Series Editors

Bernhard A. Herzog
John P. Greenwood
Sven Plein

Cardiovascular Magnetic Resonance

Pocket Guide
Editors
Bernhard A. Herzog
John P. Greenwood
Sven Plein
Pankaj Garg
Philip Haaf
Second Edition May 2017 Sebastian Onciul
Foreword
Cardiovascular Magnetic Resonance (CMR) is now an established diagnostic procedure with a wide range of
clinical indications. This pocket guide aims to provide a brief overview of the use of CMR in routine clinical
practice. It provides a summary of the most commonly used CMR methods, clinical applications and normal
ranges for CMR measurements. The pocket guide is intended for day-to-day use on the scanner or reporting
station and provides typical scan protocols, tips and tricks and guidance for reporting for the most common
clinical applications of CMR. This second edition of the pocket guide has been enriched with many more case
examples and a new section on the differential diagnoses of common CMR findings.

Bernhard Herzog
John Greenwood
Sven Plein

The Cardiovascular Magnetic Resonance Pocket Guide represents the views of the authors and the European
Association of Cardiovascular Imaging. It was arrived at after careful consideration of the available evidence at
the time it was written. Health professionals are encouraged to take it fully into account when exercising their
clinical judgment. This pocket guide does not, however, override the individual responsibility of health
professionals to make appropriate decisions in the circumstances of the individual patients, in consultation
with that patient and, where appropriate and necessary, the patient's guardian or carer. It is also the health
professional's responsibility to verify the applicable rules and regulations applicable to drugs and devices at
the time of prescription.

We acknowledge the support and advice we have received from Regina Herzog, Gavin Bainbridge, Ananth
Kidambi, Manish Motwani, Akhlaque Uddin, Filip Zemrak, Juliano de Lara Fernandes, Maciej Garbowski and
Amna Abdel-Gadir.
Table of Contents
1 Standard views 5 • Stress perfusion imaging 28
2 Image quality 12 • Dobutamine stress imaging 31
• Difficult Imaging 12 • Transmurality of myocardial infarction 33
• Artefacts 13 • Fatty replacement in myocardial 34
infarction
3 Components of CMR protocols 15 5 Acute myocardial infarction 35
• Anatomy, LV and RV function 15 6 Anomalous coronary arteries 37
• Oedema 16 7 Cardiomyopathies 39
• T2★ Mapping 16 Dilated cardiomyopathy 39
• T1 Mapping 17 Hypertrophic cardiomyopathy 41
• Tagging 20 Infiltrative cardiomyopathies 43
• Angiography 20 • Amyloidosis 43
• Coronary Artery Imaging 21 • Anderson Fabry disease 47
• Phase Velocity Encoded Flow 22 • Iron overload cardiomyopathy 49
• Perfusion 23 Sarcoidosis 51
• Gadolinium enhancement 24 Tako-Tsubo Cardiomyopathy 53
4 Chronic coronary heart disease 25 Non Compaction Cardiomyopathy 55
Arrhythmogenic Right Ventricular
• Coronary supply 25 Cardiomyopathy
58
• The 17 segment model 27 Becker and Duchenne Muscular Dystrophy 62
 Table of Contents
Endomyocardial fibrosis 64 • LGE patterns 93
8 Myocarditis 65 • LV recesses and outpouchings 98
9 Pericardial disease 67 • LV hypertrophy 100
• Pericarditis 67 • RV dilatation 102
• Constrictive pericarditis 68 14 Normal values 106
• Pericardial effusion 70 • Male LV reference values 106
10 Valvular heart disease 72 • Female LV reference values 107
• Mitral valve imaging 73 • Male RV reference values 108
• Mitral regurgitation 74 • Female RV reference values 109
• Mitral stenosis 76 • Atrial reference values 110
• Aortic valve imaging 77 • Aortic root reference values 111
• Aortic regurgitation 78 15 Safety 112
• Aortic stenosis 79 • Gadolinium contrast agents 112
• Tricuspid and pulmonary valves 80 • Common devices 113
11 Aortic disease 81 16 Miscellaneous 114
• Aortic diameters 82 • Common MR terminology 114
12 Cardiac masses 85 • Abbreviations 115
13 Differential diagnosis 93 • References 116
5 Standard Views - Localizers
Localizers
• A CMR study begins with acquisition of
a stack of localizer scans

• Localizers are acquired in transaxial,

sagittal and coronal orientations

• Localizers are used to plan additional

scan planes

• They are typically acquired with low

resolution and free breathing

• Localizers allow a first overview of

cardiac anatomy and planning of
subsequent views
Tips & Tricks
• Check if patient is in the isocentre of
the magnet: ensure sufficient signal in
the heart
• Check coil element selection: ensure
signal seen from all relevant coil
elements.
Standard Views - Left Ventricle 6
Obtaining LV pseudo- views
• Planning of pseudo-views uses the
localizer images obtained previously

• Pseudo 2 chamber (p2CH) view (also

called Vertical Long Axis view): is
obtained by positioning a plane
perpendicular to the transaxial plane
through the LV apex and mitral valve
(this is an oblique 2 chamber plane
rather than a true perpendicular one)

• Pseudo 4 chamber (p4CH) view (also

called Horizontal Long Axis view): is
obtained from the p2CH by cutting an
orthogonal plane through the apex and
MV (this is also not yet a true 4CH view)

• True short axis (SA) view: is obtained

by cutting a plane orthogonal to both
the p2CH and p4CH views

• Typically a stack of SA cines covering

the entire LV is then obtained
7 Standard Views - Left Ventricle
Obtaining LV true-views
• 4CH view: is obtained by planning a
plane orthogonal to the SA view and
the p2CH view, dissecting the RV at its
maximal lateral dimension and the LV
below the antero-lateral papillary
muscle
• 2CH view: is obtained by planning a
plane orthogonal to the p4CH or 4CH
view and the SA view, dissecting the
inferior and anterior LV wall parallel to
the septum
• 3CH view: is obtained by planning a
plane orthogonal to the 2CH or 4CH
view and the basal SA view, dissecting
the aortic valve and posterior wall

Tips & Tricks

• Simplified planning: Use p2CH and
p4CH instead of 2CH and 4CH
• Synonyms: 2CH=VLA; 4CH=HLA;
3CH=Sagittal LVOT
*A dilated aortic root may remain in view
even in 4CH
Standard Views - Right Ventricle 8
Obtaining standard RV views
• RV transaxial stack: can be obtained in
a transaxial plane from the level of the
diaphragm to the pulmonary
bifurcation or as a stack of 4CH cines
• Sagittal RVOT: is obtained by planning
a sagittal plane directly through the
main pulmonary artery, the pulmonary
valve and RV cavity
• Coronal RVOT: is obtained by planning
an orthogonal plane through the
sagittal RVOT image
• RV in-/outflow: is best obtained by 3-
point planning. The 3 points are placed
on the tricuspid valve, the RV apex in
4CH view and the pulmonary valve in
the RVOT view
Tips & Tricks
• For RV transaxial stack the slice
positions can be copied from the
transaxial localizer
• RV measurements can also be made
from the SA LV stack.
 Standard Views - Pulmonary
9 Arteries
Obtaining standard PA views
• Left and right PA: are obtained by
planning orthogonal planes through
the respective pulmonary arteries in
transaxial views

• Different angulations of these planes

provide proximal vs distal views of
both pulmonary arteries
Standard Views - Aortic Valve & Aorta 10
Obtaining standard aortic valve views
• Coronal LVOT/AV view: is obtained by
prescribing an orthogonal plane
through the aortic root in the 3CH view
• In plane AV view: is planned
perpendicular to aortic root and
3CH view
parallel to aortic valve in 3CH and
coronal LVOT views
Obtaining standard aorta views
• Aortic arch: use the 3-point planning
technique – in the transaxial stack set
one point in the ascending, one point
in the descending aorta and one point
at the level of the aortic arch
3CH view

Tips & Tricks

• Acquire several in plane AV slices
(usually 4-5)
• Also review axial images for
assessment of the aorta
 Standard Views - Flow Aorta &
11 Pulmonary Arteries
Obtaining standard flow views
• Aortic flow view: is obtained by
prescribing a plane perpendicular to
the aortic root in both sagittal and
coronal LVOT views
• Main pulmonary artery (MPA) flow
view: is obtained by prescribing a
plane perpendicular to MPA in both
sagittal and coronal RVOT views
• Left PA flow view: is obtained by
prescribing a plane perpendicular to
the left PA in both transaxial view and
its cross-cut plane
• Right PA flow view: is obtained by
prescribing a plane perpendicular to
the right PA in both transaxial view and
in its cross-cut plane
Tips & Tricks
• Simplified planning: directly from
coronal and axial localizers
• The position of the aortic flow view
relative to the AV may affect aortic
regurgitation measurements
Difficult Imaging 12
Dealing with poor breath-holders
Acceleration technique Comment
• Reduce number of slices acquired per breath-hold • Increases overall scan time
• Reduce number of phase encoding steps
Partial Fourier ky (Halfscan) • Reduces SNR
Increase voxel size • Decreases spatial resolution
Use parallel imaging • Reduces SNR, can cause artefacts

• Use respiratory navigator • Increases overall scan time

• Acquire images in inspiration • More variation in slice position between
breath-holds
• Consider general anaesthesia

Dealing with arrhythmias

Technique Comment
• Heart rate and/or rhythm control before scanning • Use beta-blockers or other antiarrhythmic
medication
• Use Arrhythmia Rejection • Increases breath-hold time
• Use Prospective triggering • Decrease SNR; the end of diastole is not
acquired
• Use Real-time imaging • Reduces temporal and spatial resolution as
well as SNR
13 Artefacts

Wrapping artefact (fold-over, back-folding)

• Increase FOV • Use selective tissue saturation bands
• Add phase encoding steps • Use a surface coil
(phase-oversampling, foldover • Select only relevant coil elements
suppression, no phase wrap)
• Swap phase and frequency
direction
Ghosting artefact from motion (respiratory)
• Strict breath-holding plus • Swap phase and frequency direction
acceleration techniques • Use selective tissue saturation bands to
• Respiratory gating or navigator suppress the signal from the anterior
echoes abdominal wall

Ghosting artefact from motion (pulsatile flow)

• Use ECG triggering / gating • Use selective tissue saturation bands to
• Use flow compensation suppress the blood signal
• Swap phase and frequency direction
Artefacts 14
Flow-related signal loss and Radiofrequency
flow jets interference artefact
• Reduce echo time • Check for sources of
interference and
• Use flow compensation
eliminate (e.g. make
• Use unbalanced sure scan room door is
sequences closed)
Chemical shift artefact Slow flow artefact
• Compare with other • Usually in T2w images
images as they are • Increase black blood
sequence dependent pre-pulse slice thickness

Dark rim artefact Metal artefact

• Often seen in perfusion • Usually less prominent
imaging on spin echo images
• Reduce contrast than gradient echo
dose/infusion speed images
• Increase in-plane spatial • Avoid balanced SSFP
resolution imaging
 15 Anatomy, LV and RV Function
Anatomy stack Tips & Tricks
1. T1w axial black blood imaging (diaphragm to 1. Acquire the anatomy stack in diastole to reduce
above aortic arch) motion artefact
2. Free breathing or breath-hold (high resolution)
3. Slice thickness: 8-10mm (contiguous) 2. To reduce breath-hold times use acceleration
techniques
LV Function
1. Cine SSFP pulse sequence (parallel imaging as 3. Contouring:
required) • In a healthy heart there is usually one less
2. 2CH, 4CH, SA and LVOT (2 orthogonal) cine slice to contour in end-systole at the base of
images the heart (longitudinal shortening). Correlate
3. SA cine stack (from mitral valve to apex) SA to long axis view if available to identify
• Slice thickness 6-10mm atrio-ventricular valve plane
• Use the movie function of the analysis
• Inter-slice gap 0-4mm to equal 10mm
software for correct alignments
4. Temporal resolution ≤ 45ms • Different methods have been proposed to
RV Function deal with trabeculation and papillary muscles.
1. Cine SSFP pulse sequence (parallel imaging as Use a consistent approach and the correct
required) normal values for the chosen method
2. Trans-axial cine stack (from diaphragm to • RV volumes are more reproducible when
pulmonary bifurcation) or SA cine stack as for LV calculated from an axial imaging plane
• Slice thickness 6-8mm
• Inter-slice gap 0mm
3. Temporal resolution ≤ 45ms
Oedema T2★ Mapping 16
Description Description
1. T2w images are oedema sensitive 1. Single breath-hold, multi-echo, T2★ sequence
2. Acquire prior to contrast administration (gradient echo or modified black blood sequence)
3 Slice thickness: 2. Single mid-ventricular slice
• ≥ 10mm to ensure good SNR 3. Single transaxial slice of the liver
• Slice thickness of the dark blood pre-pulse
should be greater than the longitudinal Tips & Tricks
shortening of the LV 1. Ensure good patient breath-holding by coaching
4. Mid-diastolic readout as the scan duration is long
2. Make sure the septum is of good image quality as
Tips & Tricks this is where quantification is most reproducible
1. Use body coil or alternatively functional surface coil 3. Position the transverse liver slice correctly:
intensity correction algorithms to correct for coil- • Avoid large hepatic vessels for correct T2*
related signal differences measurement in the liver tissue
2. Slow flow artefacts may cause high signal at
endocardial border A B
3. Consider T2 mapping for oedema detection and
quantification (if available)

