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European Journal of Heart Failure 2000 2(3):241-252; doi:10.1016/S1388-9842(00)00096-9
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© 2000 European Society of Cardiology

The role of cardiovascular magnetic resonance in heart failure

Kim Rajappan*, Nicholas G. Bellenger, Lisa Anderson and Dudley J. Pennell

Cardiovascular MR Unit, Royal Brompton Hospital Sydney Street, London SW3 6NP, UK

* Corresponding author. Tel: +44-207-351-8800; fax: +44-207-351-8816. E-mail address: kumaran.rajappan{at}ic.ac.uk (K. Rajappan).


   Abstract
Top
 Abstract
1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
 References
 
Cardiovascular magnetic resonance (CMR), is an accepted gold standard for non-invasive, accurate, and reproducible assessment of cardiac mass and function. The interest in its use for viability, myocardial perfusion and coronary artery imaging is also widespread and growing rapidly as the hardware and expertise becomes available in more centres, and the scans themselves become more cost effective. In patients with heart failure, accurate and reproducible serial assessment of remodelling is of prognostic importance and the lack of exposure to ionizing radiation is helpful. The concept of an integrated approach to heart failure and its complications using CMR is fast becoming a reality, and this will be tested widely in the coming few years, with the new generation of dedicated CMR scanners.

Key Words: Cardiovascular magnetic resonance • Heart failure

Received April 20, 2000; Revised May 30, 2000; Accepted June 1, 2000


   1. Introduction
Top
 Abstract
 1. Introduction
2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
 References
 
Despite advances in therapeutic interventions for patients with cardiac dysfunction and heart failure, the prevalence continues to rise [1,2]. Coronary artery disease is the commonest underlying aetiology. Accurate and reproducible assessment of ventricular function and mass is important for establishing the presence of ventricular dysfunction and its nature, for prognostic purposes, for determining the need for therapeutic interventions and for monitoring of therapy [3–6]. CMR is ideally suited to fulfilling this task. This review looks at how CMR can be applied in heart failure, both in research and in clinical practice.


   2. Technical aspects of CMR
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
 References
 
The physical phenomenon of nuclear magnetic resonance was first described in 1946, but only much more recently has its application to the heart become a clinically useful and valuable tool. Recent rapid advances in technology and software capability have resulted in ultrafast scanner performance. This has improved both the quality of images obtained using conventional gated scans taken during a short breath-hold [7,8], as well as producing real-time CMR at frame rates equal to, or greater than, echocardiography [9]. The fast acquisition of images effectively eliminates artefacts from both cardiac and respiratory motion, and has allowed the development of clinically viable rapid three-dimensional assessment of ventricular function and mass. Complete functional studies, therefore, can now be completed quickly with good patient comfort, even in patients with orthopnoea, such as in heart failure.

The assessment of function by CMR has some advantages over other techniques such as echocardiography and radionuclide ventriculography, namely the ability to provide accurate and reproducible tomographic static and dynamic images of high spatial and temporal resolution in any desired plane without exposure to ionizing radiation or limitation by acoustic access. CMR produces images with natural contrast between tissue and flowing blood thereby removing the need for a contrast agent in routine imaging. Comparisons between CMR and the more established techniques are now being reported. Whilst the mean value in a study population of a parameter such as ejection fraction is similar between techniques, there is very considerable scatter of results. This is due to variations in accuracy and other technical factors, and suggests that the results between techniques are not directly comparable [10]. This needs to be taken into consideration when comparing novel with more established techniques.


