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Stress Cardiovascular Magnetic Resonance: Wall Motion

Master and Oppenheimer described the first stress test in 1929. Several methods of assessing myocardial ischemia have subsequently been developed, including those that incorporate electrocardiograms (ECGs), echocardiography, myocardial scintigraphy, and, most recently, cardiovascular magnetic resonance (CMR). Since 1987, stress CMR has been used to identify inducible ischemia, measure contractile reserve, and identify those at risk of future myocardial infarction (MI) and cardiac death. In this chapter,…

Assessment of Cardiac Function

The accurate and reproducible assessment of cardiac function is a fundamental aim of noninvasive cardiac imaging. It forms the foundation upon which much of the assessment and management of myocardial dysfunction, ischemia, viability, remodeling, valvular, and other cardiac disorders are based. In this chapter, we discuss the importance of the measurement of global cardiac function, compare techniques, show differences according to magnetic fields, provide a practical…

Normal Cardiac Anatomy

Cardiovascular magnetic resonance (CMR) can be used to obtain images of the heart in any plane. Thus to define normal anatomy and function, it is useful to define standard imaging planes to develop knowledge of normal anatomy, anatomic variants, and potential artifacts. Standard CMR planes have evolved from other imaging modalities, including body computed tomography (CT) imaging, echocardiography, and x-ray contrast angiography; consistent nomenclature across imaging…

Clinical Cardiovascular Magnetic Resonance Imaging Techniques

The first dedicated cardiovascular magnetic resonance (CMR) clinical services opened in the United States in mid-1990s. Since that time, CMR imaging has become routine at most academic medical centers, with a number of centers now running multiple CMR scanners dedicated to cardiovascular imaging studies. Although different centers still differ somewhat with regard to the exact clinical CMR imaging protocols employed, in recent years cross-institutional CMR protocols…

Human Cardiac Magnetic Resonance at Ultrahigh Fields: Technical Innovations, Early Clinical Applications and Opportunities for Discoveries

The development of ultrahigh field magnetic resonance (UHF-MR, B 0 ≥ 7 T, f ≥ 298 MHz) is moving forward at an amazing speed that is breaking through technical barriers almost as fast as they appear. UHF-MR has become an engine for innovation in experimental and clinical research. With nearly 40,000 magnetic resonance (MR) examinations already performed, the reasons for moving UHF-MR into clinical applications are more compelling…

Special Considerations: Cardiovascular Magnetic Resonance in Infants and Children

Clinical cardiovascular magnetic resonance (CMR) had been in use for nearly 35 years and has become firmly established in the evaluation of congenital heart disease (CHD) in many ways, including anatomy, physiology, ventricular function, blood flow, and tissue characterization. In many instances, it is used as an adjunct to other imaging modalities such as noninvasive echocardiography and invasive angiography; however, in a number of areas such…

Pacemaker and Implantable Cardioverter-Defibrillator Safety and Safe Scanning

Magnetic resonance imaging (MRI) has gained popularity over the last decade because of its excellent soft tissue imaging capability and superior spatial resolution as well as lack of ionizing radiation. These properties have led to expanded indications for MRI. At the same time, with the aging of the US population, the need for cardiac implantable electronic devices (CIEDs) is increasing in parallel to that for MRI…

Special Considerations for Cardiovascular Magnetic Resonance: Safety, Electrocardiographic Setup, Monitoring, and Contraindications

During the last three decades, cardiovascular magnetic resonance (CMR) has developed into an important diagnostic clinical tool in cardiology. Not only the anatomy of the heart but also its function, metabolism, and perfusion, as well as the coronary arteries, can be evaluated with CMR. There are advantages of CMR over other diagnostic imaging methods: first, CMR does not use ionizing radiation; second, the radiofrequency (RF) radiation…

Cardiac Magnetic Resonance Spectroscopy

Introduction Cardiovascular magnetic resonance (CMR) imaging uses the 1 H nucleus in water (H 2 O) and fat (CH 2 and CH 3 groups) molecules as its only signal source, and therefore offers little insight into the biochemical state of cardiac tissue. In contrast, MR spectroscopy (MRS) of the heart allows the study of many other nuclei. It is the only available method for the noninvasive…

Cardiovascular Magnetic Resonance Assessment of Myocardial Oxygenation

Myocardial Oxygenation: Supply Versus Demand Under physiologic conditions, myocardial blood flow (MBF), myocardial oxygen consumption (MVO 2 ), and myocardial mechanics are intimately related. Therefore it is not surprising that the key disease processes involving the heart manifest from imbalances between myocardial oxygen supply and demand. Consequently, the noninvasive assessment of imbalances in myocardial oxygen supply and demand, particularly on a regional basis, is of critical…

