to the mass of reference standard perfusion territories (M_REF) by M_MCP = 0.99M_REF + 0.39 g (r = 1.00; R² = 1.00). The mass of AHA perfusion territories (M_AHA) was related to M_REF by M_AHA = 0.81M_REF + 5.03 g (r = 0.99; R² = 0.98).

CONCLUSION

The vessel-specific MCP myocardial perfusion territory assignment technique more accurately quantifies LCA and RCA perfusion territories as compared with the current standard AHA 17-segment model. Therefore, it can potentially provide a more comprehensive and patient-specific evaluation of coronary artery disease.

KEY POINTS

• The minimum cost path (MCP) technique accurately determines left and right coronary artery perfusion territories, as compared with the American Heart Association 17-segment (AHA) model. • The minimum cost path (MCP) technique could be applied to cardiac computed-tomography angiography images to accurately determine patient-specific left and right coronary artery perfusion territories. • The American Heart Association 17-segment (AHA) model often fails to accurately determine left and right coronary artery perfusion territories, especially in the inferior and inferoseptal walls of the left ventricular myocardium.

Quantification of vessel-specific coronary perfusion territories using minimum-cost path assignment and computed tomography angiography: Validation in a swine model

BACKGROUND

As combined morphological and physiological assessment of coronary artery disease (CAD) is necessary to reliably resolve CAD severity, the objective of this study was to validate an automated minimum-cost path assignment (MCP) technique which enables accurate, vessel-specific assignment of the left (LCA) and right (RCA) coronary perfusion territories using computed tomography (CT) angiography data for both left and right ventricles.

METHODS

Six swine were used to validate the MCP technique. In each swine, a dynamic acquisition comprised of twenty consecutive volume scans was acquired with a 320-slice CT scanner following peripheral injection of contrast material. From this acquisition the MCP technique was used to automatically assign LCA and RCA perfusion territories for the left and right ventricles, independently. Each animal underwent another dynamic CT acquisition following direct injection of contrast material into the LCA or RCA. Using this acquisition, reference standard LCA and RCA perfusion territories were isolated from the myocardial blush. The accuracy of the MCP technique was evaluated by quantitatively comparing the MCP-derived LCA and RCA perfusion territories to these reference standard territories.

RESULTS

All MCP perfusion territory masses (Mass_MCP) and all reference standard perfusion territory masses (Mass_RS) in the left ventricle were related by Mass_MCP = 0.99Mass_RS+0.35 g (r = 1.00). Mass_MCP and Mass_RS in the right ventricle were related by Mass_MCP = 0.94Mass_RS+0.39 g (r = 0.96).

CONCLUSION

The MCP technique was validated in a swine animal model and has the potential to be used for accurate, vessel-specific assignment of LCA and RCA perfusion territories in both the left and right ventricular myocardium using CT angiography data.

Comprehensive Assessment of Coronary Artery Disease by Using First-Pass Analysis Dynamic CT Perfusion: Validation in a Swine Model

Purpose To retrospectively validate a first-pass analysis (FPA) technique that combines computed tomographic (CT) angiography and dynamic CT perfusion measurement into one low-dose examination. Materials and Methods The study was approved by the animal care committee. The FPA technique was retrospectively validated in six swine (mean weight, 37.3 kg ± 7.5 [standard deviation]) between April 2015 and October 2016. Four to five intermediate-severity stenoses were generated in the left anterior descending artery (LAD), and 20 contrast material-enhanced volume scans were acquired per stenosis. All volume scans were used for maximum slope model (MSM) perfusion measurement, but only two volume scans were used for FPA perfusion measurement. Perfusion measurements in the LAD, left circumflex artery (LCx), right coronary artery, and all three coronary arteries combined were compared with microsphere perfusion measurements by using regression, root-mean-square error, root-mean-square deviation, Lin concordance correlation, and diagnostic outcomes analysis. The CT dose index and size-specific dose estimate per two-volume FPA perfusion measurement were also determined. Results FPA and MSM perfusion measurements (P_FPA and P_MSM) in all three coronary arteries combined were related to reference standard microsphere perfusion measurements (P_MICRO), as follows: P_{FPA_COMBINED} = 1.02 P_{MICRO_COMBINED} + 0.11 (r = 0.96) and P_{MSM_COMBINED} = 0.28 P_{MICRO_COMBINED} + 0.23 (r = 0.89). The CT dose index and size-specific dose estimate per two-volume FPA perfusion measurement were 10.8 and 17.8 mGy, respectively. Conclusion The FPA technique was retrospectively validated in a swine model and has the potential to be used for accurate, low-dose vessel-specific morphologic and physiologic assessment of coronary artery disease. ^© RSNA, 2017.

