Download Coronary Imaging With Cardiovascular Magnetic Resonance

Progress in Cardiovascular Diseases 54 (2011) 240 – 252
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Coronary Imaging With Cardiovascular Magnetic Resonance:
Current State of the Art
Amedeo Chiribiri⁎, Masaki Ishida, Eike Nagel, Rene M. Botnar
Division of Imaging Sciences and Biomedical Engineering, King’s College London, UK
Abstract
Cardiovascular magnetic resonance allows noninvasive and radiation-free visualization of both
the coronary arteries and veins, with the advantage of an integrated assessment of cardiac
function, viability, perfusion, and anatomy. This combined approach provides valuable
integrated information for patients with coronary artery disease and patients undergoing cardiac
resynchronization therapy. Moreover, magnetic resonance offers the possibility of coronary
vessel wall imaging, therefore assessing the anatomy and pathology of the normal and diseased
coronary vessels noninvasively.
Coronary magnetic resonance angiography is challenging because of cardiac and respiratory
motion and the small size and tortuous path of the coronary vessels. Several technical solutions
have been developed to optimize the acquisition protocol to the specific clinical question.
The aims of this review are to provide an update on current technical improvements in
coronary magnetic resonance angiography, including how to optimize the acquisition
protocols, and to give an overview of its current clinical application. (Prog Cardiovasc Dis
2011;54:240-252)
© 2011 Elsevier Inc. All rights reserved.
Keywords:
Angiography; Coronary artery; Coronary vein; Gadolinium; Magnetic resonance imaging
Despite substantial improvements in prevention and
treatment, 1 coronary artery disease (CAD) remains the
leading cause of death and disability in the Western
world. 2 The current criterion standard for the diagnosis of
CAD is cardiac catheterization. In the United States alone,
16,300,000 patients have CAD and approximately
1,000,000 cardiac catheterizations are performed each
Statement of Conflict of Interest: see page 249.
From King’s College London BHF Centre of Excellence, NIHR
Biomedical Research Centre and Wellcome Trust and EPSRC Medical
Engineering Centre at Guy’s and St. Thomas’ NHS Foundation Trust,
Division of Imaging Sciences, The Rayne Institute, London, UK.
⁎ Address reprint requests to Amedeo Chiribiri, MD, PhD, King's
College London-Division of Imaging Sciences, The Rayne Institute, 4th
Floor Lambeth Wing, St. Thomas' Hospital, London SE1 7EH.
E-mail address: [email protected] (A. Chiribiri).
0033-0620/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.pcad.2011.09.002
year. 2 In up to 40% of examined patients, no significant
coronary artery stenoses are diagnosed. 3 Therefore, a
noninvasive test that could directly assess the integrity of
the coronary lumen would be desirable. 4 Cardiovascular
magnetic resonance (CMR) allows a comprehensive
evaluation of myocardial function, perfusion, and morphology in patients with CAD. 5 In addition, magnetic
resonance angiography (MRA) can be used for direct
visualization of the coronary artery lumen, whereas blackblood techniques allow for visualization of the coronary
vessel wall, 6 making CMR a tool capable to provide all
required diagnostic information in one single examination.
Moreover, the same MRA techniques allow the
visualization of the anatomy of the coronary veins, which
is of interest for the optimal placement of pacemaker leads
in cardiac resynchronization therapy. 7,8
This review provides an update on current improvements in coronary MRA and an overview on its current
clinical use.
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Abbreviations and Acronyms
2D = 2-dimensional
3D = 3-dimensional
Technical challenges
and general imaging
strategies for coronary
CMR
CAD = coronary artery
disease
Coronary MRA demands dedicated techCMR = cardiovascular
niques to optimize image
magnetic resonance
contrast and ensure a
ECG = electrocardiogram
high signal-to-noise ratio
(SNR) yielding a clear
MRA = magnetic resonance
delineation of blood-filled
angiography
structures or the vessel
MSCT = multislice computed
walls with high spatial
tomography
resolution. Because high
NPV = negative predictive
spatial resolution is revalue
quired for adequate visualization of the coronary
SNR = signal-to-noise ratio
vessels, the concomitant
SSFP = steady-state free
intrinsic cardiac and respiprecession
ratory motion poses a
major challenge to coronary MRA and vessel
wall imaging.
