Quantitative assessment of myocardial perfusion with a spin-labeling technique: preliminary results in patients with coronary artery disease

Update on state-of-the-art for arterial spin labeling (ASL) human perfusion imaging outside of the brain

This review article provides an overview of developments for arterial spin labeling (ASL) perfusion imaging in the body (i.e., outside of the brain). It is part of a series of review/recommendation papers from the International Society for Magnetic Resonance in Medicine (ISMRM) Perfusion Study Group. In this review, we focus on specific challenges and developments tailored for ASL in a variety of body locations. After presenting common challenges, organ-specific reviews of challenges and developments are presented, including kidneys, lungs, heart (myocardium), placenta, eye (retina), liver, pancreas, and muscle, which are regions that have seen the most developments outside of the brain. Summaries and recommendations of acquisition parameters (when appropriate) are provided for each organ. We then explore the possibilities for wider adoption of body ASL based on large standardization efforts, as well as the potential opportunities based on recent advances in high/low-field systems and machine-learning. This review seeks to provide an overview of the current state-of-the-art of ASL for applications in the body, highlighting ongoing challenges and solutions that aim to enable more widespread use of the technique in clinical practice.

Quantification of Myocardial Perfusion With Vasodilation Using Arterial Spin Labeling at 1.5T

BACKGROUND

Myocardial perfusion is evaluated in first-pass MRI using a gadolinium-based contrast agent, which limits its repeatability and restricts its use in patients with abnormal kidney function. Arterial spin labeling (ASL) is a promising technique for measuring myocardial perfusion without contrast injection. The ratio of stress to rest perfusion, termed myocardial perfusion reserve (MPR), is an indicator of the severity of stenosis in patients with coronary artery disease (CAD).

PURPOSE

To quantify perfusion increases with pharmacological vasodilation, explore MPR differences between segments with and without perfusion defects, and examine the correlations between quantitative ASL and semiquantitative first-pass measurements.

STUDY TYPE

Prospective.

SUBJECTS

Sixteen patients with suspected CAD: 10 classified as "healthy," having normal perfusion on first-pass and no enhancement on late gadolinium enhancement (LGE), and six as "nonhealthy," having hypoperfused segments including ischemic and infarcted.

FIELD STRENGTH/SEQUENCE

Flow-sensitive alternating inversion recovery (FAIR) rest-stress cardiac ASL with balanced steady-state free precession (bSSFP), rest-stress first-pass imaging using gradient-echo and LGE using a phase-sensitive inversion-recovery bSSFP at 1.5T.

ASSESSMENT

For healthy subjects, rest-stress perfusion data were compared in global, coronary artery territory, and segment regions of interest (ROIs). A segmental MPR comparison was performed between normal segments from healthy subjects and abnormal segments from nonhealthy subjects. Correlations between ASL and first-pass parameters were explored.

STATISTICAL TESTS

Wilcoxon-signed-rank test, nonparametric factorial analysis of variance (ANOVA), and Pearson's/Spearman's correlations.

RESULTS

Perfusion increases were significant globally (P = 0.005), per coronary artery territory (P = 0.015), and per segment (P = 0.03 for all segments in ASL and first-pass, except anteroseptal in ASL P = 0.04). MPR differences between normal and abnormal segments were significant (P = 0.0028: ASL, P = 0.033: first-pass). ASL and first-pass measurements were correlated (MPR: r = 0.64, P = 0.008 and perfusion: rho = 0.47, P = 0.007).

DATA CONCLUSION

This study demonstrates the feasibility of ASL to detect hyperemia, the potential to differentiate segments with and without perfusion defects, and significant correlations between ASL and semiquantitative first-pass.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY STAGE: 1.

Gadolinium-Free Cardiac MR Stress T1-Mapping to Distinguish Epicardial From Microvascular Coronary Disease

BACKGROUND

Novel cardiac magnetic resonance (CMR) stress T1 mapping can detect ischemia and myocardial blood volume changes without contrast agents and may be a more comprehensive ischemia biomarker than myocardial blood flow.

OBJECTIVES

This study describes the performance of the first prospective validation of stress T1 mapping against invasive coronary measurements for detecting obstructive epicardial coronary artery disease (CAD), defined by fractional flow reserve (FFR <0.8), and coronary microvascular dysfunction, defined by FFR ≥0.8 and the index of microcirculatory resistance (IMR ≥25 U), compared with first-pass perfusion imaging.