   3. Assessment of global cardiac function
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
 References
 
Several approaches to the assessment of cardiac function are possible with CMR. A relatively simple qualitative assessment may be made using cine CMR in the vertical and horizontal long axes, typically with 16–20 frames per cardiac cycle (Fig. 1). These views allow direct visualization of global and regional cardiac function in similar orientations obtainable with other techniques, and, therefore, are already familiar to cardiologists. However, in order to capitalize on the strengths of CMR, quantitative methods are preferred. As with two-dimensional echocardiography, end diastolic volume (EDV) and end systolic volume (ESV) may be calculated using the area-length method [11]. With a single four-chamber view, the left ventricular endocardial border can be traced, as well as the length from the apex to the mitral valve annulus (L). The volume can then be calculated: volume=0.85x(endocardial area)2/L. This method is improved by using both long axis planes to measure two orthogonal areas (A and B) and two lengths from apex to mitral annulus and then calculating volume from the equation: volume=0.85x(area A xarea B)/the smaller of the two measured lengths. Although simple and time-efficient, these methods rely on the geometric assumption that the left ventricle may be represented as an ellipsoid shape, which is often not the case, especially in ventricles of patients with heart failure that may have distorted morphology as a result of infarction, and have regional differences in wall motion. The most important CMR method therefore deals with these issues by calculating the EDV and ESV from a stack of contiguous short axis slices encompassing the entire left and right ventricles in a three-dimensional fashion (Simpson’s method, Fig. 2). Endocardial contours are traced on the diastolic and systolic images (using simple software manually, or one of the more complex automated programs) [12] and the ventricular volume (diastolic or systolic) is then equal to the sum of all the endocardial areas (of the diastolic or systolic images respectively) multiplied by the slice thickness. From EDV and ESV the stroke volume (SV) and ejection fraction (EF) is calculated in the normal way (SV=EDV–ESV; EF=SV/EDV). The ventricular myocardial mass may also be calculated by tracing the epicardial borders in diastole, applying Simpson’s method to obtain an epicardial volume, and then subtraction of the EDV from this to give volume of myocardium. Multiplication of this value by the specific gravity of muscle (1.05 g/ml) yields the myocardial mass. Although more time-consuming than the simple two-plane method, the areas, volumes, and mass generated by these methods are independent of geometric assumptions and accurate compared with in-vitro gold standards [13,14]. Conventional ECG-gated, free breathing, gradient-echo cine sequences require a total scanning time of approximately 30 min, but with more modern breath-hold fast low angle shot (FLASH) cine sequences, each one of the contiguous short axis slices may be acquired in a single breath-hold, reducing the total scanning time to less than 10 min. In patients with heart failure the required breath-hold of approximately 10 s may sometimes be problematic but the development of advanced respiratory gating techniques allows acquisition of short axis images of comparable or better quality during free breathing, within the same total time [15]. The latest generation of ultrafast scanners may eradicate the problem of multiple breath-holds altogether as they can acquire the entire short axis three-dimensional dataset in a single breath-hold of approximately 12 s [16], and real time solutions are also applicable during free-breathing [8,9].


Figure 1
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  		Fig. 1 Long axis CMR of a patient with heart failure, following anteroapical transmural infarction, and extensive remodelling. Note the very thin anteroapical and septal wall, and the very asymmetric ventricular geometry. (a) Vertical long axis, (b) horizontal long axis. LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle; Ao, descending aorta; MV, mitral valve leaflets.

 


Figure 2
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  		Fig. 2 Calculation of volumes using a stack of contiguous short axis slices according to Simpson’s Method. ED, end-diastolic images; ES, end-systolic images. The epicardial borders (white) are defined on the end diastolic images, and the endocardial (black) borders are defined on both the end-diastolic and end-systolic images. This allows accurate measurement of the area of the blood pool and myocardium for each short axis slice, and subsequently calculation of ventricular volumes and mass. The process is easily extended to calculate the same parameters for the right ventricle. Note the signal loss (arrow) around the sternum caused by sternal wires in this heart transplant patient does not affect LV volume assessment.

 
It is also possible to assess diastolic function with CMR, although this is much less studied [17]. Ventricular inflow measurements may be made in a manner similar to echocardiography; CMR velocity mapping of the E wave agrees with that of echo but tends to underestimate the A wave due to beat-to-beat variability that occurs in the diastolic period [18]. Decreases and reversal of the E:A ratio has been shown with CMR in cases of reduced ventricular compliance, and cine CMR allows direct visualization of abnormal diastolic filling in dilated ventricles. Another technique recently became available, and uses the time-volume curve of the left ventricle. This is calculated from the analysis of all the phases in the three-dimensional cine stack that is used for measuring the ESV and EDV. In practice, this can only be achieved using automated software due to the number of slices involved [12]. The peak filling rate can be calculated from these data in the same way as is done using radionuclide ventriculography. Future techniques for diastolic function assessment may focus on the use of myocardial velocity mapping [19,20], or tagging or ventricular torsion [21], but at present experience with these techniques is still very limited.


