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Case example. Standard and high-resolution stress perfusion CMR in a patient with three-vessel coronary artery disease. Standard-resolution shows perfusion defects (arrows) in the basal-inferior (A), mid-inferior, mid-inferoseptal (B), apical-anterior and apical-inferior segments (C). High-resolution shows a similar distribution of perfusion defects but demonstrates additional ischaemia in the basal-lateral (D), mid-anterior, and mid-anterolateral segments (E) with a circumferential defect in the apical slice (F). Perfusion defects are also better delineated at high-resolution and the transmural extent of ischaemia more clearly seen.
Source publication
This study compared the myocardial ischaemic burden (MIB) in patients with angiographic three-vessel coronary artery disease (3VD) using high-resolution and standard-resolution myocardial perfusion cardiovascular magnetic resonance (perfusion CMR) imaging.
One hundred and five patients undergoing coronary angiography had two separate stress/rest pe...
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Background
Perfusion cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) are emerging as the most accurate tools for the assessment of myocardial ischemia noninvasively or in the catheter laboratory. However, there is limited data comparing CMR and FFR in patients with multi-vessel disease. This study aims to evaluate the corr...
The CE-MARC study assessed the diagnostic performance investigated the use of cardiovascular magnetic resonance (CMR) in patients with suspected coronary artery disease (CAD). The study used a multi-parametric CMR protocol assessing 4 components: i) left ventricular function; ii) myocardial perfusion; iii) viability (late gadolinium enhancement (LG...
Citations
... However, this visual assessment is a qualitative measure of perfusion and may be inaccurate when MBF is globally reduced, as in three-vessel CAD [32]. In fact, some studies have found that qualitative visual analysis using CMR is only able to detect significant multi-vessel CAD in up to two-thirds of patients [33,34]. Furthermore, Rahman et al. [35] showed that visual assessment of poorly perfused myocardial segments had poor accuracy in detecting coronary microvascular disease when compared to invasive CRT measurements (diagnostic accuracy: 58%, specificity: 41%, sensitivity: 83%), as seen in Table 2. Abbreviations: AUC = area under the curve; CMR = cardiac magnetic resonance; CRT = coronary reactivity testing; IMR = index of microcirculatory resistance; MPRENDO = subendocardial myocardial perfusion reserve; MPR = myocardial perfusion reserve; MBF = myocardial blood flow. ...
Ischemia with no obstructive coronary arteries (INOCA) is a relatively newly discovered ischemic phenotype that affects patients similarly to obstructive coronary artery disease (CAD) but has a unique pathophysiology and epidemiology. Patients with INOCA present with ischemic signs and symptoms but no obstructive CAD seen on coronary CTA or invasive coronary angiography, which can assess epicardial vessels. The mechanisms of INOCA can be grouped into three endotypes: coronary microvascular dysfunction, epicardial coronary vasospasm, or a combination of both. Accurate and comprehensive assessment of both epicardial and microvascular disease in suspected cases of INOCA is crucial for providing targeted therapy and improving outcomes in this underrepresented population. This review aims to clarify the complex pathophysiology of INOCA, present an overview of invasive and non-invasive diagnostic methods, and examine contemporary approaches for coronary perfusion assessment using cardiac magnetic resonance (CMR). We also explore how recent advancements in quantitative CMR can potentially revolutionize the evaluation of suspected INOCA by offering a rapid, accurate, and non-invasive diagnostic approach, thereby reducing the alarming number of cases that go undetected.
... A limiting factor of CMR is an underestimated burden of multivessel CAD attributed to current common-place clinical practice of qualitative visual interpretation. [44] A novel CMR technology, automated pixelwise perfusion mapping, allows for quantitative measurement of regional myocardial blood flow and has demonstrated superior detection of multivessel CAD versus current qualitative visual measurement [45]. Another limiting factor of CMR has been the FDA non-approval of gadolinium-based contrast agents for detection of CAD. ...
