Introduction
Magnetic resonance (MR) imaging is widely recog- nized as providung an accurate and reliable means of assessing the function and anatomy of the heart and great vessels. Previously, the means to obtain images of the cardiovascular system were compromised by ex- tremely long examination times and software that was available only at specialized centers. With the recent development of specialized cardiovascular MR scan- ners, cardiac MR applications have become more wide- ly used on a routine basis. In this article, the technical aspects of MR scanning of the cardiovascular system are outlined, followed by a discussion of its applica- tions to the heart and aorta.
Understanding the Basic Pulse Sequences
It is extremely helpful to understand the strategy behind the MR pulse sequence being used. This allows the radi- ologist to determine the length of time for the acquisition and the corresponding imaging strategy to be employed.
A fundamental characteristic of all pulse sequences is that the image is generated in the frequency domain, al- so referred to as ‘k-space.’ Fourier reconstruction is then employed to generate the image. The ‘k-space’ represen- tation of the image is a pixel array that is generated one line at a time, and typically 128-256 lines must be gener- ated. Traditionally, each line of the image required one heart beat to acquire, thus imaging times were relatively long. For example, if 256 lines were generated, 256 heart beats at 60 beats per min required 256/60=4.3 min. An improvement in imaging speed by a factor of 4-64 times or more is now commonplace. The most useful pulse se- quences are briefly explained below.
Spin-Echo Imaging
Spin-echo images are the fundamental MR pulse se- quences used to evaluate the cardiovascular system. As in all other parts of the body, a complete examination con- sists of T1- and T2-weighted images. T1 images clearly
display the anatomy, while T2 images accentuate patho- logic changes, such as edema from infarction or the rela- tionship of a tumor to the pericardium. Advantages of spin echo are excellent signal-to-noise ratio (SNR) as well as excellent contrast between the heart, epicardial fat, and adjacent structures. The primary disadvantage is that these are very time-consuming sequences. As in the example discussed above, they require between 128 and 256 heart beats or more to acquire, depending on the desired reso- lution. Blood is typically made to appear dark (‘black blood’ images) and no cine information is obtained.
Despite these drawbacks, echo images remain important for: (1) imaging of congenital anomalies, (2) pericardium evaluation, (3) assessment of right ventricular dysplasia, and (4) identification of cardiac tumors.
Fast/Turbo Spin-Echo Imaging
Fast, or turbo, spin-echo imaging reduces acquisition times by an acceleration factor typically ranging from 16 to 32. Parallel imaging can further accelerate speed by a factor of two to three. Essentially all spin-echo im- ages of the cardiovascular system are now acquired with fast/turbo spin echo imaging, usually during a breath-hold.
Cine-Gradient Echo Imaging
Cine-gradient echo images are used to evaluate motion gated to the cardiac cycle. Information from 4-12 car- diac cycles is used in order to obtain cine information during the entire cardiac cycle. This is termed ‘seg- mented k-space cine’ MR imaging. Older MR scanners use so-called conventional gradient-echo pulse se- quences in combination with ‘gradient moment nulling,’
or ‘flow compensation’ to make blood appear bright (‘bright-blood images’). In nearly all new MR scanners, however, ‘steady-state free precession’ (SSFP, also known as TrueFISP, Fiesta, balanced fast-field echo) images are used with segmented k-space acquisition.
SSFP images are acquired very rapidly, and the blood is of very high signal intensity compared to the ventricu- lar wall. Due to the large amount of signal available, the
IDKD 2007
Applications of Magnetic Resonance Imaging in Cardiac Disease
M.Y. Desai
1, D.A. Bluemke
21Division of Cardiology, Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
2Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, MD, USA
SSFP technique is often combined with parallel imag- ing. The latter improves imaging speed by a factor of two to three.
The different and emerging clinical applications of cardiac MR imaging are described below.
