Additive value of magnetic resonance coronary angiography in a comprehensive cardiac magnetic resonance stress-rest protocol for detection of functionally significant coronary artery disease: a pilot study

Fully automated pixel-wise quantitative CMR-myocardial perfusion with CMR-coronary angiography to detect hemodynamically significant coronary artery disease

OBJECTIVES

We applied a fully automated pixel-wise post-processing framework to evaluate fully quantitative cardiovascular magnetic resonance myocardial perfusion imaging (CMR-MPI). In addition, we aimed to evaluate the additive value of coronary magnetic resonance angiography (CMRA) to the diagnostic performance of fully automated pixel-wise quantitative CMR-MPI for detecting hemodynamically significant coronary artery disease (CAD).

METHODS

A total of 109 patients with suspected CAD were prospectively enrolled and underwent stress and rest CMR-MPI, CMRA, invasive coronary angiography (ICA), and fractional flow reserve (FFR). CMRA was acquired between stress and rest CMR-MPI acquisition, without any additional contrast agent. Finally, CMR-MPI quantification was analyzed by a fully automated pixel-wise post-processing framework.

RESULTS

Of the 109 patients, 42 patients had hemodynamically significant CAD (FFR ≤ 0.80 or luminal stenosis ≥ 90% on ICA) and 67 patients had hemodynamically non-significant CAD (FFR ˃ 0.80 or luminal stenosis < 30% on ICA) were enrolled. On the per-territory analysis, patients with hemodynamically significant CAD had higher myocardial blood flow (MBF) at rest, lower MBF under stress, and lower myocardial perfusion reserve (MPR) than patients with hemodynamically non-significant CAD (p < 0.001). The area under the receiver operating characteristic curve of MPR (0.93) was significantly larger than those of stress and rest MBF, visual assessment of CMR-MPI, and CMRA (p < 0.05), but similar to that of the integration of CMR-MPI with CMRA (0.90).

CONCLUSIONS

Fully automated pixel-wise quantitative CMR-MPI can accurately detect hemodynamically significant CAD, but the integration of CMRA obtained between stress and rest CMR-MPI acquisition did not provide significantly additive value.

KEY POINTS

• Full quantification of stress and rest cardiovascular magnetic resonance myocardial perfusion imaging can be postprocessed fully automatically, generating pixel-wise myocardial blood flow (MBF) and myocardial perfusion reserve (MPR) maps. • Fully quantitative MPR provided higher diagnostic performance for detecting hemodynamically significant coronary artery disease, compared with stress and rest MBF, qualitative assessment, and coronary magnetic resonance angiography (CMRA). • The integration of CMRA and MPR did not significantly improve the diagnostic performance of MPR alone.

Diagnostic accuracy of whole heart coronary magnetic resonance angiography: a systematic review and meta-analysis

BACKGROUND

The purpose of this meta-analysis was to comprehensively investigate the diagnostic ability of 1.5 T and 3.0 T whole heart coronary angiography (WHCA) to detect significant coronary artery disease (CAD) on X-ray coronary angiography.

METHODS

A literature search of electronic databases, including PubMed, Web of Science Core Collection, Cochrane advanced search, and EMBASE, was performed to retrieve and integrate articles showing significant CAD detectability of 1.5 and 3.0 T WHCA.

RESULTS

Data from 1899 patients from 34 studies were included in the meta-analysis. 1.5 T WHCA had a summary area under ROC of 0.88 in the patient-based analysis, 0.90 in the vessel-based analysis, and 0.92 in the segment-based analysis. These values for 3.0 T WHCA were 0.94, 0.95, 0.96, respectively. Contrast-enhanced 3.0 T WHCA had significantly higher specificity than non-contrast-enhanced 1.5 T WHCA on a patient-based analysis (0.87, 95% CI 0.80-0.92 vs. 0.74, 95% CI 0.64-0.82, P = 0.02). There were no differences in diagnostic performance on a patient-based analysis by use of vasodilators, beta-blockers or between Asian and Western countries.

CONCLUSIONS

The diagnostic performance of WHCA was deemed satisfactory, with contrast-enhanced 3.0 T WHCA exhibiting higher specificity compared to non-contrast-enhanced 1.5 T WHCA in a patient-based analysis. There were no significant differences in diagnostic performance on a patient-based analysis in terms of vasodilator or beta-blocker use, nor between Asian and Western countries. However, further large-scale multicentre studies are crucial for the widespread global adoption of WHCA.