To overcome this, a standard coronary MRA protocol
comprises (1) electrocardiogram (ECG) triggering for
synchronization of the heart motion with the data acquisition, (2) respiratory navigation for synchronization/compensation of the respiratory motion, (3) prepulses to modify
the magnetization (spin preparation) and ensure sufficient
image contrast, and (4) the imaging sequence itself (Fig 1).
Compensation of cardiac motion: ECG triggering
To freeze cardiac motion, data acquisition has to be
synchronized with the cardiac cycle and to be limited to
241
Table 1
Comparison between systolic and diastolic coronary CMR
Diastolic Resting Period
Systolic Resting Period
Advantages
Longer acquisition window
(∼100-125 ms/heartbeat)
Higher blood flow (higher signal
in gradient echo sequences)
Disadvantage
Higher sensitivity to
heart rate variability
Advantages
Less sensitive to heart
rate variability
Larger diameter of the
venous vessels
Disadvantage
Shorter acquisition window
(∼50 ms/heartbeat)
periods of minimal cardiac movement. 9 Resting periods
occur in end-systole (approximately 280-350 milliseconds
after the R wave) and in mid-diastole (immediately before
atrial systole). Both acquisition strategies (systolic or
diastolic) have advantages and disadvantages (Table 1).
The optimal trigger delay and the length of the
acquisition window depends on the patients' heart rate,
the type of imaging sequence used, the structure to
visualize (arteries vs veins), and other hemodynamic
factors. Although the use of a heart rate–dependent
formula to identify the mid-diastolic resting period is
effective in many subjects, there may be considerable
intersubject variation. 10 Therefore, the resting period
should be identified for each patient from a free-breathing
high–temporal resolution cine scan in the 4-chamber view
performed shortly before the coronary scan. 9 Real-time
arrhythmia rejection to exclude irregular heartbeats may
further improve coronary MRA image quality. 11-14
Another important parameter to consider is the duration
of the resting period. It is typically longer for the left
compared with the right coronary artery system. Thus the
length of the acquisition window of a whole-heart
acquisition is determined by the duration of right coronary
artery diastasis.
Compensation of respiratory motion: navigator
Fig 1. Schematic representation of pulse sequence elements for MR
angiography, adapted from Botnar et al. 28 Image acquisition is performed
in mid-diastole after a trigger delay from the R wave of the ECG. The
imaging block is preceded by a contrast-enhancing spin preparation (T2
PREP), a 2D selective real-time navigator pulse for respiratory motion
compensation, and a frequency-selective fat suppression prepulse
(FATSAT). These sequence blocks are repeated with every heart cycle.
The displacement of the heart due to respiration can
exceed 2 to 3 cm, requiring synchronization of image
acquisition with the respiratory cycle. High-resolution
3-dimensional (3D) data sets are not compatible with
breath-hold acquisitions. Several approaches have been
tested to reduce the effect of respiratory motion on image
quality. Prospective real-time navigator gating and
correction techniques are the current approach to minimize
respiratory motion artifacts. 15,16 A pencil beam 1dimensional navigator typically positioned on the dome
of the right hemidiaphragm is used to monitor the foot
head motion 17 of the diaphragm immediately before
coronary image acquisition (Fig 2). Depending on the
position of the diaphragm, the data are either accepted
when the position falls within a certain acceptance window
(usually 3-5 mm) or rejected. In the latter case, the data
have to be remeasured in the subsequent cardiac cycle.
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Fig 2. Planning of the navigator and of the whole-heart imaging volume from scout images. A pencil beam 1-dimensional navigator is positioned on the
dome of the right hemidiaphragm. A 3D volume covering the entire heart is planned in the axial plane for data acquisition and includes 2 cm cranial of the
aortic root and caudal to the diaphragm. (A) Coronal scout view. (B) Axial scout view.
