Heart Failure
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Author: Teresa Castiello

Date: 3/1/18

Indications and Purpose of the Scan:

Heart Failure (HF) is a syndrome that can be caused by heterogeneous aetiologies. We currently define three type of left-sided HF(preserved, reduced and mid-range ejection fraction) and right-sided HF. 

CMR is therefore requested:

  • For initial or subsequent evaluation of left/ right ventricular function (LVEF/ RVEF)
  • To identify  aetiology of HF  and new onset of congestive cardiac failure:
    • Myocardial infarction (acute or chronic)
    • Infiltrative myocardial diseases (Sarcoidosis, Amyloidosis, Fabry’s disease, Hemochromatosis)
    • Inflammatory myocarditis (infectious or noninfectious such as Chagas disease, Viral myocarditis, bacterial endocarditis, systemic inflammatory reaction syndrome (SIRS), endomyocardial fibrosis, rheumatologic causes such as Lupus, rheumatoid arthritis or connective tissue disorders)
    • Valvular heart lesions/ severity (mitral regurgitation, aortic regurgitations, tricuspid or pulmonary valve lesions)
    • Genetic disorders such as muscular dystrophies, hypertrophic cardiomyopathy, arrhythmogenic RV and LV cardiomyopathy (ARVC/ALVC), inherited dilated cardiomyopathy, including left ventricular non-compaction (LVNC)
    • Hypertensive heart disease
    • Athletes heart
    • Diastolic dysfunction and diastolic congestive HF
    • Constrictive pericarditis
    • Toxic cardiomyopathy and Cardio-oncology diseases
    • Congenital heart disease
    • Takotsubo cardiomyopathy 

Description:

Studies are typically performed according to standardized protocol. A typical HF protocol takes 40-45 minutes . All studies start with volume and function images, usually using steady-state free precession (SSFP) ECG gated cine imaging. Tissue characterization are the key sequences: late gadolinium enhancement images are most commonly done at the end of the scan. Additional sequences can be used, depending on suspected aetiology and referral request. Such as oedema images (T2 STIR), iron quantification (T2*), T1-weighted images, myocardial blood velocities/flow, early gadolinium images, tagging (diastolic dysfunction and pericardial constriction) stress images and, most recently, T1 and T2 mapping.

Why CMR (specific advantages for this topic):

CMR is very useful in the aetiology work up and can highlight the cause of HF. It can also provide information on congestion, looking at extra-cardiac (liver, lungs), that can be missed with objective examination or with a chest X ray. It provides excellent quality images, with accurate definition of cardiac structure and function, without exposure to ionising radiation. Tissue characterization, which is unique to CMR, gives key information. The images are highly accurate and reproducible.

Precise measurements and observations from CMR leads to accurate diagnosis, prognosis and treatment.

Evidence:

  • ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. 2010 Jun 8; 55(23): 2614–2662. 
    •  The consensus document describes the technique to assess cardiovascular structure and function, the advantages of the study, the application of CMR in HF.
  • The role of cardiovascular magnetic resonance imaging in heart failure. Karamitsos TD, Francis JM, Myerson S, Selvanayagam JB, Neubauer S.  J Am Coll Cardiol. 2009 Oct 6;54(15):1407-24.
  • The role of Cardiovascular Magnetic Resonance in Heart Failure . Peterzan MA, Rider OJ, Anderson L. Card Fail Rev. 2016 Nov; 2(2): 115–122.
    • Both papers  explain why CMR plays an established role in the assessment of patients with suspected and confirmed heart failure syndromes, in particular identifying aetiology. They highlight the  role in informing prognosis and guiding  therapy and the specific advantages over other non-invasive imaging modalities.
  • Gimelli A, Lancellotti P, Badano LP et al. Non-invasive cardiac imaging evaluation of patients with chronic systolic heart failure: a report from the European Association of Cardiovascular Imaging (EACVI). Eur Heart J. 2014;35:3417–3425. 10.1093
    • The paper explains diagnosis, prognosis and management of heart failure patients based on imaging parameters.

Contradictions

  • Implanted devices that are not MRI compatible are currently considered absolute contraindication in most Centers.
  • Intravascular clips or metallic prosthesis /object are not safe.  
  • Inability to lie flat is a common contraindication in severe decompensated HF patient ( e.g. pulmonary oedema).
  • Claustrophobia, altered mental status prohibit the study.
  • eGFR <30mL/min unless risk-benefit analysis suggests otherwise.
  • Severe arrhythmias and inability to hold breath, affect quality images and represent relative contraindication to the study. 

References:

  1. ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. 2010 Jun 8; 55(23): 2614–2662.
  2. Ponikowski P, Voors AA, Anker SD ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016. 10.1002/ejhf.592. 2016. 20.
  3. The role of cardiovascular magnetic resonance imaging in heart failure. Karamitsos TD, Francis JM, Myerson S, Selvanayagam JB, Neubauer S.  J Am Coll Cardiol. 2009 Oct 6;54(15):1407-24.
  4. The role of Cardiovascular Magnetic Resonance in Heart Failure . Peterzan MA, Rider OJ, Anderson L. Card Fail Rev. 2016 Nov; 2(2): 115–122.
  5. Cardiovascular Magnetic Resonance in Myocarditis: A JACC White Paper
  6. Matthias G. Friedrich, Udo Sechtem, Jeanette Schulz-Menger, Godtfred Holmvang, Pauline Alakija, Leslie T. Cooper, James A. White, Hassan Abdel-Aty, Matthias Gutberlet, Sanjay Prasad, Anthony Aletras, Jean-Pierre Laissy, Ian Paterson, Neil G. Filipchuk, Andreas Kumar, Matthias  Pauschinger, Peter Liu. J Am Coll Cardiol. Author manuscript; available in PMC 2010 Apr 28.Published in final edited form as: J Am Coll Cardiol. 2009 Apr 28; 53(17): 1475–1487.
  7. Gimelli A, Lancellotti P, Badano LP et al. Non-invasive cardiac imaging evaluation of patients with chronic systolic heart failure: a report from the European Association of Cardiovascular Imaging (EACVI). Eur Heart J. 2014;35:3417–3425. 10.1093/
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