Role of Cardiac Magnetic Resonance Imaging in Myocardial Infarction

Case Report: Anaphylactic shock and ST-elevation myocardial infarction following a bee sting: two deadly diseases in a patient with Kounis syndrome

Kounis syndrome is an acute coronary syndrome occurring in the setting of an allergic reaction, usually caused by drug administration, food ingestion, or insect sting. We report the case of an elderly woman who presented to the emergency room suffering from an anaphylactic shock caused by a bee sting and who was diagnosed with an anterolateral ST-elevation myocardial infarction (STEMI) with moderately impaired left ventricular ejection. The patient was successfully managed with the administration of intravenous antihistaminic drugs and steroids, intravenous fluid volume resuscitation, and intramuscular epinephrine. The patient then underwent emergency coronary angiography, which showed a thrombotic subtotal occlusion of the proximal left anterior descending artery (LAD) and occlusion of the very distal apical LAD due to a spontaneous embolism. This was treated by primary percutaneous coronary intervention with thrombus aspiration and drug-eluting stent implantation in the proximal LAD, achieving a good angiographic result. Nevertheless, on day 3, the patient developed a left ventricular apical thrombosis, as assessed by cardiac magnetic resonance, requiring oral anticoagulation with rivaroxaban, de-escalation of dual antiplatelet therapy from ticagrelor to clopidogrel with acetylsalicylic acid, and finally a switch to dual antithrombotic therapy. The 3-month follow-up was uneventful. This case highlights the importance of prompt identification of Kounis syndrome in patients presenting with severe allergic reactions to allow for the timely implementation of appropriate reperfusion strategies in such high-risk patients with STEMI.

Frequency of myocardial infarcts on conventional, non-gated CT: An often-overlooked entity

Objectives

The objective of this study was to determine how often myocardial infarctions are retrospectively visible on conventional, non-gated, non-cardiac computed tomography (CT) scans. Our goal was to evaluate a cohort of patients with myocardial infarctions visible on cardiac magnetic resonance imaging (MRI) to determine how often the area of infarction was retrospectively visible by preceding, conventional CT. We also sought to evaluate how often the diagnosis of myocardial infarction was reported at the time of initial study review.

Material and Methods

The Institutional Review Board approval was obtained for the creation and retrospective analysis of a database of patients undergoing cardiac MRI. We started with a cohort of 252 patients who had undergone cardiac MRI at our institution, over a 4-year period. We identified 160 patients who had a myocardial infarct visible on MRI.

Results

Of the 160 patients who had been identified as having an infarct on cardiac MRI, 54 patients had undergone a recent (within 30 days) conventional CT scan, usually done for non-cardiac indications. In addition to the review of reports, non-cardiac CT scans were also evaluated retrospectively by two experienced, cardiothoracic imaging physicians, including a radiologist and a cardiologist. In 26 of these patients (48.1%), an infarct was visible on the CT images. In 12 of these 26 cases (46.1%), the infarct was noted in the initial report. In the remaining 14 of these 26 cases (53.8%), the infarct was unrecognized at the time of initial study interpretation.

Conclusion

Our retrospective analysis demonstrates that myocardial infarctions may be frequently observed on non-gated, non-cardiac CT scans but may be underrecognized and under-reported.

Clinical impact of multimodality assessment of myocardial viability

Coronary artery disease (CAD) is a prevalent cause of left ventricular dysfunction. Nevertheless, effective elective revascularization, particularly surgical revascularization, can enhance long-term outcomes and, in selected cases, global left ventricular contractility. The assessment of myocardial viability and scars is still relevant in guiding treatment decisions and selecting patients who are likely to benefit most from blood flow restoration. Although the most recent randomized studies challenge the notion of "hibernating myocardium" and the clinical usefulness of assessing myocardial viability, the advancement of imaging techniques still renders this assessment valuable in specific situations. According to the guidelines of the European Society of Cardiology, non-invasive stress imaging may be employed to define myocardial ischemia and viability in patients with CAD and heart failure before revascularization. Currently, several non-invasive imaging techniques are available to evaluate the presence and extent of viable myocardium. The selection of the most suitable technique should be based on the patient, clinical context, and resource availability. This narrative review evaluates the characteristics of available imaging modalities for assessing myocardial viability to determine the most appropriate therapeutic strategy.

