CMR for myocardial characterization in ischemic heart disease: state-of-the-art and future developments

Abstract

Ischemic heart disease and its sequelae are one of the major contributors to morbidity and mortality worldwide. Over the last decades, technological developments have strengthened the role of noninvasive imaging for detection, risk stratification, and management of patients with ischemic heart disease. Cardiac magnetic resonance (CMR) imaging incorporates both functional and morphological characterization of the heart to determine presence, acuteness, and severity of ischemic heart disease by evaluating myocardial wall motion and function, the presence and extent of myocardial edema, ischemia, and scarring. Currently established clinical protocols have already demonstrated their diagnostic and prognostic value. Nevertheless, there are emerging imaging technologies that provide additional information based on advanced quantification of imaging biomarkers and improved diagnostic accuracy, therefore potentially allowing reduction or avoidance of contrast and/or stressor agents. The aim of this review is to summarize the current state of the art of CMR imaging for ischemic heart disease and to provide insights into promising future developments.

Keywords: Coronary artery disease; Heart; Magnetic resonance imaging; Myocardial infarction; Myocardial ischemia.

Fig. 1

Thirty-two-year-old man with acute anteroseptal myocardial infarction. Diastolic phase, post-contrast cine bSSFP image indicates areas of myocardial edema and wall motion abnormalities (a, white arrows). Systolic phase image (b) is shown with myocardial displacement overlay. 3D visualization with Feature Tracking radial strain overlay indicates reduced contractility (c, blue area) in the affected territory. bSSFP Balanced steady-state free precession

Fig. 2

Thirty-two-year-old man with acute anteroseptal myocardial infarction (same patient as in Fig. 1). T2-STIR image shows excessive edema (a, white arrows), corresponding to increased native T1 (b, white arrows) and T2 (c, white arrows) relaxation times in the affected myocardium. T2-STIR, T2-weighted short-tau inversion recovery

Fig. 3

First pass perfusion at rest (a) and stress (c) in a 58-year-old man with suspected coronary artery disease. Semiquantitative parametric slope maps (b) show no perfusion defects at rest, while extensive perfusion deficit (white arrows) in the anterior septum (left anterior descending area) and lateral wall (circumflex area) is demonstrated at stress (d), indicating transient ischemia likely due to left main disease

Fig. 4

Conventional LGE (a), dark blood LGE (b), according Muscogiuri et al [108], and T1 map (c) are shown in a 62-year-old male with known coronary artery disease. Conventional LGE shows small area of hyperenhancement in the inferoseptal and inferior segments (white arrow), corresponding to myocardial infarct in the right coronary artery territory. The same area is depicted by dark-blood LGE and the T1 map (white arrows). Note that the discrimination of blood and infarct signals is improved on dark-blood LGE compared with the conventional technique. LGE Late gadolinium enhancement

Fig. 5

Eighty-year-old woman with chronic antero-apical myocardial infarction. The affected left ventricular territory is shown by blue arrows in the corresponding conventional LGE image (a), dark-blood LGE image (b), according to Holtackers et al. [110], and post-contrast T1 map (c). LGE Late gadolinium enhancement