Reduction of the acceptance window reduces the motion
artifacts but increases the overall acquisition time because
more data are rejected. An acceptance window of 5 mm
usually allows an efficiency approaching 50%. 18-20
To increase the percentage of accepted data, the
position of the imaging slice can be prospectively adapted
to the measured respiratory position. Normally, the
movement of the heart due to breathing is less pronounced
than the motion of the diaphragm itself; and a scale factor
between 0.4 and 0.6 has been used for optimal slice
tracking. However, also with the use of these techniques,
respiratory-induced motion of the heart often cannot be
completely modeled by a simple translation along the foothead direction; and it has been shown that in up to 30% of
patients, an affine transformation models the respiratory
motion more accurately. 21,22
Other proposed approaches include the use of imagebased navigators that directly track cardiac motion,
navigators that monitor the movement of the epicardial
fat, 23 scanning in prone position, 24,25 and the use of an
abdominal or thoracic banding. 25,26
Coronary artery imaging
Sequences
Three-dimensional approaches require long acquisition
times and were initially not feasible. The first approaches
to coronary artery angiography were attempted by Edelman et al 22 and Manning et al 27 by 2-dimensional (2D)
gradient-echo techniques. One slice was acquired in
16 heartbeats (in a single breath-hold), and patients were
free to breath between acquisitions. The introduction of
navigator techniques allowed the acquisition of data in free
breathing, and 3D techniques became feasible. These
sequences can be acquired using a whole-heart or targetvolume approach (Table 2).
Table 2
Planning of a coronary MRA examination
Whole-Heart Imaging
Target-Volume Imaging
Axial-, sagittal-, or coronaloriented imaging volume
Planning on set of axial, sagittal,
and coronal scout images to
include the entire heart
Preferably isotropic spatial
resolution to allow for 3D
reformatting along the course
of the coronary vessels
Full coverage (simultaneous
acquisition of the
venous system)
Long acquisition time
Limited in-flow effect (less
contrast, particularly in
gradient echo techniques)
Typical spatial resolution:
isotropic voxels with
1.3 × 1.3 × 1.3–mm 3 size
Right and left coronaries are
imaged in 2 individually
planned thin slabs
Quicker planning performed on a
low-resolution free-breathing
coronary scout scan
The central slice is defined by
selection of 3 points located on
the path of the coronary vessel
Targeted coverage
Shorter acquisition time than
whole-heart approach
Noninotropic voxels with in-plane
spatial resolution of 1 × 1 mm 2 and
slice thickness of 2-3 mm
Two different approaches are currently in use: the whole-heart and the
vessel-targeted approach, which requires an individual planning
procedure. Whole-heart techniques have been also used for coronary
vein imaging. 36,59
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Contrast-enhancing spin preparations
The use of 3D acquisitions has the advantage of
improved SNR and higher spatial resolution but also has
the disadvantage of reduced contrast between blood and
the myocardium (less in-flow effects). Therefore, contrastenhancing spin preparations techniques 28-30 in combination with steady-state free-precession (SSFP) techniques
have been developed to provide sufficient contrast for
the delineation of the coronary arteries 31. Steady-state
free-precession sequences are currently preferred to T1weighted gradient echo sequences on 1.5-T systems
because of the higher intrinsic SNR and the better contrast
between blood and myocardium. 31-33 However, SSFP
sequences have limitations at 3 T due to longer repetition
times (more stringent specific adsorption rate model) and
thus increased sensitivity to off-resonance and the need for
higher flip angles to obtain enough contrast between blood
and myocardium. At 3 T and higher field strengths, 34
gradient echo techniques appear as promising alternative
to SSFP techniques.
For non-contrast agent–enhanced imaging, spin preparation usually includes fat suppression and T2 preparation. Frequency selective prepulses can be applied to
saturate the signal from fat tissue, allowing the visualization of the coronaries. 22,29,30 To enhance the contrast
between the coronary lumen and the underlying myocardium, T2 preparation techniques can be used 28,29 to
suppress signal from myocardium, as blood and myocardium have similar T1 but different T2 (Fig 3).
T2 preparation also suppresses deoxygenated venous
blood and therefore is not suited for coronary vein imaging.
A few other techniques to improve contrast between the
vessel lumen and the myocardium have been proposed but
are not widely adopted. Among these are spin-locking 35
and magnetization transfer techniques 30. Magnetization
transfer preparation does not affect the signal from
deoxygenated venous blood and can therefore be used to
image the coronary veins. 36 Further improvement of
contrast between blood and the surrounding tissues can be
achieved by application of contrast agents.
