Cardiac Magnetic Resonance Imaging in Heart Failure

Abstract

Heart failure (HF) is a clinical syndrome with a wide variety of clinical presentations, pathophysiologies, and natural histories. HF is becoming more prevalent globally, thus increasing effects on healthcare systems. Cardiac magnetic resonance (CMR) imaging is a valuable tool for better understanding HF and its prognosis. The commonly used reference standard of CMR cine imaging provides accurate assessment of chamber size and function. Phase contrast imaging can be used to assess the degree of valvular regurgitation and complex flow patterns. Stress perfusion imaging can detect subtle areas of ischemia and microvascular dysfunction. Late gadolinium enhancement imaging aids in diagnosing causes of HF and guiding revascularization in ischemic cardiomyopathy. Supported by histological validation, T1 and T2 mapping provides non-invasive information on tissue characteristics in inflammatory and infiltrative cardiomyopathies. CMR also provides various techniques to measure strain in the atria and ventricles at high spatial and temporal resolution. CMR continues to serve as an important modality for the evaluation of HF.

Keywords: cardiac magnetic resonance; heart failure; late gadolinium enhancement; parametric mapping; phase contrast; stress perfusion.

Figure 1

Cine Imaging with Segmentation. Cine imaging (left) in the short axis for volumetric assessment with automated segmentation of the left ventricular endocardium (red), left ventricular epicardium (green), and right ventricle (teal). The inferior right ventricular insertion point is marked (pink). The volumetric and function measurements are shown (right). CI, Cardiac index; CO, Cardiac output; EDV, End-diastolic volume; EDVI, End-diastolic volume index; EF, Ejection fraction; ESV, End-systolic volume; ESVI, End-systolic volume index; SV, Stroke volume; SVI, Stroke volume index.

Figure 2

Stress Perfusion Imaging in a Patient with Obstructive Coronary Disease. A perfusion defect (top) is seen in the short-axis basal to mid inferoseptal, inferior, and inferolateral wall on stress (white arrows), but is not visualized on rest imaging. The quantitative stress flow in this area is reduced to 0.7–1.3 mL/min/g, as compared with the normal myocardium (2.2–2.9 mL/min/g). Coronary angiography (bottom) demonstrated obstructive CAD with 70% stenosis in the left circumflex artery (LCx) and 100% occlusion of the RCA (labeled arrows). The left anterior descending artery (LAD) had a 40% nonobstructive lesion. Adapted from Pan et al.

Figure 3

Different Patterns of Late Gadolinium Enhancement Based on Cardiomyopathy. Examples of short-axis LGE patterns are shown for different cardiomyopathies. Ischemic cardiomyopathy (top left) seen with subendocardial late gadolinium enhancement (LGE) in the basal to mid inferoseptal and inferior myocardium (arrows) consistent with right coronary artery infarction. Dilated cardiomyopathy (top right) seen with a septal mid-wall stripe of LGE (arrows). Hypertrophic cardiomyopathy (middle left) seen with asymmetric hypertrophy and LGE in the septum and inferior right ventricular insertion point (arrows). Myopericarditis (middle right) seen with patchy subepicardial LGE in the anteroseptum and inferolateral walls (arrows). Pericardial effusion and enhancement of the pericardium are also present. Cardiac sarcoidosis (bottom left) seen with extensive subepicardial LGE in the anterolateral, anterior, anteroseptal, inferoseptal, and inferior wall (arrows). Cardiac amyloidosis (bottom right) seen with diffuse transmural LGE. The myocardium could not be nulled correctly.

Figure 4

Parametric Mapping in a Porcine Infarction Model. Multiparametric imaging with cine, T2, pre-contrast T1, post-contrast T1, and late gadolinium (LGE) in the short axis, performed in porcine models before and after left anterior descending artery occlusion. The evolution from acute infarction to chronic remodeling can be seen at day 2, day 30, and day 60 on parametric mapping. Adapted from Lopez et al.

Figure 5

Feature Tracking Strain Analysis of the Left Atrium and Ventricle. The left atrium (orange), left ventricular endocardium (red), and left ventricular epicardium (green) are segmented in the two-chamber and four-chamber views. Strain is color-coded in the left ventricle and tracked in the left atrium (maroon wavy lines). Longitudinal strain plots are shown for the left atrium (upper right) and left ventricle (lower right).