ROIs are placed in the ventricular septum (A)

and the liver (B)
 17 T1 Mapping
Description A B C
1. Scout imaging as per LV function
2. Appropriate vendor recommended optimum T1-
mapping sequence (e.g. MOLLI/ShMOLLI/SASHA
etc.)
3. SA images - single mid-ventricular slice or 3 slices
planned using “3 of 5” technique
4. Gadolinium injection (0.1 – 0.2mmol/kg) 200ms 1600ms 0% 100%
5. Wait at least 15 min post contrast injection to Multi-parametric tissue characterisation at mid-slice
acquire post-contrast T1 in a case of acute re-perfused ST-elevation
6. Take full blood count for haematocrit to calculate myocardial infarction affecting the inferior wall
extracellular volume (ECV)
Tips & Tricks • T1 mapping (A): Native T1-values are raised in
the area of risk (>1000ms) and also in the remote
1. Acquire one slice per breath hold myocardium
2. Native T1 values are reproducible but they vary • LGE imaging (B): inferior infarction with an area
by magnet strength (with 3T resulting in longer
native T1 times), vendor platforms and the of microvascular obstruction (yellow arrow)
mapping sequence • ECV mapping (C): ECV is raised in the infarct zone
Check scanner generated native T1 map for but low in the MVO as this area does not take up
3. any contrast (yellow arrow) (red areas represent
breathing artefact. Consider changing voxel size,
fold-over or adding SENSE to reduce breath-hold ECV greater than 30%)

4. FOV and voxel size should not be changed

between pre/post contrast T1 acquisition to
allow generation of ECV maps

Reference 42
T1 & T2 Mapping at a glance 18

Native T1 ↑ Native T1 ↓
 Oedema  Fat/Lipid overload
e.g. tissue water↑ in acute MI, inflammation, e.g. lipomatous metaplasia in chronic MI,
pericardial effusion Anderson-Fabry, lipoma
 Increase of interstitial space  Iron overload
e.g. (replacement) fibrosis, scar,
cardiomyopathy, amyloid deposition

T2 ↑ T2 ↓
 Oedema  Fat/Lipid overload
e.g. tissue water↑ in acute MI, inflammation,
pericardial effusion (T2 more sensitive than  Iron overload (T2*↓)
native T1 for oedema detection)
 Tissue characterisation with T1
19 >1200msec
Mapping and ECV
Acute
MI
Tissue
AL amyloidosis
characterisation using
native T1 and
ATTR
amyloidosis extracellular volume
Acute fraction (ECV)
Native T1 values (milliseconds)

HCM, myocarditis Chronic

DCM Takotsubo MI Absolute values for
RA Syst. native T1 depend
Sclerosis
greatly on field
Normal
strength (1.5 T or 3 T),
pulse sequence,
scanner manufacturer
<900mse

Fabry and rules of

measurements.
Iron
For the purpose of
Lipomatous
<900msec

comparability, only
metaplasia,
studies using 1.5 T
fat
scanners were
considered in this
0% 100% figure.
Extra cellular volume (ECV)
Reference 42
Tagging Angiography 20
Description Description
1. Scout imaging as per LV function 1. Prepare infusion pump with contrast agent and
2. Choose line tagging or grid tagging pattern flush
3. Choose slice orientation from cine study • Gadolinium dose: 0.1–0.2mmol/kg
4. Acquire data in breath-hold 2. Define 3D target region (usually a very large
volume)
3. Define required timing of acquisition (arterial /
Tips & Tricks
venous)
1. Reference modality for evaluating
4. Determine best timing parameters for data
multidimensional strain
acquisition (pre-bolus or automatic triggering)
2. Temporal resolution about 15-20ms
5. Perform a dummy acquisition
3. Acceleration techniques used to shorten the
6. Perform acquisition with contrast administration
breath-hold time are the same as for cine imaging
4. Use a low flip angle to reduce tissue saturation
and prolong the tagging pattern throughout the Tips & Tricks
cardiac cycle 1. Optimize timing technique:
5. Mid-myocardial circumferential strain from SA is • Ensure that the centre of k space is acquired
B
most reproducible at the same time as the bolus of contrast
arrives in the vessel of interest
A B C 2. Ensure that the FOV covers the whole area of
interest including any collateral or aberrant
vessels

Apical (A), mid-ventricular (B) and basal (C) grid-tagging

 21 Coronary Artery Imaging
Description • Breath-hold techniques if poor image quality
1. Determine coronary rest period or if navigators are unavailable or are of poor
• Acquire 2CH with high temporal resolution quality
(50 phases) to determine coronary rest period Tips & Tricks
2. Navigator-gated, free-breathing 3D pulse 1. Coronary rest period:
sequence: • Repeat high temporal resolution 4CH scan at
• Trans-axial stack(from the proximal main the correct heart rate (HR)
pulmonary artery to the middle of the right • Consider cine scan during free-breathing if
atrium; entire cardiac coverage if desired) or HR changes during breath-hold
sagittal stack • As a compromise, scan with longest trigger
• Slice thickness: 1-1.5 mm delay and a tight window (<50 ms)
• Spatial resolution in-plane: 1.0 mm or less • Coronary rest period may differ between LCA
• Number of slices: typically 50 – 80 and RCA
• Adjust trigger delay and acquisition window 3. High HR (≥ 90bpm)
according to observed coronary artery rest • Use shortest scan window possible to
period minimize blurring
• Parallel acquisition preferred • Consider scanning at systolic rest period
• Navigator placed over the right hemi- 4. Keep scan times to a sensible limit
diaphragm 5. Higher spatial resolution equals longer scan times
3. Optional:
• Consider contrast to increase vessel
conspicuity
• T2-prepared sequence may be useful
Phase Velocity Encoded Flow 22
Description Tips & Tricks
1. Choose the appropriate imaging plane 1. VENC settings:
perpendicular to direction of flow • Optimal within 25% of the true peak velocity
- Too low: flow aliasing
2. Consider orthogonal acquisition to define peak
- Too high: underestimating velocity
velocity
• Correct direction of flow (Right-Left, Foot-
3. Set required direction of flow Head)
• Image plane distal from valve leaflet tips
4. Choose appropriate velocity encoding (VENC): • Flow assessment: perpendicular to the vessel
• Normal aortic flow: 150cm/s • Maximal velocity assessment: perpendicular
• Normal pulmonary flow: 100cm/s to the jet
• Adjust in pathological situations
2. Avoid underestimation of velocities. Check
(severe valve stenosis > 400cm/s)
adequate temporal resolution (phases)
• Free-breathing acquisition: 30 phases
5. Choose adequate spatial resolution
• Breath-hold acquisition: 20-25 phases
• minimum of 4-6 pixels per vessel diameter
3. Rotate FOV - orthogonal
B to the direction of flow
4. Slice thickness: <7mm
 23 Myocardial Perfusion
Description 3. Field of View
1. Scout imaging as per LV function • As small as possible
2. Saturation-recovery gradient echo pulse • Parallel to the anterior chest wall
sequence
4. Use “3 out of 5” technique to position slices
3. Parallel imaging (typical two-fold acceleration)
4. Acquisition in SA plane (at least three slices), plus “3 out of 5” technique
optional long axis planes • Plan in end-systole in long axis views (2CH and
• Slice thickness 8-10mm 4CH)
• In-plane resolution < 2.5mm • Plan 5 slices perpendicular to the longitudinal
axis and adjust the slice gap so that the first
• Ideally obtain data every heart beat
slice is in the plane of the mitral valve and the
5. Contrast (0.05 - 0.1mmol/kg, rate: 3 - 7ml/s) last slice is at the apex.
followed by 30ml saline flush (3-7ml/s)
• Remove the outer slices (1st and 5th) by
6. Breath-hold starts during early phases of contrast
reducing the number of slices from 5 to 3
infusion before contrast reaches the LV cavity
• The resulted 3 slices are in accurate and
7. Image for >40 heartbeats
reproducible positions and can be used for
perfusion assessment
Tips & Tricks
1. Always perform a “dummy” scan to check
• Correct slice positioning
• Artefacts
2. Switch to alternate heartbeat acquisition if HR is
too high or reduce number of slices
Early/Late Gadolinium Enhancement 24
Description Tips & Tricks
1. Segmented IR GRE (inversion recovery gradient 1. Scan in mid- or late-diastole to minimize motion
echo) imaging during diastolic rest period artefacts
2. 4CH, 3CH, 2CH, SA images 2. Use saturation bands across the spinal column
3. In-plane resolution : <2mm and the anterior chest wall to reduce ghosting
4. Contrast dose 0.1 – 0.2mmol /kg artefacts
3. Late enhancement on images:
4. Early Gadolinium Enhancement (EGE): acquire 1-
3 min after contrast, TI >400ms • Use “Phase Swap” (changing the phase
5. Late Gadolinium Enhancement (LGE): acquire encoding direction) to confirm
≥10min after contrast injection pathology/detect artefact
• Consider imaging earlier if lower Gd doses are • Always consider a different plane cross-
used cutting through the enhanced area
• Consider imaging later in a low output state 4. Increase TI times by 10 – 15ms every few minutes
or repeat Look Locker scout regularly, because
6. TI set to null normal myocardium:
the correct TI for “nulling” of normal myocardium
• TI scout or Look Locker sequence changes over time
• Phase-sensitive sequence with fixed TI as 5. To reduce breath-hold times use acceleration
alternative techniques
7. Readout: 6. Acquiring the images during every second or third
• Usually every other heartbeat heartbeat can help if there are problems with
• Every heartbeat in the setting of bradycardia arrhythmia
• Every third heartbeat in the setting of 7. Consider infiltrative disease (amyloidosis) if
tachycardia normal myocardium is hard to null despite correct
technique
 25 Coronary Supply

4 chamber 2 chamber 3 chamber

basal mid apical

LAD LAD or CX

CX LAD or RCA

RCA CX or RCA

Reference 1
Coronary Supply 26

LGE SA stack (A), 4CH (B), 2CH (C), 3CH (D): LGE SA stack (A), 4CH (B), 2CH (C), 3CH (D):
Transmural myocardial infarction of the Transmural myocardial infarction of the
anteroseptal (midventricular), anterior anterolateral and inferolateral (basal to
(midventricular to apical) and septal (apical) wall as midventricular) as well as lateral (apical) wall, which
well as the apex, corresponding to the LAD corresponds to the CX territory.
territory.
 27 The 17 Segment AHA Model
standard views 4 chamber 2 chamber 3 chamber
apex
A apical S L I A L A
AL
mid IS AL I A IL AS

IS AL I A IL AS
I basal

17-segment model
1
basal mid apical
A A A A
17L AL AS AL
15
IS IL
I
I I

1: basal anterior A; 2: basal anteroseptal AS; 3: basal inferoseptal IS; 4: basal inferior I; 5: basal inferolateral IL;
6: basal anterolateral AL; 7: mid-anterior A; 8: mid-anteroseptal AS; 9 mid-inferoseptal IS; 10 mid-inferior I; 11
mid-inferolateral IL; 12 mid-anterolateral AL; 13: apical anterior A; 14: apical septal S; 15: apical inferior I; 16:
apical lateral L; 17: apex
Reference 1
Stress Myocardial Perfusion Imaging 28
Protocol Vasodilator Stress agents
1. Anatomy 1. Adenosine:
2. Myocardial perfusion “dummy“ without contrast • Standard dose 140mcg/kg/min at least 3 min
injection (to check position and artefact) • Consider 170 or 210mcg/kg/min, if
3. Myocardial perfusion STRESS hemodynamic response is inadequate
4. LV function 2. Regadenoson 0.4 mg single injection
5. Myocardial perfusion REST (optional) 3. Dipyridamole 0.56 mg/kg in 4 minutes
6. LGE 4. Contraindications for all vasodilators: known
hypersensitivity, 2nd /3rd AV nodal block, severe
Report reversible obstructive airways disease
1. Dimensions (corrected for BSA) and function
Tips & Tricks
• LV: EDV, ESV , SV, EF / RV: EDV, ESV, SV, EF
1. Low contrast uptake in spleen at first pass
• Regional wall motion abnormalities (17 suggests adequate adenosine effect (‘splenic
segments) switch off’).
2. Presence and transmural extent of scar 2. Regadenoson does not cause splenic switch off
• ≤25%, 26-50%, 51-75%, 76-100% 3. Dobutamine may be used for stress imaging but
causes high heart rate and ischaemia
3. Presence and transmural extent of stress Contrast Contrast Contrast (top-up)
perfusion defect
4. Correlation between scar and perfusion defect Stress

time (min)
5. Comment on potential suitability of
Localizer

LV stack
Survey

SENSE

Stress
revascularization based on ischaemia and viable

Rest

EGE

LGE
ref

LL
myocardium
6. (Presence and location of artefacts)
0 10 20 30 40 50
Reference 2
29 Stress Perfusion Imaging
A 64 year old male with typical angina
• Adenosine stress perfusion (A):
extensive perfusion defect in the
anterior and anteroseptal segments

• Rest perfusion (B): normal

B
• LGE (C): normal signal suppression in
the myocardium

• Report: Extensive ischaemia in the

LAD territory affecting 6/17
myocardial segments (approximately
30% of myocardium)
C C
LGE
Stress Myocardial Perfusion Imaging 30
A 72-year-old woman with exercise angina
• Adenosine stress perfusion (A):
extensive perfusion defect in the
anterior, antero-septal, infero-septal
and inferior walls from base to apex
(10/17 segments).