Assessment of Ventricular Function
Ejection fraction and ventricular volumes can be mea- sured in three dimensions accurately, noninvasively, and with high reproducibility using MR imaging. For this reason, it has become the ‘gold standard’ to which other modalities are compared [1]. Simpson’s rule is applied to determine the ejection fraction and volumes. For assess- ment of volumes and mass, bright-blood gradient-echo sequences are most often obtained, with 10-30 phases per cardiac cycle. Breath-holding techniques with acqui- sition times of about 6-12 s are preferred in order to re- duce blurring of the endocardial border. Generally, for accurate measurement of volume and mass, entire cov- erage of the left ventricle with short-axis views from the mitral plane are recommended. Slice thickness should not exceed 10 mm; in the presence of subtle changes, the thickness should be reduced appropriately. MR imaging is the method of choice for longitudinal follow-up in pa- tients undergoing therapeutic interventions [2]. From a research perspective, the sample size needed to detect left ventricular parameter changes in a clinical trial is far less, in the range of one order of magnitude, with MR imaging than with 2D echocardiography, which marked- ly reduces the time and cost of patient care and pharma- ceutical trials [3].
A unique MR technique called myocardial tagging (SPAMM technique) has been developed. It labels the heart muscle with a dark grid and enables 3D analysis of cardiac rotation, strain, displacement, and deformation of different myocardial layers during the cardiac cycle (Fig. 1). This helps in assessing regional wall motion of the myocardium [4, 5].
Assessment of Cardiomyopathies
Magnetic resonance imaging is a noninvasive tool that has a high degree of accuracy and reproducibility in the visualization of left and right ventricular morphology and function [6]. It is also superior to echocardiography in the determination of ventricular mass and volumes [3, 7] and is fast becoming the method of choice for in vivo identi- fication of the phenotype of cardiomyopathies [1].
Dilated Cardiomyopathy
In dilated cardiomyopathy (DCM), MR imaging is use- ful in the study of ventricular morphology and function (Fig. 2). Gradient-echo sequences are obtained, as these have low inter- and intra-observer variability with re- spect to the determination of left ventricular mass and volumes [6]. MR imaging is also employed in the analy- sis of wall thickening [8], impaired fiber shortening [9], and end-systolic wall stress, which is a very sensitive parameter of a change in left ventricular systolic func- tion [10]. This approach can accurately assess the mor- phology and function of the right ventricle, which is al- so frequently affected in DCM [11]. MR spectroscopy has been used to reveal changes in phosphate metabo- lism in DCM [12]. A ratio of phosphocreatine to adeno- sine triphosphate has some prognostic value in assess- ing the disease.
Contrast-enhanced T1-weighted images are also help- ful in detecting changes characteristic of acute myocardi- tis. The increased gadolinium accumulation is thought to be due to inflammatory-hyperemia-related increased flow, slow wash-in/wash-out kinetics, and diffusion into necrotic cells. There is some evidence of similar changes in chronic DCM [13]. Contrast-enhanced MR imaging
Fig. 1. Cardiac magnetic resonance tagging. Mag- netic strips are placed in the heart and then fol- lowed throughout the car- diac cycle in order to measure regional contrac- tion of different portions of the heart
Fig. 2.Bright-blood image showing a dilated, thin left ventricle (LV) due to a large anterior-wall infarct, with a mural thrombus adjacent to the infarcted myocardium (arrows)
increases the sensitivity of endomyocardial biopsy by al- lowing visualization of inflamed areas, which aids in de- termining the biopsy site [14].
Hypertrophic Cardiomyopathy
Due to its high accuracy, MR imaging is becoming the preferred method to assess morphology, function, tissue characterization, and degree of left ventricular outflow tract (LVOT) obstruction in patients with hypertrophic cardiomyopathy (HCM) (Fig. 3). It is also very accurate in assessing left ventricular mass, regional hypertrophy patterns, and different phenotypes of the disease (e.g., apical HCM) [7]. Post-surgical changes after myomecto- my can also be reliably monitored [15]. The turbulent jet during systolic LVOT obstruction is also easily detected with suitable echo times (about 4 ms). MR imaging re- veals the systolic anterior motion of the mitral valve in the four-chamber view or with a short-axis view at the valvular plane [16]. Mitral regurgitation can also be well- documented and quantified by MR techniques [17]. MR spectroscopy reveals changes in phosphate metabolism in patients with HCM [18]. Also in these patients, MR analysis of blood flow in the coronary sinus can indicate alterations in coronary flow reserve [19]. A relatively newer technique is to measure the effective LVOT area by MR planimetry during systole. This method has the po- tential to overcome the problem of interstudy variability of the LVOT gradient due to its independence from the hemodynamic status [20]. There are preliminary data that MR assessment of diastolic function may be superior to conventional echocardiography parameters. Analysis of the early untwisting motion of the myocardium may aid in assessing diastolic function [21]. Other functional changes can be evaluated by myocardial tagging; these
include a reduction in posterior rotation, reduced radial displacement of the inferoseptal myocardium, and re- duced 3-D myocardial shortening and heterogeneity of regional function [17]. MR imaging allows the follow-up of patients who have undergone surgical or pharmaco- logic interventions [16], and easily detects acute and chronic changes after septal artery ablation [22].