ACR Appropriateness Criteria® Chronic Chest Pain-High Probability of Coronary Artery Disease: 2021 Update

Management of patients with chronic chest pain in the setting of high probability of coronary artery disease (CAD) relies heavily on imaging for determining or excluding presence and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions, as well as course of management and long-term prognosis. In patients with no known ischemic heart disease, imaging is valuable in determining and documenting the presence, extent, and severity of obstructive coronary narrowing and presence of myocardial ischemia. In patients with known ischemic heart disease, imaging findings are important in determining the management of patients with chronic myocardial ischemia and can serve as a decision-making tool for medical therapy, angioplasty, stenting, or surgery. This document summarizes the recent growing body of evidence on various imaging tests and makes recommendations for imaging based on the available data and expert opinion. This document is focused on epicardial CAD and does not discuss the microvascular disease as the cause for CAD. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Non-contrast coronary magnetic resonance angiography: current frontiers and future horizons

Coronary magnetic resonance angiography (coronary MRA) is advantageous in its ability to assess coronary artery morphology and function without ionizing radiation or contrast media. However, technical limitations including reduced spatial resolution, long acquisition times, and low signal-to-noise ratios prevent it from clinical routine utilization. Nonetheless, each of these limitations can be specifically addressed by a combination of novel technologies including super-resolution imaging, compressed sensing, and deep-learning reconstruction. In this paper, we first review the current clinical use and motivations for non-contrast coronary MRA, discuss currently available coronary MRA techniques, and highlight current technical developments that hold unique potential to optimize coronary MRA image acquisition and post-processing. In the final section, we examine the various research-based coronary MRA methods and metrics that can be leveraged to assess coronary stenosis severity, physiological function, and atherosclerotic plaque characterization. We specifically discuss how such technologies may contribute to the clinical translation of coronary MRA into a robust modality for routine clinical use.

Diagnostic Accuracy of Three-Dimensional Whole-Heart Magnetic Resonance Angiography to Detect Coronary Artery Disease with Invasive Coronary Angiography as a Reference: A Meta-Analysis

Objective: We aimed to evaluate the diagnostic performance of three-dimensional whole-heart magnetic resonance coronary angiography (MRCA) in detecting coronary artery disease (CAD) with invasive coronary angiography as the reference standard.Methods: We searched PubMed and Embase for studies evaluating the diagnostic performance of three-dimensional whole-heart MRCA for the diagnosis of CAD with invasive coronary angiography as the reference standard. The bivariate mixed-effects regression model was applied to synthesize available data. The clinical utility of whole-heart MRCA was calculated by the posttest probability based on Bayes’s theorem.Results: Eighteen studies were included, of which 16 provided data at the artery level. Patient-based analysis revealed a pooled sensitivity of 0.90 (95% confidence interval [CI] 0.87‐0.93) and specificity of 0.79 (95% CI 0.73‐0.84), while the pooled estimates were 0.86 (95% CI 0.82‐0.89) and 0.89 (95% CI 0.84‐0.92), respectively, at the artery level. The areas under the summary receiver operating characteristic curve were 0.93 (95% CI 0.90‐0.95) and 0.92 (95% CI 0.90‐0.94) at the patient and artery levels, respectively. With a pretest probability of 50%, the patients’ posttest probabilities of CAD were 81% for positive results and 11% for negative results.Conclusions: Whole-heart MRCA can be an alternative noninvasive method for diagnosis and assessment of CAD.

Three-Dimensional Free-Breathing Whole-Heart Coronary Magnetic Resonance Angiography at 1.5 T: Gadobutrol-Enhanced Gradient-Echo Acquisition Sequence Versus Non-Contrast-Enhanced Steady-State Free Precession Sequence

OBJECTIVES

The objective of this study was to compare gadobutrol-enhanced gradient-echo sequence (GRE) acquisition with T2-prepared non-contrast-enhanced steady-state free precession (SSFP) in coronary magnetic resonance angiography at 1.5 T.

METHODS

Twenty-one subjects successfully completed GRE and SSFP acquisition. Signal-to-noise ratio (SNR), contrast-to-noise ratio, image quality, sharpness, visibility, length, and lumen diameter of vessels were analyzed by 2 experienced radiologists.

RESULTS

The SNR at whole left circumflex artery, left main artery, and proximal left descending artery (LAD) was significantly higher in SSFP acquisition (P < 0.05). The SNR of distal LAD was slightly higher in GRE acquisition (P < 0.05). The contrast-to-noise ratio at distal LAD, proximal and distal RCA were significantly higher with GRE acquisition (P < 0.05).