   4. Assessment of regional function
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
 References
 
CMR allows both a qualitative and quantitative approach to the assessment of regional function. Cine CMR sequences allow qualitative assessment in a manner similar to echo but without the limitations of acoustic windows. Wall motion analysis can be performed at rest, with low dose dobutamine for the detection of viable myocardium [22,23], and high dose dobutamine for the detection of ischaemia [24–26]. Several methods also exist for quantitative assessment of wall motion and wall thickening based on cine CMR [27–31], but all of these methods require a degree of manual interaction, and in reality myocardial dynamics are more complicated than simple myocardial thickening and the two-dimensional model commonly used. Myocardial tagging offers a method of quantification which allows for the complex interaction of contraction, expansion, twisting and through-plane motion that occurs in three dimensions [32,33]. A grid of magnetically altered lines is physically placed in the heart at end-diastole, for example on a short axis slice (Fig. 3). The distortion of this grid during the cardiac cycle may be tracked and analysed by computer algorithms, and a quantitative measure of cardiac deformation and strain can be made using finite element analysis. This technique has been applied successfully in various clinical settings including quantification of remodelling and viability post-myocardial infarction [34,35], and assessing the effects of therapeutic interventions [35,36]. Phase velocity mapping has an even higher resolution than tagging and involves the use of velocity mapping of the myocardium to track the movement of individual pixels [37,38]. Although velocity mapping is routinely used for flow quantification through valves and vessels [39], this technique is yet to be widely evaluated in its role of regional myocardial function assessment. Both myocardial tagging and velocity mapping are now being used with dobutamine stress to demonstrate localized dynamics of both normal and dysfunctional myocardium in patients with reversible ischaemia [40,41] and are likely to be of importance in the future, because of their objective and quantitative nature.


Figure 3
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  		Fig. 3 CMR tagging. A grid of low signal tagging lines is placed in the myocardium at end-diastole to form a lattice-work of regular shaped squares (as can be seen in the liver, where contraction has not occurred). Deformation of the lines is followed during the cardiac cycle, and in this example, the tags are viewed in early systole. Deformation of the lines towards the blood (radial lengthening) caused by myocardial contraction is seen as curvature of the lines towards the centre of the blood pool, and circumferential shortening is seen as bunching of the lines closer together. Thus the squares become distorted thinned rectangles during contraction. Quantification is performed by mapping the tag line intersection points which allows myocardial strain analysis. This has the advantage of being an objective and quantifiable measure of contractility, which is not dependent on endocardial excursion. (Image courtesy of Dr C. Kramer, Allegheny General Hospital, Pittsburgh.)

 

   5. Myocardial viability
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
 References
 
Delayed enhancement patterns after the intravenous injection of the contrast agent gadolinium have recently received a great deal of interest for the high resolution assessment of myocardial viability. Enhancement in necrotic tissue occurs after acute infarction, both with [42,43] and without [44,45] reperfusion, and is of prognostic significance both in terms of infarct size and also by identifying microvascular obstruction [46]. In both acute and chronic infarction the region of hyperenhancement is very similar in size to the area of irreversible injury, whilst non-enhancing regions are viable (Fig. 4) [47]. Thus, a combination of contrast CMR and cine CMR in the same planes can be used to distinguish between myocardial scar (hyperenhanced and with reduced contractile dysfunction), hibernating myocardium (not hyperenhanced but with reduced contractile dysfunction), and normal myocardium (not hyperenhanced and with normal function) [47]. The technique has already been shown to predict recovery of function after revascularization according to the transmural extent of scar [48], and the applications are clear for determining both the extent of irreversible infarction burden and the potential reversibility of function in heart failure associated with ischaemic heart disease. It could also have value in differentiating ischaemic from non-ischaemic cardiomyopathy [49]. High signal-to-noise images with transmural resolution are easily and quickly achieved with this technique and it is likely to be rapidly incorporated into clinical practice in heart failure.


Figure 4
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  		Fig. 4 Myocardial viability can be determined using the enhancement pattern approximately 20 min after administration of gadolinium. The bright areas shown by the straight arrows are infarcted tissue. In the top row, images are shown in the short axis and in the bottom row the images are in the vertical long axis. The left column shows an end-diastolic frame from a gradient echo acquisition, where the blood-pool is bright. The right column shows the viability image in the same plane where normal myocardium is black and infarcted tissue is brightly enhanced (straight arrows). The infarct in the short axis plane extends from the inferior wall to the anterolateral wall, and is mainly non-transmural. In particular, at 4 o’clock, a significant rim of viable epicardial tissue is present and wall thickness is preserved. However, wall thinning has occurred elsewhere where the transmural extent of infarction is greater. The infarct in the anterior wall of the vertical long axis plane is transmural, however, and considerably greater thinning and ventricular remodelling has taken place. This technique allows transmural high-resolution infarct depiction in-vivo for the first time. The curved arrow shows a pericardial effusion. (Images courtesy of Raymond Kim and Robert Judd, Northwestern University, Chicago.)