Clinical implications of cardiac magnetic resonance imaging fibrosis

Cardiac magnetic resonance (CMR) is a non-invasive imaging method that allows to characterize myocardial tissue. In particular, using the late gadolinium enhancement technique, it is possible to identify areas of focal fibrosis. Specific distribution patterns of this fibrosis allow us to distinguish ischaemic cardiomyopathy (iCMP) from non-ischaemic cardiomyopathy (nCMP) and sometimes to identify the aetiology of the latter. Diffuse fibrosis can also be identified using the parametric T1 mapping sequences. For this purpose, the native T1 of the tissue is measured before the administration of the contrast agent (c.a.) or the extracellular volume is calculated after c.a. Both focal and diffuse fibrosis evaluated with CMR appear to be strong prognostic predictors for the identification of threatening ventricular arrhythmias and sudden cardiac death. These evidence open the doors to a possible role of CMR in the selection of the patient to be sent to a defibrillator implant in primary prevention. In this review, we will briefly review the techniques used in CMR for the evaluation of fibrosis. We will then focus on the clinical role of myocardial tissue fibrosis detection in iCMP and nCMP.

Prognostic value of myocardial salvage index assessed by cardiovascular magnetic resonance in reperfused ST-segment elevation myocardial infarction

Aims

Cardiovascular magnetic resonance (CMR) is a powerful tool to quantify the myocardial area at risk (AAR) and infarct size (IS), and evaluate the extent of myocardial salvage in acute ST-segment elevation myocardial infarction (STEMI). This study aimed to assess the prognostic value of myocardial salvage index (MSI) assessed by CMR in reperfused STEMI and investigate whether MSI could improve the predictive efficacy of the Global Registry of Acute Coronary Events (GRACE) risk score.

Methods and results:

About 104 consecutive patients who were hospitalized with first-time STEMI and received reperfusion therapy were prospectively enrolled. The primary endpoint was the incident of major adverse cardiovascular event (MACE) including all-cause mortality, non-fatal myocardial reinfarction and congestive heart failure within 36 months after the index event. Cox regression analysis was used to evaluate the prognostic association of MSI with MACE risk. About 21 (20.2%) patients developed MACE during the 3-year follow-up period, and patients with MSI < median had a higher incidence of MACE than those with MSI ≥ median [16 (30.8%) vs. 5 (9.6%), P = 0.007]. After adjusting all the parameters associated with MACE in univariate Cox analysis, MSI assessed by CMR remained independently significant as a predictor of MACE in multivariate Cox analysis (hazard ratio 0.963, 95% CI: 0.943–0.983; P < 0.001). Adding MSI to the GRACE risk score significantly increased the prognostic accuracy of the GRACE risk score (area under the curve: 0.833 vs. 0.773; P = 0.044), with a net reclassification improvement of 0.635 (P = 0.009) and an integrated discrimination improvement of 0.101 (P = 0.002).

Conclusion

This study confirmed that MSI assessed by CMR had a good long-term prognostic value in reperfused STEMI and improve the prognostic performance of the GRACE risk score.

Image Quality and Reliability of a Novel Dark-Blood Late Gadolinium Enhancement Sequence in Ischemic Cardiomyopathy

PURPOSE

The aim of this study was to assess the reliability of a 2D dark-blood phase-sensitive late gadolinium enhancement sequence (2D-DBPSLGE) compared with 2D phase-sensitive inversion recovery late gadolinium enhancement sequence (2D-BBPSLGE) in patients with ischemic cardiomyopathy (ICM).

MATERIALS AND METHODS

A total of 73 patients with a clinical history of ICM were prospectively enrolled. The following endpoints were evaluated: (a) comparison of image quality between 2D-BBPSLGE and 2D-DBPSLGE for differentiation between blood pool-late gadolinium enhancement (LGE), remote myocardium-LGE, and blood pool-remote myocardium; (b) diagnostic accuracy of 2D-DBPSLGE compared with gold standard 2D-BBPSLGE for the evaluation of infarcted segments; (c) diagnostic accuracy of 2D-DBPSLGE for the evaluation of microvascular obstruction (MVO); (d) comparison of transmurality index between 2D-BBPSLGE and 2D-DBPSLGE; (e) comparison of papillary muscle hyperenhancement between 2D-BBPSLGE and 2D-DBPSLGE; inter-reader agreement for depiction of hyperenhanced segments in both LGE sequences. Data were analyzed using paired t test, Wilcoxon test, and McNemar test, and η coefficient and intercorrelation coefficient (ICC).