METHODS

Ninety subjects (60 patients with angina; 30 healthy control subjects) underwent CMR (1.5- and 3-T) to assess left ventricular function (cine), ischemia (adenosine stress/rest T1 mapping and perfusion), and infarction (late gadolinium enhancement). FFR and IMR were assessed ≤7 days post-CMR. Stress and rest images were analyzed blinded to other information.

RESULTS

Normal myocardial T1 reactivity (ΔT1) was 6.2 ± 0.4% (1.5-T) and 6.2 ± 1.3% (3-T). Ischemic viable myocardium downstream of obstructive CAD showed near-abolished T1 reactivity (ΔT1 = 0.7 ± 0.7%). Myocardium downstream of nonobstructive coronary arteries with microvascular dysfunction showed less-blunted T1 reactivity (ΔT1 = 3.0 ± 0.9%). Stress T1 mapping significantly outperformed gadolinium-based first-pass perfusion, including absolute quantification of myocardial blood flow, for detecting obstructive CAD (area under the receiver-operating characteristic curve: 0.97 ± 0.02 vs. 0.91 ± 0.03, respectively; p < 0.001). A ΔT1 of 1.5% accurately detected obstructive CAD (sensitivity: 93%; specificity: 95%; p < 0.001), whereas a less-blunted ΔT1 of 4.0% accurately detected microvascular dysfunction (area under the receiver-operating characteristic curve: 0.95 ± 0.03; sensitivity: 94%; specificity: 94%: p < 0.001).

CONCLUSIONS

CMR stress T1 mapping accurately detected and differentiated between obstructive epicardial CAD and microvascular dysfunction, without contrast agents or radiation.

Non-contrast assessment of microvascular integrity using arterial spin labeled cardiovascular magnetic resonance in a porcine model of acute myocardial infarction

BACKGROUND

Following acute myocardial infarction (AMI), microvascular integrity and function may be compromised as a result of microvascular obstruction (MVO) and vasodilator dysfunction. It has been observed that both infarcted and remote myocardial territories may exhibit impaired myocardial blood flow (MBF) patterns associated with an abnormal vasodilator response. Arterial spin labeled (ASL) CMR is a novel non-contrast technique that can quantitatively measure MBF. This study investigates the feasibility of ASL-CMR to assess MVO and vasodilator response in swine.

METHODS

Thirty-one swine were included in this study. Resting ASL-CMR was performed on 24 healthy swine (baseline group). A subset of 13 swine from the baseline group underwent stress ASL-CMR to assess vasodilator response. Fifteen swine were subjected to a 90-min left anterior descending (LAD) coronary artery occlusion followed by reperfusion. Resting ASL-CMR was performed post-AMI at 1-2 days (N = 9, of which 6 were from the baseline group), 1-2 weeks (N = 8, of which 4 were from the day 1-2 group), and 4 weeks (N = 4, of which 2 were from the week 1-2 group). Resting first-pass CMR and late gadolinium enhancement (LGE) were performed post-AMI for reference.

RESULTS

At rest, regional MBF and physiological noise measured from ASL-CMR were 1.08 ± 0.62 and 0.15 ± 0.10 ml/g/min, respectively. Regional MBF increased to 1.47 ± 0.62 ml/g/min with dipyridamole vasodilation (P < 0.001). Significant reduction in MBF was found in the infarcted region 1-2 days, 1-2 weeks, and 4 weeks post-AMI compared to baseline (P < 0.03). This was consistent with perfusion deficit seen on first-pass CMR and with MVO seen on LGE. There were no significant differences between measured MBF in the remote regions pre and post-AMI (P > 0.60).

CONCLUSIONS

ASL-CMR can assess vasodilator response in healthy swine and detect significant reduction in regional MBF at rest following AMI. ASL-CMR is an alternative to gadolinium-based techniques for assessment of MVO and microvascular integrity within infarcted, as well as salvageable and remote myocardium. This has the potential to provide early indications of adverse remodeling processes post-ischemia.

