Teaching Cases
JAN BOGAERT
Cases 1-20
CLINICAL CARDIAC MRI
SECOND EDITION
Cases 1-20
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Cardiac Compression by Depressed
Sternum
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Cardiac amyloidosis (2 patients)
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DCM (3 patients)
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ARVC/D (2 patients)
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Endomyocardial fibrosis
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Inflammatory-constrictive pericarditis
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Cardiac angiosarcoma
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Caseous calcification of MVL
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Cardiac Chloroma
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(Epi)-Myocarditis
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Myocarditis (acute phase + FU)
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Obstructive HCM (2 patients)
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Apical HCM
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LVNC
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LVNC-Ebstein’s Disease
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Unclassified CMP
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Acute MI (Non-STEMI)
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Restrictive CMP
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Healed lateral MI
Abbreviations
 Ao, aorta / AR, aortic regurgitation / AS, aortic stenosis / ARVC-D,
arrhythmogenic RV cardiomyopathy-dysplasia / ASD, atrial septal defect / AV,
aortic valve / CAD, coronary artery disease / CMP, cardiomyopathy / CT,
computed tomography / DCM, dilated cardiomyopathy / DILV, double inlet
LV / EDV, end-diastolic volume / EF, ejection fraction / ESV, end-systolic
volume / HCM, hypertrophic cardiomyopathy / ICD, intracardiac device /
IVC, inferior vena cava / LA, left atrium / LV, left ventricle / LVM, left
ventricular mass / LVNC, left ventricular non-compaction / LVOT, LV outflow
tract / MAPCA, major aortic pulmonary collateral artery / MI, myocardial
infarction / MPI, myocardial perfusion imaging / MR, mitral regurgitation /
MV, mitral valve / MVL, mitral valve leaflet / PAHT, pulmonary arterial
hypertension / PAPVR – partial anomalous pulmonary venous return / PCMRI, phase-contrast MRI / PCI, percutaneous coronary intervention / PR,
pulmonary regurgitation / PS, pulmonary stenosis / PV, pulmonary valve /
RA, right atrium / RFA, radiofrequency ablation / RV, right ventricle /
RVOT, RV outflow tract / STEMI, ST-elevation MI / SVC, superior vena cava
/ TGA, transposition of the great arteries / TOF, tetralogy of Fallot / TR,
tricuspid regurgitation / US, ultrasound / UVH, univentricular heart / VSD,
ventricular septal defect / WT, wall thickness.
Cardiac Compression by Depressed Sternum
 17-year-old woman
 Referred to MRI to evaluate severity
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of cardiac compression by pectus
excavatum (depressed sternum).
Minimal distance between sternum
and spine is 33 mm.
Left-sided displacement of the
heart.
Compression of RA and RV with
restricted outward excursion of RV
free wall and RA wall.
Normal LV and RV volumes and
rest systolic function.
Cardiac Amyloidosis (patient 1)
 74-year-old man referred to
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MRI with clinical diagnosis of
HCM.
Poorly functioning ventricles
(LV EF 28% / RV EF 34%).
Important concentric
hypertrophy (LVM 205 g
/max. WT 18 mm).
Late Gd MRI shows strong
heterogeneous myocardial
enhancement (arrows), most
pronounced in
subepicardium and in RV.
Small pericardial effusion.
Biopsy: senile cardiac
amyloidosis.
See similar patient Fig 50 Heart Muscle Diseases
Cardiac Amyloidosis (patient 2)
 58-year old man presenting with pericardial effusion since CABG (1year ago),
cardiac MRI requested to exclude pericardial disease / congestive heart disease.
 Cardiac MRI: LV EDV 116 ml – EF 43% / RV EDV 132 ml – EF 33%. Biventricular
hypertrophy (septal WT 17 mm) with decreased contractility. Enlarged atria.
Pericardial and bilateral pleural effusion.
 Diffuse myocardial enhancement on late Gd imaging (right panel), without
possibility to adequate null signal of normal myocardium using a wide range of
inversion times.
 Findings highly suspected of cardiac amyloidosis, confirmed by myocardial biopsy.
See similar patient Fig 51 Heart Muscle Diseases
DCM (patient 1)
 65-year-old man presenting with moderately dilated and severely dysfunctional
LV on cardiac US.