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Contrast agents
Extracellular, 37 blood-pool, 38-41 and contrast agents
with weak albumin binding 42-44 have been used to improve
contrast-to-noise and image quality of coronary MRA. As
coronary artery imaging protocols should ideally become
part of a routine ischemia/CAD diagnostic imaging
protocol, the choice of the contrast agent depends on a
balance between increasing contrast between lumen and
myocardium while maintaining the ability to provide
useful scar information in late gadolinium enhancement
images. Extracellular contrast agents allow limited coronary artery enhancement because of the rapid extravasation
in the interstitial space. Blood-pool contrast agents offer
the highest contrast between the vessel lumen and the
surrounding tissues but may face limitations for late
enhancement imaging. Contrast agents with weak albumin-binding appear most promising for combined coronary artery and infarct imaging because of their prolonged
retention time in blood and their higher relaxivities (useful
to improve image quality of coronary MRA), 45 while
maintaining good late enhancement properties. 46 To
take advantage of contrast agents for coronary MRA,
a saturation 47 or inversion prepulse 48 is usually applied
instead of T2 preparation. The rapid T1 recovery of
blood after contrast agent administration (native T1
of blood = 1200 milliseconds, T1 of blood with contrast
agent = 50-100 milliseconds, native T1 of myocardium =
850 milliseconds) allows the generation of high contrast
between the coronary lumen and myocardium.
Recent improvements in acquisition speed and resolution
Faster image acquisition can result in better image
quality due to reduced sensitivity to motion because of a
shorter acquisition window or shorter overall data
acquisition time. To accelerate data acquisition and/or
reduce motion sensitivity, several approaches have been
proposed, such as faster encoding of k-space by use of
echo planar imaging 49,50 or more efficient k-space
sampling using spiral 51 or less motion-sensitive k-space
sampling using radial trajectories. 52 These techniques
Fig 3. Endogenous contrast enhancement (T2 preparation), adapted from Brittain et al 29 and Botnar et al. 28 The T2 preparation allows suppression of
tissues with short T2 relaxation times (cardiac muscle, cardiac veins, and epicardial fat), while minimally influencing tissues with long T2 relaxation times,
like arterial blood. A 90° radiofrequency (RF) pulse flips the magnetization vector from the z direction into the xy plane. An even number of nonselective
RF refocusing pulses minimizes flow sensitivity of the T2 preparation, while allowing T2-dependent decay of the signal. Finally, a −90° RF tip up pulse
restores the magnetization in the z direction.
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have not yet become established standards for coronary
MRA because of their off-resonance sensitivity (echo
planar imaging, spiral) or signal-to-noise penalty (radial).
More recently developed parallel imaging techniques
such as sensitivity encoding 53 or simultaneous acquisition
of spatial harmonics 54 have been successfully applied to
reduce the overall MRA acquisition time while maintaining image quality. With the advent of 2D coil arrays (eg,
32-channel coils), acceleration along the slice encoding
and phase encoding direction can be applied, thereby
further reducing scan time. However, acceleration factors
greater than 4 can hardly be realized because of SNR
limitations and increasing reconstruction artifacts. 54,55
Coronary vein imaging
In the past decades, coronary imaging has been mainly
focused on the coronary arteries. With the advent of
resynchronization devices, the assessment of the course of
the coronary veins has become increasingly important and
has recently gained interest for preinterventional identification of optimal placement site for the left ventricular
lead of resynchronization devices. Three-dimensional MR
coronary vein angiograms can be overlaid onto real-timeacquired x-ray images to provide improved guidance for
catheter implantation. 56,57
Because of the low oxygen saturation of coronary
venous blood (causing a strong reduction of blood T2
values), T2 preparation is not suitable for coronary vein
imaging. Current approaches include non–contrastenhanced imaging by magnetization transfer preparation 36,58
or using gadolinium contrast, including blood-pool, 7,8,59
extracellular, 60 and contrast agents with weak albumin
binding. 61 Of interest is the approach proposed by Duckett
et al 61 of slow infusion of a high-relaxivity contrast agent
during coronary vein MRA acquisition, which offers the
possibility to acquire late gadolinium enhancement images
after the redistribution of the contrast agent.
The optimal acquisition window for coronary vein
imaging is in end-systole, when the coronary vein
diameter is maximal. 36 However, ECG triggering may
be difficult in patients with heart failure due to tachycardia,
orthopnea, and the asynchronous contraction of the LV,
making the resting period different in independent
segments of the left ventricular chamber. In these cases,
the acquisition parameters should be adapted; and data
acquisition in end-diastole might be an alternative (Fig 4).