Purpose of the Review
Clinical atherosclerotic cardiovascular disease (ASCVD) requires years to manifest, providing a window of opportunity for preventive cardiovascular management. Subclinical atherosclerosis imaging leverages this long latency period to estimate and improve future ASCVD risk.
Recent Findings
Coronary artery calcium (CAC) scoring has the most robust data in the detection of subclinical atherosclerosis. CAC scan significantly enhances cardiovascular risk stratification in addition to traditional risk models. Coronary computed tomography angiography data show similar strengths in subclinical atherosclerosis detection in addition to plaque morphology characterization with inherent limitations. Carotid intima-media thickness and ankle-brachial index are other modalities whose predictive value becomes incremental when added to the aforementioned modalities.
Summary
When added to traditional risk models, subclinical atherosclerosis imaging modalities personalize future ASCVD risk stratification and assist in the initiation and rate of intensification of preventive therapies. Emerging imaging techniques exist but further research is required for primetime clinical use.
... M ultivessel coronary artery disease (2- Stress perfusion cardiac magnetic resonance (CMR) is a highly accurate tool for the detection of obstructive coronary artery disease (CAD) (3,4), but it has been suggested that CMR may underestimate the burden of ischemia in patients with MVCAD (5,6). It has previously been shown that perfusion defects in all 3 coronary territories are only present in up to 58% of patients with known obstructive 3VD (7). ...
... Our data suggest that less than one-half of cases are correctly graded as 2VD or 3VD when first-pass images are analyzed visually. This is consistent with data from Motwani et al. (5) who found that only 29% of patients with 3VD had perfusion defects in all 3 coronary territories with standard-resolution perfusion CMR, although this improved to 57% with highresolution imaging. The only other study assessing the same question found perfusion defects in all 3 territories in 58% of cases with 3VD (7). ...
... Furthermore, these results outperform previously published studies of CMR perfusion in multivessel disease (5,7). The threshold used to define a coronary perfusion territory as ischaemic in this study was 2 adjacent segments using the AHA-defined coronary territory model. ...
OBJECTIVES: The authors sought to compare the diagnostic accuracy of quantitative perfusion maps to visual assessment (VA) of first-pass perfusion images for the detection of multivessel coronary artery disease (MVCAD). BACKGROUND: VA of first-pass stress perfusion cardiac magnetic resonance (CMR) may underestimate ischemia in MVCAD. Pixelwise perfusion mapping allows quantitative measurement of regional myocardial blood flow, which may improve ischemia detection in MVCAD. METHODS: One hundred fifty-one subjects recruited at 2 centers underwent stress perfusion CMR with myocardial perfusion mapping, and invasive coronary angiography with coronary physiology assessment. Ischemic burden was assessed by VA of first-pass images and by quantitative measurement of stress myocardial blood flow using perfusion maps. RESULTS: In patients with MVCAD (2-vessel [2VD] or 3-vessel disease [3VD]; n = 95), perfusion mapping identified significantly more segments with perfusion defects (median segments per patient 12 [interquartile range (IQR): 9 to 16] by mapping vs. 8 [IQR: 5 to 9.5] by VA; p < 0.001). Ischemic burden (IB) measured using mapping was higher in MVCAD compared with IB measured using VA (3VD mapping 100 % (75% to 100%) vs. first-pass 56% (38% to 81%) ; 2VD mapping 63% (50% to 75%) vs. first-pass 41% (31% to 50%); both p < 0.001), but there was no difference in single-vessel disease (mapping 25% (13% to 44%) vs. 25% (13% to 31%). Perfusion mapping was superior to VA for the correct identification of extent of coronary disease (78% vs. 58%; p < 0.001) due to better identification of 3VD (87% vs. 40%) and 2VD (71% vs. 48%). CONCLUSIONS: VA of first-pass stress perfusion underestimates ischemic burden in MVCAD. Pixelwise quantitative perfusion mapping increases the accuracy of CMR in correctly identifying extent of coronary disease. This has important implications for assessment of ischemia and therapeutic decision-making.
