Quantitative Magnetic Resonance Perfusion Imaging Detects Anatomic and Physiologic Coronary Artery Disease as Measured by Coronary Angiography and Fractional Flow Reserve
Marco A. Costa, MD, PhD, FACC*,*,
Steven Shoemaker, MD*,
Hideki Futamatsu, MD, PhD*,
Chris Klassen, MD ,
Dominick J. Angiolillo, MD, PhD, FACC*,
Minh Nguyen, MD,
Alan Siuciak, MS,
Paul Gilmore, MD, FACC*,
Martin M. Zenni, MD, FACC*,
Luis Guzman, MD, FACC*,
Theodore A. Bass, MD, FACC* and
Norbert Wilke, MD, FACC*,
* Division of Cardiology, University of Florida Shands Jacksonville, Jacksonville, Florida
Division of Radiology, University of Florida Shands Jacksonville, Jacksonville, Florida.
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Figure 1 Base, Middle, And Apical Short-Axis CMR Slices Divided Into 8 Equidistant Radial Sectors
(Lower right panel) Schematic representation of the 3 concentric left ventricle short-axis slices segmented radially on a polar map. The plus (+) sign in blue in the cardiac magnetic resonance (CMR) images represents the anterior insertion of the right ventricle. The segments were assigned based on anatomic location of left anterior descending (base 1, 2, 8; middle 9, 10, 16; apical 17, 18, 24), diagonal branches (middle 9, 10; apical 17, 18), circumflex (base 3, 4; middle 11, 12; apical 19, 20), obtuse marginal branches (middle 11, 12; apical 19, 20), right coronary (base 5, 6, 7; middle 13, 14, 15; apical 21, 22, 23), posterior descending (apical 21, 22, 23), and posterior lateral (apical 20,21) arteries.
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Figure 2 Correlation Between MPR and Quantitative Coronary Angiography
The myocardial perfusion reserve (MPR) data (left panel) are reported in graphics for individual slices of cardiac magnetic resonance (CMR) (S1 to S8; first graphic corresponding to left ventricle blood pool). Purple and green lines represent the fitting curves for rest and stress, respectively. The MPR values (Pr) are depicted for each slice at the bottom of each graphic. Rest and stress flow are also reported in the bar graph, with each bar corresponding to 1 CMR slice. Note that slice S4 shows an average MPR of 1.79, which corresponds to the left circumflex artery territory. Coronary angiography (middle bottom panel) revealed a 65% stenosis in the first obtuse marginal branch of the left circumflex artery, which had a fractional flow reserve of 0.65. Middle upper panel shows the middle CMR slides with the quantitative contours. Perfusion magnetic resonance imaging images at both stress and rest are shown in the right panels. It is important to note that the perfusion defect was not visualized in the stress image, and was only detected by the quantitative method. DS = diameter stenosis; FFR = fractional flow reserve.
 Please see the Appendix for accompanying video.
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Figure 3 MRI Rest and Stress Perfusion Images (Middle Slices)
The stress image shows the perfusion defect in the inferior cardiac wall (lower signal, darker image; arrows) corresponding to significant disease in the right coronary artery. There is no perfusion defect observed in the magnetic resonance imaging (MRI) image at rest. The perfusion defect can be appreciated in the video files of the mid perfusion MRI images at rest and stress.
Please see the Appendix for accompanying video.
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Figure 4 Sensitivity and Specificity of MPR to Detect CAD With FFR  0.75
Graphics showing sensitivity (Sens), specificity (Spec), and predictive values of myocardial perfusion reserve (MPR) using a cutoff of 2.04 as determined by receiver-operating curve analysis to detect coronary artery disease (CAD) with fractional flow reserve (FFR) 0.75. Heterogeneity of variance in MPR levels correlated with FFR was evaluated by Welch approximation for unequal variances from the independent-sample t test (p = 0.008).
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Figure 5 Sensitivity and Specificity of MPR to Detect CAD With  50% DS
Graphics showing sensitivity, specificity, and predictive values of MPR using a cutoff of 2.04 as determined by receiver-operating curve analysis to detect CAD with 50% DS. Heterogeneity of variance in MPR levels correlated with percentage diameter stenosis (DS) was evaluated by the Welch approximation for unequal variances from the independent-sample t test (p = <0.0001). Abbreviations as in Figure 4.
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