Demonstration of velocity selective myocardial arterial spin labeling perfusion imaging in humans

PURPOSE

Transit delay is a potential source of error in cardiac arterial spin-labeled (ASL) in heart failure or with collateral circulation. This study demonstrates the feasibility of using transit delay insensitive velocity selective ASL and compares its performance with flow-sensitive alternating inversion recovery (FAIR) ASL.

METHODS

Velocity selective labeling was achieved using an adiabatic BIR8 preparation. FAIR and velocity-selective ASL (VSASL) with various velocity cutoffs (V_C  = 10-40 cm/s) and labeling directions (anterior-posterior X, lateral-septal Y, and apical-basal Z) were carried out in 10 healthy volunteers (1F/9M age 23-30 y). Myocardial blood flow (MBF) and temporal signal-to-noise (TSNR) were measured.

RESULTS

VSASL sensitivity to perfusion decreased with increasing V_C . At low V_C (<5 cm/s), spurious labeling of myocardium occurs and overestimates MBF. MBF measured with FAIR (1.12 ± 0.26 ml/g/min) and VASL (1.26 ± 0.27 ml/g/min) at V_C of 10 cm/s in Z were comparable (TOST with difference of 0.30 ml/g/min, P = 0.049). TSNR was 2.8 times larger using FAIR (13.62 ± 5.25) than in VSASL (4.87 ± 1.58). VSASL was insensitive to perfusion in the Y direction. X and Z performed similarly with TSNR of 4.17 ± 2.32 and 3.97 ± 0.56, respectively.

CONCLUSION

VSASL is a promising alternative to FAIR ASL in the heart and is well suited for scenarios when transit delays are long. Magn Reson Med 80:272-278, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Clinical recommendations for cardiovascular magnetic resonance mapping of T1, T2, T2* and extracellular volume: A consensus statement by the Society for Cardiovascular Magnetic Resonance (SCMR) endorsed by the European Association for Cardiovascular Imaging (EACVI)

Parametric mapping techniques provide a non-invasive tool for quantifying tissue alterations in myocardial disease in those eligible for cardiovascular magnetic resonance (CMR). Parametric mapping with CMR now permits the routine spatial visualization and quantification of changes in myocardial composition based on changes in T1, T2, and T2*(star) relaxation times and extracellular volume (ECV). These changes include specific disease pathways related to mainly intracellular disturbances of the cardiomyocyte (e.g., iron overload, or glycosphingolipid accumulation in Anderson-Fabry disease); extracellular disturbances in the myocardial interstitium (e.g., myocardial fibrosis or cardiac amyloidosis from accumulation of collagen or amyloid proteins, respectively); or both (myocardial edema with increased intracellular and/or extracellular water). Parametric mapping promises improvements in patient care through advances in quantitative diagnostics, inter- and intra-patient comparability, and relatedly improvements in treatment. There is a multitude of technical approaches and potential applications. This document provides a summary of the existing evidence for the clinical value of parametric mapping in the heart as of mid 2017, and gives recommendations for practical use in different clinical scenarios for scientists, clinicians, and CMR manufacturers.

Myocardial arterial spin labeling

Arterial spin labeling (ASL) is a cardiovascular magnetic resonance (CMR) technique for mapping regional myocardial blood flow. It does not require any contrast agents, is compatible with stress testing, and can be performed repeatedly or even continuously. ASL-CMR has been performed with great success in small-animals, but sensitivity to date has been poor in large animals and humans and remains an active area of research. This review paper summarizes the development of ASL-CMR techniques, current state-of-the-art imaging methods, the latest findings from pre-clinical and clinical studies, and future directions. We also explain how successful developments in brain ASL and small-animal ASL-CMR have helped to inform developments in large animal and human ASL-CMR.

Revision of the Troponin T Release Mechanism from Damaged Human Myocardium

BACKGROUND

Cardiac troponin T (cTnT) is released from damaged heart tissue in patients with acute myocardial infarction. It is presumed that most cTnT is tightly bound and released following the degradation of myofibrils in necrotic cardiomyocytes, resulting in sustained increases in circulating cTnT. Evidence of a large irreversibly bound fraction is based on the inability to extract most cTnT from cardiac tissue in cold low-salt extraction buffers.

METHODS

Here we examined in vitro extraction of cTnT from human cardiac tissue in serum at 37 °C.

