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 Table of Contents  
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 45-50

The incremental role of cardiac magnetic resonance imaging as diagnostic and prognostic tool in cardiovascular diseases

De Gasperis Cardio Center, CMR Unit, Niguarda Hospital, Milan, Italy

Date of Web Publication22-Aug-2019

Correspondence Address:
Dr. Alberto Roghi
CMR Unit, Niguarda Hospital, Milan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_1_19

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Cardiac Magnetic Resonance Imaging offers incremental value as diagnostic and prognostic tool in a wide range of cardiac diseases in front of the traditional non-invasive imaging techniques. Tissue characterization with and without non-nephrotoxic contrast-media offers the opportunity of precise assessment of myocardial fibrosis, edema and fatty infiltration. The quantitative assessment of myocardial mass, left and right ventricular volumes is considered a gold standard reference with important effects on clinical decision making and cost effectiveness ratio. The recent introduction of new sequences for mapping tissue resonance signal and myocardial strain will improve the diagnostic and prognostic accuracy for cardiovascular diseases.

Keywords: Cardiac magnetic resonance, coronary artery disease, cardiomyopathy, congenital heart disease, cardiac imaging

How to cite this article:
Roghi A, Pedrotti P. The incremental role of cardiac magnetic resonance imaging as diagnostic and prognostic tool in cardiovascular diseases. Heart Mind 2018;2:45-50

How to cite this URL:
Roghi A, Pedrotti P. The incremental role of cardiac magnetic resonance imaging as diagnostic and prognostic tool in cardiovascular diseases. Heart Mind [serial online] 2018 [cited 2023 Apr 1];2:45-50. Available from: http://www.heartmindjournal.org/text.asp?2018/2/2/45/265157

  Introduction Top

Cardiac magnetic resonance imaging (CMR) has gained increasing relevance as a diagnostic and prognostic tool in cardiovascular diseases since the late 90s. The rapid improvement of dedicated sequences for myocardial tissue characterization and functional assessment, coupled with the development of dedicated software to analyze and quantify cardiac volumes and mass, edema, scar, iron, and fat infiltration, offer the unique opportunity to have of a sort of virtual, noninvasive pathology.

Since the first demonstration of clinical utility in the management of iron chelation therapy in Thalassemia and iron overload-related diseases in the early 2000s,[1] the diagnostic relevance of CMR has rapidly grown in the assessment of all cardiac diseases.

Despite important limitations related to high costs and time-consuming procedures in comparison to conventional cardiovascular imaging techniques, CMR has gained a definite role in the diagnostic workup of cardiac diseases. The most important incremental value of CMR in comparison with other imaging techniques is the tissue characterization of myocardium obtained without exposition to ionizing radiation and with nonnephrotoxic contrast media. [Table 1] reassumes the principal characteristic of imaging techniques comparing mean examination time, X-ray exposition, contrast media nephrotoxicity, mean examination cost, and tissue characterization.
Table 1: Relative comparison of imaging variables between cardiac magnetic resonance and traditional imaging techniques (quality scale 1-4)

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[Table 1] shows the relative comparison of imaging variables between CMR and traditional imaging techniques (quality scale 1–4). Time = length of examination; X-ray = ionizing radiation exposition; nephrotoxicity = contrast media nephrotoxicity.

[Figure 1] represents different patterns of myocardial fibrosis with late gadolinium enhancement (LGE) technique. The typical ischemic pattern follows the coronary artery distribution territory from subendocardium layer to transmural extension. Myocarditis pattern shows a typical epicardial or intramyocardial distribution, while infiltrative cardiomyopathies like amyloidosis shows diffuse enhancement pattern.[2]
Figure 1: Late gadolinium enhancement ischemic and nonischemic patterns (from Mahrholdt, European Heart Journal 2005;26:1461-74, modified)

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  Cardiomyopathy Top

In the diagnostic workup of dilated cardiomyopathy, CMR tissue characterization improves the assessment of etiology while the detection of fibrosis and the accurate quantification of volumes and mass help in risk stratification and therapeutic planning.[3] Scar quantification and accurate left and right ventricles volumes assessment by CMR improve the selection of patients being worthy of implantable cardiac defibrillator (ICD), reducing inappropriate implantations and improving cost-effectiveness.[4],[5]

In hypertrophic cardiomyopathy (HCM), a common genetic disease with an estimated prevalence of 1:500 in the general population, the role of CMR is crucial to differentiate young athletes with athlete's heart from those affected by the disease, preventing one of the most common causes of sudden cardiac death in young people.[6] In the risk stratification assessment of the minority of HCM patients at risk of sudden cardiac death, myocardial fibrosis quantification by CMR seems to be of relevant help in the difficult decision-making process of ICD therapy.[7]