Accuracy of Area at Risk Quantification by Cardiac Magnetic Resonance According to the Myocardial Infarction Territory

INTRODUCTION AND OBJECTIVES

Area at risk (AAR) quantification is important to evaluate the efficacy of cardioprotective therapies. However, postinfarction AAR assessment could be influenced by the infarcted coronary territory. Our aim was to determine the accuracy of T₂-weighted short tau triple-inversion recovery (T₂W-STIR) cardiac magnetic resonance (CMR) imaging for accurate AAR quantification in anterior, lateral, and inferior myocardial infarctions.

METHODS

Acute reperfused myocardial infarction was experimentally induced in 12 pigs, with 40-minute occlusion of the left anterior descending (n = 4), left circumflex (n = 4), and right coronary arteries (n = 4). Perfusion CMR was performed during selective intracoronary gadolinium injection at the coronary occlusion site (in vivo criterion standard) and, additionally, a 7-day CMR, including T₂W-STIR sequences, was performed. Finally, all animals were sacrificed and underwent postmortem Evans blue staining (classic criterion standard).

RESULTS

The concordance between the CMR-based criterion standard and T₂W-STIR to quantify AAR was high for anterior and inferior infarctions (r = 0.73; P = .001; mean error = 0.50%; limits = -12.68%-13.68% and r = 0.87; P = .001; mean error = -1.5%; limits = -8.0%-5.8%, respectively). Conversely, the correlation for the circumflex territories was poor (r = 0.21, P = .37), showing a higher mean error and wider limits of agreement. A strong correlation between pathology and the CMR-based criterion standard was observed (r = 0.84, P < .001; mean error = 0.91%; limits = -7.55%-9.37%).

CONCLUSIONS

T₂W-STIR CMR sequences are accurate to determine the AAR for anterior and inferior infarctions; however, their accuracy for lateral infarctions is poor. These findings may have important implications for the design and interpretation of clinical trials evaluating the effectiveness of cardioprotective therapies.

Distal coronary embolization following acute myocardial infarction increases early infarct size and late left ventricular wall thinning in a porcine model

BACKGROUND

Distal coronary embolization (DCE) of thrombotic material occurs frequently during percutaneous interventions for acute myocardial infarction and can alter coronary flow grades. The significance of DCE on infarct size and myocardial function remains unsettled. The aims of this study were to evaluate the effects of DCE sufficient to cause no-reflow on infarct size, cardiac function and ventricular remodeling in a porcine acute myocardial infarction model.

METHODS AND RESULTS

Female Yorkshire pigs underwent 60 min balloon occlusion of the left anterior descending coronary artery followed by reperfusion and injection of either microthrombi (prepared from autologous porcine blood) sufficient to cause no-reflow (DCE), or saline (control). Animals were sacrificed at 3 h (n = 5), 3 days (n = 20) or 6 weeks (n = 20) post-AMI. Cardiovascular magnetic resonance (CMR), serum troponin-I, and cardiac gelatinase (MMP) and survival kinase (Akt) activities were assessed. At 3d, DCE increased infarct size (CMR: 18.8% vs. 14.5%, p = 0.04; serum troponin-I: 13.3 vs. 6.9 ng/uL, p < 0.05) and MMP-2 activity levels (0.81 vs. 0.49, p = 0.002), with reduced activation of Akt (0.06 versus 0.26, p = 0.02). At 6 weeks, there were no differences in infarct size, ventricular volume or ejection fraction between the two groups, although infarct transmurality (70% vs. 57%, p< 0.04) and ventricular thinning (percent change in mid anteroseptal wall thickness:-25.6% vs. 0.7%, p = 0.03) were significantly increased in the DCE group.

CONCLUSIONS

DCE increased early infarct size, but without affecting later infarct size, cardiac function or ventricular volumes. The significance of the later remodelling changes (ventricular thinning and transmurality) following DCE, possibly due to changes in MMP-2 activity and Akt activation, merits further study.

Coronary microembolization causes long-term detrimental effects on regional left ventricular function

OBJECTIVES

To investigate whether coronary microemboli have long-term effects on left ventricular (LV) function in an experimental model. Furthermore, to determine if first-pass perfusion and late gadolinium enhancement (LGE) patterns differs between small- and large-sized microemboli.

DESIGN

Six pigs underwent left anterior descending (LAD)-coronary microembolization with small-sized (40-120 μm, n ∼ 250 000) microemboli using a combined x-ray and MRI-system. MR-images before, one hour after and 7-8 weeks after microembolization were obtained. Results were compared to MRI obtained by large-sized (100-300 μm, n ∼ 7200) microemboli.