Arrhythmogenic Right Ventricular Dysplasia
Arrhythmogenic right ventricular dysplasia (ARVD) is a rare disorder in which there is fibrofatty replacement of the right ventricular free wall. MR imaging is rapidly be- coming the diagnostic technique of choice for ARVD (Fig. 4), as it allows visualization of the ventricular cavi- ties and walls, with excellent depiction of the myocardial anatomy. T1-weighted spin-echo images reveal fatty in- filtration, thinned walls, and dysplastic trabecular struc- tures. Axial and short-axis views are usually recom- mended for optimal results [17]. Standard gradient-echo images reveal characteristic regional changes in wall mo- tion, localized early-diastolic bulging, wall thinning, and saccular aneurysmal out-pouchings [23, 24]. However, MRI is not as specific as endomyocardial biopsy in the detection of myocardial fat [25], although biopsy may be falsely negative. Currently, the working group classifica- tion proposed by Mckenna et al. is the recognized stan- dard to arrive at a diagnosis of ARVD [26].
Restrictive Cardiomyopathy
Primary infiltration of the myocardium by fibrosis or oth- er tissues leads to the development of restrictive car- diomyopathy, which is characterized by normal left ven- tricular size and systolic function, severe diastolic dys-
Fig. 3.Long-axis view of the heart (black-blood image) shows a se- verely thickened left ventricular wall due to hypertrophic car- diomyopathy (arrows)
Fig. 4.Axial black-blood image of the heart showing enlargement of the right ventricle (RV) as well as increased (similar to fat) sig- nal in the RV free wall (arrow), consistent with fatty deposits com- patible with arrhythmogenic RV dysplasia. LV, Left ventricle
function, and biatrial enlargement. This condition needs to be differentiated from constrictive pericarditis, which is a primary disease of the pericardium rather than the myocardium. Left ventricular size and thickness are quantified using gradient-echo sequences. Atrial enlarge- ment is assessed in a four-chamber view. The potential presence of mitral regurgitation should also be examined.
The following different restrictive diseases can be ef- fectively evaluated using MR imaging [17].
Sarcoidosis
The incidence of myocardial involvement in systemic sar- coidosis is 20-30%, and up to 50% [27] of the deaths in sarcoidosis may be due to cardiac involvement. MR imaging is a useful tool in the assessment of this disease.
Sarcoid lesions may lead to different signal intensities, most likely due to different disease stages. In some in- stances, high-intensity areas in T2-weighted images have been reported, while in others a central low-intensity area surrounded by a high signal ring on T1- and T2-weight- ed imaging has been described [28]. Gadolinium has al- so been reported to accumulate in sarcoid lesions and is thought to be due to fibrotic non-active granulomatous nodules and the inflammatory response of the surround- ing tissue [29]. Thus, T2-weighted imaging followed by T1-weighted spin-echo techniques in short- and long-ax- is views with and without gadolinium could be useful to detect and/or exclude sarcoid granulomas. Occasionally, MR imaging can be useful in guiding endomyocardial biopsy to evaluate sarcoidosis [17].
Hemochromatosis
Extensive iron deposits leading to wall thickening, ven- tricular dilatation, congestive heart failure, and death characterize cardiac hemochromatosis. Usually, the iron deposits are subepicardial; hence, endomyocardial biop- sy may fail to confirm the diagnosis [17]. However, due to the very strong paramagnetic properties of iron, MR imaging can be used to detect iron deposits. MR images of this disease show extensive signal loss in native T1- and T2-weighted images [30]. The pattern of focal signal loss in a dysfunctional myocardium associated with an abnormally ‘dark’ liver might be sufficient to confirm the diagnosis of systemic hemochromatosis. Left ventricular function in patients with cardiac hemochromatosis can be accurately assessed by MR techniques, which are also useful in the follow-up of patients receiving intensified medical therapy [17].