In infiltrative cardiomyopathies such as amyloidosis[8] and sarcoidosis,[9] the role of CMR in the diagnostic assessment is crucial, with the assessment of the characteristic patterns of gadolinium contrast media distribution within the myocardium.[10]

In arrhythmogenic cardiomyopathy, a rare genetic disease characterized by a progressive fibrofatty infiltration of both ventricles with high risk of sudden cardiac death during physical exercise,[11] the role of CMR in the diagnostic workup of patients and related families is relevant.[12] CMR offers the opportunity to assess the dynamic evolution of this insidious disease in young individuals belonging to affected families, as well as to follow up those patients with full-blown disease.[13]

In the survivors of out-of-hospital full cardiac arrest, CMR has proved to identify the etiology in 50% of those without diagnosis after a traditional diagnostic workup including echocardiography and coronary angiography.[14]

In Takotsubo syndrome, a clinical condition mimicking acute coronary syndromes in which an emotional stress is precipitating chest pain, transitory electrocardiogram (ECG) modifications, and typical left ventricular regional impairment, the contribution of CMR to the comprehension of the complex physiopathology of clinical picture has been essential.[15] At angiography, coronary artery is typically normal, and there is no evidence or mild increase of markers of myocardial necrosis. There is a prevalence in the female gender, with a good prognosis following the normalization of the ECG modifications and the left ventricular impairment.[16] The characteristic left ventricle apex ballooning mimicking the shape of the recipients used by Japanese fisherman to catch octopus (Takotsubo) is explained by catecholamine cardiotoxicity [Figure 2]. In the acute phase of Takotsubo, both epinephrine and norepinephrine released from adrenal medullar chromaffin cells are significantly increased with parallel increase stimulation of myocardial sympathetic nerve terminals.[17] In the left ventricle, the β2 adrenoceptors are distributed with a gradient of increasing concentration between the base and the apex of the heart. The different distribution along the left ventricle of β2 adrenoceptors is generally accepted to explain the different subtypes of left ventricular impairment described in the literature, with left ventricular apex ballooning largely prevalent. Epicardial and microvascular coronary spasm and increased cardiac workload are directly related to catecholamine toxicity, leading to the transitory myocardial damage.
Figure 2: Normal heart in comparison with Takotsubo heart. Evidence of catecholamine surge inducing peripheral and coronary vasoconstriction with increased left ventricular afterload and direct myocardial toxic effect mediated by receptor distribution. (a) Normal left ventricle and aortic systolic pressure. (b) Catecholamine surge effects: Coronary artery spasm, beta-adrenoceptors stimulation, peripheral vasoconstriction.

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  Coronary Artery Disease Top

CMR has demonstrated to be a powerful tool in the management of patients with ischemic heart disease since the first demonstration of its clinical relevance in the assessment of myocardial viability in ischemic cardiomyopathy in the early 2000s.[18] The role of CMR as diagnostic and prognostic tool has rapidly expanded, offering the opportunity to detect myocardial ischemia with adenosine or dobutamine stress testing,[19] to assess in vivo complications of ST elevation myocardial infarction like microvascular obstruction or hemorrhage,[20] and to define site and extension of fibrosis to guide cardiac resynchronization therapy in patients with ischemic cardiomyopathy.[21]

In patients with clinical presentation mimicking acute myocardial infarction and normal coronary arteries, CMR has proved to be useful to identify etiology[22] and has been identified as the key diagnostic tool in this clinical setting by a panel of experts of the European Society of Cardiology.[23]

  Myocarditis Top

Acute myocarditis has been traditionally regarded as a rare and devastating cardiac disease with a high mortality rate. The clinical course is characterized by the sudden onset of chest pain, fever, and malaise followed by fast deterioration of cardiac function, cardiac shock, and death. Some patients recover after intensive care therapies including mechanical ventilation support, extracorporeal membrane oxygenation, or heart transplantation.[24] In this setting, myocardial biopsy has been considered mandatory to confirm diagnosis and to identify those patients with subtypes of myocarditis susceptible to particular therapy.[25] In the last 10 years, with the increasing diffusion of CMR, a second type of acute myocarditis has been observed with increasing evidence.[26] The presenting pattern is similar to the previous described but with a more benign course and no evidence of severe cardiac failure. Recently, the result of a 4-year follow-up study from a regional registry of acute myocarditis has been published.[27] The diagnostic criteria for myocarditis included CMR Lake-Louise criteria[28] besides the clinical and laboratory standards suggested by current guidelines, resulting in a very homogeneous population of patients. The most interesting finding of the study is that fulminant myocarditis with early deterioration of left ventricular function and cardiogenic shock occurs in a minority of patients, portending a worst prognosis. The vast majority of patients showed no evidence of left ventricular failure, recovered rapidly, and had no cardiac adverse events at follow-up. In this retrospective study, endomyocardial biopsy was reserved to patients with fulminant presentation (46%) only. The results of this study underscore the role of CMR in the diagnostic workup and in the follow-up of patients with nonfulminant acute myocarditis.