Use of Navigator Echoes in Cardiovascular Magnetic Resonance and Factors Affecting Their Implementation

Respiration has been shown to be an important factor influencing the quality of cardiovascular magnetic resonance (CMR) images. In addition to cardiac motion, which can be addressed reasonably well by electrocardiographic (ECG) triggering, respiratory motion moves the position and distorts the shape of the heart by several millimeters between inspiration and expiration. In 1991, Atkinson and Edelman showed the detrimental effects of breathing on the quality…

Blood Flow Velocity Assessment

The idea of mapping measurements of blood flow onto a magnetic resonance (MR) image was first discussed in an article by Singer in 1978. The methods that followed could generally be categorized into time-of-flight (TOF) or phase shift types and were based on the techniques that had previously been described for nonimaging MR flow studies. A number of review articles have covered the subject and described…

Myocardial Perfusion Cardiovascular Magnetic Resonance: Advanced Techniques

The physiologic basis for and the general principles of myocardial perfusion cardiovascular magnetic resonance (CMR) are covered in detail in other chapters. The key challenge of first-pass dynamic contrast-enhanced acquisition is to capture data with high temporal and spatial resolution during the myocardial contrast passage. The recommended minimal requirements for standard perfusion CMR are to acquire data in three short-axis sections of the heart according to…

Myocardial Perfusion Imaging Theory

Introduction The concept of injecting a tracer into the blood stream and detecting its transit and distribution in the heart muscle for the assessment of myocardial perfusion is well established in nuclear cardiology and cardiovascular magnetic resonance (CMR). Both exogenous, injected contrast agents and endogenous contrast mechanisms have been used to assess myocardial perfusion with CMR. The use of a gadolinium (Gd)-based contrast agents for the…

Cardiovascular Magnetic Resonance Contrast Agents

Although currently not approved by the US Food and Drug Administration (FDA) for cardiac imaging, the vast majority of cardiovascular magnetic resonance (CMR) studies use a gadolinium-based contrast agent. The CMR contrast agent typically makes diseased tissue appear brighter (or in some cases darker) than the surrounding tissue. Cardiovascular applications, such as magnetic resonance angiography (MRA), functional imaging of myocardial perfusion, and viability with late gadolinium…

Techniques for T1, T2, and Extracellular Volume Mapping

Many disease processes alter the local molecular environment of the myocardium, and consequently the longitudinal (T1) and transverse (T2) relaxation times can change. While such changes may be observed directly as changes in image contrast, the tissue processes may be global and diffuse, hampering reliable detection of the disease. Quantitative methods for characterizing myocardial tissue based on parametric mapping of T1 and T2 have been proposed…

Basic Principles of Cardiovascular Magnetic Resonance

Introduction This introduction to the basic principles of cardiovascular magnetic resonance (CMR) describes the concepts of magnetization, T1, T2, T2*, and image formation, and describes some common CMR pulse sequences and parameters. These basic ideas will require some time and rereading to fully appreciate, but each new concept will add to the understanding of CMR. The human body is composed of mostly water, and a lot…

Congenital Heart Disease

Cardiac malformations are the most common congenital anomalies. The reported incidence of congenital heart disease (CHD) varies widely because of differences in counting minor lesions. The incidence of moderate and severe forms of CHD is about 6/1000 live births. This increases to 19/1000 if the potentially serious bicuspid aortic valve (BAV) is included, and increases to 75/1000 if tiny muscular ventricular septal defects (VSDs) present at…

Thoracic Aortic Disease

Introduction Primary cardiac problems can influence the function of other organ systems. Similarly, diseases or abnormalities in other organ systems can result in secondary cardiac dysfunction. Ascertaining the afflicting primary abnormality can pose a diagnostic dilemma. To illustrate, in a patient with aortic regurgitation, is the primary abnormality the intrinsic aortic valve disease resulting in secondary aortic dilatation or is it the aortic aneurysm with dilatation…

Valvular Heart Disease

Valvular heart disease is a significant clinical problem, with a reported prevalence of 2.5% in the United States. Between 10% and 20% of cardiac surgical procedures in the United States are performed for the treatment of valvular disease. Some of the goals of imaging evaluation of valves are to: 1. Identify morphological structure and abnormalities of the valve; 2. Identify stenosis or regurgitation of one or…