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Technology Insight: assessment of myocardial viability by delayed-enhancement magnetic resonance imaging

Nature Clinical Practice Cardiovascular Medicine volume 2, pages 150–158 (2005)Cite this article

Abstract

Myocardial viability is of established importance to the management of cardiac patients being considered for revascularization. Existing noninvasive imaging tests to examine myocardial viability, such as stress echocardiography and nuclear scintigraphy, are of recognized utility but are subject to intrinsic limitations. Over the past few years delayed-enhancement MRI (DE-MRI) has emerged as an alternative to traditional tests and for the first time allows direct visualization of the transmural extent of myocardial viability. In this paper we review the scientific data that underlie the use of DE-MRI in patients with ischemic heart disease. Progress in this area is largely the result of the development of a new MRI pulse sequence in the late 1990s, which improved the detection of necrotic and scarred myocardial tissue. Following this technical development, a series of detailed histologic comparisons in large animal models revealed that both acute and healed myocardial infarcts appeared as brighter (hyperenhanced) areas than viable regions, and that the effect is independent of contractile function. The resulting 'bright is dead' hypothesis has thus far proven of significant use in patients with ischemic heart disease. Data are now emerging which suggest that the DE-MRI technique also has important implications for patients with nonischemic forms of cardiomyopathy.

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Figure 1: Short-axis images obtained with all the magnetic resonance techniques applied in one dog.
Figure 2: Contrast magnetic resonance images and corresponding histologic slices of myocardium after acute myocardial infarction.
Figure 3: The relationship between the transmural extent of hyperenhancement before revascularization and the likelihood of increased contractility after revascularization.
Figure 4: Example of partial volume effect in an ex vivo image.
Figure 5: Interpretation of a delayed-enhancement magnetic resonance image of an infarct.
Figure 6: Clinical interpretation of myocardial viability based on cine and delayed-enhancement magnetic resonance images.
Figure 7: Chart to show how the combination of cine and contrast magnetic resonance imaging allows the distinction of various forms of myocardial injury in patients with coronary artery disease.

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Acknowledgements

We thank Joao AC Lima, Elias A Zerhouni, Francis Klocke, Robert O Bonow, Thomas Holly, Michelle Parker, Kathleen Harris, Todd Parrish, Paul Finn, Orlando Simonetti, Jeffrey Bundy and Michael Elliot for their helpful contributions to the development of the delayed enhancement technique and to the understanding of its physiologic relevance. Grants were received from NIH (National Institutes for Health) and NHLBI (National Heart, Lung, and Blood Institute).

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Author notes

  1. Robert M Judd, Anja Wagner, Timothy Albert and Raymond J Kim: RM Judd is Co-Director, A Wagner is a visiting faculty member, T Albert is a Cardiology Fellow and RJ Kim is Co-Director

Authors and Affiliations

  1. Duke Cardiovascular Magnetic Resonance Center, Duke University, Durham, NC, USA

    Robert M Judd, Anja Wagner, Timothy Albert & Raymond J Kim

  2. senior scientist at Siemens Medical Solutions, based at Duke Cardiovascular Magnetic Resonance Center,

    Wolfgang G Rehwald

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  1. Robert M Judd
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Correspondence to Robert M Judd.

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Competing interests

Robert M Judd and Raymond J Kim are consultants for Tyco and Mallinckrodt, and are inventors on a related US patent owned by Northwestern University

Glossary

DELAYED-ENHANCEMENT MRI (DE-MRI)

Images are acquired 5–30 min after contrast agent administration rather than during the myocardial first pass, hence 'delayed enhancement'

CINE MRI

Sequential cinematic presentation of multiple images (typically 16–20) corresponding to different phases of the cardiac phases to assess contractile function

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Judd, R., Wagner, A., Rehwald, W. et al. Technology Insight: assessment of myocardial viability by delayed-enhancement magnetic resonance imaging. Nat Rev Cardiol 2, 150–158 (2005). https://doi.org/10.1038/ncpcardio0134

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