RESULTS

We found that over 80% of the cTnT can be extracted from human cardiac tissue in 90 min using large volumes of human serum at 37 °C. The release ratio was highly dependent on the extraction volume and was only 3% if an equal volume of serum and heart tissue was used. In contrast, extraction of the cytoplasmic cardiac damage markers myoglobin and creatinine kinase was much less affected by changing these conditions. Purified cTnT was poorly soluble in a low-salt extraction buffer at 0 °C, previously used to define the free cTnT fraction.

CONCLUSIONS

Our data indicate that the diffusible fraction of cTnT is likely substantially larger in vivo than previously reported and likely is not fixed but dependent on local plasma flow. It is therefore possible that the sustained increase in circulating cTnT after myocardial infarction is at least in part due to a slow washout of cTnT that interacts reversibly with tropomyosin in myofibrils.

Myocardial arterial spin labeling perfusion imaging with improved sensitivity

BACKGROUND

Myocardial arterial spin labeling (ASL) is a noninvasive MRI based technique that is capable of measuring myocardial blood flow (MBF) in humans. It suffers from poor sensitivity to MBF due to high physiological noise (PN). This study aims to determine if the sensitivity of myocardial ASL to MBF can be improved by reducing image acquisition time, via parallel imaging.

METHODS

Myocardial ASL scans were performed in 7 healthy subjects at rest using flow-sensitive alternating inversion recovery (FAIR) tagging and balanced steady state free precession (SSFP) imaging. Sensitivity encoding (SENSE) with a reduction factor of 2 was used to shorten each image acquisition from roughly 300 ms per heartbeat to roughly 150 ms per heartbeat. A paired Student's t-test was performed to compare measurements of myocardial blood flow (MBF) and physiological noise (PN) from the reference and accelerated methods.

RESULTS

The measured PN (mean ± standard deviation) was 0.20 ± 0.08 ml/g/min for the reference method and 0.08 ± 0.05 ml/g/min for the accelerated method, corresponding to a 60% reduction. PN measured from the accelerated method was found to be significantly lower than that of the reference method (p=0.0059). There was no significant difference between MBF measured from the accelerated and reference ASL methods (p=0.7297).

CONCLUSIONS

In this study, significant PN reduction was achieved by shortening the acquisition window using parallel imaging with no significant impact on the measured MBF. This indicates an improvement in sensitivity to MBF and may also enable the imaging of subjects with higher heart rates and imaging during systole.

Quantitative myocardial perfusion in mice based on the signal intensity of flow sensitized CMR

BACKGROUND

In the conventional approach to arterial spin labeling in the rodent heart, the relative difference in the apparent T(1) relaxation times corresponding to selective and non-selective inversion is related to perfusion via a two compartment model of tissue. But accurate determination of T(1) in small animal hearts is difficult and prone to errors due to long scan times and high heart rates. In this study we introduce the theoretical frame work for an alternative method (SI-method) based purely on the signal intensity of slice-select and non-select inversion recovery images at a single inversion time at short repetition time.

METHODS

A modified Bloch equation was solved to derive perfusion as a function of signal intensity of flow sensitized segmented gradient echo acquisitions. A two compartment fast exchanging model of tissue was assumed. To test the new technique first it was implemented on a flow phantom and then it was compared with the conventional T(1) method in an in vivo study of healthy C57BL/6 mice (n=12). Finally the SI-method was used in comparison to a Late Gadolinium Enhanced (LGE) method to qualitatively and quantitatively assess perfusion deficits in an ischemia-reperfusion mouse model (n=4).

RESULTS

The myocardial perfusion of healthy mice obtained by the SI-method, 5.6 ± 0.5 ml/g/min, (mean ± standard deviation) was similar (p=0.38) to that obtained by the conventional method, 5.6 ± 0.3 ml/g/min. The variance in perfusion within the left ventricle was less for the SI-method than that for the conventional method (p<0.0001). The mean percentage standard deviation among repeated measures was 3.6%. The LGE regions of the ischemia reperfusion model were matched with regions of hypo-perfusion in the perfusion map. The average perfusion in the hypo perfused region among all four IR mice was 1.2 ± 0.9 ml/g/min and that of the remote region was 4.4 ± 1.2 ml/g/min.

CONCLUSIONS

The proposed signal intensity based ASL method with a segmented acquisition scheme allows accurate high resolution perfusion mapping in small animals. It's short scan time, high reproducibility and ease of post process makes it a robust alternative to the conventional ASL technique that relies on T(1) measurements.

