Adenosine stress perfusion

a) SCMR official document standardized acquisition guidelines – relevant extract

LV structure and function module (alternatively this can be performed between stress and rest perfusion, although performance immediately after gadolinium infusion may reduce the contrast of the blood-endocardium interface)
Two intravenous lines should be available, one for gadolinium and one for adenosine, one in each arm. Preferential site of contrast infusion is antecubital. Blood pressure cuff should be used with care taken not to interfere with gadolinium or adenosine infusion.
Adenosine stress perfusion imaging (at least 3 minute infusion of 140 ug/kg body weight/min). Option – initial adenosine infusion may be performed with the patient outside the bore of the magnet.
a. First pass perfusion module
b. During last minute of adenosine, gadolinium is injected
c. After imaging for 40–50 heart beats by which time gadolinium has passed through the LV myocardium, adenosine is stopped.
d. Continous ECG monitoring and BP measured at baseline, during infusion, and for at least 2 minutes post-infusion of adenosine.
Rest Perfusion
a. Need at least 10 minute wait for gadolinium to wash out from stress perfusion imaging. During this period stress images can be reviewed, cine imaging can be completed (e.g long-axis views), valvular evaluation can be performed, etc.
b. Perfusion imaging repeated without adenosine using same dose of gadolinium
c. If stress images are normal and free of artifacts, rest perfusion can be skipped. Additional gadolinium may be given as needed for late gadolinium enhancement (for a total of 0.1 – 0.2 mmol/kg)
Late gadolinium enhancement module. Need to wait at least 5 minutes after rest perfusion
Analysis
a. Interpret visually using 17 segment AHA segment model (16-segment model can be used, leaving out apex)
b. Optional – Quantitative analysis of the inflow curves could be considered in cases without obvious visual perfusion defect.
c. Helpful to view cines, stress and rest perfusion, and LGE images all side-by-side in equivalent slices

b) SCMR official document reporting recommendations – relevant extract

As described in the non-imaging findings component of the reported list above, parameters such as vital signs, medications, and contrast agent administration should be reported.The SCMR recommends the reporting of LV myocardial information in the format of a 17-segment model through the use of a chart, table, or bipolar maps (so called “Bullseye” plot) standard cardiac segmentation

Existing literature regarding the prognostic significance of qualitative perfusion defects is unavailable at this time; nevertheless, SCMR suggests that perfusion in each of the 17 segments (Figure 1) be defined according to the transmurality, and persistence of the defect. The committee recommends that stress induced (vasodilator or inotropic) perfusion defects be compared with co-registered rest perfusion or late enhancement segments in order to identify ischemic, infarcted, or non-ischemic areas. The SCMR also recognizes that observed defects may be characterized as artifacts. These should be described.

c) Standardized web based images

Perfusion case full dataset
Case notes: Case from the Heart Hospital, London. Here, stress has been done first with the LV volumes module between stress and rest perfusion. There are extensive stress induced perfusion defects (series_12_1-3) not present at rest (series_23_1-3). There is a small circumflex subendocardial infarct (seen series_30)

d) Case of the Week example(s)

Number 10-17: Clinical role of perfusion CMR *** CASE WINNER
History: **best case of the week in 2011. A patient with chest pain had echocardiography suspicious for HCM - CMR resolved the true diagnosis of multivessel CAD.

Number 10-08: Perfusion Abnormalities in Cardiac Amyloidosis
History: A 68 year-old hypertensive male patient presented with typical chest pain. The ECG showed new characteristic ischemic changes and troponin dosage was positive. An urgent coronary angiogram revealed unobstructed epicardial coronary arteries. The echo showed a significant degree of septal wall thickening, out of proportion with his well-controlled blood pressure profile, suggesting possible hypertrophic cardiomyopathy.

Number 07-06: Microvascular Obstruction by CMR
History: A 41 year-old man admitted with 3 hours of chest pain with initial thrombolysis (tenecteplase) and salvage angioplasty one hour later.