 LV EDV 549 ml – EF 28% - LVM 316 g – diffuse hypokinetic wall motion –
dyskinetic motion of ventricular septum (mid/late systole) with phenomenon of
apical rocking.
 Late Gd imaging shows increased myocardial enhancement in subepicardial
inferolateral wall (arrows, right panel).
 MRI findings compatible with dilated cardiomyopathy.
DCM (patient 2)
 49-year-old woman with clinical history of idiopathic DCM. ECG shows
complete left bundle branch block.
 Cardiac MRI: severe dilated LV (EDV353 ml – EF 26% - LVM 181 g) / normal
RV (EDV 135 ml – EF 62%). Dyssynergia with severe septal dyskinesia, and
‘apical rocking’ motion.
 Late Gd imaging shows mild focal enhancement at the insertion of the RV
inferior wall.
DCM (patient 3)
 63-year-old man with extreme form of DCM of unknown origin.
 Cardiac MRI shows extremely dilated and dysfunctional LV (EDV 877 ml – EF
12%) / RV EDV 248 ml – EF 42%). Severe dyskinesia with important
dyssunergia. Important mitral regurgitation secondary to mitral valve ring
dilatation. Regurgitant fraction of 45 ml.
 Late Gd imaging shows subepicardial enhancement in mid inferior wall, and
mid-myocardially in ventricular septum.
See Fig 24 Heart Muscle Diseases
ARVC/D (patient 1)
 51-year old man presenting with retrosternal chest pain, palpitations. ECG:
sustained VT with electrical reconversion. Cardiac catheterization: no CAD –
inferior hypokinesia.
 MRI: LV EDV 127ml – EF 64% / RV EDV 211 ml – EF 42%. Severe hypokinesia
to akinesia of RV inferior wall, apex and RVOT. Late Gd MRI: focal, strong
enhancement of RV free wall. Presumptive diagnosis: ARVC/D.
 Electrophysiology: positive late potentials.
 Diagnosis: ARVC/D – Treatment: ICD placement.
See Figs. 32 and 35 Heart Muscle Diseases
ARVC/D (patient 2)
 65-year-old man. Screening for ARVC/D – son has a phakophilin gene deletion
(PKP-2 gen) and HCM phenotype. Cardiac US: severe dilated RV with decreased
function.
 MRI: LV EDV 168 ml - EF 65%/ RV EDV 278 ml – EF 32%. Diffuse
moderate/severe hypokinesia to akinesia in basal and mid RV free wall and
RVOT. Focal wall thinning and increased trabeculations. Late Gd MRI: diffuse
RV wall enhancement.
 Genetic profiling: PKP-2 gen deletion. Tentative diagnosis of ARVC/D.
Endomyocardial Fibrosis
 78-year-old woman presenting with hypereosinophilia and findings on
cardiac US of apical HCM.
 MRI shows important thickening of LV apex obliterating the cavity,
deformation of papillary muscles. First-pass perfusion MRI shows
extensive perfusion defect suspected of mural thrombus. Late Gd MRI
shows focal enhancement in thickened myocardium, representing
myocardial fibrosis.
 MRI findings of endomyocardial fibrosis with mural thrombus.
See Fig. 56 Heart Muscle Diseases
Inflammatory - Constrictive Pericarditis
 59-year-old man with recent extensive anterior MI.
 First MRI study (left panel) shows thickened, irregularly delineated
pericardial layers, mild pericardial effusion, and restricted RV expansion.
 Follow up MRI (10 days later) (right panel) shows increased pericardial
fluid (note presence of diffuse intrapericardial fibrinous strands), signs of
RA collapse, increased compression on RV, and increased septal shift.
 Pericardiectomy: heavily thickened, inflamed and constrictive pericardium.
Histology: active, chronic pericardial inflammation
See Fig. 13 Pericardial Disease
Cardiac Angiosarcoma
 54-year-old woman presenting with dyspnea, chest pain, dry cough. Chest film
shows cardiomegaly with diffuse hazy-defined pulmonary nodules suspected of
diffuse pulmonary metastases.