 

   6. Myocardial perfusion and coronary artery imaging
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
 References
 
CMR perfusion studies are performed using ultrafast imaging sequences and paramagnetic contrast agents, most usually gadolinium [50]. The bolus of contrast is given intravenously and myocardial signal changes are assessed during the first pass with multi-slice short axis cuts [51]. The time taken to reach peak signal intensity, the level of the peak signal intensity, and the rate of signal increase are measured, and parametric maps can be generated to show perfusion parameters [52]. Myocardium perfused by a diseased vessel shows lower peak signal intensity and rate of signal increase, and longer time to reach peak (Fig. 5). Revascularization has been shown to redress this, and increase the peak signal intensity[53] and slope [54]. Pharmacological stress with dipyridamole or adenosine allows calculation of the myocardial perfusion reserve [51,55,56], with results similar to nuclear imaging techniques [57,58]. The application of theoretical models already developed [59] and newer intravascular contrast agents [60,61] may allow reliable quantitative assessment of absolute myocardial blood flow in the future [62,63]. Currently, CMR yields the highest resolution perfusion images available in-vivo with subendocardial resolution easily achievable, and further technical improvements are to be expected. The availability of this high fidelity tool, which is free from ionizing radiation, makes CMR very attractive for clinical and research purposes, in determining the importance of subendocardial ischaemia in hypertrophic and dilated hearts, as well as the ischaemic burden in heart failure associated with ischaemic heart disease, which may be used to predict functional improvement after revascularization [64].


Figure 5
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  		Fig. 5 An example of a reversible inferior perfusion defect in a patient with right coronary artery disease (arrow) using single slice CMR echo-planar perfusion imaging (lower row in black and white) compared with thallium SPECT (upper row in colour). The CMR images are early single frames taken from the first pass series during the passage through the myocardium of a bolus of MR contrast agent (gadolinium). Note the good concordance in size and position of the CMR and thallium defects.

 
The coronary arteries may also be assessed directly using CMR [65–67]. Although coronary angiography remains the gold standard, ultrafast imaging with ECG and respiratory gating has enabled MR coronary angiography to be performed with some success. At present, CMR can consistently image the proximal coronary circulation but is mainly limited to the assessment of anomalous coronaries [68,69], and bypass grafts [70,71] (Fig. 6). Further developments are being made for improving detection of proximal coronary stenoses including new sequences [72], intravascular contrast agents [73], and the quantification of coronary flow reserve [74], but these techniques are not yet sufficiently robust for routine use in clinical practice.


Figure 6
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  		Fig. 6 (a–e) Series of non-contrast enhanced, CMR images demonstrating a patent saphenous venous graft (b,c,d) and its insertion (d) into a stenosed native right coronary artery (e). RCA, right coronary artery; SVG, saphenous vein graft; LV, left ventricle; RV, right ventricle; Ao, aorta. (Images courtesy of Dr N. Bunce, Royal Brompton Hospital, London, UK.)

 

   7. CMR in remodelling research
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
8. CMR and specific...
 9. Problems with CMR
 References
 
CMR is the reference technique for the non-invasive assessment of cardiac function and myocardial mass. Its accuracy [75,76] and reproducibility (Fig. 7) in both normal and abnormal ventricles [77–80] makes it ideal for serial assessment of individuals with heart failure [81]. The high reproducibility of CMR has also been demonstrated in patients with heart failure [82]. For research, this results in a considerable reduction in the sample size required to show a given change, when compared with echocardiography. For example, in a study of a new drug thought to attenuate myocardial remodelling, in order to demonstrate a 10-ml difference in EDV and ESV and a 10-g difference in mass, with a power of 90% and a P-value of 0.05, only 12, 10, and 9 patients would be needed for each of these parameters, respectively, by CMR vs. 97, 53, and 190 patients by two-dimensional echocardiography [83]. Similar findings have been reported in patients with hypertension [84]. This reflects the geometric assumptions made with echocardiography and the fact that there is no account of regional changes in architecture made with calculations from either echocardiographic M-mode or two-dimensional images [85–88]. Three-dimensional echocardiography has the potential to overcome these problems [89], but at present is still a research tool and is not as well developed as CMR in this area. CMR is now also being increasingly used to study remodelling in transgenic mice [90].


Figure 7
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  		Fig. 7 Comparison of the standard deviation of inter-study reproducibility between echocardiography and CMR. This standard deviation is central to determining sample size for drug trials. Sample size rises with a square function of the ratio in standard deviations between the techniques. For all parameters of function and mass, the variability of two-dimensional echocardiogrphy is greater. It should be noted that the comparative figures come from different patient groups. (Echocardiography from Otterstad et al., Eur Heart J 1997;18:507–513 and CMR from Bellenger et al. [83]).