Number 08-05: Acute MI, normal coronaries
History: A 44 yr old lady transferred for primary PCI for chest pain with lateral ST elevation. Troponin I 26, CK 1233. Normal lipids (TC:HDL 3.17). Only risk factor for IHD was hypertension: non-smoker.

e) Expert opinion – ‘How we do’

"How we do Perfusion CMR" (Robert Manka, Rolf Gebker, Eike Nagel)

f) Relevant Online Talks

Free talks

CMR Myocardial perfusion in ischaemic heart disease
By Juerg Schwitter
Recorded at Advanced Cardiac Imaging Course for the Interventional Cardiologist, 2008, London

Perfusion CMR
By Juerg Shwitter
Recorded at EuroCMR 2008

Perfusion CMR
By Sven Plein
Recorded at EuroCMR 2008

Members only talks - general
Perfusion-CMR in Non-atherosclerotic Ischemic Syndromes: Takotsubo, Syndrome X and Cardiomyopathies
By Ali Yilmaz - Robert-Bosch-Krankenhaus
Recorded at SCMR 2009 Clinical Perfusion and Ischemic Heart Disease - Current Evidence for clinical Application
Evidence Based Perfusion Data Analysis: Performance, Precision and Reproducibility
By Michael Jerosch-Herold - Brigham and Women's hospital
Recorded at SCMR 2009 Clinical Perfusion and Ischemic Heart Disease - Current Evidence for clinical Application
Perfusion CMR - Is there an optimum balance between speed, coverge, contrast medium dose and examination duration?
By Sven Plein - University of Leeds
Recorded at SCMR 2009 Clinical Perfusion and Ischemic Heart Disease - Current Evidence for clinical Application
Myocardial Ischemia
By Raymond Kwong - Brigham and Women's Hospital
Recorded at SCMR 2009 Physician preconference

Members only talks - cutting edge
Exercise-stress perfusion
By Orlando Simonetti - The Ohio State University
Recorded at SCMR 2009 Novel Approaches to CMR perfusion
Quantification of Perfusion in Ischemia and Infarction
By Frederick Epstein - University of Virginia s
Recorded at SCMR 2009 Novel Approaches to CMR perfusion
CT/CMR Fusion for assessment of ischemic heart disease
By Richard White - University of Florida - College of Medicine
Recorded at SCMR 2009 Novel Approaches to CMR perfusion
Ischemia assessment at 3T
By Theodoros Karamitsos
Recorded at SCMR 2009 Novel Approaches to CMR perfusion
Myocardial Perfusion using ASL
By Eric Wong - University of California
Recorded at SCMR 2009 Novel Approaches to CMR perfusion
Myocardial perfusion using BOLD
By Rohan Dharmakumar - Northwestern University
Recorded at SCMR 2009 Novel Approaches to CMR perfusion
From ischemia to rejection: molecular imaging of myocardial disease
By David Sosnovik - Harvard Medical School
Recorded at SCMR 2009 Basic Science - Molecular MRI
Myocardial Perfusion ASL Imaging
By Krishna S Nayak - University of Southern California
Recorded at SCMR 2009 New Developments in Cardiac Imaging

g) Useful Documents for a CMR service

DOBUTAMINE & ADENOSINE ADMINISTRATION FOR STRESS MRI from Southampton General Hospital, Uk

h) Relevant papers (starting point):

Bodi V, Sanchis J, Lopez-Lereu MP et al. Prognostic value of dipyridamole stress cardiovascular magnetic resonance imaging in patients with known or suspected coronary artery disease. J Am Coll Cardiol. 2007;50:1174-9

Pilz G, Jeske A, Klos M, Ali E, Hoefling B, Scheck R, Bernhardt P. Prognostic value of normal adenosine-stress cardiac magnetic resonance imaging. Am J Cardiol. 2008 15;101:1408-12

Schwitter J, Wacker CM, van Rossum AC, Lombardi M, Al-Saadi N, Ahlstrom H, Dill T, Larsson HB, Flamm SD, Marquardt M, Johansson L. MR-IMPACT: comparison of perfusion-cardiac magnetic resonance with single-photon emission computed tomography for the detection of coronary artery disease in a multicentre, multivendor, randomized trial.Eur Heart J. 2008 Feb;29(4):480-9.

Myocardial first-pass perfusion cardiovascular magnetic resonance: history, theory, and current state of the art
Bernhard L Gerber, Subha V Raman, Krishna Nayak, Frederick H Epstein, Pedro Ferreira, Leon Axel, Dara L Kraitchman
Journal of Cardiovascular Magnetic Resonance 2008, 10:18 (28 April 2008)
[Abstract] [Full Text] [PDF]