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Myocardial Perfusion and Viability

Michael Jerosch‐Herold¹, Arthur E. Stillman¹

¹University of Minnesota, Minneapolis, Minnesota

Publication Name:

Current Protocols in Magnetic Resonance Imaging

Unit Number:

Unit A11.3

DOI:

10.1002/0471142719.mia1103s00

Online Posting Date:

May, 2001

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Abstract

Both first-pass perfusion studies and imaging of delayed hyperenhancement can be combined in one patient exam. The MRI protocols for myocardial perfusion and viability assessment are presented together in this unit due to the complimentary information that is obtained with both protocols. Also, the imaging techniques used for both protocols are closely related. The first protocol assesses the functional severity of coronary artery lesions, while the second, used in addition to first basic protocol, is used in patient presents with symptoms of myocardial infarction or post-coronary revascularization. The procedures are useful in determining the presence and extent of nonviable myocardium.

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Unit Introduction
Basic Protocol 1: Imaging Myocardial Perfusion During First-Pass Contrast-Enhancement
Basic Protocol 2: Imaging Myocardial Viability
Commentary
Bibliography
Figures
Tables

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Materials

Basic Protocol 1: Imaging Myocardial Perfusion During First-Pass Contrast-Enhancement

Materials

Normal saline (0.9% NaCl), sterile
Extravascular GD-DTPA contrast agent (e.g., Magnevist or Omniscan)
16-G i.v. needle and injection line
Disposable syringes for power injector

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Figures

Figure A11.3.1

Scout images for transverse (step ), pseudo-vertical long axis (step ), and pseudo-horizontal long axis (step ) in left-to-right order. The images were acquired with a fast steady-state free-precession (SSFP) scout imaging technique (“true FISP”), which was used because of the excellent definition of anatomical structures that is achieved with this technique. The use of SSFP imaging is currently limited to MRI systems with high-performance gradient systems. The thick white lines denote the image plane orientation for the next scout image to the right.

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Figure A11.3.2

Schematic sequence diagram of multislice perfusion imaging sequence with nonslice-selective saturation-recovery (SR) preparation before each FLASH readout. The delay between the SR preparation and the FLASH readout can be kept as short as 10 msec and still provides good T₁-weighting of the signal intensity. By comparison, an inversion recovery preparation requires a relaxation delay (T_I) of ~100 msec. A slice-selective magnetization-preparation would lead to modulation of the signal intensity from spins flowing into the magnetization-prepared volume. A nonslice-selective preparation pulse eliminates this flow-dependent modulation of the signal intensity.

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Figure A11.3.3

Selected frames from a multislice first pass perfusion study acquired in a 53 year old male patient with a scarred infarct in the inferior wall. The images are arranged in separate rows for each slice position, and in each row the images show the sequential appearance of the contrast agent bolus in the right ventricle, the left ventricle, and enhancement of myocardial tissue. Images were acquired while the patient held his breath. The images in this example have not been cropped and they illustrate how the rectangular field of view is adjusted to avoid wrap-around in the phase encoding direction, which can otherwise obstruct the view of the heart.

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Figure A11.3.4

Magnified multislice perfusion images in a patient with an inferior perfusion defect. The perfusion defect results in a reduced and slowed contrast enhancement after the first pass through the left ventricle. Patient had shown a fixed defect in the inferior wall segment on single plot on emission computed tomography (SPECT).

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Figure A11.3.5

Timing diagram for segmented, ECG-gated gradient echo sequence with inversion recovery preparation for imaging of delayed enhancement. The inversion-recovery preparation is repeated before acquisition of each segment of phase-encoding lines, and a sufficient delay on the order of 2 to 3 heartbeats needs to be placed between the inversion pulse and the previous segment acquisition. The inversion time (T_I) is adjusted 1 to 2 min after injection of the contrast agent to null the signal in normal myocardium.

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Figure A11.3.6

Images of early (left) and delayed (right) contrast enhancement in a 65 year old male patient 4 days after his first acute large anterior myocardial infarction (creatine kinase >7000). In the images of the early enhancement a dark region in the antero-septal region indicates the presence of a no-reflow zone. The image acquired with a 10 min delay shows hyperenhancement in the same area and clearly delineates the extent of the infarction. The images were acquired with an ECG-gated fast gradient echo sequence with an inversion recovery preparation for maximum T₁-weighting. Blood signal supression was used for better delineation of the endocardial border, and images were acquired at end-diastole. Images courtesy of Drs. João Lima and Bernhard Gerber, Johns Hopkins Medical Institution, Baltimore.

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Figure A11.3.7

Images of delayed contrast enhancement obtained in a 49-year-old male with a history of two myocardial infarctions—one myocardial infarction (MI) four years before MRI followed by percutaneous transluminal coronary angioplasty (PTCA) and stent to his right coronary artery (RCA). The images shown in the figure were acquired 2.5 months after a second, anterior wall MI and subsequent coronary artery bypass graft (CABG) surgery. Gadolinium DTPA of 40 ml was used and imaging was performed ~30 min after contrast injection with a segmented turbo FLASH sequence as shown in Fig. A11.3.5. Images provided by Dr. R. White, Cleveland Clinic Foundation.

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Figure A11.3.8

Signal intensity curves from regions of interest (ROI) in a series of perfusion images, that is also shown in Fig. A11.3.4. The signal intensity curves correspond to the basal slice position. The dashed line represents the signal changes in for an ROI in the center of the left ventricular (LV) cavity. The signal curves with open circles and triangles were obtained for transmural ROI's in the anterior and posterior segments, respectively. Signal curves were scaled to correct for inhomogeneity of sensitivity profile of the receiver coil. Relevant parameters for assessing perfusion in a semiquantitative manner are the up-slope during contrast agent wash-in, and the peak amplitude. The definition of these two parameters is illustrated in the inset of this figure. Perfusion in the inferior/posterior wall segment was abnormally low in this patient.

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Literature Cited

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Internet Resources
	http://www.heartmri.com
This web site is addressed at users of GE scanners and provides specifics on sequences and techniques for imaging of myocardial perfusion and viability.
	http://www.drad.umn.edu/cvmr/home/html
The authors' web site has a document in Adobe Acrobat format with specific instructions on how to perform myocardial perfusion studies on a Siemens Vision scanner.
	http://nsr.bioeng.washington.edu
This is a useful site for readers interested in state-of-the-art tracer kinetic analysis that has been applied for analysis of MRI perfusion data. The National Simulation Resource is an NIH-funded resource.