Cardiovascular Magnetic Resonance Imaging in Myocardial Disease

Abstract

Cardiovascular magnetic resonance (CMR) is the central non-invasive imaging investigation for the evaluation of myocardial disease. It is the well-established gold standard for measuring cardiac chamber volumes, systolic function, and left ventricular mass, and it brings unique information for therapeutic decisions. In addition, its tissue characterization capability, through T1, T2, and T2* mapping, as well as early and late gadolinium enhancement (LGE) sequences, allows to differentiate in many cases among ischemic, inflammatory, and infiltrative heart disease and permits the quantification of myocardial fibrosis, providing valuable diagnostic and prognostic information. This review aims to highlight the main CMR features of different cardiomyopathies.

Keywords: cardiology; cardiomyopathies; cardiovascular magnetic resonance imaging; late gadonlinium enhancement; myocardial disease.

Figure 1. CMR images of a 45-year-old male patient diagnosed with dilated cardiomyopathy

CMR: Cardiac magnetic resonance Late Gadolinium enhancement images (LGE) in short axis (A) and four-chamber views (B), respectively, showing mid-myocardial focal interventricular septal fibrosis (yellow arrowheads), suggesting an idiopathic cardiomyopathy. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 2. CMR examination of a 23-year-old male patient diagnosed with myocarditis-T2 images

CMR: Cardiac magnetic resonance (A): T2-weighted CMR image showing subepicardial oedema in the inferolateral, inferior, and anterior segments. B: Computer-aided signal intensity analysis of the T2-weighted image with color-coded display of relative signal intensity, normalized to skeletal muscle. Blue indicates a signal intensity ratio of myocardium/skeletal muscle of ≥2.0, indicating oedema, and green indicates normal signal intensity. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 3. CMR examination of a 23-year-old male patient diagnosed with myocarditis-LGE images

CMR: Cardiac magnetic resonance, LGE: Late Gadolinium Enhancement LGE acquired in longitudinal four-chamber (A), three-chamber (B), and two-chamber views (C), respectively, showing areas of sub-epicardial to mid-myocardial hyperenhancement (yellow arrowheads), not corresponding to a coronary artery distribution,  predominantly in inferolateral and anterolateral walls, suggestive of myocarditis. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 4. CMR examination of a 32-year-old female patient with hypertrophic cardiomyopathy-cine images

CMR: Cardiac magnetic resonance Diastolic phase of a balanced steady-state free precession (B-SSFP) cine images, in short axis views, demonstrating asymmetrical septal hypertrophy, predominantly to the interventricular septum (yellow lines). Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 5. CMR examination of a 32-year-old female patient known with hypertrophic cardiomyopathy-LGE images

CMR: Cardiac magnetic resonance, LGE: Late Gadolinium enhancement LGE acquired in short-axis views shows mid-myocardial LGE in an area of maximal hypertrophy (yellow arrows). Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 6. CMR examination of a 54-year-old male patient diagnosed after a dosage of alpha-galactosidase enzyme with Aderson-Fabry disease

CMR: Cardiac magnetic resonance (A) Contrast-enhanced cardiovascular magnetic resonance diastolic frame of cine image in four-chamber view, showing severe left ventricular (LV) wall thickness predominantly to the interventricular septum of a maximum 27 mm (yellow line).  (B) Late gadolinium enhancement image in two chamber view shows an area of hyperenhancement in the basal mid myocardial inferior wall. (C) Native T1 mapping shows low T1 times (927 ms) suggesting a possible intracellular storage disease of the heart. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 7. CMR examination of a 74-year-old female diagnosed with AL amyloidosis after fat pad biopsy-cine images

CMR: Cardiac magnetic resonance, AL: Amyloid light-chain Diastolic phase of a balanced steady-state free precession (bSSFP) cine sequence of the short axis( A) and four chambers views (B), respectively.  The basal antero-septum is 15 mm thick (yellow line), while the other walls are not hypertrophied. Small, circumferential pericardial effusion is also noted. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 8. CMR examination of a 74-year-old female diagnosed with AL amyloidosis after fat pad biopsy-LGE image

CMR: Cardiac magnetic resonance, LGE: Late Gadolinium Enhancement, AL: Amyloid light-chain LGE was acquired in short axis (A) and longitudinal three-chamber (B) views, respectively. Difficult nulling of the myocardium, with areas of transmural hyperenhancement (yellow arrowheads) without respecting a coronary artery distribution. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 9. CMR examination of a 47-year-old man with a medical history of dilatated cardiomyopathy, normal coronary artery and permanent pacemaker for complete AV block-LGE images

CMR: Cardiac magnetic resonance, LGE: Late Gadolinium Enhancement, AV: Atrioventricular, LV: Left ventricle, RV: Right ventricle LGE acquired in short axis (A) and longitudinal two-chamber (B) views, respectively, show extensive sub-epicardial to transmural patchy fibrosis at the level of LV and RV and raised the suspicion of cardiac sarcoidosis that was confirmed by endomyocardial biopsy (EMB). Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 10. CMR exam of a 23-year-old female known with major beta thalassemia and frequent blood transfusions