 

   8. CMR and specific heart failure causation
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
9. Problems with CMR
 References
 
Some specific causes of heart failure have particularly exploited CMR capabilities. CMR has a special role in the assessment of cardiac failure caused by iron overload, whether induced by transfusion therapy or haemochromatosis. In addition to measuring the left ventricular function and mass, the degree and distribution of myocardial iron can be simultaneously assessed [91,92]. The characteristic epicardial deposition of iron, described at autopsy [93] can be easily observed on gradient echo images (Fig. 8). Quantification of cardiac iron stores is made possible by measurement of the myocardial T2 value and this has been shown to be related to myocardial iron concentration [94] in animals and serum ferritin concentrations in man [95]. Iron-induced cardiomyopathy is reversible following iron store reduction by venesection or desferrioxamine chelation therapy [96–99]. Serial CMR studies can therefore be used to guide treatment and monitor progress in both myocardial iron content and function over time [92,100].


Figure 8
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  		Fig. 8 Example of iron deposition in a patient with thalassemia. The dark epicardial rim of iron is arrowed. Note that liver deposition is very heavy, and the liver is therefore black. The signal loss occurs because of disturbances in the relaxation parameters of the tissues brought about by the iron causing alterations in the local magnetic field. There is very poor correlation between iron deposition in the liver and the heart, which prevents adequate management of the cardiac complications of myocardial iron overload (arrhythmia, heart failure and death) from liver biopsy results.

 
CMR is also employed in the diagnosis of heart failure caused by sarcoid infiltration. Myocardial infiltration has been demonstrated at autopsy in 27% of patients with sarcoidosis [101]. Most patients are asymptomatic and myocardial involvement may go undetected; however, sudden death due to heart block or ventricular tachyarrythmias is a common manifestation of cardiac sarcoidosis [102,103]. Diagnosis is difficult because of the lack of symptoms and the variable myocardial distribution, resulting in sampling error from endocardial biopsies and false negative results [104]. CMR aids diagnosis as areas of the myocardium affected by sarcoidosis show increased signal intensity after the administration of gadolinium as a contrast agent [105]. Both the ventricular arrhythmias and myocardial function have been shown to improve following the administration of corticosteroids [106,107]. CMR therefore is developing a place in the diagnosis, risk assessment and guidance of therapy in patients with myocardial sarcoidosis, but further studies are needed in this area.

CMR has also proved an effective tool in the diagnosis and follow-up of patients with heart failure due to myocarditis [108]. Signal enhancement of the myocardium is seen in these patients on T2 weighted images, and on T1 weighted images following the administration of gadolinium [109,110]. Serial scans allow the clinical progress to be monitored and a reduction in the extent of the inflammatory process may be observed during follow-up [108].


   9. Problems with CMR
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
References
 
Some patients cannot undergo CMR. Claustrophobia is an occasional problem but this is improving with newer open scanner designs. It may affect up to 4% of patients, but the use of anxiolytics (benzodiazepines) with reassurance can reduce this rate to 1% [111]. Absolute contraindications to CMR are few, but patients with implantable devices such as pacemakers and defibrillators, cochleal implants, and cerebral aneurysm clips usually cannot be scanned except under very well controlled and clinically urgent circumstances [112,113]. Scanning patients with sternal wires is safe and the associated signal loss is localized to an area anterior to the heart, which rarely interferes with image analysis. All prosthetic heart valves are CMR compatible and scanning of patients with intra-coronary stents is also safe [114–116], and is undertaken routinely at our institution. Although the cardiac rhythm should ideally be regular to allow satisfactory gating, controlled atrial fibrillation is tolerable. Significant arrhythmia results in poor quality images unless real time imaging is used [117]. Image artefact secondary to excessive respiratory motion may also be a problem, but respiratory gating techniques, such as navigator imaging, have overcome this [15]. Finally, the time for analysis may be an issue with some of the manual techniques involved, but the development of new software and edge detection systems has reduced this considerably [12,118,119].


   References
Top
 Abstract
 1. Introduction
 2. Technical aspects of...
 3. Assessment of global...
 4. Assessment of regional...
 5. Myocardial viability
 6. Myocardial perfusion and...
 7. CMR in remodelling...
 8. CMR and specific...
 9. Problems with CMR
 References
 

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