B • Rest perfusion (B): normal

• LGE (C): no evidence of myocardial

infarction or focal fibrosis

• Report: extensive and prognostically

significant inducible ischaemia in the
LAD and RCA territories which are
entirely viable and likely to recover
C
function following revascularisation
(likely hibernation)
 31 Dobutamine Stress Imaging
Protocol Key Issues
1. Anatomy 1. Check BP at each stage of protocol / monitor ECG
2. LV function - 3 SA, 2-3 long axis views 2. Always view cine loops during stress online
3. Dobutamine Stress 3. Stop test, if any of the following occurs:
• 3min-intervals: 10 / 20 / 30 / 40 mcg/kg/min • New wall motion abnormalities
• HR target = 0.85 x (220-age)
• Serious side effects
• Consider 0.5 mg atropine x 2 to increase HR
• Achievement of peak HR
• Repeat cine images at each stress level
4. Contraindications for atropine: narrow-angle
4. LGE
glaucoma, myasthenia gravis, obstructive
Report uropathy, obstructive gastrointestinal disorders
1. Dimensions (corrected for BSA) and function
• LV: EDV, ESV , SV, EF / RV: EDV, ESV, SV, EF Tips & Tricks
• Regional wall motion abnormalities (17 1. Use “3 out of 5” technique to position SA slices
segments) 2. Consider acquiring perfusion images at peak
- Improvement during low-dose stress stress
(=viability)
- Improvement or biphasic response during Contrast
Dobutamine
high-dose stress (=ischaemia)
2. Presence and transmural extent of scar

time (min)
Localizer

Atropine
LV stack
Survey

SENSE

3. Summarize: resting function, contractile reserve,

EGE

LGE
ref

20
10

30
40

LL
wall motion index, ischaemia for coronary
territories
0 10 20 30 40 50
4. Comment if any valvular regurgitation worsens
Dobutamine Stress Imaging 32
Ischaemic Wall Motion Score Index
Myocardial Wall Motion
Conditions (WMSI)
Low-Dose High-Dose
Rest Dobutamine (sum of wall motion scores / number
Dobutamine
of segments)

Normal 1
Normal
Hypokinetic 2
Akinetic 3
Ischaemia Dyskinetic 4
Aneurysmal 5

Hibernation A WMSI of 1 is considered normal

Subendocardial
scar

Transmural
scar
 Transmurality of myocardial
33 infarction
Microinfarction 25-50% transmurality

50-75% transmurality 100% transmurality

Fatty replacement in chronic
myocardial infarction 34
A B C 60-year-old man with a chronic LAD
infarction
• Cine SA (A): thinned and akinetic
anteroseptal wall
• T1w black blood SA (B): high
signal within the thinned septum
indicating fatty replacement
• T1w black blood image with fat
suppression SA (C): signal
suppression in the same area

A B C Chronic RCA infarction in a 75-year-old

woman
• LGE SA (A) and 2CH (B): infarction
of the inferior wall
• Native T1 mapping 2CH (C): low
native T1 values in the inferior
wall suggestive of fatty
replacement
 35 Acute Myocardial Infarction
Protocol Key Points
1. Anatomy 1. T2w imaging may differentiate acute from
2. LV function chronic myocardial infarction
2. MVO:
3. Oedema • Equates to angiographic “no reflow”
4. EGE – LGE appearance
• High risk feature
5. T2 mapping (if available) for detection of oedema
3. Risk assessment:
• Infarction size
Report
• LV / RV function
1. Dimensions (corrected forBSA) and function
• MVO
• LV: EDV, ESV , SV, EF / RV: EDV, ESV, SV, EF
4. Assessment of LV thrombus on EGE images
• Regional wall motion abnormalities
Tips & Tricks
2. Presence of oedema (=area at risk) 1. MVO best seen on EGE images at TI > 400ms

2. T2w images must be acquired before contrast

3. Presence and transmural extent of scar
administration

4. Presence and extent of microvascular obstruction 3. Compare LGE images with cine images if unsure
about differentiation between blood pool and
endocardial late enhancement

References 3, 4
Acute myocardial infarction 36
A B 45-year-old man with lateral
STEMI due to circumflex artery
occlusion
• Diastolic (A) and systolic (B)
phases of a cine SA dataset
showing akinesia of the
lateral wall

• EGE 4CH (C) showing

microvascular obstruction in
the basal to mid lateral wall

C D • LGE SA (D) demonstrating

microvascular obstruction of
the lateral wall
 37 Anomalous Coronary Arteries
Protocol Key Points
1. Coronary artery imaging 1. Spatial resolution can be less than that required
• 3D MRA (free breathing navigator gated) to assess coronary lumen
• Targeted 2D MRA
2. Malignant course:
Report • Inter-arterial course between aorta and RVOT,
1. Origin particular left coronary artery from right sinus
• High / low / commissural
3. Possible causes of ischaemia:
• From opposite coronary sinus
• Inter-arterial dynamic compression
• Outside coronary sinuses • Slit-like origin
• Separate ostium for LAD and CX • Myocardial bridging
2. Anomalous course
• Inter-arterial, retro-aortic, etc Tips & Tricks
1. Optimize image quality:
3. Anomalies of intrinsic coronary arterial anatomy • Use isotropic voxel sizes
• Ectasia, aneurysm, hypoplasia • Short acquisition window (< 150ms)
• Intramural coronary artery (muscular bridge)
4. Anomalies of coronary termination 2. Consider dobutamine stress (rather than
adenosine) to demonstrate a regional wall motion
5. Anomalous collateral vessels abnormality (if inter-arterial course)
Anomalous Coronary Arteries 38

LCA from right sinus with RCA from left sinus with
inter-arterial course inter-arterial course

LCA from right sinus with Kinking of the proximal LCA

retro-aortic course after arterial switch procedure
 39 Dilated Cardiomyopathy
Protocol Key Points
1. Anatomy 1. Mid-wall fibrosis indicative of DCM
2. LV function 2. Risk factors for sudden cardiac death:
3. T1 mapping (optional) • LV impairment, EF <35%
4. Oedema • Frequent repetitive NSVT
5. RV function • Presence end extent of mid-wall fibrosis
• Raised ECV
6. LGE

Tips & Tricks

Report 1. Use acceleration techniques to reduce breath-
1. Dimensions (corrected for BSA) and function hold times
• LV: EDV, ESV , SV, EF, end-diastolic diameter 2. Consider unrecognized CAD if you identify:
• Marked regional wall motion abnormalities
• RV: EDV, ESV, SV, EF
• Subendocardial or transmural
2. Presence and severity of valvular regurgitation
hyperenhancement on LGE
3. Presence, location, and extent of fibrosis 3. Consider abnormal vascular connections / shunts
4. Tagging may help identify wall motion
abnormalities
5. Perfusion imaging can be difficult to interpret
(thin myocardium, presence of scar and slower
flow)
Dilated Cardiomyopathy 40
A B A

C D

Tissue Characterisation. T2w SA (A): no evidence of LGE 4CH (A) and 2CH (B): typical
oedema; Native T1-map SA (B): slightly higher native T1 mid-wall fibrosis, which, however is
values; LGE 4CH (C) and 2CH (D): no evidence of fibrosis missing in most DCM patients
 41 Hypertrophic Cardiomyopathy
Protocol Key Points
1. Anatomy 1. HCM criteria
2. LV function • Wall thickness >15mm (>13mm in familial
HCM; >20mm if Afroamerican/black) in the
3. LVOT cines (2 orthogonal views) absence of other causes
4. Velocity encoding in- and through- LVOT planes • Septal to lateral wall thickness ratio >1.3
5. T1 mapping (optional) • Apical to basal wall thickness ratio >=1.3 to
1.5 in apical HCM
6. LV tagging (3 SA slices, 4CH) – optional
2. Consider possible obstruction under stress
7. LGE conditions

Report Tips & Tricks

1. Dimensions, mass (corrected for BSA) and 1. LGE at the insertion points of the RV to the LV is
function non-specific and often seen even in normal
EDV, ESV , SV, EF and mass subjects
2. Thickening and function of myocardial segments 2. Suggestive of HCM:
• Localized hypertrophy
3. Presence of LVOT obstruction at rest
• Reduced contraction of hypertrophied
4. Presence of systolic anterior motion (SAM) segments (tagging may help visualise)
5. Presence and extent of fibrosis • Presence of LGE
3. Myocardial crypts may help to define HCM
mutation carriers without LV hypertrophy

Reference 5
Hypertrophic Cardiomyopathy 42
A HCM – Common findings
• LGE SA stack (A): severe fibrosis at
the RV insertion points
• Cine 3CH (B): LVOT obstruction due to
SAM of the mitral valve leaflets.
• Cine 2CH (C): multiple myocardial
crypts in the inferior wall. These
crypts may help to define HCM
mutation carriers without LV
hypertrophy. Note that myocardial
crypts can be easily missed on SA
views (D) due to partial volume

B C D
 43 Amyloidosis
Protocol Key Points
1. Anatomy 1. Restrictive LV pattern (non-dilated ventricles,
preserved LV function, restrictive filling pattern,
2. LV function (RV function)
enlarged LA / RA) and global LV hypertrophy
3. Oedema 2. LGE
• On Look-Locker images the blood pool and
4. EGE / LGE
myocardium cross zero (appear black) at
5. T1 Mapping similar timepoints
• Myocardial nulling difficult to achieve on LGE
images despite good technique
Report
• Predominantly global sub-endocardial
1. Dimensions, mass (corrected for BSA), and
distribution
function
• Other patterns such as patchy subendocardial
• LV: EDV, ESV , SV, EF, longitudinal function,
or transmural enhancement can also occur
mass
3. Atrial septal hypertrophy of >6mm (in <20% of
• RV: EDV, ESV, SV, EF, longitudinal function
cases)
• Regional wall motion abnormalities 4. Pericardial and pleural effusion are common
• Thickness of interatrial septum
2. Valve regurgitation Tips & Tricks
3. LGE pattern 1. Cross check skeletal muscle signal intensity
while choosing optimal inversion time
4 Pericardial / pleural effusion
2. For differential diagnosis AL amyloidosis vs.
ATTR amyloidosis see table on next page
Amyloidosis 44
AL amyloidosis ATTR amyloidosis QALE score for DD AL and ATTR
• Mildly increased • Markedly increased
LV mass
< 100 g/m2 > 100 g/m2
Septum
Septum AL < Septum ATTR
thickness
4 3 2
• Less extensive LGE • More extensive LGE
• Often (global) • Often more diffuse and
LGE subendocardial transmural pattern
pattern
• QALE score < 13 • QALE score ≥ 13 1 0 (No LGE)
> 1050 - 1150 ms
Native T1
Native T1AL > Native T1ATTR
>0.40
ECV
ECVAL < ECVATTR
• Chemotherapy • Novel TTR-specific
Therapy
treatment (Phase III)
• Worse (despite less • Better (despite more
Prognosis +6, If any RV LGE
extensive LGE) extensive LGE)

AL - light chain amyloid

ATTR - transthyretin-related amyloidosis
Reference 6, 7
45 Amyloidosis
68 year old patient with suspected
A
cardiac amyloidosis
• Look Locker post contrast (A):
blood and myocardium are
nulled at a similar TI.

• LGE SA stack (B): predominantly

subendocardial enhancement in
myocardium; note poor nulling of
myocardial signal.

B
Amyloidosis 46
73 year old patient with
suspected cardiac
amyloidosis
• Native T1 maps (1)
acquired with a
MOLLI method at
1.5T: diffusely
elevated native T1
values
(> 1000 ms)

• Extra-Cellular Volume
maps (2): diffusely
elevated ECV values
(>35%)

• LGE SA (3): poor

nulling of myocardial
signal and islets of
patchy enhancement.

a: apex, b: midventricular,
c: base
 47 Anderson Fabry Disease
Protocol 3. Concentric LVH
1. Anatomy • Relatively late disease manifestation (3rd
2. LV function decade in men, 4th decade in women)
3. T1 Mapping • Patterns of hypertrophy often
4. LGE indistinguishable from HCM
• LVH associated with progressive myocardial
Report fibrosis
1. Dimensions, mass (corrected for BSA) and
function 4. LGE
• LV: EDV, ESV , SV, EF, longitudinal • Present in 50% of cases
function, mass • Mid-wall or subepicardial LGE of the
• Regional wall motion abnormalities inferolateral wall of mid to basal LV
2. LGE pattern
3. Native T1 and ECV (if available) 5. T1 mapping
Key Points • Native T1↓ of septum (< 940ms (1.5T))
1. General • ECV↓
• Multi-system lysosomal storage disease • Inferolateral LGE: pseudonormalisation native
• X-linked (men > women) T1 normal/↑ possible if the effects of
replacement fibrosis exceed the fatty-related
2. Disease pathophysiology: T1 decrease
• Accumulation of globotriaosylceramide Tips & Tricks
in the vascular endothelium, leading to • AFD is underdiagnosed (prevalent in dialysis
ischaemia and infarction in the kidney, heart patients, late-onset “HCM”)
and brain
Anderson Fabry Disease 48
34 year old patient with Anderson Fabry Disease
A
• LGE SA (A): hyperenhancement of basal
inferolateral and inferior segments

• Native T1 map (B): low septal T1 (780 ms)

appearing blue (white arrow).

