The role of cardiac magnetic resonance imaging in the assessment of heart failure with preserved ejection fraction

Abstract

Heart failure (HF) is a major cause of morbidity and mortality worldwide. Current classifications of HF categorize patients with a left ventricular ejection fraction of 50% or greater as HF with preserved ejection fraction or HFpEF. Echocardiography is the first line imaging modality in assessing diastolic function given its practicality, low cost and the utilization of Doppler imaging. However, the last decade has seen cardiac magnetic resonance (CMR) emerge as a valuable test for the sometimes challenging diagnosis of HFpEF. The unique ability of CMR for myocardial tissue characterization coupled with high resolution imaging provides additional information to echocardiography that may help in phenotyping HFpEF and provide prognostication for patients with HF. The precision and accuracy of CMR underlies its use in clinical trials for the assessment of novel and repurposed drugs in HFpEF. Importantly, CMR has powerful diagnostic utility in differentiating acquired and inherited heart muscle diseases presenting as HFpEF such as Fabry disease and amyloidosis with specific treatment options to reverse or halt disease progression. This state of the art review will outline established CMR techniques such as transmitral velocities and strain imaging of the left ventricle and left atrium in assessing diastolic function and their clinical application to HFpEF. Furthermore, it will include a discussion on novel methods and future developments such as stress CMR and MR spectroscopy to assess myocardial energetics, which show promise in unraveling the mechanisms behind HFpEF that may provide targets for much needed therapeutic interventions.

Keywords: CMR in HFpEF; HFpEF; diastolic dysfunction; diastolic function; diastolic heart failure.

Figure 1

Approaches to the assessment of HFpEF by CMR. CMR, cardiovascular magnetic resonance; HFpEF, heart failure with preserved ejection fraction; LA, left atrial; LV, left ventricular; LVH, left ventricular hypertrophy; RV, right ventricular.

Figure 2

Feature tracking CMR strain analysis. (A) Feature tracking CMR in the 4-chamber view generating (B) longitudinal strain curves, (C) displayed as a polar map for each AHA segment. AHA, American Heart Association.

Figure 3

Myocardial tissue characterization by native T1 and ECV differentiating disease processes in HFpEF. (A) Normal native T1 and (B) normal ECV maps. Hypertensive heart disease with LVH showing diffuse myocardial fibrosis on (C) native T1 map and (D) increased ECV. Fabry disease showing (E) globally reduced native T1 values and (F) replacement fibrosis in the basal inferolateral wall on ECV map; Cardiac amyloidosis showing globally elevated (G) native T1 and (H) ECV values. Color scales are represented for native T1 in milliseconds and ECV in percentage. ECV, extracellular volume; HFpEF, heart failure with preserved ejection fraction; LVH, left ventricular hypertrophy.