Arterial spin labeled CMR detects clinically relevant increase in myocardial blood flow with vasodilation

OBJECTIVES

This study sought to determine whether arterial spin labeled (ASL) cardiac magnetic resonance (CMR) is capable of detecting clinically relevant increases in regional myocardial blood flow (MBF) with vasodilator stress testing in human myocardium.

BACKGROUND

Measurements of regional myocardial perfusion at rest and during vasodilatation are used to determine perfusion reserve, which indicates the presence and distribution of myocardial ischemia. ASL CMR is a perfusion imaging technique that does not require any contrast agents, and is therefore safe for use in patients with end-stage renal disease, and capable of repeated or continuous measurement.

METHODS

Myocardial ASL scans at rest and during adenosine infusion were incorporated into a routine CMR adenosine induced vasodilator stress protocol and was performed in 29 patients. Patients who were suspected of having ischemic heart disease based on first-pass imaging also underwent x-ray angiography. Myocardial ASL was performed using double-gated flow-sensitive alternating inversion recovery tagging and balanced steady-state free precession imaging at 3-T.

RESULTS

Sixteen patients were found to be normal and 13 patients were found to have visible perfusion defect based on first-pass CMR using intravenous gadolinium chelate. In the normal subjects, there was a statistically significant difference between MBF measured by ASL during adenosine infusion (3.67 ± 1.36 ml/g/min), compared to at rest (0.97 ± 0.64 ml/g/min), with p < 0.0001. There was also a statistically significant difference in perfusion reserve (MBF(stress)/MBF(rest)) between normal myocardial segments (3.18 ± 1.54) and the most ischemic segments in the patients with coronary artery disease identified by x-ray angiography (1.44 ± 0.97), with p = 0.0011.

CONCLUSIONS

This study indicates that myocardial ASL is capable of detecting clinically relevant increases in MBF with vasodilatation and has the potential to identify myocardial ischemia.

Emerging MRI methods in translational cardiovascular research

Cardiac magnetic resonance imaging (CMR) has become a reference standard modality for imaging of left ventricular (LV) structure and function and, using late gadolinium enhancement, for imaging myocardial infarction. Emerging CMR techniques enable a more comprehensive examination of the heart, making CMR an excellent tool for use in translational cardiovascular research. Specifically, emerging CMR methods have been developed to measure the extent of myocardial edema, changes in ventricular mechanics, changes in tissue composition as a result of fibrosis, and changes in myocardial perfusion as a function of both disease and infarct healing. New CMR techniques also enable the tracking of labeled cells, molecular imaging of biomarkers of disease, and changes in calcium flux in cardiomyocytes. In addition, MRI can quantify blood flow velocity and wall shear stress in large blood vessels. Almost all of these techniques can be applied in both pre-clinical and clinical settings, enabling both the techniques themselves and the knowledge gained using such techniques in pre-clinical research to be translated from the lab bench to the patient bedside.

Estimation of perfusion and arterial transit time in myocardium using free-breathing myocardial arterial spin labeling with navigator-echo

Arterial spin labeling (ASL) provides noninvasive measurement of tissue blood flow, but sensitivity to motion has limited its application to imaging of myocardial blood flow. Although different cardiac phases can be synchronized using electrocardiography triggering, breath holding is generally required to minimize effects of respiratory motion during ASL scanning, which may be challenging in clinical populations. Here a free-breathing myocardial ASL technique with the potential for reliable clinical application is presented, by combining ASL with a navigator-gated, electrocardiography-triggered TrueFISP readout sequence. Dynamic myocardial perfusion signals were measured at multiple delay times that allowed simultaneous fitting of myocardial blood flow and arterial transit time. With the assist of a nonrigid motion correction program, the estimated mean myocardial blood flow was 1.00 ± 0.55 mL/g/min with a mean transit time of ∼ 400 msec. The intraclass correlation coefficient of repeated scans was 0.89 with a mean within subject coefficient of variation of 22%. Perfusion response during mild to moderate stress was further measured. The capability for noninvasive, free-breathing assessment of myocardial blood flow using ASL may offer an alternative approach to first-pass perfusion MRI for clinical evaluation of patients with coronary artery disease.