Reference 8, 9
 49 Iron Overload Cardiomyopathy
Protocol 3. Other diagnostic signs
1. Anatomy and LV/RV function • Focal signal loss in native T1- and T2-
2. T2★ weighted images
Report • Abnormally "dark" liver
1. Dimensions, mass (corrected for BSA), and 4. Serial follow-up of iron loading to guide chelation
function therapy
• LV: EDV, ESV , SV, EF, longitudinal function, 5. Isolated cardiac or liver involvement is possible
mass
• RV: EDV, ESV, SV, EF, longitudinal function Tips & Tricks
1. Assess T2* values in the septum (fewer artefacts)
2. T2★ (ms), R2★ (Hz) and dry weight iron content
as iron deposition is similar in all LV segments
Key Points 2. High correlation of T2* values and native T1
1. Iron overload cardiomyopathy
• Potentially reversible cause of heart failure values (T2*↓, native T1↓)
under effective therapy
• Dilated phenotype – majority of patients,
impaired systolic function
• Restrictive phenotype - non-dilated
ventricles, preserved systolic function,
diastolic dysfunction, enlarged atria
2. Risk of developing heart failure
• T2* > 20 ms: low
• T2* 10-20 ms: intermediate T2* contours: ROIs are placed in the ventricular
• T2* <10 ms: high septum (A) and the liver (B).
Iron Overload Cardiomyopathy 50
B
T2* calculation: Graphs of the relaxation
A
of T2* values over time to compute T2*
values of myocardium (A) and liver (B).
T2* of the ventricular septum was 16.5ms
consistent with mild myocardial iron
overload and intermediate risk of
developing heart failure, T2* of liver was
2.1ms consistent with severe iron overload
of the liver.

Myocardial Myocardial R2* Dry weight Hepatic T2* Hepatic R2* Dry weight Classification
T2*(ms) (Hz) (MIC) (mg/g) (ms) (Hz) (LIC) (mg/g)

≥20 ≤ 50 ≤ 1.16 ≥15.4 ≤ 65 ≤2 None

14-20 50 – 71 1.16 – 1.8 4.5-15.4 65 - 224 2-7 Mild

10-14 71 – 100 1.8 – 2.7 2.1 – 4.5 224 - 475 7-15 Moderate

≤10 ≥ 100 ≥ 2.7 ≤2.1 ≥ 475 ≥ 15 Severe

Liver Iron Content (LIC) calculated according to Ref 10; Myocardial Iron Content (MIC) calculated according to Ref 11
 51 Sarcoidosis
Protocol 3. Myocardial granulomas on LGE images:
1. Anatomy • Intramural
2. LV function (RV function) • Spotty
3. Oedema
• Predominantly basal lateral
4. LGE
• Respond to immunosuppressive drugs
Report
1. Dimensions, mass (corrected for BSA), and • Enhancement not in CAD territory
function distribution
• LV: EDV, ESV , SV, EF, longitudinal function, 4. LV dysfunction is common
mass 5. Focal oedema indicates inflammation
• RV: EDV, ESV, SV, EF, longitudinal function • may mimic hypertrophic cardiomyopathy
• Regional wall motion abnormalities 6. Usually accompanied with extra-cardiac findings:
2. Myocardial granulomas on LGE images • Hilar lymphadenopathy
3. Extra-cardiac findings
• Involvement of any other organ system
Key Points possible
1. Restrictive LV pattern (non-dilated ventricles,
preserved LV function, restrictive filling pattern, Tips & Tricks
enlarged LA / RA) 1. High degree AV nodal blocks, AF and NSVT are
2. Cardiac involvement: common in sarcoidosis
• in about 25% of patients with systemic
sarcoidosis
Sarcoidosis 52
A B

LGE SA stack (A) and 2CH (B): Typical spotty enhancement in the regions of wall motion abnormalities
representing granulomas. Note, that the enhancement is not in a coronary artery territory distribution.
 53 Tako-Tsubo Cardiomyopathy
Protocol Key Points
1. Anatomy 1. Transient acute left ventricular dysfunction due
2. LV function (RV function) to neurogenic myocardial stunning
3. Oedema 2. Usually in post-menopausal women and in the
4. LGE setting of acute emotional or physical stress
5. T2 mapping for oedema detection (if available) 3. Recovery takes place over a few days with full
recovery over a few weeks
Report
4. Typical Tako-Tsubo pattern
1. Dimensions (corrected for BSA) and function
• LV: EDV, ESV , SV, EF • Apical akinesia / ballooning
• RV: EDV, ESV, SV, EF • Basal / mid-ventricular hyperkinesia
• Regional wall motion abnormalities 5. Inverted Tako-Tsubo pattern
2. Presence of oedema
• Mid-ventricular and basal akinesia /
3. Presence of LGE
ballooning
• Apical hyperkinesia
6. Oedema in the areas of wall motion
abnormalities
7. Classically NO signs of LGE
• Infarct-like hyperenhancement has been
described in a few rare cases
Tako-Tsubo Cardiomyopathy 54
A 55-year old lady with acute onset chest
pain and troponin rise. Normal invasive
coronary angiography. Recent
bereavement in immediate family.
• Cine 2CH (A) and 4CH (B) diastolic
and systolic frames: classical apical
ballooning with preserved basal
contraction

• LGE SA (C): no evidence of

myocardial infarction.
B
• Native T1 map SA (D): significantly
raised T1 values in mid ventricle
suggestive of myocardial oedema

C D
 Left Ventricular Non -
55 Compaction Cardiomyopathy
Protocol Key Points
1. Anatomy 1 Current diagnostic criteria:
2. LV function • Multiple criteria (* table)
• No need for routine reporting of the
3. LGE trabeculation

Report 2. Excessive trabeculation is benign and not

1. Dimensions, mass (corrected for BSA) and associated with adverse outcomes
function
• LV: EDV, ESV , SV, EF 3. Diagnosis of the LVNC cannot be based on
• Do not routinely report the extent of imaging criteria alone
trabeculation • Pre-test probability is relevant
• Often over-diagnosed, particular in DCM
A B (thin compacted myocardium) and in
2. Overall cardiac appearance: “ otherwise normal” patients of Afro-American descent
vs. “structural or developmental” abnormality • Significant if found with other
morphological/developmental
abnormalities, neuromuscular disorders
3. Pre-test probability for LVNC: family history,
and/or family history of cardiomyopathy
neuromuscular disorder, significant arrhythmia
Left Ventricular Non-Compaction:
Criteria 56
Modality Echo (ref 43) CMR (ref 44) CMR (ref 45) CMR (ref 46) CMR (ref 47)
Criteria • NC/C in • Two-layered • Total LV mass • Apical SA • SA views
parasternal SA myocardium (SA SSFP cines) views 16 to • Loss of base-
• Deep perfused • Long axis SSFP • Compacted 24 mm from to-apex fractal
inter- cine myocardial the true dimension
trabecular • Measured at mass (SA SSFP apical slice (FD)* gradient
recesses on the most cines) • Region with
Colour pronounced • Trabecular the largest *FD is an index
Doppler trabeculation mass = Total NC/C ratio of how
• Decreased • Measurement LV mass minus completely an
thickening and perpendicular compacted object fills
hypokinesia to compacted myocardial space.
within, but not myocardium mass
limited to, NC
segments
Cardiac End-systole End-diastole End-diastole End-systole End-diastole
phase
Definition NC/C ratio > 2 NC/C ratio > 2.3 Trabecular NC/C ratio ≥ 2 FD ≥1.30
mass> 20%
Sensitivity Sens 86% Sens 93.7% Sens 83-100%
specificity n/a Specif 99% Specif 93.7% n/a Specif 86-100%
 Left Ventricular Non-Compaction
57 Cardiomyopathy
A B Patient with family history of
cardiomyopathy
• Cine 4CH (A) and 2CH (B): marked
trabeculation of all LV walls except
the interventricular septum
• Excessive LV trabeculation is a
part of gross morphological
abnormalities and positive family
history
• This is most likely LV non-
compaction cardiomyopathy

B
Patient with no clinical features of
A
LVNC
• Cine SA (A) and 4CH (B): marked
LV trabeculation, primarily in the
lateral wall
• No other abnormalities
• Most likely anatomical variant
• Consider that the diagnosis of
LVNC is challenging and may not
be based on imaging criteria alone
Arrhythmogenic Right Ventricular
Cardiomyopathy 58
Protocol Key Points
1. Anatomy 1. Diagnosis cannot be based on imaging criteria
2. LV function alone
3. RV function (transaxial and RVOT) - See modified 2010 Task Force ARVC criteria
2. RV wall motion abnormalities at the moderator
• Slice thickness 6-8mm without inter-slice
band insertion point is common in normal
gap
subjects
4. T1w axial black blood (optional)
5 T1w axial fat suppressed black blood (optional) Tips & Tricks
6. LGE in same orientations 1. Focus on RV volumes and functional RV
• T1 nulling for RV abnormalities
Report 2. Consider antiarrhythmic drugs in patients with
1. Dimensions, mass (corrected for BSA) and VES
function 3. Consider alternative causes (abnormal vascular
• LV: EDV, ESV , SV, EF, longitudinal function, connections / shunts) in patients with dilated RV
mass
• RV: EDV, ESV, SV, EF, longitudinal function
• RV regional wall motion abnormalities
(inflow, apex, outflow)
2. Presence of morphological RV abnormalities
(aneurysms, outpouchings)
3. Presence of fatty RV or LV infiltration
4. Presence and extent of fibrosis
 Arrhythmogenic Right Ventricular
59 Cardiomyopathy

LGE 4CH: Fibrosis in the RV free wall (yellow LGE SA: Fibrosis in the LV (red arrow) in a non-ischaemic
arrows) with involvement of the LV lateral pattern.
wall (red arrow) in a non-ischaemic pattern.
ARVC diagnostic criteria I 60
1. Global or regional dysfunction and structural alterations Definite diagnosis
Major • Regional RV akinesia or dyskinesia or dyssynchronous RV contraction • 2 major or 1 major and
• and 1 of the following: 2 minor criteria
- Ratio of RV end-diastolic volume to BSA ≥110mL/m2 (male) • 4 minor criteria
or ≥100mL/m2 (female) Borderline diagnosis
- or RV ejection fraction ≤40% • 1 major and 1 minor3
Minor • Regional RV akinesia or dyskinesia or dyssynchronous RV contraction • 3 minor criteria
• and 1 of the following: Possible diagnosis
- Ratio of RV end-diastolic volume to BSA ≥100 to <110mL/m2 (male) • 1 major or 2 minor
or ≥90 to <100mL/m2 (female) criteria
- or RV ejection fraction >40% to ≤45%
2. Tissue characterization of wall (Histological)
Major • Residual myocytes <60% by morphometric analysis (or <50% if estimated), with fibrous replacement of the
RV free wall myocardium in ≥1 sample, with or without fatty replacement of tissue on endomyocardial
biopsy
Minor • Residual myocytes 60% to 75% by morphometric analysis (or 50% to 65% if estimated), with fibrous
replacement of the RV free wall myocardium in ≥1 sample, with or without fatty replacement of tissue on
endomyocardial biopsy
3. Repolarization abnormalities
Major • Inverted T waves in right precordial leads (V1, V2, and V3) or beyond in individuals >14 years of age (in the
absence of complete right bundle-branch block QRS ≥120ms)
Minor • Inverted T waves in leads V1 and V2 in individuals >14 years of age (in the absence of complete right
bundle-branch block) or in V4, V5, or V6
• Inverted T waves in leads V1, V2, V3, and V4 in individuals >14 years of age in the presence of complete
right bundle-branch block
Reference 40
 61 ARVC diagnostic criteria II
4. Depolarization / conduction abnormalities
Major • Epsilon wave (reproducible low-amplitude signals between end of QRS complex to onset of the T wave) in
the right precordial leads (V1 to V3)
Minor • Late potentials by SAECG in ≥1 of 3 parameters in the absence of a QRS duration of ≥110ms on the
standard ECG
• Filtered QRS duration (fQRS) ≥114ms
• Duration of terminal QRS <40µV (low-amplitude signal duration) ≥38ms
• Root-mean-square voltage of terminal 40ms ≤20 µV
• Terminal activation duration of QRS ≥55ms measured from the nadir of the S wave to the end of the QRS,
including R’, in V1, V2, or V3, in the absence of complete right bundle-branch block
5. Arrhythmias
Major • Nonsustained or sustained ventricular tachycardia of left bundle-branch morphology with superior axis
(negative or indeterminate QRS in leads II, III, and aVF and positive in lead aVL)
Minor • Nonsustained or sustained ventricular tachycardia of RV outflow configuration, left bundle-branch block
morphology with inferior axis (positive QRS in leads II, III, and aVF and negative in lead aVL) or of unknown
axis >500 ventricular extrasystoles per 24 hours (Holter)
6. Family history
Major • ARVC confirmed in a first-degree relative who meets current Task Force criteria
• ARVC confirmed pathologically at autopsy or surgery in a first-degree relative
• Identification of a pathogenic mutation† categorized as associated or probably associated with ARVC in
the patient under evaluation
Minor • History of ARVC in a first-degree relative in whom it is not possible or practical to determine whether the
family member meets current Task Force criteria
• Premature sudden death (<35 years of age) due to suspected ARVC in a first-degree relative
• ARVC confirmed pathologically or by current Task Force Criteria in second-degree relative
Becker and Duchenne Muscular
Dystrophies 62
Protocol 5. Biventricular impairment, hypertrophy and/or
1. Anatomy dilatation
2. LV/RV function 6. LGE: subepicardial fibrosis inferolateral (BMD,
DMD) remarkably similar to viral myocarditis
3. T1 mapping (native & post-contrast) 7. Fat-suppressed imaging/native T1 mapping may
4. LGE help delineate the extent of myocardial
Report fibrosis/myocardial fat infiltration
1. Dimensions, mass (corrected for BSA) and 8. T1 mapping
function • ECV elevated (29+/-6%)
2. LV: EDV, ESV , SV, EF, longitudinal function • shorter T1 post-contrast than in controls may
3. Regional wall motion abnormalities detect diffuse fibrosis
4. LGE pattern • pseudonormalisation of native T1 if effects of
5. Native T1 and ECV (if available) replacement fibrosis cancel out fat related T1
decrease
Key Points
1. BMD and DMD commonest muscular dystrophies Tips & Tricks
(80% of all muscular dystrophies) with high rate of 1. Cardiac involvement characterized by myocardial
cardiomyopathy fibrosis - DCM, heart failure, (malignant)
2. X-linked (men > women); female carriers may also arrhythmias, heart block
present cardiac involvement and similar pattern of 2. LGE can be “transmural” in the absence of
myocardial fibrosis coronary artery disease (additive prognostic value)
3. Disease pathophysiology: affecting the synthesis 3. Early detection for early heart failure therapy may
of dystrophin delay the progression of LV dysfunction
4. ECG: increased R-to-S ratio in the right precordial 4. Clinically overt heart failure in dystrophinopathies
leads, deep lateral Q waves, conduction may be delayed or absent, due to relative physical
abnormalities, arrhythmias (SVT>VT) inactivity
Reference 12, 13
 Becker and Duchenne Muscular
63 Dystrophy
B 25 year old man with Duchenne
A
Muscular Dystrophy
• LGE 4CH (A) and SA (B):
septal mid-wall enhancement
and patchy inferolateral
enhancement (fibro-fatty
replacement)