 Extensive mass involving the entire RA wall, extending to the RV free wall and
pericardium. Presence of several nodular appearing pericardial masses. Some
of them present a fluid-fluid level. Presumptive diagnosis of angiosarcoma with
diffuse pulmonary metastasis.
 Histology: angiosarcoma
See Fig. 21 Cardiac Masses
Caseous Calcification of Mitral Valve Leaflet (1)
 85-year-old woman admitted with retrosternal chest pain and dyspnea.
 Chest film: presence of dense well-defined ovaloid retrocardiac mass.
 Cardiac US: large, mildly hyperechogenic ovaloid mass on ventricular side of
PMVL, moderately severe MR (3/4).
 Cardiac catheterization: severe 3vessel CAD – calcified ovaloid mass.
See Fig. 44 Cardiac Masses
Caseous Calcification of Mitral Valve Leaflet (2)
 Presence of extensive hypo-intense mass in LV infero- and laterobasal wall,
compressing the surrounding myocardium, and narrowing the mitral valve
area. Presence of a thin wall strongly enhancing following contrast
administration. Presence of bilateral pleural effusion.
 Findings compatible with caseous calcification of posterior mitral valve leaflet
(also called ‘liquefaction necrosis of mitral annulus calcification’).
See Fig. 44 Cardiac Masses
Cardiac Chloroma
56-year-old man with history of acute myeloid leukemia (AML) treated with allogenic
bone marrow transplantation (2001), having a decreased exercise capacity since one year.
 Referred to MRI because of increasing pericardial fluid and 2nd degree AV-block (type
Wenckebach).
 Presence of a soft-tissue like structure diffusely involving the right atrioventricular
groove. Invasion of LV inferior /inferseptal wall, having a thickened appearance and
exhibiting impaired contractility. Presence of an important pericardial effusion with
evidence of cardiac tamponade.
 Cardiac biopsy: AML recurrence (‘cardiac chloroma’).

See Fig. 27 Cardiac Masses
(Epi)-Myocarditis
22-year-old man presenting with
arrhythmias since 2 years: ventricular
extrasystoles worsening during
exercise, and incomplete right bundle
branch block.
 Cardiac US shows slightly dilated and
dysfunctional LV.
 MRI: mildly dilated and moderately
dysfunctional LV (EDV 190ml - EF
39%) with regional mild to severe
hypokinesia most pronounced in lateral
wall. Strong subepicardial
enhancement in LV anterior-lateral and
inferior wall extending to adjacent
epicardial fat. Focal midwall
enhancement in basal part of
ventricular septum.
 Tentative diagnosis of chronic (epi)myocarditis.

See Fig. 44 Heart Muscle Diseases
Myocarditis (acute phase)
 41-year-old woman presenting with chest pain, irradiating to back, decreased
appetite and generalized weakness since 4 days. Recent history of respiratory
infection. Temporary inotropic support needed.
 Cardiac MRI: moderately dysfunctional LV (EF: 43%) with thickened,
hypocontractile walls. Moderate pericardial effusion, without hemodynamic
compromise. T2w-imaging: diffuse myocardial edema, late Gd imaging: mild
subepicardial enhancement in LV lateral wall and midwall ventricular septum.
 Myocardial biopsy: fulminant myocarditis.
See Fig. 45 Heart Muscle Diseases
Myocarditis (10 months FU)
 Follow up MRI 10 months after the acute event, shows normalization of LV
function (EF 67%) and myocardial wall thicknesses, disappearance of
myocardial edema but persistence of mild myocardial enhancement and subtle
pericardial effusion.
 Despite favorable cardiac evolution, persistence of fatigue, clinically fitting in a
chronic fatigue syndrome.
See Fig. 45 Heart Muscle Diseases
Obstructive HCM (Patient 1)
 57-year-old woman with HCM with
LVOT obstruction and secondary
MR.
 MRI shows asymmetrical septal
HCM (24 mm) with LVOT
narrowing. Flow acceleration
during onset of systole (signal void
on cine imaging in LVOT).
Complete SAM of anterior MVL
with secondary MR. PC-MRI in
LVOT shows high velocities in early
systole with complete occlusion of
LVOT during mid systole.
 Alcoholization of 1st septal
perforator with decrease LVOT
gradient (82 to 18 mm Hg).