CONCLUSIONS

Double-dose gadobutrol-enhanced GRE and unenhanced SSFP coronary magnetic resonance angiography at 1.5 T have their own characteristics, and the combined use of the 2 methods may be taken into consideration.

Additive value of 3T cardiovascular magnetic resonance coronary angiography for detecting coronary artery disease

BACKGROUND

The purpose of the work was to evaluate the incremental diagnostic value of free-breathing, contrast-enhanced, whole-heart, 3 T cardiovascular magnetic resonance coronary angiography (CE-MRCA) to stress/rest myocardial perfusion imaging (MPI) and late gadolinium enhancement (LGE) imaging for detecting coronary artery disease (CAD).

METHODS

Fifty-one patients with suspected CAD underwent a comprehensive cardiovascular magnetic resonance (CMR) examination (CE-MRCA, MPI, and LGE). The additive diagnostic value of MRCA to MPI and LGE was evaluated using invasive x-ray coronary angiography (XA) as the standard for defining functionally significant CAD (≥ 50% stenosis in vessels > 2 mm in diameter).

RESULTS

90.2% (46/51) patients (54.0 ± 11.5 years; 71.7% men) completed CE-MRCA successfully. On per-patient basis, compared to MPI/LGE alone or MPI alone, the addition of MRCA resulted in higher sensitivity (100% vs. 76.5%, p < 0.01), no change in specificity (58.3% vs. 66.7%, p = 0.6), and higher accuracy (89.1% vs 73.9%, p < 0.01) for CAD detection (prevalence = 73.9%). Compared to LGE alone, the addition of CE-MRCA resulted in higher sensitivity (97.1% vs. 41.2%, p < 0.01), inferior specificity (83.3% vs. 91.7%, p = 0.02), and higher diagnostic accuracy (93.5% vs. 54.3%, p < 0.01).

CONCLUSION

The inclusion of successful free-breathing, whole-heart, 3 T CE-MRCA significantly improved the sensitivity and diagnostic accuracy as compared to MPI and LGE alone for CAD detection.

Combined Assessment of Stress Myocardial Perfusion Cardiovascular Magnetic Resonance and Flow Measurement in the Coronary Sinus Improves Prediction of Functionally Significant Coronary Stenosis Determined by Fractional Flow Reserve in Multivessel Disease

Background

Recent studies using stress‐rest perfusion cardiovascular magnetic resonance (CMR) demonstrated a close correlation between myocardial ischemia and reduced fractional flow reserve (FFR). However, its diagnostic concordance may be reduced in patients with multivessel disease. We sought to evaluate the concordance of adenosine stress‐rest perfusion CMR for predicting reduced FFR, and to determine the additive value of measuring global coronary flow reserve (CFR) in the coronary sinus in multivessel disease.

Methods and Results

Ninety‐six patients with angiographic luminal narrowing >50% underwent comprehensive CMR study and FFR measurements in 139 coronary vessels. FFR <0.80 was considered hemodynamically significant. Global CFR was quantified as the ratio of stress‐rest coronary sinus flow measured by phase‐contrast cine CMR. In 25 patients with single‐vessel disease, visual assessment of perfusion CMR yielded high diagnostic concordance for predicting flow‐limiting stenosis, with the area under receiver operating characteristic curve of 0.93 on a per‐patient basis. However, in 71 patients with multivessel disease, perfusion CMR underestimated flow‐limiting stenosis, resulting in the reduced area under receiver operating characteristic curve of 0.74. When CFR of <2.0 measured in the coronary sinus was considered as global myocardial ischemia, combined assessment provided correct reclassifications in 7 patients with false‐negative myocardial ischemia, and improved the diagnostic concordance to 92% sensitivity and 73% specificity with the area under receiver operating characteristic curve of 0.88 (95% confidence interval, 0.80%–0.97%, P=0.002).

Conclusions

Visual analysis of stress‐rest perfusion CMR has limited concordance with FFR in patients with multivessel disease. Multiparametric CMR integrating stress‐rest perfusion CMR and flow measurement in the coronary sinus is useful for detecting reduced FFR in multivessel disease.

Effects of adenosine and regadenoson on hemodynamics measured using cardiovascular magnetic resonance imaging

BACKGROUND

Adenosine or regadenoson vasodilator stress cardiovascular magnetic resonance (CMR) is an effective non-invasive strategy for evaluating symptomatic coronary artery disease. Vasodilator injection typically precedes ventricular functional sequences to efficiently reduce overall scanning times, though the effects of vasodilators on CMR-derived ventricular volumes and function are unknown.