CMR: Cardiac magnetic resonance (A) Diastolic phase of a balanced steady-state free precession (BSSFP) cine sequence of 4 chambers view shows no dilated heart, with diastolic dysfunction. Bilateral pleural effusion is also noted, in patients with confirmed hemochromatosis. (B) Native T1 mapping shows low T1 times (791 ms). (C) Native T2* mapping shows a low value (12.9 ms); less than 20 ms (on a 1.5 T system) indicates significant iron deposition. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 11. CMR examination of a 19-year-old male patient diagnosed after genetic tests with Pompe disease

CMR: Cardiac magnetic resonance (A) Contrast enhanced cardiovascular magnetic resonance diastolic frame of cine image in short chamber view, showing severe left ventricular wall thickness and free right ventricular thickness. (B) Late gadolinium enhancement image in short axis shows an area of hyperenhancement in the mid myocardial inferolateral wall. (C) Native T1 mapping shows low T1 times (955 ms) while the calculation of the extracellular volume (ECV) showed no interstitial expansion (ECV- 18%) suggesting a possible intracellular storage disease of the heart. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 12. CMR examination of a 41-year-old male patient with toxocariasis with cardiac involvement

CMR: Cardiac magnetic resonance Horizontal long axis (HLA) views: T2-weighted STIR image (A) and T2 mapping image (B) showing subendocardial oedema in the inferolateral wall and medium inferior septum (yellow arrows).  (C) Late gadolinium enhancement images show focal fibrosis at the level of basal inferolateral wall and medium inferior septum (yellow arrows).  Right pleural effusion is present. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 13. CMR examination of a 45-year-old male patient known with Duchenne neuromuscular dystrophy

CMR: Cardiac magnetic resonance (A) Contrast enhanced cardiovascular magnetic resonance diastolic frame of cine image in four-chamber view, showing severe left ventricular (LV) dilatation and severe systolic dysfunction(B) Late gadolinium enhancement image in short axis shows extensive area of hyperenhancement, predominantly subendocardial and epicardial in all LV segment and  in the right ventricle free wall. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 14. CMR examination of a 27-year-old male patient with dilatated cardiomyopathy suggestive for non-compaction

CMR: Cardiac magnetic resonance (A-B) Contrast enhanced cardiovascular magnetic resonance diastolic frame of cine image in short chamber view, with a measure of the non-compacted myocardium (Jacquier criteria). (C)  Contrast enhanced cardiovascular magnetic resonance diastolic frame of cine image in a four-chamber view shows the presence of a noncompact (yellow line)/compact (red line) ratio of more than 2.3 (Petersen criteria). Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 15. CMR exam of a 29-year-old male diagnosed with ARVC after positive genetic tests for desmoplakine mutation

CMR: Cardiac magnetic resonance Contrast enhanced cardiovascular magnetic resonance diastolic frame of cine image in four-chamber view shows micro-aneurysms at the level of right ventricle (RV) free wall. Late gadolinium enhancement image (LGL) four-chamber (B) and short axis (C), respectively, showing fibrosis of the level of RV free wall (yellow arrows) and subendocardial fibrosis of the level of inferolateral wall (red arrow). Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 16. CMR exam of a 29-year-old male diagnosed with ARVC after positive genetic tests for desmoplakine mutation

CMR: Cardiac magnetic resonance, ARVC: Arrhythmogenic right ventricular cardiomyopathy Horizontal long axis (HLA) views. Native T1 image (A) and T1 fat-saturation image (B) showing subepicardial fat in the inferolateral wall (yellow arrows). Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 17. CMR examination of a 68-year-old female patient with Takotsubo cardiomyopathy

CMR: Cardiac magnetic resonance Vertical long axis (VLA) views from left to right : A shows a T2-weighted STIR image. B shows T2 mapping image showing apical circumferential subepicardial oedema (yellow arrows). C shows late gadolinium enhancement image shows no area of hyperenhancements suggesting the absence of focal myocardial fibrosis. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 18. . CMR examination of a 67-year-old male patient with large anterior infarct

CMR: Cardiac magnetic resonance Late gadolinium enhancement images short axis (A), longitudinal two-chamber (B) and three-chamber (C), respectively, showing transmural fibrosis (>75%) (yellow arrows)-non-viable territory. Note small circumferential pericardial effusion. Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.

Figure 19. Stress CMR with adenosine in a patient known with triple coronary artery by-pass and heart failure symptoms

CMR: Cardiac magnetic resonance Perfusion short axis view, shows perfusion defect in the inferior wall (yellow arrow). Image courtesy: Personal archive of Dr. Oana Popa. Patient consent was obtained.