Improved arterial spin labeling after myocardial infarction in mice using cardiac and respiratory gated look-locker imaging with fuzzy C-means clustering

Experimental myocardial infarction (MI) in mice is an important disease model, in part due to the ability to study genetic manipulations. MRI has been used to assess cardiac structural and functional changes after MI in mice, but changes in myocardial perfusion after acute MI have not previously been examined. Arterial spin labeling noninvasively measures perfusion but is sensitive to respiratory motion and heart rate variability and is difficult to apply after acute MI in mice. To account for these factors, a cardiorespiratory-gated arterial spin labeling sequence using a fuzzy C-means algorithm to retrospectively reconstruct images was developed. Using this method, myocardial perfusion was measured in remote and infarcted regions at 1, 7, 14, and 28 days post-MI. Baseline perfusion was 4.9 +/- 0.5 mL/g min and 1 day post-MI decreased to 0.9 +/- 0.8 mL/g min in infarcted myocardium (P < 0.05 versus baseline) while remaining at 5.2 +/- 0.8 mL/g min in remote myocardium. During the subsequent 28 days, perfusion in the remote zone remained unchanged, while a partial recovery of perfusion in the infarct zone was seen. This technique, when applied to genetically engineered mice, will allow for the investigation of the roles of specific genes in myocardial perfusion during infarct healing.

Resting myocardial perfusion quantification with CMR arterial spin labeling at 1.5 T and 3.0 T

BACKGROUND

The magnetic resonance technique of arterial spin labeling (ASL) allows myocardial perfusion to be quantified without the use of a contrast agent. This study aimed to use a modified ASL technique and T1 regression algorithm, previously validated in canine models, to calculate myocardial blood flow (MBF) in normal human subjects and to compare the accuracy and repeatability of this calculation at 1.5 T and 3.0 T. A computer simulation was performed and compared with experimental findings.

RESULTS

Eight subjects were imaged, with scans at 3.0 T showing significantly higher T1 values (P < 0.001) and signal-to-noise ratios (SNR) (P < 0.002) than scans at 1.5 T. The average MBF was found to be 0.990 +/- 0.302 mL/g/min at 1.5 T and 1.058 +/- 0.187 mL/g/min at 3.0 T. The repeatability at 3.0 T was improved 43% over that at 1.5 T, although no statistically significant difference was found between the two field strengths. In the simulation, the accuracy and the repeatability of the MBF calculations were 61% and 38% higher, respectively, at 3.0 T than at 1.5 T, but no statistically significant differences were observed. There were no significant differences between the myocardial perfusion data sets obtained from the two independent observers. Additionally, there was a trend toward less variation in the perfusion data from the two observers at 3.0 T as compared to 1.5 T.

CONCLUSION

This suggests that this ASL technique can be used, preferably at 3.0 T, to quantify myocardial perfusion in humans and with further development could be useful in the clinical setting as an alternative method of perfusion analysis.

Cardiac MR imaging: state of the technology

Recent developments in magnetic resonance (MR) imaging of the heart have refocused attention on the potential of MR and continue to attract intense interest within the radiology and cardiology communities. Improvements in speed, image quality, reliability, and range of applications have evolved to the point where cardiac MR imaging is increasingly seen as a practical clinical tool. As is often the case with MR imaging, not all of the most powerful techniques are necessarily easy to master or understand, and many-nonspecialists and specialists alike-are challenged to stay abreast. This review covers some of the major milestones that have led to the current state of cardiac MR and attempts to put into context some concepts that, although technical, have a real impact on the diagnostic power of cardiac MR imaging. Topics discussed include functional imaging, myocardial viability and perfusion imaging, flow quantification, and coronary artery imaging. A review such as this can only scratch the surface of what is a dynamic interdisciplinary field, but the hope is that sufficient information and insight are provided to stimulate the motivated reader to take his or her interest to the next level.