RESULTS

Image quality was superior for 2D-DBPSLGE for differentiation of blood pool-LGE (P<0.001). 2D-DBPSLGE, compared with 2D-BBPSLGE, showed a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 96.93%, 99.89%, 99.71%, 98.78, and 99.04%, respectively. Concerning MVO detection, 2D-DBPSLGE showed a sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of 66.67%, 100.00%, 100.00%, 80.95%, and 86.21%, respectively. 2D-DBPSLGE underestimated the transmurality (P=0.007) and identified papillary muscle hyperenhancement (P<0.001). Both LGE sequences showed comparable interobserver agreement for the evaluation of infarcted areas (2D-BBPSLGE: ICC 0.99;2D-DBPSLGE: ICC 0.99).

CONCLUSIONS

Compared with 2D-BBPSLGE, 2D-DBPSLGE sequences provide better differentiation between LGE and blood-pool, while underestimating LGE trasmurality and the presence of MVO.

Impact of age on reperfusion success and long-term prognosis in ST-segment elevation myocardial infarction - A cardiac magnetic resonance imaging study

Background

Coronary collateral circulation and conditioning from remote ischemic coronary territories may protect culprit myocardium in the elderly, and younger STEMI patients could suffer from larger infarcts. We evaluated the impact of age on myocardial salvage and long-term prognosis in a contemporary STEMI cohort.

Methods

Of 1603 included STEMI patients 807 underwent cardiac magnetic resonance. To assess the impact of age on infarct size and left ventricular ejection fraction (LVEF) as well as the composite endpoint of death and re-hospitalization for heart failure we stratified the patients by an age cut-off of 60 years.

Results

Younger STEMI patients had smaller final infarcts (10% vs. 12%, P = 0.012) and higher final LVEF (60% vs. 58%, P = 0.042). After adjusting for multiple potential confounders age did not remain significantly associated with infarct size and LVEF. During 4-year follow-up, the composite endpoint occurred less often in the young (3.2% vs. 17.2%; P < 0.001) with a univariate hazard ratio of 5.77 (95% CI, 3.75–8.89; p < 0.001). Event estimates of 4 subgroups (young vs. elderly and infarct size beyond vs. below median) showed a gradual increase in the occurrence of the composite endpoint depending on both age and acute infarct size (log-rank p < 0.001).

Conclusion

Having a STEMI after entering the seventh decade of life more than quadrupled the risk of future death or re-hospitalization for heart failure. Risk of death and re-hospitalization depended on both advanced age and infarct size, albeit no substantial difference was found in infarct size, LVEF and salvage potential between younger and elderly patients with STEMI.

Stress CMR in Known or Suspected CAD: Diagnostic and Prognostic Role

The recently published 2019 guidelines on chronic coronary syndromes (CCS) focus on the need for noninvasive imaging modalities to accurately establish the diagnosis of coronary artery disease (CAD) and assess the risk of clinical scenario occurrence. Appropriate patient management should rely on controlling symptoms, improving prognosis, and guiding each therapeutic strategy as well as monitoring disease progress. Among the noninvasive imaging modalities, cardiovascular magnetic resonance (CMR) has gained broad acceptance in past years due to its unique features in providing a complete assessment of CAD through data on cardiac anatomy and function and myocardial viability, with high spatial and temporal resolution and without ionizing radiation. In detail, evaluation of the presence and extent of myocardial ischemia through stress CMR (S-CMR) has shown a high rule-in power in detecting functionally significant coronary artery stenosis in patients suspected of CCS. Moreover, S-CMR technique may add significant prognostic value, as demonstrated by different studies which have progressively evidenced the valuable power of this multiparametric imaging modality in predicting adverse cardiac events. The latest scientific progress supports a greater expansion of S-CMR with improvement of quantitative myocardial perfusion analysis, myocardial strain, and native mapping within the same examination. Although further study is warranted, these techniques, which are currently mostly restricted to the research field, are likely to become increasingly prevalent in the clinical setting with the scope of increasing accuracy in the selection of patients to be sent to invasive revascularization. This review investigates the diagnostic and prognostic role of S-CMR in the context of CAD, by analysing a strong, long-standing, scientific evidence together with an appraisal of new advanced techniques which may potentially enrich CAD management in the next future.