• Native T1 map 2CH (C) and

SA (D): decreased native T1
values in the mid inferolateral
wall indicating fatty
infiltration
C D
Endomyocardial Fibrosis 64
Protocol Key Points
1. Anatomy 1. Tropical or non-tropical (Löffler’s syndrome/
2. LV function (RV function) eosinophilic cardiomyopathy) eosinophilic
3. Oedema endomyocardial fibrosis
2. Usually increased eosinophil count
4. EGE / LGE
3. Restrictive LV pattern (non-dilated ventricles,
preserved LV function, restrictive filling pattern,
Report
enlarged LA / RA)
1. Dimensions, mass (corrected for BSA), and
4. Endocardial thickening and scarring
function
• LV: EDV, ESV , SV, EF, longitudinal function, 5. RV involvement in about 50% of cases
mass 6. Ventricular thrombi are common (EGE images)
• RV: EDV, ESV, SV, EF, longitudinal function 7. LGE pattern
2. Presence and extent of fibrosis • Circumferential sub-endocardial
3. Presence of ventricular thrombus hyperenhancement
• Rarely affects more than 50% of the wall
thickness
• Endomyocardial pattern of fibrosis in both
ventricles at the apex (“V sign“).

Tips & Tricks

1. Hypereosinophilia and cardiac involvement are
LGE 4CH: endomyocardial pattern of fibrosis in both also seen in other diseases, i.e. Churg–Strauss
ventricles at the apex (“V sign“). Severely dilated atria syndrome
 65 Myocarditis
Protocol • Regional or global myocardial SI increase on
1. Anatomy T2w
2. LV function (RV function) SI ratio of myocardium over skeletal muscle
of ≥2.0
3. T1 mapping (optional) • Global myocardial SI increase on EGE
4. T2 mapping (optional) SI ratio of myocardium over skeletal muscle
5. Oedema of ≥ 4.0 or absolute myocardial enhancement
6. LGE of ≥45%
• At least 1 focal lesion with non-ischaemic
Report regional distribution (sub-epicardial layer or
1. Dimensions (corrected for BSA) and function mid-wall)
• LV: EDV, ESV , SV, EF Infarction always involves sub-endocardial
layer
• RV: EDV, ESV , SV, EF
2. Presence of LV dysfunction or pericardial
• Regional wall motion abnormalities effusion provides additional, supportive evidence
2. Presence and location of oedema 3. Repeat scan in 1-2 weeks after the first study, if
3. Presence and location of LGE • None of the criteria are present plus very
4. Pericardial effusion / enhancement recent onset of symptoms plus strong clinical
evidence
Key Points • One of the criteria is present
1. Diagnostic CMR criteria
Tips & Tricks
Myocardial inflammation (≥ 2 of the following 1. Right ventricular dysfunction seems to be the
criteria)
greatest predictor of mortality and cardiac
Myocyte injury and / or scar (if focal lesion is
transplantation
present)
Reference 41
Myocarditis 66
A 23 year old patient with chest pain and raised
troponin
• T2w STIR SA (A): increased subepicardial signal
of the basal infero-lateral segment and mid to
apical lateral wall, suggesting myocardial
oedema in these areas
• EGE 4CH and 2CH (B): patchy
hyperenhancement of the mid-apical lateral wall
B and apical anterior wall
• LGE SA (C), 4CH (D) and 2CH (E): subepicardial
hyperenhancement in the basal inferior and
infero-lateral walls and mid lateral and apical
anterior and anterolateral walls.

C D E
 67 Pericarditis
Protocol Report
1. Anatomy 1. Dimensions (corrected for BSA) and function
2. LV function (RV function) • LV: EDV, ESV , SV, EF
3. Oedema • RV: EDV, ESV, SV, EF
4. LGE • Regional wall motion abnormalities
2. Presence and location of oedema
3. Presence and location of LGE
4. Pericardial effusion / enhancement

A B C

LGE 4CH (A), 3CH (B) and SA (C): Pericardial hyperenhancement secondary to pericardial inflamation without
any pericardial effusion
Reference 14
Constrictive Pericarditis 68
Protocol 3. Typical findings:
1. Anatomy including T1w and T2w • Septal shift towards LV during inspiration
2. LV / RV function • Dilated atria
3. Real-time dynamic respiratory cine • Definitive diagnosis requires additional
4. LGE studies
4. Constriction can be localized but often leads to
Report an impairment of biventricular filling
1. Dimensions (corrected for BSA) and function 5. Common causes: post cardiac surgery / trauma,
irradiation, inflammation, connective tissue
• LV: EDV, ESV , SV, EF
disease, idiopathic
• RV: EDV, ESV, SV, EF
Tips & Tricks
2. Septal motion during normal and dynamic
respiration 1. Pericardial constriction may be present even with
3. Pericardial thickening ≥3mm a normal pericardial thickness or patchy
thickening
4. Presence or absence of RV diastolic collapse
2. Real-time dynamic respiratory sequence in
5. LGE enhancement in RV, LV and pericardium several SA views and in a 4-ch view (paradoxical
Key Points septal motion is often being limited to one part of
1. Pericardial thickening, calcification, scarring with the septum)
preserved LV function, but impaired diastolic 3. CMR cannot conclusively detect calcification
filling
2. Constrictive pericarditis is usually a chronic
disease, but consider transient constriction in
inflammation states
 69 Constrictive Pericarditis
Diastole Systole
A 59-year-old man with history of
predominantly right heart failure
A • Real time SA (A) showing ventricular
interdependence: septal shift to the
LV during inspiration in diastole.
Inspiration

During expiration diastolic bulging of

the interventricular septum towards
the RV
• LGE 4CH (B): severely thickened and
enhanced pericardium. Note the
moderate bi-atrial dilatation and
pleural effusions.

B
Expiration

Reference 14
Pericardial Effusion 70
Protocol Key Points
1. Anatomy including T1 and T2 weighted imaging 1. Pericardial tamponade is a clinical diagnosis
2. LV function (RV function) • Even a small and focal effusion can be
3. Consider: haemodynamically significant
• Tumour protocol 2. Signs of tamponade:
• Valve protocol • RA / LA collapse, RV / LV collapse
• Real-time free-breathing cine (2 planes) • Septal shift towards LV during inspiration
4. LGE 3. Typical causes of pericardial effusion:
• Global: uremic, infectious, myxoedema,
neoplastic
Report • Regional: postoperative, trauma, purulent,
1. Pericardial thickness (normal <3mm) cyst
2. Presence and extent of pericardial effusion
Tips & Tricks
3. Dimensions (corrected for BSA) and function • Pericardial effusion and pleural effusion are both
• LV: EDV, ESV , SV, EF seen as high signal in cine images, but differ on
• Regional wall motion abnormalities TSE sequences
• Septal wall motion during normal respiration CMR appearance T1 Cine SI (b-SSFP)
and breath holding Transudate  simple 
4. Presence or absence of atrial or ventricular
Exudate  complex 
diastolic collapse
5. LGE in RV, LV and pericardium Hemorrhage  complex 
Chylous  simple 
Reference 14
 71 Pericardial Effusion
Severe Dressler syndrome in a
65-year-old patient with history
of anterior STEMI
• Real Time cine SSFP 4CH and
Inspiration

SA: RA and RV collapse

during expiration when intra-
thoracic pressures rise above
RA/RV pressures.

A • Dilated LV with impaired

systolic function and akinetic
LAD territory. Large
pericardial effusion and
bilateral pleural effusion
Expiration
Valvular heart disease 72
General Tips & Tricks
1. CMR study for evaluating valvular heart disease 1. Reduce slice thickness to <6mm
has the following objectives: 2. Consider overlapping of slices
1. Provide insight into the mechanism of the
valvular lesion (via anatomic assessment) Limitations
2. Quantify the severity of the valvular lesion 1. Degree of stenosis or regurgitation – cine
3. Discern the consequences of the valvular imaging
lesion • Visual assessment from cine images alone is
NOT recommended due to a signal void in
2. Comprehensive valve assessment: turbulent flow
• LV/RV dimensions, mass, fibrosis, and 2. Valve area – planimetry
function • Correct imaging planes at the tip of the leaflets
• Forward and regurgitant flow / fraction are fundamental
• Mean / peak velocity • Note that a perfect 2D image plane of a 3D
• Jet detection, direction and origin structure is impossible
• Valve area by direct planimetry 3 Flow velocity encoding– forward flow / peak
velocity
Pulse Sequence Indication
SSFP cine • Anatomy and • VENC tends to underestimate velocities due to
motion partial volume averaging / slice orientation
• LV/RV volumes and NOT perpendicular to the flow
function 4 Flow velocity encoding– regurgitation volume
Gradient echo cine • Valve leaflet motion / fraction
• Turbulent flow • Consider volume shift through moving aorta or
PA during cardiac cycle
Flow velocity encoding • Forward / • Consider regular back-flow into the coronary
regurgitant volume arteries
 73 Mitral Valve Imaging
Protocol Report
1. Anatomy / LV function / RV function 1. Dimensions, mass (corrected for BSA) and
function
2. Optimized cine views for MV:
• Slice thickness 5mm - consider overlapping • LV and RV: EDV, ESV, SV, EF
2. Mitral valve morphology
• Standard long-axis views - 4CH, 2CH, 3CH
• 3CH cine stack (perpendicular to the • Leaflets: thickened, restricted, tethered,
commissure) bowing, prolapse, or flail
3. Phase contrast velocity encoded – AV (MV - • Annulus: thickened, fibrosis on LGE
unreliable) • Sub-valvular apparatus: thickened,
restrictive, rupture
Anatomy 3. Mitral regurgitation
1. MV components • MV regurgitation volume / fraction
• Leaflets (anterior and posterior) (RegV/RegF)
• Anterolateral and posteromedial 4. Mitral stenosis
commissure • MV orifice area planimetry (cm²)
• Annulus (oval and saddle shape) • MV pressure gradients unreliable because
• Sub-valvular apparatus (chordae and of motion of MV apparatus
papillary muscles
2. Mitral valve leaflets
• Anterior leaflet: 3 scallops A1, A2, and A3
(tongue shaped)
• Posterior leaflet: 3 scallops P1, P2, and P3
(crescent-shaped)
• A1 / P1 located near to the LAA (antero-
lateral)
Mitral valve segmentation
Reference 15-20
Mitral regurgitation 74
Degenerative (primary) mitral regurgitation A B
Caused by a primary abnormality of components of
the valve apparatus
• Chordae tendineae rupture (fibroelastic
deficiency: FED)
• Myxomatous degeneration with prolapse
and/or flail (FED +, forme fruste, Barlow's
disease) Cine 3CH: Prolapse of the anterior mitral leaflet (A)
leading to severe mitral regurgitation in telesystole
• Rheumatic heart disease (B). Note the volume overloaded LV and the
• Endocarditis severely dilated LA
• Papillary muscle rupture (eg. post MI)
• Mitral annular calcification A B