  Pericardial Diseases Top

Pericardial diseases are generally assessed by a multimaging approach including echocardiography, CMR, computed tomography, and positron emission tomography. The role of CMR in acute pericarditis is related to the assessment of indirect signs of inflammation (increased T2-weighted signal), useful in the follow-up to monitor therapy's adequacy and compliance, to evaluate the evidence of myocardial involvement, and to assess the presence of constriction in complicated cases.[29] The differential diagnosis between constrictive pericarditis and restrictive cardiomyopathy is notoriously difficult. CMR is an important diagnostic tool in this setting, offering the opportunity of a noninvasive assessment of anatomy, tissue characterization, and functional assessment.[30]

  Congenital Heart Diseases Top

High-quality images with wide field-of-view including the thoracic-abdominal region, the use of non-nephrotoxic contrast media without exposition to ionizing radiation render CMR the ideal imaging modality for congenital heart disease.[31],[32] Quantitative assessment of shunts and of valvular gradients and regurgitations offers the opportunity of a complete diagnostic workup of congenital cardiac diseases including angiography of systemic and pulmonary venous returns and of arterial trunks.[33]

  Right Ventricle Assessment Top

The limitations of the most diffuse imaging techniques as echocardiography and nuclear cardiology in the study of the right ventricle have been overcome by the unlimited opportunity of study offered by CMR. The complex anatomy of the right ventricle is not ideal for the geometric assumptions of echocardiography, while CMR is able to assess right ventricular volumes and contractile function with extreme precision.[34],[35] The impairment of right ventricular function is an early sign of cardiac dysfunction in many cardiac diseases including cardiomyopathies, ischemic heart disease, congenital heart diseases, and pulmonary hypertension from different causes.[36],[37]

[Table 2] summarizes the principal contributions of CMR imaging in the workup of cardiac diseases.
Table 2: Clinical indications for CMR imaging

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  Perspectives Top

Myocardial strain represents the tridimensional deformation of myocardial fibers, which can be impaired in the very early phases of myocardial disease. Strain analysis can be performed with different techniques with CMR, thus offering a powerful tool for the early, preclinical detection of disease.[38]

In the last 30 years, the most important imaging parameter for prognostic risk assessment of cardiac diseases has been the left ventricular ejection fraction (LVEF) obtained with two-dimensional echocardiography.[39] Since LVEF is a ratio between end-diastolic and end-systolic volumes, this parameter is very robust and useful to select those patients with the most severe impairment of left ventricular function (<40%) and those with normal function (>50%). For the same value of LVEF, a wide range of volumes can be represented with significant differences in cardiac risk assessment.[40] The introduction of the quantitative assessment of left and right ventricular volumes by CMR gives the opportunity to improve the selection of high-risk patients as well as to monitor the efficacy of drug therapy.[5]

A novel contribution of tissue characterization by CMR is represented by the quantification of myocardial interstitial space.[41] Myocardial fibrosis is a common endpoint of many cardiac diseases, resulting in heart failure, arrhythmias, and sudden death. The traditional CMR assessment of focal myocardial fibrosis by LGE is not feasible in a variety of cardiac diseases characterized by diffuse myocardial fibrosis, as there are no reference regions of normal myocardium. T1 mapping techniques performed both with and without contrast enable the quantification of diffuse myocardial fibrosis and myocardial infiltration.[42] The use of gadolinium allows measurement of the extracellular volume fraction, reflecting interstitial space. T1 mapping has been proposed for iron overload assessment, to improve T2* limitations.[43],[44]

CMR acquisition and postprocessing technologies are improving very quickly, and fast, free-breathing, multiparametric acquisitions (MR fingerprinting)[45],[46] will speed up acquisition process, while machine learning is rendering postprocessing smoother, thus laying the ground for wider CMR diffusion.


Despite significant improvement of technology, CMR imaging is still limited in claustrophobic patients and in unstable clinical conditions. Patients with pacemakers and intracardiac defibrillators can be safely studied in referral centers only. Pediatric patients with complex congenital heart diseases can be studied with adequate sedation in referral centers with dedicated imaging program. In patients with end-stage renal disease, gadolinium contrast media are contraindicated but CMR offers the opportunity of tissue characterization with T1 and T2 mapping. The high cost relative to scanners and to the training of the technical team (physician, nurse, and technician) is still limiting CMR imaging to referral centers with high volumes of patients.

  Conclusions Top

The virtual pathology obtained with CMR imaging represents an incremental value in front of the traditional diagnostic techniques. Accurate quantitative determination of cardiac anatomy and function and tissue characterization without biological harm offers significative advantages in the workup of cardiac diseases. The inclusion of CMR imaging in the diagnostic guidelines of the most important scientific societies is the expected future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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