Amyloidosis
Infiltration of the heart by amyloid deposits is found in almost all patients with primary amyloidosis and in 25%
of patients with familial amyloidosis. MR imaging can be useful in the detection of amyloidosis and its differentia- tion from HCM. A thickness of the atrial septum or right
atrial posterior wall >6 mm is fairly specific for amyloid infiltration and consistent with previously published echocardiographic data [31]. Tissue characterization in cardiac amyloidosis has not been well-studied. However, one study reported a decrease in the signal intensity of the amyloid-infiltrated myocardium compared to the ref- erence tissue [31]. The mechanism underlying this hy- pointensity is uncertain, but is likely due to abnormal in- terstitium and fibrosis.
Assessment of Myocardial Viability
The concept of myocardial viability is of great signifi- cance in patients with ischemic heart disease, in terms of achieving the maximum benefit from revascularization [32]. Revascularization improves the function of viable myocardium, but not of myocardium that has been re- placed by fibrous scar. It is therefore imperative to dis- tinguish between scar and viable myocardium. Contrast- enhanced MR imaging is coming of age in terms of its ability to accurately predict myocardial viability. Two en- hancement patterns have been described. The first is seen on first-pass perfusion images and consists of an area of hypoenhancement within the infarcted region, which has been found to correlate with microvascular obstruction and is related to ‘no reflow’ inside the infarct zone [33].
The second can be observed 10-30 min after contrast in- jection (delayed hyperenhancement, DHE) and is depict- ed with a breath-hold inversion-recovery gradient-echo sequence (Fig. 5). This pattern of DHE, seen after acute as well as chronic myocardial infarction, reflects nonvi- able, infarcted tissue and fibrosis, respectively. In patients with a chronic myocardial infarction, DHE can accurate- ly locate and determine the extent and transmurality of the infarct [33-35]. Thus, because of its high spatial res- olution, high reproducibility, and predictive value, MRI is fast becoming the reference standard for the assessment of myocardial viability. Further development of necrosis- specific contrast agents and refinement of MR spec- troscopy to assess regional chemistry and metabolism will enhance the utility of this imaging strategy.
Fig. 5. Delayed gadol- inium short-axis im- age of the heart in a patient with a prior myocardial infarction.
The bright high-signal portion of the anterior and anterolateral wall (arrows) of the left ventricle is the area of prior infarction
Assessment of Pericardial Disease
Evaluation of the pericardium is ideally suited to MR imaging (Fig. 6). T1-weighted spin-echo imaging demonstrates normal pericardium as a thin band (<2 mm) of low signal, bordered by epicaridal and pericardial fat, which have a high signal. Since pericardial thickness varies at different levels, it is generally recommended to measure the thickness in axial images at the level of the right atrium, right ventricle, and left ventricle. A thick- ness of >4 mm is considered abnormal and suggestive of fibrous pericarditis, either acute or chronic (due to surgery, uremia, tumor, infection or connective tissue disease) [36]. Contrast-enhanced MR imaging may help to better delineate the pericardium in patients with effu- sive-constrictive pericarditis [37]. Breath-hold or real- time cine-gradient-echo images of the ventricles and phase-velocity mapping of the cardiac valves may aid in assessing the significance of pericardial pathology.
These techniques are also useful in detecting other dis- orders, such as congenital absence of pericardium, peri- cardial cysts, or pericardial effusion undetected by other modalities.
Evaluation of Cardiac and Paracardiac Masses
Primary cardiac tumors are rare (0.002-0.3% incidence), and the majority (75%) are benign. Metastatic tumors are 20- to 40-fold more common than primary tumors. MR imaging is excellent for delineating the morphologic de- tails of a mass, including extent, origin, hemorrhage, vas- cularity, calcification, and effects on adjacent structures.
Protocols include the combined use of axial black-blood sequences and axial bright-blood cine images. Functional MR images are useful to study the pathophysiologic con- sequences of the mass.
Specifically, benign myxomas (the most common car- diac tumor) appear brighter than myocardium on T2 weighting, and cine images may reveal the characteristic mobility of the pedunculated tumor. Lipomas (Fig. 7) are brighter on spin-echo T1-weighted images and the diag- nosis is verified by a decrease in signal intensity using a fat-suppression technique.
