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Acute MI

a) SCMR official document standardized acquisition guidelines – relevant extract

1. LV structure and function module
2. Optional – T2 weighted imaging (see non-ischemic cardiomyopathies protocol for sequence details, at least areas with wall motion abnormalities)
3. First pass perfusion module (only at rest)
4. To look for microvascular obstruction, scan for consider repeat first pass perfusion sequence or early gadolinium enhancement, i.e within the first 1–3 minutes after contrast infusion
5. Late gadolinium enhancement module

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.

Microvascular obstruction (MVO):

If MVO is observed during LGE, its location and presence within the 17 myocardial segments should be provided.

c) Standardized web based images

Acute MI
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 10-10: The Case of Three Ventricles
History: Large left ventricular basilar aneurysm with thrombus secondary to infarct

Number 10-07: Sludge infarcts due to homozygous sickle cell anemia
History: 16 y/o male with homozygous sickle cell anemia presenting with a history of chest pain and normal coronary angiography.

Number 10-04: Hemorrhagic myocardial infarction
History: Case demonstrating CMR sequences which can aid in the effective diagnosis of hemorrhagic infarct

Number 09-12: Role of CMR in acute myocardial infarction, primary angioplasty, and autologous stem cell therapy
History: 50 y/o male with a 3 week history of accelerated angina...

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 CMR in acute infarction" (Dr D Hausenloy, The Heart Hospital, London), members only

f) Relevant Online Talks

Free talks

ACS in patients with unobstructed coronary artery: usefulness of CMR
By Chiara Bucciarelli-Ducci
Recorded at Advanced Cardiac Imaging Course for the Interventional Cardiologist, 2008, London

Members only talks - general

By
Recorded at

MDCT for assessment of chest pain syndromes in the ER
By Kavitha Chinnaiyan - William Beaumont Hospital
Recorded at SCMR 2010

CMR for assessment of chest pain syndromes in the ER - the quadruple rule-out
By Eike Nagel - King's College London
Recorded at SCMR 2010

Myocardial Infarction
By Hassan Abdel-Aty - Berlin Medical University
Recorded at SCMR 2009 Physician preconference

The Importance of Microvascular Damage and No Reflow Following Reperfusion Therapy for MI
By Robert A. Kloner - Keck School of Medicine, USC
Recorded at SCMR 2008: Plenary session 1 Defining Better Therapeutic Targets by CMR

T2-weighted Sequences
By Anthony Aletras - NIH
Recorded at SCMR2008 Physician Pre-Conference Section 1: MR Physics

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

Members only talks - cutting edge

Day 4
By
Recorded at

Point/Counterpoint: Reversible Ischemic Injury: T2 Weighted Imaging of Reversible Injury is not Ready for Prime Time
By Han Kim - Duke Cardiovascular Magnetic Resonance 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

g) Acquisition movie

Pending from James, subject to funding

h) Relevant papers (starting point):

Wu KC, et al: Prognostic significance of microvascular obstruction by CMR in patients with acute myocardial infarction. Circulation. 1998;97:765-72. 
Gerber BL, et al: Microvascular obstruction and left ventricular remodeling early after acute MI. Circulation. 2000;101:2734-41
Choi KM, et al: Transmural extent of acute myocardial infarction predicts long-term improvement in contractile function. Circulation 2001;104:1101–7.
Kwong RY et.al: Detecting acute coronary syndrome in emergency department with CMR .Circulation. 2003;107:531-537
Aletras AH et al. ACUT2E TSE-SSFP: a hybrid method for T2-weighted imaging of edema in the heart. Magn Reson Med. 2008;59:229-35