Stress Cardiovascular Magnetic Resonance: Clinical Myocardial Perfusion

Abstract

Abstract The rationale for perfusion imaging is based on the fact that patient outcome is mainly driven by myocardial ischemic events. With repetitive episodes of plaque ruptures the luminal narrowing increases and ischemia in situations of increased oxygen demand can develop, which can result in malignant arrhythmias. Also, acute vessel occlusions can occur by plaque ruptures with thrombus formation. The risk of total occlusion in case of plaque rupture increases with increasing stenosis degree or increased plaque volume. Therefore ischemia detected by cardiac magnetic resonance (CMR) identifies patients at risk for arrhythmias and cardiac death, and it also identifies high-degree stenoses prone to result in vessel occlusions (in case of rupture) potentially causing acute myocardial infarctions. In this chapter the different types of vasodilators used for perfusion CMR studies are discussed as well as the various contrast media and their dosing. Then, the various techniques of data analysis (i.e., visual vs. quantitative) and their diagnostic performances are illustrated. In particular, the diagnostic performance is given for single- and multi-center trials and for 1.5\u202fT versus 3\u202fT systems, with coronary anatomy or invasive FFR-based ischemia testing used as reference, and CMR performance is also compared to other modalities like scintigraphy. Finally, extensive evidence demonstrates the strong prognostic power of perfusion CMR (i.e., to exclude relevant coronary artery disease or to guide revascularization in case of ischemia-positive CMR studies). The prognostic data represent approximately 9800 patients of whom 3647 were collected in the European CMR registry, thus reflecting excellent daily clinical routine performance in 59 centers of 18 countries.