Accurate myocardial T1 measurements: toward quantification of myocardial blood flow with arterial spin labeling

In this study, we investigated a method for accurately measuring myocardial T(1) for the quantification of myocardial blood flow (MBF) with arterial spin labeling (ASL). A single-shot gradient-echo (GE)-based ASL sequence with an adiabatic hyperbolic secant inversion recovery pulse was modified to acquire a pair of myocardial T(1)'s within a breath-hold. A multivariable regression algorithm that accounted for the magnetization saturation effects was developed to calculate T(1). The MBF was then determined with a well-developed model. The accuracy of our T(1) calculation was first evaluated in a phantom, and then in six dogs for the MBF calculation, with (N = 4) and without (N = 2) coronary artery stenosis. In the phantom study, the accuracy of T(1) measured with a slice-selective inversion prepared pulse was within 2.5% of error. In healthy dogs, the MBF increased 2-5 times during vasodilation. In contrast, regional differences of MBF were well visualized in the stenotic dogs during vasodilation (perfusion reserve of 2.75 +/- 0.83 in normal myocardium, and 1.46 +/- 0.75 in the stenotic area). A correlation analysis revealed a close agreement in MBF between the ASL and microsphere (MS) in both healthy and stenotic dogs. In summary, the modified ASL technique and T(1) regression algorithm proposed here provide an accurate measurement of myocardial T(1) and demonstrate potential for reliably assessing MBF at steady state.

T1 measurement using a short acquisition period for quantitative cardiac applications

Myocardial signal intensity curves for myocardial perfusion studies may be made quantitative by the use of T1 measurements made after the first-pass of contrast agent. A short data acquisition method for T1 mapping is presented in which all data for each T1 map are acquired in a short breath hold, and the slice geometry and timing in the cardiac cycle exactly match that of the dynamic first-pass perfusion sequence. This allows accurate image registration of the T1 map with the first-pass series of images. The T1 method is based on varying the preparation-pulse delay time of a saturation recovery sequence, and in this implementation employs an ECG-triggered, single-shot, spoiled gradient echo technique with SENSE reconstruction. The method allows T1 estimates of three slices to be made in fifteen heartbeats. For a range of samples with T1 values equivalent to those found in the myocardium during the first-pass of contrast agent, T1 estimates were accurate to within 6%, and the variation between slices was 2% or less.

In vivo functional NMR imaging of resistance artery control

Arterial spin labeling (ASL) in combination with NMR imaging is an in vivo technique that quantifies tissue perfusion in absolute values (ml blood x min(-1) x g tissue(-1)) with high temporal (1-10 s) and spatial (0.1-3 mm) resolution. It uses the arterial water spins as endogenous freely diffusible markers of perfusion and, hence, is a totally noninvasive method. The technique has been successfully applied to quantify baseline perfusion in many organs, including the heart, in humans and animals, and results were validated by comparison with gold standards, PET and microspheres, respectively. Because of the high sampling rate of perfusion with ASL and the possibility that measurements could be obtained without harm over indefinite periods of time, the technique has the potential for use in functional investigations of microcirculation regulation and resistance artery control in vivo. We describe examples of the use of ASL to this end. With use of specific technological developments, ASL determination of perfusion can be coupled with simultaneous acquisitions of (1)H and (31)P NMR spectroscopy data. These protocols offer new possibilities whereby the microcirculatory control of cell oxygenation and high-energy phosphate metabolism can be explored.

Myocardial blood flow mapping in mice using high-resolution spin labeling magnetic resonance imaging: Influence of ketamine/xylazine and isoflurane anesthesia

Genetically modified mouse models of many human diseases reflecting cardiovascular alterations are currently available. To date, little information on absolute myocardial perfusion in mice is found in the literature. High-resolution quantitative myocardial blood flow maps (in-plane resolution 156 x 312 mum(2), slice thickness 1.5 mm) have been obtained noninvasively within 25 min at 4.7 T in 30 freely breathing C57/Bl6J mice using electrocardiogram- and respiration-gated spin labeling magnetic resonance imaging (MRI). Regional myocardial blood flow measurements were carried out, and the effects of isoflurane at two different concentrations and ketamine/xylazine anesthesia were assessed. The mean blood flow value in the left ventricular myocardium was 6.0 +/- 1.9 mL g(-1) min(-1) under ketamine/xylazine and 6.9 +/- 1.7 mL g(-1) min(-1) (group average +/- SD) under isoflurane (1.25%). Under the influence of higher isoflurane concentration (2.00%), myocardial blood flow increased dramatically to 16.9 +/- 1.8 mL g(-1)min(-1) with no significant change in heart rate. This work illustrates the feasibility of noninvasive quantitative myocardial perfusion mapping in mice using MRI. The study of the influence of anesthesia shows that myocardial blood flow is highly sensitive to isoflurane concentration. The method employed offers a noninvasive approach to longitudinal studies of murine models of cardiac disease.