Evaluation of Congenital Heart Disease
Due to its unparalleled resolution and 3D imaging ca- pacity, MR imaging plays an important role in diagnos- ing and serially following patients with various congeni- tal heart diseases, complementary to echocardiography. It is a very good tool for identifying and sizing atrial and ventricular septal defects. Phase-velocity mapping at the level of the shunt also allows calculation of the shunt fraction (Qp/Qs ratio). The different imaging sequences, including MR angiography, facilitate the diagnosis of le- sions such as anomalous pulmonary venous return, trans- position of the great vessels, aortic rings, truncus arterio- sus, double-outlet right ventricle, tetralogy of Fallot, pul- monary atresia, and pulmonary artery stenosis. They can also be used to follow these patients for effects and com- plications after corrective surgery. Venous anomalies, such as persistent superior vena cava and interruption of the inferior vena cava with azygos continuation, can be diagnosed with MR angiography.
Fig. 7. Black-blood image of the heart in a long-axis view shows a mass (arrow) posterior to the right atrium (RA) that was subse- quently diagnosed as lipoma. LV, Left ventricle; RV, right ventri- cle; DA, descending aorta
Fig. 6.Black-blood image of the heart in long-axis view shows a thickened pericardium (arrows). LV, Left ventricle; RV, right ven- tricle; DA, descending aorta. Pericardial thickening ≥4 mm is ab- normal and indicative of constrictive pericarditis
Evaluation of Valvular Diseases
Echocardiography with color Doppler is usually the first- line imaging modality for diagnosing valvular diseases.
MR imaging is generally reserved for use when other modalities fail or provide suboptimal information.
Double-inversion recovery sequences can show valve morphology and evidence of secondary changes, such as chamber dilatation, myocardial hypertrophy, post-stenotic changes in the great vessels, and thrombus in any of the chambers. Semi-quantitative assessment of valvular stenosis or regurgitation can be obtained by measuring the area of signal void on gradient-echo images. The duration or extent of the signal void correlates with the severity of aortic stenosis, and the total area of signal loss correlates with the severity of mitral regurgitation. This technique has a very high sensitivity (98%), specificity (95%), and accuracy (97%) for diagnosing aortic and mitral regurgi- tation. The signal void, however, is dependent upon cer- tain scan parameters, such as echo time, voxel size, and image orientation relative to flow jet. Phase-contrast MR allows the severity of valvular stenosis to be assessed (by measuring the peak jet velocity) by calculating the valve orifice area and transvalvular pressure gradient.
Evaluation of Myocardial Perfusion and Ischemia
Magnetic resonance imaging is emerging as a reliable and useful tool in the assessment of regional left ventric- ular perfusion. Currently, it relies upon monitoring the first pass of contrast agents. After rapid injection of in- travenous contrast material, there is marked signal en- hancement first in the right ventricular cavity, then in the left ventricular cavity, and then in the left ventricular my- ocardium. This is completed within 20-30 s and involves a prolonged breath hold. Gradient-echo sequences have been used for single-slice (mid-cavity, short-axis) perfu- sion MR imaging in humans [38]. Recently, echo planar techniques have been employed for ultrafast multislice MR imaging. The peak signal intensity is related to the concentration of the contrast agent in the local tissue and is directly proportional to the coronary blood flow.
Perfusion MR at rest and after infusion of pharmacolog- ic agents (adenosine and persantine) has been compared to standard methods (angiography or radionuclide scintigraphy) and demonstrated reasonable sensitivity (67-83%) and specificity (75-100%). Additionally, the assessment of wall motion further improved the perfor- mance of MR imaging.
Coronary Artery Imaging
Imaging of the coronary arteries using MR still remains a very challenging proposition and is thus predominant- ly relegated to research centers. In patients with left-
main or three-vessel disease, MR has a sensitivity of 100%, specificity of 85%, and accuracy of 87% for the diagnosis of coronary artery disease [39]. The drawback of current MR technology is its inability to visualize smaller distal vessels [39]. However, with the develop- ment of more sophisticated sequences, better contrast agents, routine non-invasive MR coronary angiography might soon become a reality.
Nonetheless, the role of MR imaging in assessing for an anomalous origin and course of a coronary artery is well-established. MR techniques have shown excellent results in the definition and identification (93-100% cas- es) of anomalous coronary arteries. Also, MR imaging can aid in classifying cases that could not be classified with other diagnostic methods or that were misclassified by conventional angiography [40].
Conclusions
Magnetic resonance imaging is the newest, most com- plex and rapidly emerging non-invasive test of choice for patients with a multitude of cardiovascular prob- lems. Its role in becoming the dominant imaging modal- ity in every facet of cardiology cannot be understated.