METHODS

We prospectively enrolled 25 healthy subjects to undergo consecutive adenosine and regadenoson administration. Short axis CINE datasets were obtained on a 1.5 T scanner following adenosine (140mcg/kg/min IV for 6 min) and regadenoson (0.4 mg IV over 10 s) at baseline, immediately following administration, at 5 min intervals up to 15 min. Hemodynamic response, bi-ventricular volumes and ejection fractions were determined at each time point.

RESULTS

Peak heart rate was observed early following administration of both adenosine and regadenoson. Heart rate returned to baseline by 10 min post-adenosine while remaining elevated at 15 min post-regadenoson (p = 0.0015). Left ventricular (LV) ejection fraction (LVEF) increased immediately following both vasodilators (p < 0.0001 for both) and returned to baseline following adenosine by 10 min (p = 0.8397). Conversely, LVEF following regadenoson remained increased at 10 min (p = 0.003) and 15 min (p = 0.0015) with a mean LVEF increase at 15 min of 4.2 ± 1.3%. Regadenoson resulted in a similar magnitude reduction in both LV end-diastolic volume index (LVEDVi) and LV end-systolic volume index (LVESVi) at 15 min whereas LVESVi resolved at 15 min following adenosine and LVEDVi remained below baseline values (p = 0.52).

CONCLUSIONS

Regadenoson and adenosine have significant and prolonged impact on ventricular volumes and LVEF. In patients undergoing vasodilator stress CMR where ventricular volumes and LVEF are critical components to patient care, ventricular functional sequences should be performed prior to vasodilator use or consider the use of aminophylline in the setting of regadenoson. Additionally, heart rate resolution itself is not an effective surrogate for return of ventricular volumes and LVEF to baseline.

Assessment of stable coronary artery disease by cardiovascular magnetic resonance imaging: Current and emerging techniques

Coronary artery disease (CAD) is a leading cause of death and disability worldwide. Cardiovascular magnetic resonance (CMR) is established in clinical practice guidelines with a growing evidence base supporting its use to aid the diagnosis and management of patients with suspected or established CAD. CMR is a multi-parametric imaging modality that yields high spatial resolution images that can be acquired in any plane for the assessment of global and regional cardiac function, myocardial perfusion and viability, tissue characterisation and coronary artery anatomy, all within a single study protocol and without exposure to ionising radiation. Advances in technology and acquisition techniques continue to progress the utility of CMR across a wide spectrum of cardiovascular disease, and the publication of large scale clinical trials continues to strengthen the role of CMR in daily cardiology practice. This article aims to review current practice and explore the future directions of multi-parametric CMR imaging in the investigation of stable CAD.

Individual component analysis of the multi-parametric cardiovascular magnetic resonance protocol in the CE-MARC trial

BACKGROUND

The CE-MARC study assessed the diagnostic performance investigated the use of cardiovascular magnetic resonance (CMR) in patients with suspected coronary artery disease (CAD). The study used a multi-parametric CMR protocol assessing 4 components: i) left ventricular function; ii) myocardial perfusion; iii) viability (late gadolinium enhancement (LGE)) and iv) coronary magnetic resonance angiography (MRA). In this pre-specified CE-MARC sub-study we assessed the diagnostic accuracy of the individual CMR components and their combinations.

METHODS

All patients from the CE-MARC population (n = 752) were included using data from the original blinded-read. The four individual core components of the CMR protocol was determined separately and then in paired and triplet combinations. Results were then compared to the full multi-parametric protocol.

RESULTS

CMR and X-ray angiography results were available in 676 patients. The maximum sensitivity for the detection of significant CAD by CMR was achieved when all four components were used (86.5%). Specificity of perfusion (91.8%), function (93.7%) and LGE (95.8%) on its own was significantly better than specificity of the multi-parametric protocol (83.4%) (all P < 0.0001) but with the penalty of decreased sensitivity (86.5% vs. 76.9%, 47.4% and 40.8% respectively). The full multi-parametric protocol was the optimum to rule-out significant CAD (Likelihood Ratio negative (LR-) 0.16) and the LGE component alone was the best to rue-in CAD (LR+ 9.81). Overall diagnostic accuracy was similar with the full multi-parametric protocol (85.9%) compared to paired and triplet combinations. The use of coronary MRA within the full multi-parametric protocol had no additional diagnostic benefit compared to the perfusion/function/LGE combination (overall accuracy 84.6% vs. 84.2% (P = 0.5316); LR- 0.16 vs. 0.21; LR+ 5.21 vs. 5.77).