... While the clinical utility of 2D cardiac perfusion has been established (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12), 3D cardiac perfusion has been studied less and offers several advantages. The advantages of 3D methods include increased coverage and slice resolution that aid in identifying subendocardial ischemia, offer improved handling of respiratory motion, and increased confidence that any defects have been identified (13)(14)(15)(16). Despite these advantages, reduced clinical utility of 3D methods has been historically observed because the increased acquisition time was linked to a decrease in spatial resolution (17,18). ...
Purpose
The purpose of this study was to further develop and combine several innovative sequence designs to achieve quantitative 3D myocardial perfusion. These developments include an optimized 3D stack‐of‐stars readout (150 ms per beat), efficient acquisition of a 2D arterial input function, tailored saturation pulse design, and potential whole heart coverage during quantitative stress perfusion.
Theory and Methods
All studies were performed free‐breathing on a Prisma 3T MRI scanner. Phantom validation was used to verify sequence accuracy. A total of 21 subjects (3 patients with known disease) were scanned, 12 with a rest only protocol and 9 with both stress (regadenoson) and rest protocols. First pass quantitative perfusion was performed with gadoteridol (0.075 mmol/kg).
Results
Implementation and quantitative perfusion results are shown for healthy subjects and subjects with known coronary disease. Average rest perfusion for the 15 included healthy subjects was 0.79 ± 0.19 mL/g/min, the average stress perfusion for 6 healthy subject studies was 2.44 ± 0.61 mL/g/min, and the average global myocardial perfusion reserve ratio for 6 healthy subjects was 3.10 ± 0.24. Perfusion deficits for 3 patients with ischemia are shown. Average resting heart rate was 59 ± 7 bpm and the average stress heart rate was 81 ± 10 bpm.
Conclusion
This work demonstrates that a quantitative 3D myocardial perfusion sequence with the acquisition of a 2D arterial input function is feasible at high stress heart rates such as during stress. T1 values and gadolinium concentrations of the sequence match the reference standard well in a phantom, and myocardial rest and stress perfusion and myocardial perfusion reserve values are consistent with those published in literature.
... Global stress MBF #2.25 ml/g/min with visual perfusion defects is likely to be obstructive 3-vessel disease and global stress MBF <2.25 ml/g/min without visual defects is likely to be MVD. CMR ¼ cardiovascular magnetic resonance; other abbreviations as in Figures 1 and 4. traditionally been believed to be a problem associated with PET, it has also been shown that stress perfusion CMR only diagnoses perfusion defects in all 3 territories in up to two-thirds of patients with known obstructive 3-vessel disease (29,30 ...
Objectives:
This study sought to assess the performance of cardiovascular magnetic resonance (CMR) myocardial perfusion mapping against invasive coronary physiology reference standards for detecting coronary artery disease (CAD, defined by fractional flow reserve [FFR] ≤0.80), microvascular dysfunction (MVD) (defined by index of microcirculatory resistance [IMR] ≥25) and the ability to differentiate between the two.
Background:
Differentiation of epicardial (CAD) and MVD in patients with stable angina remains challenging. Automated in-line CMR perfusion mapping enables quantification of myocardial blood flow (MBF) to be performed rapidly within a clinical workflow.
Methods:
Fifty patients with stable angina and 15 healthy volunteers underwent adenosine stress CMR at 1.5T with quantification of MBF and myocardial perfusion reserve (MPR). FFR and IMR were measured in 101 coronary arteries during subsequent angiography.
