Home » 2008 » Number 08-16: Advanced late gadolinium enhancement optimisation

Number 08-16: Advanced late gadolinium enhancement optimisation

Case from: Giovanne Quarta, Derek Hausenloy, Diana Holdright, James Moon.

History: 48 Y/O male from Kuwait presented with dyspnea and palpitations. Holter shows 2:1 heart block episodes. PMH: severe asthma.
Echo: LV impairment with regional wall motion abnormalities
Angiography: Normal. Patient referred for CMR
Cine CMR: Mild LV impairment, multiple subtle RWMAs
LGE CMR: Imaging optimization progressed through the following steps:
1. IR-FLASH - suspicion for endocardial LGE
– but blood pool bright:suggest waiting (blood pool darkens) and imaging in systole (to image when trabeculae are compressed together)

2. Switched to imaging in systole
- But image blurry with IR-FLASH (long readout – 23x6ms = 138ms so motion artefact)

3. Switched to IR-FISP imaging
-Better: The faster readout per line (3ms vs 6ms) can be used in a variety of ways.

4. Switched to IR-FISP in systole
- Better: Squashing trabeculae together (systole) and shorter readout (IR-FISP)

5. ‘Pushing the envelope’ – more of the above, but inevitably a longer breath-hold
25 lines readout (75ms) – best image: valve leaflets static and clearly seen

6. Cross cuts (othagonal plane imaging) to prove EMF
Short axis and 2-chamber confirm findings

CMR diagnosis: Probable endomyocardial fibrosis: consider filiarial disease, Churgg-Strauss. What was the eosinophil count?
Follow-up: Eosinophils normal: Unfortunately patient returned to home country before full investigation.
CMR perspective: Advanced practionners of CMR can get the most out of LGE imaging by taking many images and adjusting the acquisitions for both for patient characteristics and the disease under investigation. An SSFP readout is twice as fast and frequently this permits increased optimisation. See table below for suggested imaging modifications.

Patient characteristic	Standard IR-FLASH	Modified IR-FLASH	Modified IR-FLASH	Modified IR-FISP
Normal	Trigger 2 23 segments 20º flip angle 115-140 lines (14 heart beats)		Trigger 2 65 segments 50-60º flip angle 130 lines (12 heart-beats)
HR <800ms		Trigger 3 Segments 19-21 Flip angle 22 º	Trigger 3 or 4 Segments 45	Trigger 3 or 4 Segments 45
HR variable		Trigger 3 (if possible)		Trigger 3 or 4 Consider systolic scanning
For endoomyocardium				Trigger 3 or 4 Consider systolic scanning
Severe fluid ghosting				Increase FOV, switch PE direction, use presaturation bands. Consider shorter scan or single shot.
Poor breath-hold				Segments 65 or single shot 1 average

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