CONCLUSIONS

From this pre-specified sub-analysis of the CE-MARC study, the full multi-parametric protocol had the highest sensitivity and was the optimal approach to rule-out significant CAD. The LGE component alone was the optimal rule-in strategy. Finally the inclusion of coronary MRA provided no additional benefit when compared to the combination of perfusion/function/LGE.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN77246133.

Diagnostic accuracy of stress myocardial perfusion imaging compared to invasive coronary angiography with fractional flow reserve meta-analysis

BACKGROUND

Hemodynamically significant coronary artery disease is an important indication for revascularization. Stress myocardial perfusion imaging is a noninvasive alternative to invasive fractional flow reserve for evaluating hemodynamically significant coronary artery disease. The aim was to determine the diagnostic accuracy of myocardial perfusion imaging by single-photon emission computed tomography, echocardiography, MRI, positron emission tomography, and computed tomography compared with invasive coronary angiography with fractional flow reserve for the diagnosis of hemodynamically significant coronary artery disease.

METHODS AND RESULTS

The meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. PubMed, EMBASE, and Web of Science were searched until May 2014. Thirty-seven studies, reporting on 4721 vessels and 2048 patients, were included. Meta-analysis yielded pooled sensitivity, pooled specificity, pooled likelihood ratios (LR), pooled diagnostic odds ratio, and summary area under the receiver operating characteristic curve. The negative LR (NLR) was chosen as the primary outcome. At the vessel level, MRI (pooled NLR, 0.16; 95% confidence interval [CI], 0.13-0.21) was performed similar to computed tomography (pooled NLR, 0.22; 95% CI, 0.12-0.39) and positron emission tomography (pooled NLR, 0.15; 95% CI, 0.05-0.44), and better than single-photon emission computed tomography (pooled NLR, 0.47; 95% CI, 0.37-0.59). At the patient level, MRI (pooled NLR, 0.14; 95% CI, 0.10-0.18) performed similar to computed tomography (pooled NLR, 0.12; 95% CI, 0.04-0.33) and positron emission tomography (pooled NLR, 0.14; 95% CI, 0.02-0.87), and better than single-photon emission computed tomography (pooled NLR, 0.39; 95% CI, 0.27-0.55) and echocardiography (pooled NLR, 0.42; 95% CI, 0.30-0.59).

CONCLUSIONS

Stress myocardial perfusion imaging with MRI, computed tomography, or positron emission tomography can accurately rule out hemodynamically significant coronary artery disease and can act as a gatekeeper for invasive revascularization. Single-photon emission computed tomography and echocardiography are less suited for this purpose.

Established and emerging cardiovascular magnetic resonance techniques for the assessment of stable coronary heart disease and acute coronary syndromes

Coronary heart disease (CHD) is a leading cause of death and disability worldwide. International guidelines recommend cardiovascular magnetic resonance (CMR) as an investigative option in those presenting with chest pain to inform diagnosis, risk stratify and determine the need for revascularization. CMR offers a unique method to assess global and regional cardiac function, myocardial perfusion, myocardial viability, tissue characterisation and proximal coronary anatomy all within a single study. This results in high diagnostic accuracy for the detection of significant coronary stenoses and an established role in the management of both stable CHD and acute coronary syndromes (ACS). The growing evidence base for the prognostic value of CMR, emerging advances in acquisition techniques, improvements in hardware and the completion of current major multi-centre clinical CMR trials will further raise its prominence in international guidelines and routine cardiological practice. This article will focus on the rapidly evolving role of the multi-parametric CMR examination in the assessment of patients with stable and unstable CHD.

Cardiac magnetic resonance for prognostic assessment: present applications and future directions

Cardiac magnetic resonance is increasingly used in clinical practice for both diagnostic and prognostic purposes. In the field of ischemic heart disease, perfusion imaging permits the assessment of ischemia, which is strongly related to future cardiac events and mortality. Late gadolinium enhancement is also associated with the prognosis and can be used as a marker of functional recovery. Cardiac magnetic resonance also permits the detection of microvascular obstruction and infarct hemorrhage, both related to an adverse outcome. In non-ischemic heart disease, the presence of late gadolinium enhancement is linked to mortality and hard events. Finally, coronary angiography, as well as new techniques, such as T1 mapping, may also have a prognostic role.