Coronary vessel wall imaging
The excellent soft tissue contrast of magnetic resonance
imaging enables the visualization of the vessel wall. First,
in vivo images of coronary vessel wall were obtained by
2D fat-saturated fast spin echo techniques. 62,63 For
improved contrast between the blood and the vessel
wall, a double inversion recovery preparation was applied
to obtain black-blood images. 64
Further developments of the technique combined the
double inversion recovery prepulse with fast gradient echo
readout techniques 65 and recently with spiral 66 and radial
acquisition trajectories. 67 Clinical studies demonstrated
outwardpositiveremodelingwithrelativelumenpreservation
in patients with established CAD and increased vessel wall
thickness in patients with type I diabetes and renal
Fig 4. Magnetic resonance angiogram of the coronary veins, obtained using a whole-heart approach and an intravascular contrast agent, adapted from
Chiribiri et al. 7 A, B and C: examples showing the wide interindividual variability of the anatomy of the cardiac venous system in terms of presence,
relative position, and diameter of the coronary sinus tributaries. The knowledge of the anatomy and variations of the cardiac venous system may facilitate
the positioning of the left ventricle lead in patients undergoing cardiac resynchronization therapy. Abbreviations: CS = coronary sinus; LA = left atrium;
LV = left ventricle; LMV = left marginal vein; PIV = posterior interventricular vein; PVLV = posterior vein of the left ventricle; RA = right atrium; RV =
right ventricle; RCA = right coronary artery; SCV = small cardiac vein.
A. Chiribiri et al. / Progress in Cardiovascular Diseases 54 (2011) 240–252
68,69
dysfunction.
Confirming the findings of previous studies
done by using intravascular ultrasound, coronary vessel
wall imaging could offer an attractive and noninvasive
alternative for the clinical assessment of patients.
For selective imaging of fibrous or inflamed plaque,
several preclinical and clinical studies have been performed
using delayed gadolinium enhancement techniques, showing promising results. 70 In vivo, clinically approved
contrast agents showed nonspecific uptake in plaques
both in patients with chronic angina 71 and in patients with
acute coronary syndromes 72 (Fig 5). Contrast uptake in
patients with stable angina was associated with calcified or
mixed plaques on multislice computed tomography
(MSCT), whereas contrast uptake in patients with ACS
was transient and thus more likely related to inflammation.
In experimental animal models, several target-specific
contrast agents have been tested. Accumulation of albumin
binding blood-pool contrast agent indicates increased endothelial permeability and/or increased neovascularization. 73
The accumulation of iron oxide particles (ultra-small
super paramagnetic iron oxide) indicates increased
245
endothelial permeability and vessel wall inflammation
due to the presence of intraplaque macrophages. 74,75
Novel molecular contrast agents, which specifically
target molecules or cells, have recently been developed
that allow selective visualization of inflammatory markers
such as intercellular adhesion molecule–1, vascular
adhesion molecule-1, or matrix metalloproteinase. 76,77
Recent work also includes the specific labeling of
thrombi by a fibrin-specific contrast agent. 78,79
Molecular contrast agent may provide new opportunities for the characterization of early atherosclerotic lesions
and for the assessment of plaque vulnerability.
Special considerations: intracoronary stents
Coronary stents are currently used in a large number
of patients undergoing percutaneous revascularization.
Typically made of high-grade stainless steel, coronary
stents cause negligible attractive force and local heating
both at 1.5 T 80-85 and 3 T 86 with clinical safety
demonstrated for imaging early after implantation at
Fig 5. Localized uptake of extracellular contrast agent (Gd-DTPA) in unstable CAD, adapted from Ibrahim et al. 72 Right coronary artery from a subject
with unstable angina. A, Image fusion between coronary MRA (B) and delayed-enhancement (DE)-MRI (C) that shows significantly enhanced vessel wall
signal. D, Comparison with x-ray angiography.
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80-82
1.5 T.
In the United States, both the Cypher (Cordis,
Miami Lakes, FL) and Taxus Liberte (Boston Scientific,
Natick, MA) drug-eluting stents are approved for CMR
scanning immediately after implantation. However, coronary stents cause local susceptibility artifacts and signal
voids that preclude the assessment of peristent and
intrastent coronary integrity.