At the same time, this technique is entering an impor- tant phase in its evolution, with an anticipated exponen- tial growth in its current applications and the develop- ment of new ones.
References
1. Task Force of the European Society of Cardiology, in collabo- ration with the Association of European Pediatric Cardiologists (1998) The clinical role of magnetic resonance in cardiovascular disease. Eur Heart J 19:19-39
2. Doherty NE 3rd, Seelos KC, Suzuki J et al (1992) Application of cine nuclear magnetic resonance imaging for sequential evaluation of response to angiotensin-converting enzyme in- hibitor therapy in dilated cardiomyopathy. J Am Coll Cardiol 19:1294-1302
3. Semelka RC, Tomei E, Wagner S et al (1990) Normal left ven- tricular dimensions and function: interstudy reproducibility of measurements with cine MR imaging. Radiology 174(3 Pt 1):763-768
4. Reichek N (1999) MRI myocardial tagging. J Magn Reson Imaging 10:609-616
5. Bogaert J, Bosmans H, Maes A et al (2000) Remote myocar- dial dysfunction after acute anterior myocardial infarction: im- pact of left ventricular shape on regional function: a magnetic resonance myocardial tagging study. J Am Coll Cardiol 35:1525-1534
6. Benjelloun H, Cranney GB, Kirk KA et al (1991) Interstudy reproducibility of biplane cine nuclear magnetic resonance measurements of left ventricular function. Am J Cardiol 67:1413-1420
7. Bottini PB, Carr AA, Prisant LM et al (1995) Magnetic reso- nance imaging compared to echocardiography to assess left ventricular mass in the hypertensive patient. Am J Hypertens 8:221-228
8. Kasper EK, Agema WR, Hutchins GM et al (1994) The caus- es of dilated cardiomyopathy: a clinicopathologic review of 673 consecutive patients. J Am Coll Cardiol 23:586-590
9. MacGowan GA, Shapiro EP, Azhari H et al (1997) Noninvasive measurement of shortening in the fiber and cross- fiber directions in the normal human left ventricle and in id- iopathic dilated cardiomyopathy. Circulation 96:535-541 10. Fujita N, Duerinekx AJ, Higgins CB (1993) Variation in left
ventricular regional wall stress with cine magnetic resonance imaging: normal subjects versus dilated cardiomyopathy. Am Heart J 125(5 Pt 1):1337-1345
11. Sechtem U, Pflugfelder PW, Gould RG et al (1987) Measurement of right and left ventricular volumes in healthy individuals with cine MR imaging. Radiology 163:697-702
12. Neubauer S, Krahe T, Schindler R et al (1992) 31P magnetic resonance spectroscopy in dilated cardiomyopathy and coro- nary artery disease. Altered cardiac high-energy phosphate metabolism in heart failure. Circulation 86:1810-1818 13. Friedrich MG, Strohm O, Schulz-Menger J et al (1998)
Contrast media-enhanced magnetic resonance imaging visual- izes myocardial changes in the course of viral myocarditis.
Circulation 97:1802-1809
14. Bellotti G, Bocchi EA, de Moraes AV et al (1996) In vivo de- tection of Trypanosoma cruzi antigens in hearts of patients with chronic Chagas’ heart disease. Am Heart J 131:301-307 15. Franke A, Schondube FA, Kuhl HP et al (1998) Quantitative
assessment of the operative results after extended myectomy and surgical reconstruction of the subvalvular mitral apparatus in hypertrophic obstructive cardiomyopathy using dynamic three-dimensional transesophageal echocardiography. J Am Coll Cardiol 31:1641-1649
16. White RD, Obuchowski NA, Gunawardena S et al (1996) Left ventricular outflow tract obstruction in hypertrophic car- diomyopathy: presurgical and postsurgical evaluation by com- puted tomography magnetic resonance imaging. Am J Card Imaging 10:1-13
17. Friedrich MG (2000) Magnetic resonance imaging in car- diomyopathies. J Cardiovasc Magn Reson 2:67-82
18. Jung WI, Sieverding L, Breuer J (1998) 31P NMR spec- troscopy detects metabolic abnormalities in asymptomatic patients with hypertrophic cardiomyopathy. Circulation 97:2536-2542
19. Kawada N, Sakuma H, Yamakado T et al (1999) Hypertrophic cardiomyopathy: MR measurement of coronary blood flow and vasodilator flow reserve in patients and healthy subjects.