Results:
Twenty-seven patients had obstructive CAD and 23 had nonobstructed arteries (7 normal IMR, 16 abnormal IMR). FFR positive (epicardial stenosis) areas had significantly lower stress MBF (1.47 ± 0.48 ml/g/min) and MPR (1.75 ± 0.60) than FFR-negative IMR-positive (MVD) areas (stress MBF: 2.10 ± 0.35 ml/g/min; MPR: 2.41 ± 0.79) and normal areas (stress MBF: 2.47 ± 0.50 ml/g/min; MPR: 2.94 ± 0.81). Stress MBF ≤1.94 ml/g/min accurately detected obstructive CAD on a regional basis (area under the curve: 0.90; p < 0.001). In patients without regional perfusion defects, global stress MBF <1.82 ml/g/min accurately discriminated between obstructive 3-vessel disease and MVD (area under the curve: 0.94; p < 0.001).
Conclusions:
This novel automated pixel-wise perfusion mapping technique can be used to detect physiologically significant CAD defined by FFR, MVD defined by IMR, and to differentiate MVD from multivessel coronary disease. A CMR-based diagnostic algorithm using perfusion mapping for detection of epicardial disease and MVD warrants further clinical validation.
... Advances in the technique and the analysis of CMR perfusion studies should improve the reliability of the method, as has been shown with high resolution sequences [23], or with 3D sequences allowing for a full coverage of the left ventricle [9]. Also, the use of quantitative methods for the analysis of first-pass studies [24] has resulted in an improved diagnostic accuracy of significant coronary artery stenosis when compared with qualitative techniques. ...
Objectives
Cardiovascular magnetic resonance (CMR) provides information on myocardial ischemia through stress perfusion studies. In clinical practice, the grading of induced perfusion defects is performed by visual estimation of their extension. The aim of our study is to devise a score of the degree of ischemia and to test its prognostic value.
Methods
Between 2009 and 2011, patients with diagnosed or suspected coronary artery disease underwent stress perfusion CMR. A score of ischemic burden was calculated on the basis of (1) stress-induced perfusion defect, (2) persistence, (3) transmurality, and (4) stress-induced contractile defect. Follow-up was censored after 4 years and primary end-point was defined by a composite of death, heart failure episode, acute coronary syndrome, and ventricular arrhythmias. Univariate and multivariate logistic regressions were used to assess the strength of the association between the CMR ischemic variables, and the composite outcome.
Results
Forty-four of the 128 patients (34%) presented with adverse events, while 84 (66%) did not. Sixty-one patients (48%) had negative perfusion studies while 67 (52%) showed perfusion defect. Patients with positive perfusion studies and adverse events (n = 39) had higher number of segments with persistent defect (3.3 vs 1.3, p = 0.001) and highest score (19.6 vs 13.3 p = 0.012) than patients with positive perfusion studies and absence of events (n = 28). The number of segments with persistent defect showed the strongest predictive value of adverse events (OR 1.54; CI 1.19–2.00; p < 0.001).
Conclusions
The score of ischemic burden proposed herein has prognostic value. Persistence of a perfusion defect has the strongest impact on prognosis.
Key Points
• Cardiovascular magnetic resonance provides information on myocardial ischemia by visual estimation of the presence of perfusion defects induced by stress.
• There is not a standardized method for grading perfusion defects which, in practice, is performed by visual estimation of their extension.
• As proven in this study, the integration of several parameters of perfusion defects (in addition to extension) into a semiquantitative score has prognostic value.
... We quantitatively assessed stenosis severity on ICA using commercially available software in accordance with societal recommendations (CAAS; Pie Medical, Maastricht, The Netherlands), and an experienced interventional cardiologist interpreted the ICAs. We assessed the coronary arteries according to the 17-segment modified AHA classification (3,15), defining significant CAD on ICA as ≥ 50% reduction in lumen diameter in the left main stem or ≥ 70% stenosis in any of the main epicardial coronary arteries or their branches with a diameter of 2 mm (8,(16)(17)(18). ICA was used to ensure correct association of the 17 myocardial segments with the correct vascular territory for CMR perfusion imaging. ...