Clinical applications
The application of MRA is currently limited to the
assessment of anomalies of the coronary arteries (class I
indication) and aortocoronary bypass grafts (class II
indication). The use of MRA for the assessment of native
coronary arteries has not yet become clinically routine. 87
Coronary artery angiography for the detection of CAD
Proximal and medial segments of the main branches of
the coronary arteries can routinely be visualized by freebreathing navigator-gated fast gradient echo or SSFP
techniques. Especially the proximal segments are evaluable in nearly 100% of subjects. The left anterior
descending and the right coronary arteries are usually
imaged with better image quality than the left circumflex
coronary artery that runs in the direct vicinity of the
myocardium and at a larger distance from the coil
elements. The mean length of the vessels that were visible
in previous studies was approximately 50 mm for the left
anterior descending coronary artery, 80 mm for the right
coronary artery, and 40 mm for the left circumflex
coronary artery, 27,28,73 , 88-92 with an excellent agreement
between the proximal vessel diameters between MRA and
conventional angiography. 93 However, despite the most
recent technical developments, spatial resolution of
coronary MRA is still lower than that of invasive coronary
angiography, limiting the size of the branches that can be
assessed. Despite these limitations, coronary artery
stenosis in proximal segments can often be identified by
coronary MRA. On “bright blood” (gradient echo/SSFP)
images, a stenosis appears as a signal void in the otherwise
bright vessel (Fig 6). This is primarily due to the reduction
of the lumen and partly due to the presence of turbulence
of the blood flow distal to the stenosis that may result in a
dephasing of the signal and thus lead to an overestimation
of the severity of the stenosis with MRA when compared
with invasive angiography. 94
An international multicenter study 4 assessing the
diagnostic accuracy of coronary MRA revealed a high
sensitivity (92%) and a low specificity (59%) for the
detection of CAD. The relatively limited spatial resolution
of coronary MRA contributed to these results, as
demonstrated by the excellent performance observed for
the exclusion of left main or 3-vessel disease (sensitivity,
100%; negative predictive value [NPV], 100%). These
results have been confirmed in a series of smaller singlecenter studies, with good results for the detection of
significant coronary stenosis in the proximal coronary
segments. 26,28 , 95-102
Coronary MRA has recently been proposed in conjunction with late gadolinium enhancement to rule out ischemic
etiology in patients presenting with dilated cardiomyopathy without symptoms of myocardial infarction. 87
A recent meta-analysis compared coronary MRA and
MSCT for ruling out significant CAD in adults. 103 The
conclusion was that MSCT is more accurate than MRA and
that, therefore, MSCT should be considered as the preferred
noninvasive alternative method to coronary catheterization
to exclude CAD. However, the added value of a coronary
MRA scan integrated into a comprehensive clinical protocol
encompassing function, structure, perfusion, and viability
scans still needs to be assessed and has the potential to
provide a more accurate evaluation of patients with known
or suspected CAD. A more recent national multicenter study
Fig 6. A, Coronary artery stenosis visualized on white blood MRA images. B, Comparison with coronary artery angiography. Visualization of multiple
stenoses and wall irregularities in the proximal RCA.
A. Chiribiri et al. / Progress in Cardiovascular Diseases 54 (2011) 240–252
from Japan demonstrated that non–contrast-enhanced
whole-heart coronary MRA at 1.5 T can noninvasively
detect significant CAD with high sensitivity (88%) and
moderate specificity (72%). In the study, an NPV of 88%
indicates that whole-heart coronary MRA can rule out
CAD. 104 Of note, the NPV of this coronary MRA
multicenter trial is identical to the NPV of the Coronary
Evaluation Using Multi-detector Spiral Computed Tomography Angiography using 64 Detectors (CORE-64) MSCT
multicenter study. 105 Remarkably, the value of coronary
MRA in patients with a low pretest likelihood is similar to
computed tomography and can reliable rule out CAD in
patients with a pretest likelihood of less than 20%. 106
Coronary anomalies and aneurysms
Anomalies of the origin and path of the coronary
arteries and coronary aneurysms are accurately visualized
by coronary MRA as a result of their higher caliber and
247
preferred location in proximal or ectatic segments.
Coronary MRA has the important added benefit of
allowing a noninvasive reliable diagnosis without exposing the patient to ionizing radiation (Fig 7). This is
particularly important in younger patients and children, as
well as in younger women. 87,107
Coronary bypass grafts
The visualization of bypass grafts benefits from their
rather stationary position, straight and known course, and
large diameter as compared with the native coronary
arteries. Spin echo techniques 108-111 and gradient echo
techniques have been used. Contrast agents have been
applied for enhancement of the blood signal, 112-114 which
resulted in sensitivities between 95% and 100%.
