Tissue characterization of acute myocardial infarction and myocarditis by CMR Matthias G. Friedrich Stephenson Cardiovascular MR Centre at the Libin Cardiovascular Inatitute of Alberta, Departments of Cardiac Scienes and Radiology, University of Calgary, Calgary, AB, Canada Friedrich, J Am Coll Cardiol 2008 Abstract Currently used diagnostic tools to assess patients with acute Among the CMR techniques, several approaches can be myocardial disease such as ECG, seromarkers and combined to a comprehensive CMR exam, which provides ventricular function studies are limited in their diagnostic information not only on ventricular size morphology and accuracy and scope. Thus, for informed therapeutic function, but also on the stage, degree and extent of decision-making, tissue characterization may serve as a reversible and irreversible myocardial injury. Streamlined very important source of information in these, initially protocols allow such a CMR exam to be a time- and cost- regional diseases. efficient diagnostic tool, even in patients with acute disease. Cardiovascular Magnetic Resonance (CMR) is becoming a This paper reviews current CMR approaches for visualizing more and more important tool for phenotyping cardiac tissue pathology in vivo, presents examples and discusses patients in vivo. Recent advances of CMR hardware and the potential role of CMR tissue characterization in patients software as well as protocols have allowed for accurately with acute myocardial disease. The specific role of imaging visualizing tissue changes in patients with acute myocardial the extent and regional distribution of myocardial edema diseases. This is of special interest for acute myocardial and necrosis is discussed. infarction and acute myocarditis, since these entities may have a very similar clinical presentation and require immediate therapeutic decision-making. Friedrich, J Am Coll Cardiol 2008 Morphology Function Tissue Metabolism Echo Nuclear CT CMR Figure 1 Strengths of currently used cardiac imaging tools Friedrich, J Am Coll Cardiol 2008 Table 2 Appearance of acute myocardial infarctions in CMR images Friedrich, J Am Coll Cardiol 2008 Upper panel: Systolic frame CMR of in a short axis view. acute, non-transmural infarction Systolic frame Lower panel: T2-weighted (left) and post-contrast T1weighted ("late enhancement") showing image infarction-related transmural edema, but only subendocardial necrosis. Edema Necrosis Figure 2 Friedrich, J Am Coll Cardiol 2008 Upper panel: Systolic frame CMR of in a short axis view with acute, hypokinesis (arrows). transmural infarction Systolic frame Lower panel: T2-weighted (left) and post-contrast T1weighted ("late enhancement") image showing infarct-related transmural edema with Edema Necrosis Figure 3 transmural necrosis of the same size. Friedrich, J Am Coll Cardiol 2008 Upper panel: Systolic frame in a CMR of acute, transmural infarction with noreflow (late reperfusion) short axis view showing preserved wall thickness of the lateral wall, but regional akinesis of the anterolateral and inferolateral segments (arrows). Systolic frame Lower panel: T2-weighted (left) and post-contrast T1-weighted ("late enhancement") images with infarct-related transmural edema and matching necrosis in dysfunctional area. Both, T2weighted and late enhancement No-reflow/edema No-reflow/necrosis Figure 4 images show central no-reflow (arrowheads). Friedrich, J Am Coll Cardiol 2008 CMR of ischemic cardiomyopathy with chronic, transmural inferior infarction Upper panel: Systolic frame in a short axis view with akinesis of the inferoseptal and inferior segments (arrows). Systolic frame Lower panel: T2-weighted (left) and post-contrast T1weighted ("late enhancement", right) images showing no edema, but transmural fibrosis (arrows) Lack of edema Scar within the akinetic region. Figure 5 Friedrich, J Am Coll Cardiol 2008 Upper panel: Systolic frame CMR of acute of a cine study showing myocarditis pericardial effusion (bright signa, arrow) and largely preserved systolic function. Systolic frame Lower panel: T2-weighted (left) and post-contrast T1weighted ("late enhancement", right) images showing lateral edema (arrows) and focal fibrosis typical for the non-ischemic Edema Necrosis Figure 6 injury pattern of myocarditis (arrows). Friedrich, J Am Coll Cardiol 2008 CMR of a patient with acute myocarditis Findings: •Pathologic edema ratio •Pathologic early enhancement Edema •No definite late enhancement Systolic frame Early enh./post contrast No regional necrosis Figure 7 Friedrich, J Am Coll Cardiol 2008 CMR of a patient with acute myocarditis and chronic scar Findings: •Focal edema •Pathologic early enhancement Early enh./pre contrast Edema Early enh./post contrast Lateral scar •Focal late enhancement Systolic frame Figure8 Friedrich, J Am Coll Cardiol 2008 CMR of a patient with remote myocarditis Chronic multifocal, partially subendocardial scarring (T1-weighted "late enhancement" image) Figure 9 Friedrich, J Am Coll Cardiol 2008 Tako-Tsubo - Admission CMR of a patient with stress-induced CMP (Tako-Tsubo) - admission Findings: •Apical ballooning •Regional edema •Atypical late enhancement Edema Systolic frame Diffuse necrosis Figure 10a Friedrich, J Am Coll Cardiol 2008 Tako-Tsubo - Follow-up CMR of a patient with stress-induced CMP (Tako-Tsubo) – follow-up/4 wk Findings: •Normalizatioon of function •No edema •Some persisting late enhancement Systolic frame Edema Diffuse necrosis Figure 10 b Friedrich, J Am Coll Cardiol 2008