Functional (secondary) mitral regurgitation

Occurs despite a structurally normal mitral valve
• Ischaemic cardiomyopathy
• Dilated cardiomyopathy
Cine 3CH: Severely dilated LV with an akinetic and
• Hypertrophic cardiomyopathy
thinned inferolateral wall (A). Severe mitral
• Severe left atrial dilation regurgitation due to tethering of both, but
particular of the posterior mitral valve leaflet (B).
Reference 15-20
 75 Mitral regurgitation
Tips & Tricks 6. Regurgitant Volume of >55 mL and Regurgitant
1. Jet direction Fraction >40% predict symptom progression and
• Central (coaptation failure, symmetric other indications for surgery
tethering) 7. There is a strong correlation between post-
• Eccentric (prolapse, flail, asymmetric surgical LV remodelling and MR severity as
tethering, SAM) assessed by CMR
• Anterior: prolapse / flail posterior, 8. Consider "automatic valve tracking“ (if available)
tethering anterior Quantification
• Posterior: prolapse / flail anterior, • Regurgitant Volume (ml) = LV SV – SV from
tethering posterior phase contrast VENC above AV (not valid in the
2. Dilated LV suggests decompensation secondary presence of a VSD)
to MR or vice versa
3. Dilated LA suggests chronic mitral regurgitation • Regurgitant Volume (ml) alternatively = LV
4. Round MV annulus (diameter on 3CH and SV– RV SV (only valid in single valve disease)
commissural 2CH view similar in size) suggests
severely dilated annulus due either to LV or to LA • Regurgitant Fraction (%) = RegV / LV SV x 100
dilatation
5. Tethered MV leaflets
• Asymmetric: most common posteriorly due
to inferolateral MI affecting the papillary
muscle
• Symmetric: severely dilated LV or
secondary to rheumatic fever

Reference 15-20
Mitral stenosis 76
Causes A B
• Rheumatic valve disease
• Systemic lupus erythematous
• Degenerative
• Congenital
Quantification
• MV orifice area planimetry (cm²)
• MV pressure gradients unreliable because of
motion of MV apparatus

Tips & Tricks Rheumatic Mitral stenosis

1. Rheumatic MS: fusion and thickening at the tips • Cine 3CH (A): Restrictive opening of the
of the leaflets results in ‘doming’ of the MV thickened MV leaflets particular the
leaflets (‘hockey-stick’). posterior one. The classical sign of ‘hockey
2. Degenerative MS: Annular thickening and stick’ can be seen for the anterior MV leaflet.
calcification affect the base and body of MV
leaflet while sparing the tips • Cine SA (B): MVA planimetry
3. Progressive LA dilatation is marker of increased
LV filling pressure and worsening MS
4. Advanced MS has adverse impact on RV systolic
function (secondary to pulmonary hypertension

Reference 15-20
 77 Aortic Valve Imaging
Protocol Anatomy
1. Anatomy / LV function / RV function 1. AV components
2. Optimized cine views for AV: • Three equal cusps: left coronary cusp (LCC),
• Slice thickness 5mm - consider overlapping right coronary cusp (RCC), non-coronary cusp
• Standard long-axis views – coronal and (NCC)
sagittal LVOT • These cusps overlap by 2-3mm to form
• Short axis views through the AV commissures
3. Phase contrast velocity encoded– SA AV en-face 2 Aortic Sinus
views and sagittal oblique/coronal LVOTs The 3 AV cusps attach to three adjacent aortic
sinuses which have the same anatomical names:
Report right, left, non-coronary aortic sinuses
1. LV dimensions, mass (corrected for BSA) and
function - global LV dysfunction is poor sign for
both AR and AS
2. Aortic valve morphology
3. Aortic regurgitation volume (RegV) and fraction LCC
(RegF) RCC
4. Aortic stenosis
• AV orifice area planimetry (cm²) RV NCC
• AV peak and mean velocity through the AV
5. Any associated aortic root dilatation
Aortic regurgitation 78
Causes of AR Quantification
• Degenerative (most common with age) • Regurgitant Volume (ml): Through-plane phase
• Dilated aortic root (e.g. hypertension, Marfan contrast (ml)
syndrome, inflammatory/aortitis) • Regurgitant Volume (ml) alternatively = cine
• BAV (bicuspid aortic valve) LV SV– cine RV SV (only valid in single valve
• Infective endocarditis or rheumatic fever disease)
Aortic dissection • Regurgitant Fraction (%) = RegV / Forward flow
x 100
Tips & Tricks
1. Scan: Position image slice close to the AV to
minimize underestimation of AR (Fig: orange
lines) Cine 3CH:
2. Jet direction Severely dilated,
• Central (aortic sinus dilatation, eccentric
symmetric tethering) hypertrophied LV
• Eccentric (prolapse, flail, asymmetric due to severe AR
tethering, BAV)
4. Aortic assessment is likely to identify the cause Forward flow: 80ml
of AR AR RegV: 30 ml
5. RegF of >33% predict symptom progression and AR RegF:38%
indications for corrective surgery* VENC ascending
aorta: Severe
6. Consider flow measurement in descending aorta
holo-diastolic
to detect (holo)diastolic backflow
backflow into the
LV
*Reference 21
 79 Aortic stenosis
Causes of AS A B
• Degenerative (most common with age)
• BAV (most common in age < 40yrs)
• Rarely rheumatic (in the developed world)
Tips & Tricks
• Scan: Position phase contrast image slice at 90° to
the stenotic jet (red lines in Fig A and B)
• Most accurate method is planimetry
• CMR can under-estimate peak velocity due to C
partial volume and lower temporal resolution
• Patchy mid-wall fibrosis in conjunction with LV
hypertrophy is a prognostic sign in aortic stenosis
Quantification
• AV orifice area planimetry (cm²)
• Peak and mean velocity assessment (m/sec)

Maximal velocity assessment in a case of

degenerative aortic stenosis: Projection plane in
3CH (A) and coronal LVOT (B) orthogonal to the
Aortic valve area planimetry: cine stack parallel to aortic stenosis jet. Velocity time curve (C) with a
the annulus maximal velocity of 4.5 m/sec.
Tricuspid and pulmonary valves 80
Pulmonary Valve A
Anatomy • Consists of three semi-lunar cusps:
anterior, left and right
Scan • RVOT views (2-orthogonal planes)
• Through-plane PV cine and phase-
contrast flow
Pulmonary • Regurgitation volume/fraction from
regurgitation phase contrast VENC above
pulmonary valve
• RVSV–LVSV

Tricuspid Valve B
Anatomy • TV components: leaflets, annulus,
sub-valvar apparatus, and RV wall
contraction. Any may be involved
in dysfunction of the TV.
• Leaflets: anterior, posterior and
septal
Scan • 4CH, RV 2-chamber, and RVOT
views
• Through-plane TV cine can show
the leaflets, and identify coaptation
defects, regurgitant orifices or Carcinoid heart disease
valve stenosis. • Cine 4CH in diastole (A) and systole (B)
Tricuspid • SV from phase contrast VENC • The tricuspid leaflets are thickened and severely
regurgitation above pulmonary valve – LV SV reduced in their mobility leading to free tricuspid
• Alternatively RV SV – LV SV
regurgitation
 81 Aortic Disease
Protocol Key Points
1. Anatomy / LV function 1. CMR is the method of choice for non-acute aortic
2. Phase contrast velocity encoding diseases
3. Sagittal oblique aorta SSFP cines (candy cane 2. Standardize protocol:
view) • Measure in end-diastole from cine imaging
4 Aortic valve cine stack or MRA
5. LGE if relevant (arteritis) • Use same slice thickness (<7mm) for cines
6. MR angiogram • Aortic root (from 2 orthogonal LVOT cines or
Report AV stack)
1. Dimensions: aortic root • Asc / desc Ao (from sagittal oblique aorta
cines or MRA)
• Annulus, Sinuses of Valsalva, ST junction
Tips & Tricks
Dimensions: Asc/Desc Ao Be aware of following caveats:
• Asc Ao at level of PA • LVOT / oblique views are not planed through
• Aortic arch, usually between left carotid and the centre of the aorta
subclavian a. • MRA is usually ungated and averages
• Desc Ao at level of PA and diaphragm pulsating aortic dimensions (i.e. not end-
2. Aorta position (left or right) and tortuosity diastole)
3. Atherosclerosis, aneurysm, dissection, • Different “windowing” of MRA
inflammation • Angled view of aorta, if taken from transaxial
4. Aortic flow stack
5. Associated aortic valvular stenosis or • Inclusion of aortic wall, if taken from BB
regurgitation images
Aortic diameters 82

1. Aortic annulus
2. Sinuses of Valsalva
3. Sinotubular junction
4. Mid ascending aorta (level of the
pulmonary arteries)
5. Proximal aortic arch (at the origin
of the brachiocephalic trunk)
6. Mid aortic arch (btw. left common
carotid and subclavian arteries)
7. Proximal descending thoracic aorta
8. Mid descending aorta (level of the
pulmonary arteries)
9. At diaphragm
10. At the celiac axis origin
11. Immediately proximal to aortic
bifurcation.

Reference 22
 83 Caveats of aortic measurements

Transaxial Black
Blood

Overestimation due to: Overestimation possible due to:

• non-orthogonal plane • inclusion of aortic wall

3D whole Over- / underestimation due to: MRA

heart • Lower spatial resolution
• Motion artefacts

Oblique Over- / underestimation due to:

sagittal • Lower spatial resolution
• Motion artefacts, particular at
aortic root /Ascending aorta
• Non-ECG triggering

Underestimation due to:

• non-central or non-
perpendicular plane
Reference 22
Aortic disease: Aortic dissection 84
A B 60-year-old man with chronic type B dissection
• T1w black blood candy cane view (A):
dissection originating from the aortic arch
and running down the descending aorta.
The false lumen is typically larger than the
true lumen and is partially thrombosed
• Cine images in candy cane view (B):
higher flow in true lumen produces higher
signal than in false lumen.
Inhomogeneous signal in false lumen
consistent with thrombus.

C D • Flow velocity encoded imaging in candy

cane view (C): flow acceleration in the
true lumen
• Cine 4CH: the smaller true lumen (red
arrow) can be easily identified by the
pulsating flow. Note the organized
thrombus in the false lumen.
 85 Cardiac Masses
Protocol Key Points
1. High resolution anatomy 1. Cardiac metastatic lesions are up to 1000 times
2. Cine imaging in all standard and targeted planes more common than primary tumours
3. Consider Tagging 2. Common sources of metastatic lesions
4. In at least 2 optimized orthogonal planes • Melanoma, thyroid, breast, renal, soft tissue,
• T1w black blood images +/- fat suppression lung, oesophageal, hepatocellular carcinoma
• T2w black blood images
3. Common benign primary tumours (70%)
• First pass myocardial perfusion imaging
• Myxoma, lipoma, fibroelastoma, fibroma,
• EGE and LGE
rhabdomyoma, hemangioma
Report 4. Common malignant primary tumors (30%)
1. Location and 3 dimensional size • Angiosarcoma, rhabdomyosarcoma,
2. Relation to peri-/ myocardium, valves mesothelioma, fibrosarcoma, lymphoma
3. Signal intensity on T1, T1 fat sat, T2 and STIR 5. Typical tumour locations:
• Homogenous or heterogeneous • Any chamber: Lipoma (intramural /
• Hyper-/iso-/hypointense to myocardium intracavitary), Haemangioma (intracavitary),
4. Margins: smooth, irregular, infiltrating, pediculatd Rhabdomyosarcoma (intramural, metastases)
5. Specify motion with myocardium / pericardium • Ventricles: Fibroma (intramural),
6. Presence and location of LGE Rhybdomyoma (intramural)
7. Presence of effusion (pericardial or pleural) • Valvular: Fibroelastoma, Vegetations.
• Left Atrium: Thrombus, Myxoma,
Tips & Tricks Fibrosarcoma, Osteosarcoma, Leiomyosarcoma
1. Consider T1 and T2 mapping (posterior wall), undiffertiated sarcoma
2. CMR allows tissue characterisation, but cannot • Right Atrium: Angiosarcoma, Lymphoma
provide histopathologic information. • Pericardium: Pericardial cyst, metastases
Cardiac Masses 86
87 Cardiac Masses
Cardiac Masses –
Tissues Characteristics 88
Cardiac Mass T1w* T2w* LGE
Pseudotumors
Thrombus Low (high if recent) Low (high if recent) No uptake†
Pericardial cyst Low High No uptake
Benign
Myxoma Isointense High Heterogeneous
Lipoma High‡ High‡ No uptake
Fibroma Isointense Low Hyperenhancement
Rhabdomyoma Isointense Isointense/high No/minimal uptake
Malignant
Angiosarcoma Heterogenous Heterogenous Heterogeneous
Rhabdomyosarcoma Isointense Hyperintense Homogeneous
Undifferentiated Isointense Hyperintense Heterogeneous/Variable
sarcoma
Lymphoma Isointense Isointense No/minimal uptake
Metastasis § Low High Heterogeneous
Melanoma (metastasis) Hyperintense (paramagnetic Hypointense
metals bound by melanin)
* T1w and T2w imaging signal is given relative to myocardium; † best seen on early gadolinium enhancement
imaging (no uptake) 2 minutes after contrast (Figure 1); ‡ similar to surrounding fat signal and characterized by
marked suppression with fat-saturation pre-pulse. § the exception is metastatic melanoma which has a high T1w
and a low T2w signal.
Reference 23
89 Cardiac Masses – RA myxoma
A B 65-year-old woman with RA myxoma
• Cine 4CH (A) and oblique (B) views: mass with
an irregular border attached to the posterior
wall of the RA; global pericardial effusion
• Tumour characterisation:
• T1w 4CH (C): low signal intensity compared to
the myocardium
• T2w 4CH (D): high signal intensity
C D • EGE 4CH (E): heterogeneous signal intensity
• LGE 4CH (F): heterogeneous signal intensity
• First-pass perfusion (G): heterogeneous nature
of flow of contrast suggesting vascularity within
the mass.