... However, there was no significant difference between 1.5T and 3T CMR for the overall detection of significant CAD. The higher diagnostic accuracy of 3T CMR perfusion is attributed to the combination of significant improvement in overall image quality and a significant reduction in dark-rim artifacts (7,9,18); in the present study, none of the imaging studies was kjronline.org deemed non-diagnostic and 3T CMR had significantly higher image quality and fewer dark-rim artifacts than 1.5T CMR perfusion. ...
... Previous studies have demonstrated that the combined analysis of algorithm perfusion imaging and delayed enhancement demonstrated better sensitivity and diagnostic accuracy for the diagnosis of significant CAD at 1.5T and at 3T than analysis of perfusion alone (10,19). Delayed enhancement CMR helps distinguish true negative perfusion defects from artifacts such as matched stressrest perfusion defects and provides higher specificity for detecting significant CAD compared with perfusion alone (10,18). The diagnostic performance of both 1.5T and 3T CMR perfusion imaging for detecting significant CAD was higher in patients with SVD than in those with MVD. ...
Objective
To compare the diagnostic performance of cardiovascular magnetic resonance (CMR) myocardial perfusion at 1.5- and 3-tesla (T) for detecting significant coronary artery disease (CAD), with invasive coronary angiography (ICA) as the reference method.
Materials and Methods
We prospectively enrolled 281 patients (age 62.4 ± 8.3 years, 193 men) with suspected or known CAD who had undergone 1.5T or 3T CMR and ICA. Two independent radiologists interpreted perfusion defects. With ICA as the reference standard, the diagnostic performance of 1.5T and 3T CMR for identifying significant CAD (≥ 50% diameter reduction of the left main and ≥ 70% diameter reduction of other epicardial arteries) was determined.
Results
No differences were observed in baseline characteristics or prevalence of CAD and old myocardial infarction (MI) using 1.5T (n = 135) or 3T (n = 146) systems. Sensitivity, specificity, positive and negative predictive values, and area under the receiver operating characteristic curve (AUC) for detecting significant CAD were similar between the 1.5T (84%, 64%, 74%, 76%, and 0.75 per patient and 68%, 83%, 66%, 84%, and 0.76 per vessel) and 3T (80%, 71%, 71%, 80%, and 0.76 per patient and 75%, 86%, 64%, 91%, and 0.81 per vessel) systems. In patients with multi-vessel CAD without old MI, the sensitivity, specificity, and AUC with 3T were greater than those with 1.5T on a per-vessel basis (71% vs. 36%, 92% vs. 69%, and 0.82 vs. 0.53, respectively).
Conclusion
3T CMR has similar diagnostic performance to 1.5T CMR in detecting significant CAD, except for higher diagnostic performance in patients with multi-vessel CAD without old MI.
... SNR, signal-to-noise ratio; SNR rest , signal-to-noise ratio at the rest study; SNR stress , signal-to-noise ratio at the stress study; RSNR, stress-to-rest ratio of the signal-to-noise ratio. reserve has been shown to be useful in assisting the diagnosis of TVD with positron emission tomography [27,28] and magnetic resonance imaging [3,29]. Although SPECT-based quantification of flow has also been investigated in recent years [13,19,[30][31][32][33][34], its adoption for routine studies is still limited due to the prolonged acquisition time and other technical difficulties. ...
