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)

Abstract

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.

Keywords: Appropriate use criteria; Cardiac magnetic resonance; Cardiac masses; Cardiac transplant; Cardio-oncology and toxic cardiomyopathy; Cardiology; Congenital heart disease; Consensus document; Ischemic heart disease; Radiology.

Fig. 1

Example of stress CMR in a 54-year-old man with excertional chest pain. Rest (a) and stress (b) perfusion sequences show a large and reversible perfusion defect in the lateral mid LV wall. c No LGE is observed. d Biventricular global function was normal at cine-SSFP. e Coronary angiography confirmed a high grade stenosis of distal circumflex artery. CMR: cardiac magnetic resonance; LV: left ventricle; LGE: late gadolinium enhancement; SSFP: steady ste free-precession

Fig. 2

Examples of CMR patterns in STEMI and NSTEMI cases. A 52-years-old man with lateral NSTEMI a, b STIR and PSIR sequences show subendocardial edema (a) and LGE (b) involving the lateral wall at mid-apical level  (white arrows). c, d Patient with STEMI involving infero-lateral segments on basal and mid-ventricular plane. Transmural edema (c) and LGE (d) are present, with associated LV dilation and positive wall remodeling (yellow arrows). Aborted MI characterized by subendocardial mid-lateral  edema on short axis STIR image (e)  (*) , with no enhancement on LGE sequences (f). g, h 65-years-old man with critical stenosis of ADA and RCA. Anterior STEMI with anterior, septal and inferior wall involvement. IMH is visible in the inferior segments of apical plane (red **). NSTEMI: Non ST-elevation myocardial infarction; STIR: short tau inversion recovery; PSIR: phase sensitive inversion recovery; LGE: late gadolinium enhancement; STEMI: ST-elevation myocardial infarction; LV: left ventricle; MI: myocardial infarction; MVO: microvascular obstruction; ADA: anterior descending artery; RCA: right coronary artery; IMH: intramyocardial hemorrhage

Fig. 3

Example of CHD: CMR quantification of extra-cardiac shunt. a CMR Axial Heart SSFP images show dextroposition of aorta (white arrow). b Cine LV Sax images show right ventricular outflow tract patch. c Sax MDE sequences show a small amount of LGE around right ventricular outflow. The patient had ventricular arrhythmias with LBBB morphology. d Axial Heart SSFP images show residual VSD (yellow arrow). PC CMR of pulmonary artery (e) and ascending aorta (f) show Qp/Qs (1,49) meaning moderate shunt; moderate pulmonary regurgitation (RF 27%). CHD: congenital heart disease; CMR: cardiac magnetic resonance; SSFP: steady-state free precession; LGE: late gadolinium enhancement; LV: left ventricle; SAX: short axis; PC: phase contrast; VSD: ventricular septal defect; RF: regurgitant fraction; LBBB: left bundle branch block

Fig. 4

Examples of a typical malignant (angiosarcoma: a–c) and benign (myxoma: d–f) cardiac mass. a–c Angiosarcoma appears as a large, infiltrative lesion attached to the right atrial roof and extending in the pericardial space (***). There is inhomogeneous contrast enhancement in post-contrast T1-weighted and LGE images (b–c) as compared to pre-contrast T1-weighted short axis image  (***). Atrial myxoma on T1 weighted short axis image (d), shows spotty low signal intralesional components, consistent with presence of intratumoral calcifications (*). Lesion appears typically hyperintese in T2 weighted images (e), due to the myxoid tissue content of the mass. LGE sequences show inhomogeneous enhancement of the tumor  (f). LGE: Late Gadolinium Enhancement