SCMR Position Paper (2020) on clinical indications for cardiovascular magnetic resonance

Abstract

The Society for Cardiovascular Magnetic Resonance (SCMR) last published its comprehensive expert panel report of clinical indications for CMR in 2004. This new Consensus Panel report brings those indications up to date for 2020 and includes the very substantial increase in scanning techniques, clinical applicability and adoption of CMR worldwide. We have used a nearly identical grading system for indications as in 2004 to ensure comparability with the previous report but have added the presence of randomized controlled trials as evidence for level 1 indications. In addition to the text, tables of the consensus indication levels are included for rapid assimilation and illustrative figures of some key techniques are provided.

Fig. 1

Balanced steady state free precession (bSSFP) cine images through a superior sinus venosus defect (*): a sagittal oblique view, b transverse oblique also showing anomalously draining right pulmonary veins

Fig. 2

Multiple CMR methods of imaging coarctation of the aorta: a sagittal oblique 2D black blood, b maximal intensity projection gadolinium enhanced CMR angiogram (CMRA) and c volume rendering of gadolinium enhanced CMRA

Fig. 3

61-year old male followed up after ascending aorta replacment for Stanford type A ascending aortic dissection. Balanced steady state free precession (bSSFP) non-contrast CMRA of the ascending aorta synchronized to the diastolic rest period shows the aortic root and origin of the right coronary artery without motion artefacts. Note artefacts due to sternal wires

Fig. 4

4D flow CMR velocity maximal intensity projection (MIP) (A) and time-resolved CMRA (TR-CMRA) MIP in a patient with type B aortic dissection. While TR-CMRA demonstrates dynamic filling of the proximal false lumen (FL), 4D flow exhibits a prominent entry tear jet impinging on the wall of the distal arch (white arrow). At least one smaller hemodynamically active fenestration is also seen more distal to the primary entry tear (arrowhead). TL: true lumen. Figure courtesy of Bradley D. Allen, MD MS, and Michael Markl, Ph.D., Northwestern University, Chicago, IL

Fig. 5

65-year-old man with bilateral Fontaine IIb peripheral arterial disease. There are bilateral common femoral artery occlusions bridged by collaterals, as well as an occluded superficial femoral artery in the left leg. Collateral arteries bridge the common femoral arteries. The right superficial femoral artery shows a high-grade stenosis (arrowhead). The tibioperoneal trunk and proximal posterior tibial artery are clearly patent (horizontal arrow). There is subtle narrowing of the proximal right renal artery (oblique arrow)

Fig. 6

A 75 year-old male with hypertension and hyperlipidemia reported exertional dyspnea during rehabilitation post-stroke. Transthoracic echocardiography (TTE) showed mild left ventricular (LV) systolic dysfunction, and he had difficulty walking. Given concern for myocardial ischemia, he was referred for CMR with stress. Late gadolinium enhancement (LGE) demonstrates a small subendocardial infarct in the basal inferior wall, while myocardial perfusion acquired during adenosine infusion (stress) shows extensive perfusion abnormality that mostly resolves on resting perfusion imaging. Cine CMR demonstrates mild segmental LV dysfunction. These findings prompted invasive coronary angiography that showed high-grade multivessel coronary artery disease (CAD); post-revascularization, functional capacity improved

Fig. 7

CMR criteria for non-ischemic myocardial inflammation (“Lake Louise Criteria”)

Fig. 8

CMR in a patient with Anderson-Fabry Disease and associated myocardial inflammation. Upper row: LGE images showing inferolateral subepicardial LGE (arrowheads). Middle row: Native T1 maps showing a global decrease of native T1, specifically in the inferolateral wall (arrows). Lower row: T2 maps with increased myocardial T2, including the inferolateral wall, co-located with the areas that showed a low T1 (arrows)

Fig. 9

LGE images in a patient with pulmonary sarcoidosis and extensive cardiac involvement. There are several focal non-subendocardial based LGE areas with infiltration (arrows) in a variable pattern of transmural distribution

Fig. 10

62-year-old woman with clinical presentation of Dressler’s syndrome following mitral and tricuspid valve replacement. Axial T1-weighted FSE imaging shows mildly thickening pericardium (a, black arrows). Short-axis T2-weighted fast spin echo imaging shows diffuse hyperintense appearance of the pericardium (b, white arrows). Late gadolinium enhancement imaging in cardiac short-axis shows diffuse strong pericardial enhancement (c, white arrows). CMR findings are highly suggestive of inflammatory pericarditis without evidence of associated pericardial effusion (“dry pericarditis”)

Fig. 11

This 72-year-old male was admitted with dyspnea, pleural fluid and cirrhosis. Horizontal long-axis T1-weighted fast spin echo imaging shows (a) shows a focally thickened pericardium (black arrow) focally constricting the apical half of the right ventricle (RV). Horizontal long-axis cine imaging (b) confirms the constriction of the RV apex by the thick pericardium (white arrow). Presence of a moderate tricuspid regurgitation, bilaterally dilated atria, and right-sided pleural effusion, indirect findings compatible with constrictive pericarditis. The patient underwent successfully a pericardectomy

Fig. 12

Left atrial sarcoma (undifferentiated) obstructing mitral inflow (upper left: diastolic frame from bSSFP cine). T1W turbo spin-echo image shows the mass isointense relative to the myocardium (upper right) and hyperintense on short tau inversion recovery (STIR) T2 image (lower left). Extensive patchy enhancement within the mass is seen on LGE compatible with necrosis in this setting (lower right)

Fig. 13

Large right ventricular fibroma attached to the entire ventricular septum. Diastolic frame from bSSFP cine (upper left). T1W fast spin-echo image (upper right) and STIR T2 image (lower right) show hypointense mass with very well defined borders and a thin rim of myocardium. LGE (right lower) shows extensive almost homogenous enhancement of the mass due to high fibrous/collagen content

Fig. 14

Moderate aortic stenosis (short axis cine bSSFP image through the aortic valve tips in systole)—demonstrating the ease and reliability of direct planimetry to measure the valve area

Fig. 15

4D flow image demonstrating the extreme helical flow pattern in the ascending aorta of a patient with a bicuspid aortic valve