The Role of Cardiovascular Magnetic Resonance Imaging in Heart Failure
Theodoros D. Karamitsos, MD, PhD*,
Jane M. Francis, DCC(R), DNM*,
Saul Myerson, MD*,
Joseph B. Selvanayagam, MBBS, DPhil and
Stefan Neubauer, MD*,*
* University of Oxford Centre for Clinical Magnetic Resonance Research, Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom
Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
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Figure 1 HE Patterns for Ischemic and Nonischemic Disorders
A schematic representation of hyperenhancement (HE) patterns that are characteristic for ischemic and nonischemic disorders. Note that the area of HE in ischemic cardiomyopathy always involves the subendocardium. In contrast, midwall or epicardial HE strongly suggests a nonischemic etiology. Reprinted, with permission, from Shah et al. (19). HTN = hypertension.
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Figure 2 Three Characteristic Examples of Late Gadolinium Enhancement
(A) Ischemic cardiomyopathy: previous myocardial infarct with transmural extent of scarring (white arrows) in the inferior wall, but only subendocardial (<50%) scar in the inferolateral region (black arrows). (B) Myocarditis: midwall late enhancement in the inferolateral wall (white arrows). (C) Dilated cardiomyopathy: midwall late gadolinium enhancement in the septum (white arrows).
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Figure 3 Microvascular Obstruction on Late Gadolinium Enhancement Imaging
A patient with recent myocardial infarction and evidence of microvascular obstruction on late gadolinium enhancement imaging. Note the hypoenhanced (black) area in the lateral wall (black arrows) completely surrounded by hyperenhanced regions.
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Figure 4 Large Apical Thrombus in a Patient With Recent Transmural Anterior Infarct
Images acquired early (1 to 3 min) (A) and late (>10 min) (B) after gadolinium administration showing a large intracavitary thrombus within the left ventricular apex (black arrows) in a patient with a large transmural anterior infarct (white arrows).
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Figure 5 Example of a Patient With Hypertrophic Cardiomyopathy
(A) Still frame from horizontal long-axis cine sequence showing marked septal hypertrophy. (B) Same view with late gadolinium enhancement imaging showing patchy areas of scarring in the hypertrophied septum (black arrows). (C) Still frame from a short-axis cine sequence of the same patient illustrating the asymmetric septal hypertrophy. (D) Same short-axis view with late gadolinium enhancement imaging showing the marked diffuse fibrosis within the thickened septum involving both left and right ventricular junctions (black arrows).
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Figure 6 Example of a Patient With Arrhythmogenic Right Ventricular Cardiomyopathy
Still frames from a horizontal long-axis cine sequence in end diastole (A) and end systole (B) showing prominent aneurysmal areas in the right ventricular free wall (white arrows). See also Online Video 1.
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Figure 7 Example of a Patient With Cardiac Amyloidosis
Still diastolic frames from cines: vertical long- (A) and short-axis at the midventricular level (C) showing moderate concentric hypertrophy. (B and D) Corresponding images using the late gadolinium enhancement technique, respectively. The vertical long-axis image (B) shows diffuse, predominantly subendocardial enhancement in the left ventricle (white arrows) and atrium (white arrowheads). The short-axis image (D) shows a ring of subendocardial hyperenhancement in the left ventricle (white arrows). The septum shows biventricular subendocardial enhancement with a dark midwall (zebra appearance). There is also widespread hyperenhancement in the right ventricle (white arrowheads). Note the dark blood pool.
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Figure 8 Example of a Patient With Sarcoidosis
(A) Still frame from short-axis cine sequence showing an area of marked thinning in the anterior septum. (B) Same view after gadolinium administration showing 3 different patterns of fibrosis. Transmural hyperenhancement corresponding to the area of septal thinning (black arrows), subepicardial hyperenhancement in the inferior right ventricular insertion point (white arrow), and midwall enhancement in the inferolateral wall (white arrowheads).
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Figure 9 Example of a Patient With Pericardial Constriction
(A) T1-weighted spin-echo image showing an area of markedly thickened pericardium (measuring up to 6 mm, black arrow) overlaying the right ventricular free wall. (B) Real-time free-breathing cine revealed the presence of early inspiratory flattening of the interventricular septum in diastole resulting in a D-shaped left ventricle.
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Figure 10 Example of a Patient With a Large Atrial Myxoma
(A) Still frame from horizontal long-axis cine sequence showing the tumor almost filling the entire left atrium (black arrow). (B) T1-weighted turbo spin-echo image on the same view with the mass (black arrow) appearing to prolapse through the mitral valve obstructing flow to the ventricle, therefore resulting in functional mitral stenosis. The patient presented with dyspnea and had increased systolic pulmonary pressure (60 mm Hg) on echocardiography. Note also the circumferential pericardial effusion (*). See also Online Video 2.
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