A major limitation of bypass imaging results from the
presence of metallic clips, which cause signal voids due to
susceptibility artifacts. Although coronary MRA has been
Fig 7. Coronary MRA for the visualization of the anomalous origin of the coronary arteries, from Boffano et al. 107 T2-prepared navigator-gated whole-heart
technique shows the anomalous origin of a single coronary artery from the right sinus of Valsalva in a patient complaining for angina. A, Maximum
intensity projection image demonstrating the anomalous origin of the single coronary artery from the right sinus of Valsalva (white arrows). B, Maximum
intensity projection image showing the path of the right coronary artery and of the left coronary artery, crossing in front of the right ventricle outflow tract.
(C) Volume rendering reconstruction of the heart, showing the anomalous origin of the single coronary artery (⁎) from the aorta and the course of the RCA
and the LCA. (D) Coronary angiography in right anterior oblique projection, showing the anomalous coronary tree. Abbreviations: AO = aorta; LCA = left
coronary artery; MIP = maximum intensity projection; PA = pulmonary artery; RVOT = right ventricle outflow tract.
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A. Chiribiri et al. / Progress in Cardiovascular Diseases 54 (2011) 240–252
used in specialized centers to identify stenosis in the
bypass grafts with good accuracy compared with invasive
angiography, 87 the presence of metallic clips in the
proximity of the bypass grafts and coronary arteries
often results in signal voids that prevent a full assessment
of the respective anatomy.
Coronary vessel wall imaging
By means of black-blood techniques, the latest clinical
magnetic resonance imaging scanners can provide a
detailed visualization of the coronary artery wall. The
major impediment to clinical application of these techniques is the need for very high spatial resolution and the
related long acquisition times.
The vessel wall can be visualized either in a crosssectional view or along the path of the vessel. Because of
reduced partial volume effects, the cross-sectional orientation should provide more accurate quantification of the
vessel wall thickness but provides limited coverage. A
long-axis view of the vessel wall provides a more
extensive visualization and typically allows assessment
of the proximal 5 cm. The use of contrast agents allows for
selective plaque visualization. By using an extracellular
contrast agent, delayed enhancement images can show
focal or diffuse uptake of contrast agent and enhancement
due to the presence of a fibrous plaque or due to
inflammation. The current application of coronary vessel
wall imaging is restricted to research purposes; but in the
future, it may become part of CAD risk assessment and
monitoring of treatment response, especially if plaque
targeting agents become available.
Coronary vein imaging
Imaging of the coronary veins and the integration of
coronary vein anatomy and myocardial scar information
may help to guide the left ventricular lead implantation to
achieve optimal cardiac resynchronization therapy (Fig 8).
Early studies have shown that contrast agent–enhanced
Fig 8. Visualization of coronary veins and scar in a patient referred for cardiac resynchronization therapy. Adapted from Duckett et al. 61 A, Threedimensional reconstruction of the heart with the coronary venous system. B, Two-chamber late gadolinium enhancement, with scar in the inferior segments
of the left ventricle. C, Segmented LV registered to the scar imaging in the short axis view. D, Segmented whole heart with the coronary veins and scar all
superimposed. Abbreviation: GCV = great cardiac vein.
A. Chiribiri et al. / Progress in Cardiovascular Diseases 54 (2011) 240–252
CMR can be used for the assessment of the course of the
coronary sinus, the great cardiac vein, and the respective
tributaries. 7,8,59 A major limitation in patients with heart
failure may rise from the asynchronous contraction pattern
of the left ventricle, causing constant systolic motion of the
heart. This may disqualify the suggested use of an endsystolic trigger window, 36 and the use of a mid-diastolic
triggering window may be more effective.
Conclusions: future perspective
Although the spatial resolution of coronary MRA for
the visualization of the coronary lumen is not as high as for
MSCT, novel coronary magnetic resonance imaging
techniques have shown potential in providing additional
information including plaque burden and biology by
black-blood coronary MRI or use of nonspecific and
targeted MR contrast agents. Currently, novel contrast
agents targeting specific molecules or cells are undergoing
preclinical evaluation and some have been already tested
in humans. In addition, direct thrombus visualization and
assessment of endothelial function and coronary edema
have recently been demonstrated.
Finally, ongoing developments in motion compensation techniques will simplify the acquisition of coronary
MRA with the advantage of improved image quality and a
shorter scan time.
Statement of Conflict of Interest
All authors declare that there are no conflicts of interest.
Acknowledgment
Supported in part by the Wellcome Trust and
Engineering and Physical Sciences Research Council
(EPSRC) (grant WT 088641/Z/09/Z).
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