First pass perfusion

a) SCMR official document standardized acquisition guidelines – relevant extract

Scout imaging as per LV structure and function module
Saturation-recovery imaging with gradient echo-echo planar (GRE-EPI) hybrid, GRE, or SSFP readout
Short-axis view imaging (at least 3 slices per heart beat)
a. For ischemia evaluation, must obtain data every heart beat
b. Slice thickness 8 mm
c. Parallel imaging, 2-fold acceleration, if available
d. In-plane resolution, ~< 3 mm
e. Readout temporal resolution ~100 – 125 ms or shorter as available
f. Contrast is given (0.05 – 0.1 mmol/kg, 3–7 ml/s) followed by at least 30 ml saline flush (3–7 ml/sec)
g. Breathhold starts during early phases of contrast infusion before contrast reaches the LV cavity.
h. Image for 40–50 heart beats by which time contrast has passed through the LV myocardium

b) SCMR official document reporting recommendations – relevant extract

Cardiovascular stress testing
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)

Gadolinium, 1st pass myocardial perfusion:
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.

Integrative stress imaging:
It is recognized by the SCMR that the procedures mentioned above can be performed in a single setting and thus must be integrated to arrive at a diagnosis. The committee recommends reporting data for all 17 myocardial segments in all modalities (Figure below). Based on previously published techniques, segments should be identified as ischemic, infarcted, mixed ischemia/infarction, or normal. It is recommended that all information for baseline function be reported in patients referred for stress testing or evaluation of acute or chronic ischemic syndromes.

c) Standardized web based images

https://www.webpax.com/1524-5000-6168-2013/
Case notes: Case from the Heart Hospital, London. This case does not have first pass perfusion performed. early gadolinium enhancement was performed using a Long TI. This demonstrates extensive microvascular obstruction (MVO).

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 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.

f) Relevant Online Talks

Free talks

The Prognostic Role of Ischemia vs. Lumenography
By Juerg Schwitter - Lausanne, Switzerland
Recorded at EuroCMR 2009 Athens

Stress MRI - Technological Improvement and Clinical Trials
By Hassan Abdel-Aty - Berlin, Germany
Recorded at EuroCMR 2009 Athens

Myocardial Perfusion - Technological Improvements and CLinical Trials - Some movies in this talk do not play due to technical problems during recording
By Theodoros Karamitsos - Oxford, UK
Recorded at EuroCMR 2009 Athens

Perfusion
By Juerg Schwitter - Lausanne, Switzerland
Recorded at EuroCMR 2009 Athens

CMR for ischemia - ready for prime-time?
By Eike Nagel
Recorded at LondonCMR

Members only talks - general

Technical aspects of perfusion that affect quality and quantification
By Michael Jerosch-Herold - Brigham and Women's Hospital
Recorded at SCMR 2010

Perfusion quantification approaching a pixel resolution
By Li-Yueh Hsu - LCE/NHLBI/NIH
Recorded at SCMR 2010

Predicting Prognosis with Perfusion CMR
By Raymond Kwong - Brigham and Women's Hospital
Recorded at SCMR 2010

Perfusion CMR in non-atherosclerotic ischemic syndromes
By Ali Yilmaz - Robert-Bosch-Krankenhaus
Recorded at SCMR 2010

What next after MR-Impact
By Jurg Schwitter - University Hospital of Lausanne
Recorded at SCMR 2010

Myocardial Ischemia
By Raymond Kwong - Brigham and Women's Hospital
Recorded at SCMR 2009 Physician preconference

Tips and Tricks: Patient confort and safety during stress
By Steven Dymarkowski - University of Leuven
Recorded at SCMR 2009 Physician preconference

Members only talks - cutting edge

Hemorrhagic myocardial infarction by cardiac MRI
By
Recorded at

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

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

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 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.