See Figs. 15-16 Heart Muscle Diseases
Obstructive HCM (Patient 2)
 17-year-old man, familial history of obstructive HCM, NYHA II-III.
 Severely thickened ventricular septum (38 mm) with involvement of apical half
of RV wall, narrowing of the LVOT (resting gradient of 167 mm Hg), SAM with
moderately severe MR and LA dilatation.
 Late Gd MRI shows increased enhancement in the thickened myocardium at
the level of the anterior/posterior insertion of the RV.
Apical Hypertrophic Cardiomyopathy
 27-year-old man.
 Familial history of HCM.
 Suspicion of apical HCM on cardiac
US.
 Important apical thickening of LV
wall (thickness: 17 mm).
 Apposition of apical walls in late
systole with complete obliteration
of LV cavity.
See Fig. 12 Heart Muscle Diseases
Left Ventricular Non Compaction CMP (LVNC)
 26-year-old man with LVNC cardiomyopathy presenting with diastolic
dysfunction.
 LV EDV 190 ml – EF 57% / RV EDV 192 ml – EF 51%. Presence of a prominent
trabecular network allong the entire LV lateral wall and apex. Also more
prominent appearance of trabeculations in RV lateral wall. Moderate MR.
Restrictive inflow physiology on PC-MRI. Dilated LA with aneurysmal bulging
of atrial septum.
 Findings of LVNC with most likely also limited RV involvement.
See Fig. 38 Heart Muscle Diseases
LVNC and Ebstein’s Disease
 55-year-old man presenting with heart failure, and suspicion of LVNC on
cardiac US.
 Cardiac MRI shows presence of an extensive trabecular network, most
pronounced in LV apex. The trabeculations have a thickened appearanced
and the wall is moderately to severely hypokinetic.
 Incidental finding: obliquely implanted tricuspid valve with atrialization of
the RV: Ebstein’s malformation.
See Fig. 39 Heart Muscle Diseases
Unclassified CMP
 53-year-old woman referred for
MRI with history of HCM.
 Cardiac MRI and cardiac
catherization show mixture of wall
thickening and deep muscular clefts
in LV, and hypertrabeculations in
RV and LV.
 LV EDV 143 ml - LVEF 48%.
 The mixture of hypertrophic
myocardium and non-compacted
myocardium suggests existence of
mixed forms of HCM and LVNC,
fitting with novel cardiomyopathies
such as ‘saw-tooth’ CMP.
See Fig. 41 Heart Muscle Diseases
Acute MI (Non-STEMI)
36-year-old man admitted with
retrosternal pain, nicotine abuse.
 ECG: non-STEMI / troponin I : 16 mg/l.
 Occlusion 1st lateral branch.
 Cardiac MRI: LV EDV 219 ml - EF 57%,
mild hypokinesia in lateral wall, T2wimaging: edema in anterolateral wall
(arrows, still frames upper row), with
strong transmural enhancement on late
Gd MRI (arrows, lower panels).
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Restrictive CMP
 77-year-old man presenting with cardiac failure of unknown origin, chronic
atrial fibrillation, ECG: low-voltages.
 MRI: LV EDV 138 ml - EF 63%/ RV EDV 156 ml - EF 53% / moderate to severe
TR / moderate pericardial effusion / dilated atria and IVC / PC-MRI shows
restrictive inflow physiology / real-time MRI during respiration shows no
inspiratory septal flattening / late Gd imaging shows no abnormal myocardial
enhancement / normal T2* myocardium.
 Findings of (idiopathic) restrictive cardiomyopathy.
Healed Lateral MI
 58-year-old woman with ischemic cardiomyopathy, presenting with mild
symptoms of heart failure (NYHA I-II).
 MRI: LV EDV 259 ml - EF 26% / RV EDV 110 ml - EF 58%. Important wall
thinning of mid and lateral wall showing severe hypokinesia – akinesia /
moderate hypokinesia in non-thinned segments. Late Gd imaging shows nearly
complete transmural enhancement in thinned lateral wall.
 Although anigography yielded no coronary stenoses, MRI findings are those of
a healed lateral MI with adverse LV remodeling/severe LV dysfunction.