Modified Look-Locker inversion recovery (MOLLI) for high-resolution T1 mapping of the heart

A novel pulse sequence scheme is presented that allows the measurement and mapping of myocardial T1 in vivo on a 1.5 Tesla MR system within a single breath-hold. Two major modifications of conventional Look-Locker (LL) imaging are introduced: 1) selective data acquisition, and 2) merging of data from multiple LL experiments into one data set. Each modified LL inversion recovery (MOLLI) study consisted of three successive LL inversion recovery (IR) experiments with different inversion times. We acquired images in late diastole using a single-shot steady-state free-precession (SSFP) technique, combined with sensitivity encoding to achieve a data acquisition window of < 200 ms duration. We calculated T1 using signal intensities from regions of interest and pixel by pixel. T1 accuracy at different heart rates derived from simulated ECG signals was tested in phantoms. T1 estimates showed small systematic error for T1 values from 191 to 1196 ms. In vivo T1 mapping was performed in two healthy volunteers and in one patient with acute myocardial infarction before and after administration of Gd-DTPA. T1 values for myocardium and noncardiac structures were in good agreement with values available from the literature. The region of infarction was clearly visualized. MOLLI provides high-resolution T1 maps of human myocardium in native and post-contrast situations within a single breath-hold.

Magnetic Resonance Imaging of Myocardial Perfusion and Viability Using a Blood Pool Contrast Agent

RATIONALE AND OBJECTIVES

A comprehensive cardiac magnetic resonance (MR) examination should comprise imaging of myocardial perfusion, viability, and the coronary arteries. Blood pool contrast agents (BPCAs) improve coronary MR angiography, whereas their potential for imaging of perfusion and viability is unknown. The abilities to noninvasively image myocardial perfusion and viability using the BPCA P792 (Guerbet, France) were tested in a closed-chest model of nonreperfused myocardial infarction in 5 pigs.

MATERIALS AND METHODS

Two to 3 days after instrumentation, myocardial perfusion imaging with a saturation-recovery steady-state free precession technique and viability imaging with an inversion-recovery fast low-angle shot sequence were conducted on a 1.5-T MR scanner using the extracellular contrast agents (ECCA) Gd-DOTA (0.1 mmol Gd/kg) and blood pool contrast agent (BPCA) P792 (0.013 mmol Gd/kg).

RESULTS

Perfusion defects were visualized in all pigs with good correlation between the ECCA and the BPCA (1.77 +/- 1.16 cm2 vs. 1.80 +/- 1.19 cm2, r = 0.959, P < 0.01). Reduced myocardial perfusion was detected using the ECCA up to 80 seconds after injection. In contrast, BPCA administration enabled visualization of perfusion defects on equilibrium perfusion imaging in all cases for 10 minutes. The size of myocardial infarction detected with viability MR imaging correlated well between the standard method (ECCA) and delayed-enhancement imaging with the BPCA (5.40 +/- 3.16 versus 5.52 +/- 3.13 cm3, r = 0.994, P < 0.002).

CONCLUSIONS

The BPCA investigated in this study allows both reliable detection of perfusion defects on first pass and equilibrium perfusion imaging and characterization of viability after myocardial infarction. Thus, this contrast agent is suitable for a comprehensive cardiac MR examination.

Perfusion imaging using arterial spin labeling

Arterial spin labeling is a magnetic resonance method for the measurement of cerebral blood flow. In its simplest form, the perfusion contrast in the images gathered by this technique comes from the subtraction of two successively acquired images: one with, and one without, proximal labeling of arterial water spins after a small delay time. Over the last decade, the method has moved from the experimental laboratory to the clinical environment. Furthermore, numerous improvements, ranging from new pulse sequence implementations to extensive theoretical studies, have broadened its reach and extended its potential applications. In this review, the multiple facets of this powerful yet difficult technique are discussed. Different implementations are compared, the theoretical background is summarized, and potential applications of various implementations in research as well as in the daily clinical routine are proposed. Finally, a summary of the new developments and emerging techniques in this field is provided.