G
E F
Cardiac Masses – LV Thrombus 90
A 65-year-old man with recent anterior myocardial
infarction
• Cine 2CH (A): apical mass situated in a diskinetic
region
• EGE 2CH (B), 4CH (C) and LGE 2CH (D), 4CH (E):
apical mass with no uptake of contrast, typically in
the area of a transmural scar.

B C D E
91 Cardiac Masses – Atrial Thrombus

A B 65-year-old man with shortness of breath

• T1w 4CH (A): mass in right atrium with
intermediate signal intensity. The mass
appears to be attached to the roof of
the RA, but probably extents to the RA
from the vena cava. The surface is
smooth with a few mobile attachments
• T2w 4CH (B): the same lesion is seen
showing low signal intensity
• First pass perfusion 4CH (C): no
C D enhancement on first pass perfusion,
suggesting its avascular nature.
• LGE 4CH (D): the mass shows
homogeneous signal suppression
• The signal characteristics are
suggestive of a right atrial thrombus.
Cardiac Masses - Pseudotumours 92
A B C

Cine 4CH (A): Lipomatous Native T1 mapping 4CH (B): Cine 4CH (C): Crista terminalis
hypertrophy of the interatrial Lipomatous hypertrophy of the (yellow arrow) divides the smoth
septum. Thickening of interatrial septum; low native T1 atrial tissue from the
interatrial septum (arrow); values of septum (“barbell sign”, trabeculated part of the RA.
usually occurs in older and sparing the fossa ovalis).
obese people; the fatty nature Coumadin ridge (red arrow):
of such masses can be seen on junction of the LA appendage
fat-suppressed imaging. and the left superior pulmonary
vein.
 93 LGE Patterns – differential diagnosis
General
• LGE is not disease specific and can
be caused by ischaemic and non-
ischaemic necrosis/fibrosis,
inflammatory or infectious
pathology or tumorous lesions.
• Most current gadolinium-based Normal Necrosis / Acute MI with
contrast agents are extracelular myocardium fibrosis with ruptured myocytes
and extravascular. They do not increased increasing Gd
enter intact myocytes, they extracellular distribution
accumulate within the increased space volume
extracellular space or into
ruptured myocytes.
Coronary pattern Non-coronary pattern
From subendocardium to subepicardium (ischaemic Subendocardium spared
wave front) with increasing coronary occlusion time
Circumferential extent related to size of perfusion Often more patchy distribution, localized in mid-wall
bed and occluded coronary artery and subepicardium
Acute reperfused MI can be associated with MVO Global subendocardial LGE (uncommon even with
diffuse CAD)

Reference 24 - 26
LGE Patterns 94
Coronary pattern
1. Subendocardial infarct
• LGE transmurality correlates with likelihood of recovery after
revascularization
• LGE identifies arrhythmogenic substrate (mapping for ablation)
2. Transmural myocardial infarct
• Degree of transmurality correlates inversely with viability
3. Ischaemic cardiomyopathy
• Often also LV dilatation, differential diagnosis of DCM Subendocardial Transmural
• Coronary LGE pattern with subendocardial/transmural LGE
• LGE identifies arrhythmogenic substrate (mapping for ablation)

Non-coronary pattern
1. Cardiac amyloidosis
• Difficulty in nulling myocardial signal
• Global subendocardial distribution (non-coronary pattern) or
patchy subendocardial or transmural LGE
• Base-apex LGE gradient, blood pool early darkening
• DD AL vs. ATTR amyloidosis
• AL: less extensive LGE, often (global) subendocardial
Global Patchy
pattern, QALE score < 13
subendocardial subendocardial
• ATTR: more extensive and diffuse LGE, often more diffuse
and transmural pattern, QALE score ≥ 13

Reference 24 - 26
 95 LGE Patterns
2. Dilated cardiomyopathy
• Diffuse mid-wall or subepicardial septal LGE (reflecting fibrosis and
not matching a coronary perfusion bed)
• Often localized to the inferoseptal wall
• In most cases of DCM there is no LGE -> consider T1 mapping

3. Hypertrophic cardiomyopathy
• Focal (mid-wall) LGE of anterior and posterior RV insertion points
(hinge points) and of hypertrophied segments
• Apical HCM: apical wall may develop ischaemia with wall thinning
→ LGE can be transmural (mimicking ischaemic injury in the
absence of epicardial CAD.
• LGE in HCM indicates replacement fibrosis but may also indicate
necrosis/scarring

4. Systemic Sclerosis
• Basal to mid-interventricular septum and RV insertion points or
diffuse patchy LGE

5. Myocarditis
• Lateral, typically inferolateral or inferior wall with a mid-wall to
subepicardial enhancement
• Atypical cases of myocarditis with transmural or diffuse LGE
• Often concomitant LGE involvement of the pericardium
Reference 24 - 26
LGE Patterns 96
6. Anderson-Fabry Disease
• Mid-wall (or subepicardial) LGE of the mid to basal inferolateral wall
• Consider T1-Mapping: low ECV and low native T1 value of septum

7. Sarcoidosis
• Basal and mid-interventricular septum but also patchy LGE

8. ARVC
• Diffuse LGE of RV (and occasionally LV) wall

9. Endomyocardial fibrosis (Loeffler’s endocarditis)

• Restrictive CMP with endocardial fibrotic tissue deposition of inflow
tract and apex of one or both ventricles
• “V sign” of LGE pattern at ventricular apex, characterized by a 3-layer
appearance of dark myocardium, bright thickened fibrotic
endocardium, and overlying dark thrombus
10. False positive LGE
• Septal perforator (mimicking septal basal mid-wall enhancement)
• RV trabeculation (contrast extending underneath the muscle
mimicking septal enhancement)
Septal perforator RV trabeculation
Reference 24 - 26
97 Pitfalls in reporting septal LGE
A Not all septal hyperenhancement is myocardial fibrosis!
• Septal pseudo-enhancement due to RV blood pool
interposed between RV trabeculations and
interventricular septum (A). A similar pseudo-
enhancement may appear due to large septal
perforator arteries.
• Normal hyperenhancement of the fibrous skeleton of
the heart in the LVOT region (B)
B • Unsuccessful nulling of the myocardium caused by
choosing an incorrect inversion time (C)
• Ghosting artefact due to poor breath-holding (D)
Tips & Tricks
1. Modify the phase encoding direction. Real
myocardial fibrosis should be present irrespective
of the phase encoding direction.
2. Acquire images in orthogonal planes through the
C D
suspected hyperenhancement areas. Real fibrosis
should be seen in both original and perpendicular
planes.
3. In suspected septal perforator arteries, follow its
trajectory to the LAD in the septum.
4. Compare LGE images with cines to identify RV
trabeculation and blood pool.
LV Recesses / Outpouchings 98
LV Crypt (congenital) LV Non-Compaction (congenital)
1.Definition* 1.Definition
• Narrow V/U shaped fissure(s) confined to • Hypertrabeculated, non-compacted myocardium
compacted myocardium and penetrating >50% of • Deep intertrabecular recesses
wall, perpendicular to LV long axis 2.Contractility
2.Contractility • LV dilatation and dysfunction
• Systolic obliteration 3.Segment
3.Segment • Apex, lateral wall, inferior wall
• Inferior / inferoseptal basal / mid wall 4.LGE
4.LGE • LGE possible
• No LGE 5.Clinical relevance
5.Clinical relevance • Very difficult diagnosis; may not be based on
• Isolated clefts in normal hearts imaging criteria alone
• Early biomarker in HCM mutation carriers • Poor prognosis
without LV hypertrophy • Heart failure
* The terms cleft, crypt, crevices and fissures are • Arrhythmias (SCD)
used interchangeably. • Thromboembolism
 99 LV Recesses / Outpouchings
True aneurysm (infarction, congenital) Pseudoaneurysm (infarction, trauma)
1.Definition 1.Definition
• Wide-necked, thin (scarred) outpouching of all • Narrow-necked myocardial rupture contained
layers of the myocardium beyond epicardial by the pericardium
contour 2.Contractility
2.Contractility • Dyskinesia (systolic out-bulging) or akinesia
• Dyskinesia (systolic out-bulging) or akinesia 3.Segment
3.Segment • Mainly inferior (RCA) and lateral (CX) wall
• Mainly LAD territory, particularly LV apex 4.LGE
4.LGE • Perianeurysmal LGE in a coronary pattern but
• Transmural LGE in a coronary pattern no LGE in the pericardial sac
5.Clinical relevance 5.Clinical relevance
• Thrombus formation • 30-45% risk of rupture with high mortality rate
• Heart failure • May be difficult to differentiate from true
• Arrhythmias aneurysm
• May be difficult to differentiate from
pseudoaneurysm
LV Hypertrophy –
differential diagnosis 100
General 3. Anatomy/Function
• Echocardiography remains the first line imaging • Increased chamber dimensions and LV wall
modality to assess LVH. thickness
• In most cases, LVH may be attributable to • Symmetric LVH
hypertension, aortic stenosis, or obesity. • Endurance athletes: eccentric LVH
• Not considered in this chapter: Mitochondrial • Strength-trained athletes: concentric LVH
myopathy and mucopolysaccharidosis. • Combination athletes: overlapping
features of endurance and strength-
Athlete’s Heart versus HCM
trained athletes
Data feature Athlete's Heart HCM • Max. wall thickness ≤14 mm
Increased wall thickness Yes Yes • Black athletes show greater increases in
Atrial remodeling Yes Yes LV wall thickness
Systolic function Normal Normal
• Normal systolic function
Mechanical function (strain) Normal Abnormal
• Normal mechanical function (strain)
Diastolic physiology Normal Abnormal
ECV Low High
• Normal diastolic function
4. LGE pattern
Athlete’s Heart • No LGE or non-specific pattern
1. History 5. Follow up
• High level sporting activity • LVH↓ after deconditioning
2. ECG
• Resting bradycardia
• I° AV block
• High voltage QRS
• Early repolarisation
Reference 8, 9, 27-31
 LV Hypertrophy –
101 differential diagnosis
Aortic stenosis Hypertensive heart disease
1. History 1. History
• Severe aortic stenosis • Long-lasting hypertension
2. ECG 2. ECG
• High voltage QRS • High voltage QRS
• LV strain pattern • LV strain pattern
3. Anatomy/Function 3. Anatomy/Function
• Symmetric concentric LVH: • Symmetric concentric LVH:
• Degree of hypertrophy associated • Max. wall thickness <15 mm
with the degree of stenosis (Caucasian), <15-20 mm (Black)
• LVOT obstruction uncommon • Basal septum hypertrophy
• Normal systolic function • Common in elderly and hypertensive
• LV dilation and heart failure in patients
decompensated state • LVOT obstruction uncommon
• Abnormal mechanical function (strain) • Normal systolic function – in late
• Diastolic dysfunction stages systolic dysfunction can
4. LGE pattern develop
• Non-specific LGE pattern: patchy, diffuse or • Abnormal mechanical function (strain)
septal mid-wall LGE • Diastolic dysfunction
5. T1 mapping 4. LGE pattern
• Native T1↑ • Occasionally patchy LGE pattern or focal (mid
• ECV↑ wall) LGE of RV insertion points (hinge points)
6. Follow up 5. Follow up
• LVH↓ and fibrosis↓ after aortic valve • LVH↓ under OMT for hypertension
replacement
Reference 8, 9, 27-31
RV Dilatation - differential diagnosis 102
General Protocol
• CMR is the reference standard for calculation of 1. Anatomy
RV volumes, mass, flow and function. 2. LV function (including atria): LV cine stack, 4/2/3
CH cines
• Multiparametric properties of CMR allow for
3. RV function: transaxial RV cine stack, RVOT, RV in-
tissue characterization and aid in the differential
/outflow and RV 2CH cines
diagnosis of dilated RV pathologies.
4. MPA, PAs cines
5. MPA and Ao flow
Not considered in this chapter: congenital diseases
other than ASD and partial anomalous pulmonary 6. Whole Heart or MRA (to delineate pulmonary
venous drainage. For more information: see veins and to exclude PV stenosis post ablation)
Congenital Heart Disease Pocket guide. 7. LGE