The purpose of this study was to investigate if a novel parameter, the stress-to-rest ratio of the signal-to-noise ratio (RSNR) obtained with a cadmium zinc telluride (CZT) SPECT scanner, could be used to distinguish triple-vessel disease (TVD) patients. Methods . One hundred and two patients with suspected coronary artery disease were retrospectively involved. Each subject underwent a Tl-201 SPECT scan and subsequent coronary angiography. Subjects were separated into TVD ( n=41 ) and control ( n=61 ) groups based on coronary angiography results using 50% as the stenosis cutoff. The RSNR was calculated by dividing the stress signal-to-noise ratio (SNR) by the rest SNR. Summed scores were calculated using quantitative perfusion SPECT (QPS) for all subjects. Results . The RSNR in the TVD group was found to be significantly lower than that in the control group (0.83 ± 0.15 and 1.06 ± 0.17, resp.; P<0.01 ). Receiver-operating characteristic (ROC) analysis showed that RSNR can detect TVD more accurately than the summed difference score with higher sensitivity (85% versus 68%), higher specificity (90% versus 72%), and higher accuracy (88% versus 71%). Conclusion . The RSNR may serve as a useful index to assist the diagnosis of TVD when a fully automatic quantification method is used in CZT-based SPECT studies.
... High spatial-resolution imaging offers benefits by significantly reducing dark rim artefacts, as these are directly proportional to voxel size [34] . Moreover there is improved ability to detect subendocardial ischaemia which is critical in multivessel disease where there is a lack of reference healthy myocardium for comparison [35,36] . High spatialresolution perfusion CMR has been validated at both 1.5T and 3.0T against quantitative coronary angiography (QCA) with improved diagnostic accuracy at both field strengths compared to standard resolution perfusion imaging [27,36,37] . ...
Coronary artery disease (CAD) is a leading cause of death and disability worldwide. Cardiovascular magnetic resonance (CMR) is established in clinical practice guidelines with a growing evidence base supporting its use to aid the diagnosis and management of patients with suspected or established CAD. CMR is a multi-parametric imaging modality that yields high spatial resolution images that can be acquired in any plane for the assessment of global and regional cardiac function, myocardial perfusion and viability, tissue characterisation and coronary artery anatomy, all within a single study protocol and without exposure to ionising radiation. Advances in technology and acquisition techniques continue to progress the utility of CMR across a wide spectrum of cardiovascular disease, and the publication of large scale clinical trials continues to strengthen the role of CMR in daily cardiology practice. This article aims to review current practice and explore the future directions of multi-parametric CMR imaging in the investigation of stable CAD.
... This allows assessing each coronary artery territory independent of other territories. A recent study by Motwani et al. [22] demonstrated an increase in abnormal territories identified with higher spatial resolution (29 % by standard resolution and 57 % by high resolution imaging (p = 0.04)) due to a better visualization of subendocardial defects. However, this may also have been influenced by a higher contrast agent dose used in the high resolution scan. ...
Background
Perfusion cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) are emerging as the most accurate tools for the assessment of myocardial ischemia noninvasively or in the catheter laboratory. However, there is limited data comparing CMR and FFR in patients with multi-vessel disease. This study aims to evaluate the correlation between myocardial ischemia detected by CMR with FFR in patients with multivessel coronary disease at angiography.
Methods and results
Forty-one patients (123 vascular territories) with angiographic 2- or 3-vessel coronary artery disease (visual stenosis >50 %) underwent high-resolution adenosine stress perfusion CMR at 1.5 T and FFR measurement. An FFR value of <0.75 was considered significant.
On a per patient basis, CMR and FFR detected identical ischemic territories in 19 patients (46 %) (mean number of territories 0.7+/−0.7 in both (p = 1.0)). On a per vessel basis, 89 out of 123 territories demonstrated concordance between the CMR and FFR results (72 %). In 34 % of the study population, CMR resulted in fewer ischemic territories than FFR; in 12 % CMR resulted in more ischemic territories than FFR. There was good concordance between the two methods to detect myocardial ischemia on a per-patient (k =0.658 95 % CI 0.383-0.933) level and moderate concordance on a per-vessel (k = 0.453 95 % CI 0.294–0.612) basis.
Conclusions
There is good concordance between perfusion CMR and FFR for the identification of myocardial ischemia in patients with multi-vessel disease. However, some discrepancy remains and at this stage it is unclear whether CMR underestimates or FFR overestimates the number of ischemic segments in multi-vessel disease.