RESULTS

Cine MRI showed an acute drop in ejection fraction (from 49.5 ± 2.6% to 32.5 ± 2.8) that substantially recovered at 7-8 weeks (47.5 ± 3.2%). Regional LV-function assessed as circumferential, longitudinal and radial strain declined in both microinfarcts and remote regions followed by partial recovery at 7-8 weeks. The decline in LV function and the severe perfusion deficit from the small microemboli was similar to the large microemboli at one hour. There was a significant recovery in perfusion at 7-8 weeks in the microinfarcts. LGE demonstrated the microinfarcts at 7-8 weeks but not at one hour and the microinfarcts were confirmed by histopathology.

CONCLUSION

Microembolization causes long-term, regional LV dysfunction and this study confirmed the need of a comprehensive MRI-protocol for the detection of microinfarcts. These findings suggest that even small microemboli (40-120 μm in diameter), which may escape the distal protective devices influence cardiac function.

Four-dimensional transcatheter intra-arterial perfusion MR imaging before and after uterine artery embolization in the rabbit VX2 tumor model

PURPOSE

To test the hypothesis that four-dimensional (4D) transcatheter intra-arterial perfusion (TRIP) MR imaging can measure uterine fibroid perfusion changes immediately before and after uterine artery embolization (UAE) in the rabbit VX2 tumor model.

MATERIALS AND METHODS

Eight VX2 uterine tumors were grown in six rabbits. After positioning a catheter within the uterine artery, we performed 4D TRIP-MRI measurements with 3-mL injections of 2.5% gadopentetate dimeglumine. We used a dynamic 3D spoiled-gradient echo sequence with in vivo B(1)-field correction for improved accuracy during perfusion quantification. We performed UAE using 1 mL of gelatin microspheres (2 x 10(6) particles; diameter 40-120 mum). Two regions-of-interest were drawn within each tumor upon perfusion maps. Functional embolic endpoints were reported as the mean percent reduction in fibroid tumor perfusion. Measurements before and after UAE were compared using paired t-tests (alpha = 0.05).

RESULTS

VX2 uterine tumor perfusion decreased significantly from 27.1 at baseline to 7.09 after UAE (mL/min/100 mL of tissue, P < 0.0001). Overall perfusion reduction was 76.3% (95% confidence interval: 66.3-86.3%).

CONCLUSION

Four-dimensional TRIP MRI can objectively quantify uterine fibroid perfusion reductions during UAE in VX2 rabbits. This technique could be used clinically to potentially determine an optimal embolic endpoint with the long-term goals of improving UAE success rates and minimizing procedure-related ischemic pain.

Heterogeneous microinfarcts caused by coronary microemboli: evaluation with multidetector CT and MR imaging in a swine model

PURPOSE

To directly compare the sensitivity of 64-section multidetector computed tomography (CT) with that of 1.5-T magnetic resonance (MR) imaging in the depiction and measurement of heterogeneous 7-8-week-old microinfarcts and the quantification of regional left ventricular (LV) function and perfusion in the territory of coronary intervention in a swine model.

MATERIALS AND METHODS

Approval was obtained from the institutional animal committee. An x-ray/MR system was used to catheterize the left anterior descending (LAD) coronary artery with x-ray guidance and to delineate the perfusion territory. The vessel was selectively microembolized in six pigs with small-diameter embolic material (40-120 microm, 250000 count). At 7-8 weeks after microembolization, multidetector CT and MR imaging were used to assess LV function, first-pass perfusion, and delayed contrast enhancement in remote myocardium and microinfarct scars. Histochemical staining with triphenyltetrazolium chloride (TTC) was used to confirm and quantify heterogeneous microinfarct scars. The two-tailed Wilcoxon signed rank test was used to detect differences between modalities and myocardial regions.

RESULTS

The LAD territory was 32.4% +/- 3.8(stadard error of the mean) of the LV mass. Multidetector CT and MR imaging have similar sensitivity in the detection of regional and global LV dysfunction and extent of microinfarct. The mean LV end-diastolic volume, end-systolic volume, and ejection fraction were 93 mL +/- 8, 46 mL +/- 4, and 50% +/- 3, respectively, on multidetector CT images and 92 mL +/- 8, 48 mL +/- 5, and 48% +/- 3, respectively, on MR images (P > or = .05). The extent of heterogeneous microinfarct was not significantly different between multidetector CT (6.3% +/- 0.8 of the LV mass), MR imaging (6.6% +/- 0.5 of the LV mass), and TTC staining (7.0% +/- 0.6 of the LV mass). First-pass multidetector CT and MR imaging demonstrated significant regional differences (P < .05) in time to peak between the heterogeneous microinfarct and remote myocardium (17.0 seconds +/- 0.3 and 12.4 seconds +/- 0.6, respectively, for multidetector CT and 17.2 seconds +/- 0.8 and 12.5 seconds +/- 1.0, respectively, for MR imaging).

CONCLUSION

Modern multidetector CT and MR imaging are sensitive modalities with which to depict heterogeneous microinfarcts and determine regional LV dysfunction and decreased perfusion in the territory of intervention. (c) RSNA, 2010.