The right ventricle Ventricular interdependence

• Complex geometrical shape • Mediated by septum
• More (coarse) trabeculation and thinner walls • RV is more sensitive than LV to volume and
(3-5 mm), less compacted myocardium than LV pressure loading
• RV ejection is mostly determined by • RV volume overload → diastolic D-shaping*
longitudinal rather than circumferential
contraction • RV pressure overload → systolic D-shaping*
*Overlapping features possible

Reference 32 - 35
103 RV Dilatation - differential diagnosis
RV Infarction
• Up to 50% of inferior MI (proximal to acute
marginal RCA branches) also involve the RV;
isolated RV infarction is rare
• RV infarction not limited to RCA but also
occurs in LAD and CX infarction and rarely in
the absence of coronary disease in
substantial RV hypertrophy
• Findings: RV RWMA, impaired RV function
• Myocardial oedema on T2w imaging in acute
RV infarction
• Check for RV thrombus with subsequent PE
• LGE: Enhancement in RV +/- RCA territory of
LV
Non-ischaemic cardiomyopathy
• Various non-ischaemic cardiomyopathies
may cause RV dilatation, please see specific
chapters
RV volume overload 104
General Severe pulmonary regurgitation
• RV diastolic volumes ↑ • Rare, but frequently after post-Fallot repair
or pulmonary valvotomy
• RV function may be impaired
• Dilated RV / RVOT / MPA / PAs (Ao > MPA
• Normal RV free wall thickness diameter in healthy subjects)
• Diastolic D-shaping / bounce of the septum • Severe PR jet is laminar and difficult to
due to rapid filling of the RV in diastole visualise
(diastolic pressure ↑)
• Valve assessment – see specific chapter
• Fibrosis at RV insertion points possible
Severe left / right shunt (ASD and/or PAPVD)
• Check for Ebstein´s anomaly (frequently
associated)
Severe tricuspid regurgitation
• Dilated RA, RV, MPA, and PAs (usually Ao >
• Often secondary due to annulus dilation (RV MPA)
and/or RA dilatation)
• Dilated inferior vena cava / coronary sinus
• Always check for Ebstein´s anomaly • Percutaneous closure – check for sufficient
• Severe TR jet is laminar and difficult to rim surrounding most of the defect to lodge
visualise the device, particular inferiorly
• Red flags:
• Dilated inferior vena cava / coronary sinus
• Significant RV dilatation /
• Valve assessment – see specific chapter dysfunction
• Qp : Qs > 1.8
• Pulmonary hypertension

Reference 32 - 35
105 RV pressure overload
General Severe pulmonary stenosis
• RV dilation and dysfunction in progressive • Valvular, sub-valvular, supra-valvular
disease
• Congenital stenosis (mainly Fallot’s
• Hypertrophy of the RV free wall (>5 mm) and tetralogy)
of the interventricular septum
• → Typically mobile leaflets with fused tips
• Systolic D-shaping if severe pressure (Prussian helmet sign)
overload
• Rarely: rheumatic and carcinoid
• Fibrosis at RV and RV insertion points
• → Thickened valve with restricted
movement
Severe pulmonary hypertension
• Often post-stenotic dilatation of MPA and
• Dilated MPA, and PAs (Ao > MPA diameter in PAs with preferential dilatation of the LPA
healthy subjects) (vs. RPA): LPA with in-line orientation; RPA
• Classification takes a more right angle course from the
MPA
• PH due to left heart disease (systolic
and/or diastolic LV dysfunction, • Valve assessment – see specific chapter
valvular disease, etc)
• Chronic thromboembolic PH
• Lung disease and/or hypoxia
• Pulmonary arterial hypertension
• Other causes
Reference 32 - 35
LV Parameters Male 106

Data presented as mean (95% confidence interval). Analysed with CMR tools software from short axis SSFP cine
images. These values may vary depending on image sequence, acquisition technique and contouring.
Reference 36
107 LV Parameters Female

Data presented as mean (95% confidence interval). Analysed with CMRtools software from short axis SSFP cine
images. These values may vary depending on image sequence, acquisition technique and contouring
Reference 36
RV Parameters Male 108

Data presented as mean (95% confidence interval). Analysed with CMRtools software from short axis SSFP cine
images. These values may vary depending on image sequence, acquisition technique and contouring
Reference 37
109 RV Parameters Female
Atrial Parameters 110

LA Volume = 0.85x (Area 4CH x Area 2CH) / Length

Left atrial volumes
Men Women
4CH LA area (cm2) 15 – 29 13 – 27
2CH LA area (cm2) 12 – 30 10 – 28
4CH LA area/BSA (cm2/m2) 7 – 15 8 – 16
2CH LA area/BSA (cm2/m2) 6 – 16 6 – 16
LA Volume (Bi-plane) (ml) 43 – 163 47 – 131
LA Volume/BSA (ml/m2) 26 – 52 27 – 53

RA Volume = 0.85 x (Area 4CH x Area 2CH) / Length

Right atrial volumes
Men/Women
4CH RA area (cm2) 14 – 30
2CH RA area (cm2) 14 – 30
4CH RA area/BSA (cm2/m2) 8 – 16
2CH RA area/BSA (cm2/m2) 7 – 17
RA Volume (Bi-plane) (ml) 37 – 169
RA Volume/BSA (ml/m2) 18 – 90

References 48, 49, 50

111 Aortic Root Dimensions

sagittal coronal

Male 20-29 (years) 30-39 (years) 40-49 (years) 50-59 (years) 60-69 (years) 70-79 (years)
Annulus (s) 21.4 ± 2.4 20.7 ± 1.7 21.6 ± 2.0 22.8 ± 2.8 23.5 ± 1.8 23.3 ± 2.7
Annulus (c) 26.5 ± 1.8 25.2 ± 2.4 25.8 ± 1.5 26.4 ± 3.7 26.5 ± 1.8 26.6 ± 1.9
Aortic sinus (s) 30.5 ± 3.9 29.8 ± 3.8 32.0 ± 2.4 33.3 ± 6.1 33.6 ± 2.7 35.1 ± 3.7
Aortic sinus (c) 32.5 ± 3.4 31.8 ± 4.8 33.6 ± 2.6 34.7 ± 6.4 35.7 ± 3.3 36.1 ± 3.5
Sinotubular junction (s) 23.3 ± 3.4 22.2 ± 4.0 24.4 ± 3.3 26.6 ± 3.1 27.6 ± 3.6 28.3 ±2.7
Sinotubular junction (c) 23.7 ± 3.5 22.2 ± 3.0 24.5 ± 2.4 26.5 ± 3.7 27.5 ± 2.4 27.8 ± 1.7
Female 20-29 (years) 30-39 (years) 40-49 (years) 50-59 (years) 60-69 (years) 70-79 (years)
Annulus (s) 19.5 ± 2.4 19.2 ± 2.3 19.9 ± 2.2 20.1 ± 1.9 20.4 ± 1.1 20.2 ± 1.5
Annulus (c) 23.6 ± 3.0 22.9 ± 2.3 23.3 ± 1.5 22.7 ± 2.1 22.3 ± 1.5 23.3 ± 1.5
Aortic sinus (s) 26.5 ± 4.0 26.9 ± 3.1 31.5 ± 2.8 29.1 ± 2.5 30.1 ± 2.5 30.2 ± 2.0
Aortic sinus (c) 28.5 ± 4.9 28.2 ± 3.1 32.0 ± 2.5 30.2 ± 2.3 31.0 ± 2.7 31.3 ± 1.8
Sinotubular junction (s) 21.1 ± 3.3 21.8 ± 2.8 25.7 ± 2.3 24.1 ± 1.9 25.1 ± 3.0 25.0 ± 2.0
Sinotubular junction (c) 21.5 ± 2.7 22.1 ± 2.7 25.5 ± 2.1 23.4 ± 2.1 24.7 ± 1.6 25.1 ± 1.3

Data measured in diastole and presented as mean ± SD in mm.

Analyzed from sagittal (s) and coronal (c) SSFP LVOT cines
Reference 38
Safety - Gadolinium-containing
contrast agents 112
General Nephrogenic systemic fibrosis (NSF)
• Linear agents: gadobenic acid (MultiHance), • Linear gadolinium based contrast agents have
gadodiamide (Omniscan), gadopentetic acid been associated with NSF in patients with
severe renal impairment.
(Magnevist) and gadoversetamide (OptiMARK)
have the potential to release gadolinium in • NSF is an extremely rare but serious and
vivo, which can be retained in body tissues. potentially life-threatening condition.
• Macrocyclic agents: gadoteric acid (Dotarem), • NSF is characterised by the deposition of
gadobutrol (Gadovist), gadoteridol (Prohance) collagen in the skin and possible organ
are more stable and have a much lower involvement of other organs, including the
propensity to release gadolinium than linear lungs, liver, muscles and heart.
agents. No cases of NSF have been reported in patients
with normal renal function and macrocyclic
• Because of concerns over tissue retention, the contrast agents appear to be much less likely to
EMA has recommended the suspension of the cause NSF.
marketing authorisations for linear contrast Tips & Tricks
agents (www.ema.europa.eu).
• eGFR 30-60ml/min/1.73m2: choose safest
Brain retention contrast agent, use only with caution
• Linear gadolinium based contrast agents have • eGFR <30ml/min/1.73m2: linear contrast
been associated with gadolinium retention in agents contraindicated
the dentate nucleus and globus pallidus in the • In severe renal failure: consider haemodialysis
brain. To date, no signs of harm and no within 2 hours after contrast agent
symptoms or diseases have been linked to this administration (although not proven to prevent
retention. NSF)
• See also: www.rcr.ac.uk
 Safety
113 Common Devices
MR unsafe MR conditional
• Any device which is known • Any device which is
to threaten or pose hazard in demonstrated to pose NO
all MR environments hazard in a specific MR
• Most pacemakers environment with specified
conditions
• Insulin pumps
• Most metallic heart valves
• Most implantable cardioverter / defibrillators
• Intra-coronary stents
• Metal foreign bodies in the eye
• Prosthetic joints
• Dentures

MR safe Tips & Tricks

• Any device which is known to • If in doubt check:
pose NO hazard in all MR www.mrisafety.com
environments*
• Only assume that a device is
MR safe if it has this logo on it

Reference 39
Common MR Terminology 114
Sequence Type GE Philips Siemens
Fast Spin Echo FSE (Fast SE) TSE (Turbo SE) Turbo SE

Gradient recalled echo GRE FFE GRE

Spoiled gradient echo SPGR / MPSPGR T1 FFE FLASH

Balanced gradient echo FIESTA bFFE / bTFE TrueFISP

Gradient echo – echo planar GRE EPI FFE-EPI / TFE-EPI EPIFI

Contrast enhanced MRA Bolus Trak Care Bolus

k-space lines Views per segment Turbofactor No of segments

Parallel imaging: ASSET SENSE mSENSE

Image-based reconstruction
Parallel imaging: ARC GRAPPA
k-space-based reconstruction
115 Abbreviations
2CH 2-chamber view FOV Field of view ROI Region of interest
3CH 3-chamber view Gd gadolinium R-L Right - left
4CH 4-chamber view GFR Glomerular filtration rate RV Right ventricle
AF Atrial fibrillation HCM Hypertrophic cardiomyopathy SA Short axis
Ao Aorta HLA Horizontal long axis SAECG Signal averaged ECG
ARVC Arrhythmogenic RV cardiomyopathy HR Heart rate SAM Systolic anterior motion
Asc Ascending LAD Left anterior descending artery SD Standard deviation
AV Aortic valve LGE Late gadolinium enhancement SI Signal intensity
BMD Becker Muscular Dystrophy LV Left ventricle SNR Signal-to-noise ratio
BSA Body surface area LVNC LV non compaction cardiomyopathy SSFP Steady-state free
precession
b-SSFP Balanced steady-state free precession LVOT Left ventricular outflow tract STIR Short TI inversion recovery
CMR Cardiovascular Magnetic Resonance NC/C Non-compacted / compacted SV Stroke volume
CX Circumflex artery NSVT Nonsustained ventricular tachycardia T1w T1-weighted
DCM Dilated cardiomyopathy MR Mitral regurgitation T2w T2-weighted
Desc Descending MRA Magnetic resonance angiography T2★ T2 star
DMD Duchenne Muscular Dystrophy MVO Microvascular obstruction TI Time from inversion
EDV End-diastolic volume PA Pulmonary artery VENC Velocity Encoding
EGE Early gadolinium enhancement fQRS Filtered QRS VES Ventricular extra systole
EF Ejection fraction RA Right atrium VLA Vertical long axis
F-H Foot- head RCA Right coronary artery WMSI Wall motion score index
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NOTES 120
121 NOTES
Series Editors:

Bernhard A. Herzog Heart Clinic Lucerne. St. Anna-Strasse 32, CH-6006 Lucerne, Switzerland

John Greenwood Multidisciplinary Cardiovascular Research Centre & Division of Biomedical Imaging,
Sven Plein Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds LS2 9JT, United Kingdom