Cardiac MRI
Introduction
• CMRI ARVD
• Information to assess the abnormality of heart
• Anatomical and functional information
• Acquired or congenital heart diseases
• Modality of choice
▫ ARVD,
▫ Differentiation from constrictive pericarditis from
restrictive pericarditis, aortic dissection
▫ Precise quantification of ventricular
dimensions
▫ Myocardial viability and perfusion
ECG Gating
• ECG/EKG gating essential for motion-free image
of heart
• Images are acquired in a particular phase of
cardiac cycle in every cardiac cycle
• To avoid image blur and motion artifacts
• The image is decided by ECG gating
• Usually R-wave is used to trigger the
acquisition
• Such data acquired in the diastolic phase
• Peripheral pulse also used for gating
• But less effective than ECG gating
Imaging Sequences
• Pulse sequences used
▫ Dark-blood sequences
▫ Bright-blood sequences
• Dark-blood tech
• Spin-echo seq; that show the flowing blood as flow
void
• Seqs; include breath-hold turbo or FSE (TSE,
FSE)
• Single shot FSE
• Double inversion recovery FSE (Double-IR-
FSE)
Bright blood technique
• GRE seq: based shows blood bright
• Seqs; include spoiled GRE
▫ (turboFLASH/SPGR/T1-FSE)
▫ Balanced SSFP (TrueFISP/FIESTA/balanced
TFE)
• Balanced TFE is mainstay seq; in CMRI
• Motion loop is obtained rapid cine imaging (RCI)
• Used RCI used ventricular function
• To calculate EF, SV as well as valvular & RWM
• Phase contrast useful in velocity & flow direction
• Initial CMRI starts from black blood than bright
blood techniques used to assess functions
Imaging planes
• Orthogonal planes (axial, sagittal and coronal)
• Used for chest imaging and not suitable in CMRI
• Because cardiac axes are not parallel to body axes
• Three axes images are taken and used as localiser
1. Vertical long-axis
plan (two chamber
view)
• Axial image
• Large oblique
diameter image of LV
• Chambers; LA and
LV
2. Horizontal long-axis (Four
Chamber view)
• Planned on two chamber
view
• By a drawing line passing
through LA, MV & LV
• All four chambers, MV
and
TV assessed
• Cine GRE images obtained
on this plane to assess
function of MV, TV, AV and
LV, RV wall motion
3. Short-axis plane
• Multiple cross sections are
obtained perpendicular to
LV long axis as seen on a
two-chamber view
• Sections are taken from the
base to the apex of the
heart
• Cine GRE images allow
visualization and
quantification of systolic
myocardial wall thickening
• Images in this plane are
used for calculating
ventricle volume, mass and
EF by postprocessing
4. Five-Chamber view
• View obtained parallel
to the line passing
through the LV apex
and aortic outflow tract
on coronal images
• Apart from all four
chambers, this view
also shows aortic root
• This describe MV and
AV
5. RVOT
• Plane passing through the RV outflow tract
Clinical Applications of CMRI
1. Congenital Heart Disease (CHD)
• Complex information about heart anatomy
• When echocardiography fail
• ASD, VSD detected with high sensitivity &
specificity
• Calculate shunt size
• Conditions like
▫ TGA (transposition of Greater Arteries)
▫ Truncus arteriosus
▫ Many anomalies
CMRI in children are having limitation
ASD
Truncus
arteriosus
2. Valvular Heart Disease (VHD)
• Arrhythmogenic right ventricular dysphagia
• Enlargement and dilatation of RV
• Thinning of wall, area of dyskinesia, focal
bulging of free wall in systole
• Decreased EF and impair ventricular filling
during diastole
• HCM (Hypertrophied)
▫ Echo detect but RV involvement is
checked CMRI
• RCM (Restrictive) vs Constrictive
▫ Constrictive calcified pericardium, WT +
4mm
• Hemochromatosis
▫ Myocardial iron deposition i.e.
4. Ventricular Function
• CMRI more accurate than Echo
• It measure EF, EDV & ESV (end systolic vol)
• Done on short axis image using software
• Balanced SSFP, good contrast b/w blood
pool and myocardium
5. Coronary artery assessment
• Not good enough for visualisation of coronary
arteries and its branches
• Presently it is used for such purpose, to find
anomalies, aneurysms and bypass grafting
patency
• GRE seq; balanced SSFP C+ or C-
6. Myocardial perfusion and viability
• IV Gd
• T1-weighted GRE seq; turboFLASH
• Low signal areas of underperfusion on these images
correspond with regions of ischemia or infarct
• Myocardial viability
▫ Viability seq; run after 10-15 minutes after Gd
contrast
▫ T1-w GRE or inversion recovery balanced SSFP seq
▫ IR pulse used to suppress myocardium to get LV info
▫ Proper TI is important
▫ Infracted area on viability imaging shows
enhancement
▫ This imaging is ‘Bright is dead’
▫ Answer feasibility revascularisation procedure like
angioplasty and bypass or not
7. Cardiac and Pericardial masses
• CMRI accurate method for cardiac and
pericardial masses evaluation
• Thrombus the most common filling defect in
cardiac chamber
• Gd enhancement differentiate b/w mass or
thrombus
• Most cardiac neoplasm are metastatic
• Primary neoplasm are rare and 80%
benign
8. Pericardial disease
• Visualised with spin echo or GRE images
• Normal pericardium seen on SE images
• As a line of low signal intensity located b/w high
signals of pericardial and epicardial fat
• Normal thickness 1-2 mm; more than 4 mm is
considered thickening