Cardiac MRI in Patients with Acute Chest Pain

Acute chest pain is a common reason for visits to the emergency department. It is important to distinguish among the various causes of acute chest pain, because treatment and prognosis are substantially different among the various conditions. It is critical to exclude acute coronary syndrome (ACS), which is a major cause of hospitalization, death, and health care costs worldwide. Myocardial ischemia is defined as potential myocyte death secondary to an imbalance between oxygen supply and demand due to obstruction of an epicardial coronary artery. Unobstructed coronary artery disease can have cardiac causes (eg, myocarditis, myocardial infarction with nonobstructed coronary arteries, and Takotsubo cardiomyopathy), and noncardiac diseases can manifest with acute chest pain and increased serum cardiac biomarker levels. In the emergency department, cardiac MRI may aid in the identification of patients with non-ST-segment elevation myocardial infarction or unstable angina or ACS with unobstructed coronary artery disease, if the patient's clinical history is known to be atypical. Also, cardiac MRI is excellent for risk stratification of patients for adverse left ventricular remodeling or major adverse cardiac events. Cardiac MRI should be performed early in the course of the disease (<2 weeks after onset of symptoms). Steady-state free-precession T2-weighted MRI with late gadolinium enhancement is the mainstay of the cardiac MRI protocol. Further sequences can be used to analyze the different pathophysiologic subjacent mechanisms of the disease, such as microvascular obstruction or intramyocardial hemorrhage. Finally, cardiac MRI may provide several prognostic biomarkers that help in follow-up of these patients. Online supplemental material is available for this article. ^©RSNA, 2020.

Intracoronary compared with intravenous bolus tirofiban on the microvascular obstruction in patients with STEMI undergoing PCI: a cardiac MR study

To investigate the potential effect of intracoronary administration of the glycoprotein IIb/IIIa inhibitor tirofiban on the microvascular obstruction (MVO) assessed by cardiac magnetic resonance (CMR) imaging compared to the intravenous route in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). Two hundred eight patients were randomized into two groups (tirofiban i.v. and tirofiban i.c.). CMR was completed within 3-7 days after ST-segment-elevation myocardial infarction. One hundred thirty-two patients had a follow-up CMR at 6 months after discharge. The primary end point was the CMR measurements including myocardium strain, myocardial perfusion index, final infarct size, prevalence and extent of MVO, and the change of left ventricular end-diastolic volume (LVEDV) at six months follow-up. The second endpoint was major adverse cardiovascular events (composite of all-cause death, nonfatal reinfarction and congestive heart failure) in one year. The MVO prevalence and extent [56% versus 36%, p = 0.004; 2.08 (IQR: 1.18-5.07) g versus 1.68 (IQR: 0.30-3.28) g, p = 0.041] showed a significant difference between the intravenous and intracoronary groups. Global left ventricular peak longitudinal strain was significantly different in intracoronary groups compared to intravenous groups, - 12.5 [IQR: - 13.4 to - 10.9] versus - 12.3 [IQR: - 13.4 to - 10.4], respectively (P = 0.042). Infarcted myocardial perfusion index was significantly different in intracoronary groups compared to intravenous groups, 0.11 [IQR: 0.08 to 0.15] versus 0.09 [IQR: 0.07 to 0.14], respectively (P = 0.026). Intracoronary tirofiban was associated with a higher change in LVEDV compared with intravenous group (- 10.2% [IQR: - 13.7% to - 2.6%] versus 1.3% [IQR: - 5.6% to 6.1%], p < 0.001). Intracoronary tirofiban application showed no benefit on the occurrence of major adverse cardiovascular events during follow-up compared to intravenous administration. This CMR study in ST-segment-elevation myocardial infarction patients showed a benefit in MVO and left ventricular remodeling for intracoronary tirofiban administration compared to intravenous administration in patients undergoing PCI.

Future perspectives of nanoparticle-based contrast agents for cardiac magnetic resonance in myocardial infarction

Cardiac Magnetic Resonance (CMR), thanks to high spatial resolution and absence of ionizing radiation, has been widely used in myocardial infarction (MI) assessment to evaluate cardiac structure, function, perfusion and viability. Nevertheless, it suffers from limitations in tissue and assessment of myocardial pathophysiological changes subsequent to MI. In this issue, nanoparticle-based contrast agents offer the possibility to track biological processes at cellular and molecular level underlying the various phases of MI, infarct healing and tissue repair. In this paper, first we examine the conventional CMR protocol and its findings in MI patients. Next, we looked at how nanoparticles can help in the imaging of MI and give an overview of the major approaches currently explored. Based on the presentation of successful nanoparticle applications as contrast agents (CAs) in preclinical and clinical models, we discuss promises and outstanding challenges facing the field of CMR in MI, their translational potential and clinical application.