Radiology 211:129-135
20. Schulz-Menger J, Strohm O, Waigand J et al (2000) The value of magnetic resonance imaging of the left ventricular outflow tract in patients with hypertrophic obstructive cardiomyopathy after septal artery embolization. Circulation 101:1764-1766 21. Stuber M, Scheidegger MB, Fischer SE et al (1999)
Alterations in the local myocardial motion pattern in patients suffering from pressure overload due to aortic stenosis.
Circulation 100:361-368
22. Suzuki J, Shimamoto R, Nishikawa J et al (1999) Morphological onset and early diagnosis in apical hypertrophic cardiomyopa- thy: a long term analysis with nuclear magnetic resonance imag- ing. J Am Coll Cardiol 33:146-151
23. Blake LM, Scheinman MM, Higgins CB (1994) MR features of arrhythmogenic right ventricular dysplasia. AJR Am J Roentgenol 162:809-812
24. Ricci C, Longo R, Pagnan L et al (1992) Magnetic resonance imaging in right ventricular dysplasia. Am J Cardiol 70:1589- 1595
25. Menghetti L, Basso C, Nava A et al (1996) Spin-echo nuclear magnetic resonance for tissue characterization in arrhythmo- genic right ventricular cardiomyopathy. Heart 76:467-470 26. Corrado D, Fontaine G, Marcus FI et al (2000) Arrhythmogenic
right ventricular dysplasia/cardiomyopathy: need for an inter- national registry. Study Group on Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy of the Working Groups on Myocardial and Pericardial Disease and Arrhythmias of the European Society of Cardiology and of the Scientific Council on Cardiomyopathies of the World Heart Federation.
Circulation 101:E101-E6
27. Flora GS, Sharma OP (1989) Myocardial sarcoidosis: a re- view. Sarcoidosis 6:97-106
28. Otake S, Banno T, Ohba S et al (1990) Muscular sarcoidosis:
findings at MR imaging. Radiology 176:145-148
29. Seltzer S, Mark AS, Atlas SW (1991) CNS sarcoidosis: evalu- ation with contrast-enhanced MR imaging. AJNR Am J Neuroradiol 12:1227-1233
30. Siegelman ES, Mitchell DG, Semelka RC (1996) Abdominal iron deposition: metabolism, MR findings, and clinical impor- tance. Radiology 199:13-22
31. Fattori R, Rocchi G, Celletti F et al (1998) Contribution of magnetic resonance imaging in the differential diagnosis of cardiac amyloidosis and symmetric hypertrophic cardiomy- opathy. Am Heart J 136:824-830
32. Senior R, Kaul S, Lahiri A (1999) Myocardial viability on echocardiography predicts long-term survival after revascular- ization in patients with ischemic congestive heart failure. J Am Coll Cardiol 33:1848-1854
33. Kim RJ, Fieno DS, Parrish TB et al (1999) Relationship of MRI delayed contrast enhancement to irreversible injury, in- farct age, and contractile function. Circulation 100:1992-2002 34. Kim RJ, Chen EL, Lima JA, Judd RM (1996) Myocardial Gd- DTPA kinetics determine MRI contrast enhancement and re- flect the extent and severity of myocardial injury after acute reperfused infarction. Circulation 94:3318-3326
35. Kim RJ, Wu E, Rafael A et al (2000) The use of contrast-en- hanced magnetic resonance imaging to identify reversible my- ocardial dysfunction. N Engl J Med 343:1445-1453
36. Masui T, Finck S, Higgins CB (1992) Constrictive pericarditis and restrictive cardiomyopathy: evaluation with MR imaging.
Radiology 182:369-373
37. Watanabe A, Hara Y, Hamada M et al (1998) A case of effu- sive-constructive pericarditis: an efficacy of GD-DTPA en- hanced magnetic resonance imaging to detect a pericardial thickening. Magn Reson Imaging 16:347-350
38. Atkinson DJ, Burstein D, Edelman RR (1990) First-pass car- diac perfusion: evaluation with ultrafast MR imaging.
Radiology 174(3 Pt 1):757-762
39. Kim WY, Danias PG, Stuber M et al (2001) Coronary mag- netic resonance angiography for the detection of coronary stenoses. N Engl J Med 345:1863-1869
40. McConnell MV, Ganz P, Selwyn AP et al (1995) Identification of anomalous coronary arteries and their anatomic course by mag- netic resonance coronary angiography. Circulation 92:3158-3162
