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Chronic Ischemic heart disease and viability

a) SCMR official document standardized acquisition guidelines – relevant extract

1. LV structure and function module
2. Optional – low dose dobutamine with 5–10 minute infusion of 10 μg/kg/min of dobutamine to assess contractile reserve as improvement in wall thickening
3. Optional – adenosine stress-rest perfusion or high dose dobutamine functional imaging (see dobutamine and adenosine stress protocols for more details) to determine the presence of inducible perfusion deficits or wall motion abnormalities
4. Late Gadolinium Enhancement module
5. Analysis
   a. Helpful to view cines and LGE images of equivalent planes side-by-side
   b. Interpret using both cine and LGE data. For example, "region is dysfunctional but viable".

b) SCMR official document reporting recommendations – relevant extract

Late gadolinium enhancement (LGE):

The amount of intense signal >2 SD above the average of normal myocardium should be reported for the area within each segment.  Overall, LGE should be described as subepicardial, intramural, subendocardial, or transmural.  Patchy or linear streaks of LGE should be identified.  The transmural extent of the LGE should be defined as 0, <25%, 26% to <50%, 51% to <75%, and 76% to 100%.  In addition, the total amount of infarcted tissue (volume or grams) relative to the total myocardial volume or mass (g) may be reported.  It is not recommended, but measures of LV end-diastolic wall thickness for the 17 myocardial segments may also be reported.  When clinically appropriate, those providing an interpretation should indicate whether the pattern of LGE is consistent with ischemic heart disease, myocarditis, etc.

c) Standardized web based images

Chronic infarct case
Case notes: Case from the Heart Hospital, London. None of the optional perfusion or dobutamine stress were performed in this case.

d) Case of the Week example(s)

Number 06-09: Isolated RV infarction
History: A 61-year-old male, 24 hours of chest pain, CK raised, normal ECG.

Number 07-12: Troponin +ve Chest pain, normal coronaries
History: 6 months ago, a 48 year old body builder had troponin positive chest pain with inferior T wave inversion on ECG and normal coronary angiography. Echo had suggested possible inferior hypokinesia. Ongoing clinical uncertainty

Number 07-19: CMR guided revascularisation
History: 72 yr old man with a 3 week history of chest pain and shortness of breath presented in cardiogenic shock with pulmonary edema, acute renal failure and VT

Number 08-21: Myocardial scarring from 2 distinct pathologies
History: Asymptomatic 62 yr ?. Diagnosed with HCM more than 20 with an abnormal ECG. Recent echo demonstrated concentric LVH. CMR to further assess this.

e) Expert opinion – ‘How we do’

How We Perform Delayed Enhancement Imaging (Ray Kim and Bob Judd, Duke University)
Late enhancement imaging quiz, provided by James Moon — Questions here, Answers here

f) Relevant Online Talks

Free talks

The Role of Dobutamine
By Marco Gotte - Amsterdam, Netherlands
Recorded at EuroCMR 2009 Athens

The Role of DE
By Christoph Klein - Berlin, Germany
Recorded at EuroCMR 2009 Athens

Economic Implications of viability assessment with CMR
By Ricardo Obregon - Argentina
Recorded at Second Latin American SCMR Chapter Meeting, 2008

Ischemic CHF - revascularization and/or drug therapy
By Juerg Schwitter
Recorded at EuroCMR 2008

Incidence of silent MI and prognosis
By Frank Rademakers
Recorded at EuroCMR 2008

Members only talks - general

How to Image Myocardial Viability
By Caroline Daly - St James Hospital
Recorded at SCMR 2010

Imaging Myocardial Ischaemia
By Timothy F Christian - University of Vermont School of Medicine
Recorded at SCMR 2010

How to perform high quality Late Gadolinium Enhancement Imaging
By Afshin Farzaneh-Far - Duke University Medical Centre
Recorded at SCMR 2010

The Imaging challenges in Heart Failure
By Robert Bonow - Northwestern University Medical School
Recorded at SCMR 2009 Plenary Session 1: Heart Failure MRI - The Gold Standard

Myocardial Viability and Hibernation
By Scott Flamm - Cleveland Clinic Vascular Imaging
Recorded at SCMR 2008: Technicians Workshop

Myocardial infarction
By Hassan Abdel-Aty - Berlin
Recorded at SCMR2008 Physician Pre-Conference Section 4: Clinical Applications of CMR

Members only talks - cutting edge

Point/Counterpoint. Sudden death risk stratification: the Grey zone is not so Black or White
By Daniel Lee - Northwestern University
Recorded at SCMR 2009 Plenary Session 2: CMR assessment of myocardial injury

Historical Perspective: CMR Assessment of Myocardial Injury: the last 25 years and the future
By Albert de Roos - University Medical Center
Recorded at SCMR 2009 Plenary Session 2: CMR assessment of myocardial injury

Point/Counterpoint: Reversible Ischemic Injury: T2 weighted Imaging deliniates the area at risk
By Matthias Friedrich - Stephenson Cardiovascular MR center
Recorded at SCMR 2009 Plenary Session 2: CMR assessment of myocardial injury

Point/Counterpoint. Sudden death risk stratification: the Grey zone is the best index
By Raymond Kwong - Brigham and Women's Hospital
Recorded at SCMR 2009 Plenary Session 2: CMR assessment of myocardial injury

Interventional MRI in Heart Failure - Current Status and Prediction for the Future
By Alexander Dick - Sunnybrook Health Sciences Centre
Recorded at SCMR 2009 Plenary Session 1: Heart Failure MRI - The Gold Standard

Metabolic MRI in Heart Failure
By Stefan Neubauer - John Radcliffe Hospital
Recorded at SCMR 2009 Plenary Session 1: Heart Failure MRI - The Gold Standard

Myocardial Tissue Characterisation in Heart Failure - Late Gadolinium Enhancement and Beyond
By Christopher Kramer - University of Virginia Health Systems
Recorded at SCMR 2009 Plenary Session 1: Heart Failure MRI - The Gold Standard

Viability-CMR and spectroscopy
By Jérôme Garot
Recorded at EuroCMR 2008

g) Relevant papers (starting point):

Kim RJ, Wu E, Rafael A et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med 2000;16:1445–53.
Mahrholdt H, Wagner A, Holly TA et al. Reproducibility of chronic infarct size measurement by contrast-enhanced magnetic resonance
imaging. Circulation 2002;106:2322–7.
Klein C, Nekolla SG, Bengel FM et al. Assessment of myocardial viability with contrast-enhanced magnetic resonance imaging: comparison with positron emission tomography. Circulation 2002;105:162–7.
Selvanayagam JB, Kardos A, Francis JM et al. Value of delayed-enhancement cardiovascular magnetic resonance imaging in predicting myocardial viability after surgical revascularization. Circulation. 2004;110:1535-41
Kwong R, Sattar H, Wu H et al. Incidence and Prognostic Implication of Unrecognized Myocardial Scar Characterized by Cardiac Magnetic Resonance in Diabetic Patients Without Clinical Evidence of Myocardial Infarction. Circulation 2008;118:1011-1020