Mihaela Jekic

Real-time cine and myocardial perfusion with treadmill exercise stress cardiovascular magnetic resonance in patients referred for stress SPECT

BackgroundTo date, stress cardiovascular magnetic resonance (CMR) has relied on pharmacologic agents, and therefore lacked the physiologic information available only with exercise stress.Methods43 patients age 25 to 81 years underwent a treadmill stress test incorporating both Tc99m SPECT and CMR. After rest Tc99m SPECT imaging, patients underwent resting cine CMR. Patients then underwent in-room exercise stress using a partially modified treadmill. 12-lead ECG monitoring was performed throughout. At peak stress, Tc99m was injected and patients rapidly returned to their prior position in the magnet for post-exercise cine and perfusion imaging. The patient table was pulled out of the magnet for recovery monitoring. The patient was sent back into the magnet for recovery cine and resting perfusion followed by delayed post-gadolinium imaging. Post-CMR, patients went to the adjacent SPECT lab to complete stress nuclear imaging. Each modalitys images were reviewed blinded to the others results.ResultsPatients completed on average 9.3 ± 2.4 min of the Bruce protocol. Stress cine CMR was completed in 68 ± 14 sec following termination of exercise, and stress perfusion CMR was completed in 88 ± 8 sec. Agreement between SPECT and CMR was moderate (κ = 0.58). Accuracy in eight patients who underwent coronary angiography was 7/8 for CMR and 5/8 for SPECT (p = 0.625). Follow-up at 6 months indicated freedom from cardiovascular events in 29/29 CMR-negative and 33/34 SPECT-negative patients.ConclusionsExercise stress CMR including wall motion and perfusion is feasible in patients with suspected ischemic heart disease. Larger clinical trials are warranted based on the promising results of this pilot study to allow comparative effectiveness studies of this stress imaging system vs. other stress imaging modalities.

Cardiac function and myocardial perfusion immediately following maximal treadmill exercise inside the MRI room

Treadmill exercise stress testing is an essential tool in the prevention, detection, and treatment of a broad spectrum of cardiovascular disease. After maximal exercise, cardiac images at peak stress are typically acquired using nuclear scintigraphy or echocardiography, both of which have inherent limitations. Although CMR offers superior image quality, the lack of MRI-compatible exercise and monitoring equipment has prevented the realization of treadmill exercise CMR.It is critical to commence imaging as quickly as possible after exercise to capture exercise-induced cardiac wall motion abnormalities. We modified a commercial treadmill such that it could be safely positioned inside the MRI room to minimize the distance between the treadmill and the scan table. We optimized the treadmill exercise CMR protocol in 20 healthy volunteers and successfully imaged cardiac function and myocardial perfusion at peak stress, followed by viability imaging at rest. Imaging commenced an average of 30 seconds after maximal exercise. Real-time cine of seven slices with no breath-hold and no ECG-gating was completed within 45 seconds of exercise, immediately followed by stress perfusion imaging of three short-axis slices which showed an average time to peak enhancement within 57 seconds of exercise. We observed a 3.1-fold increase in cardiac output and a myocardial perfusion reserve index of 1.9, which agree with reported values for healthy subjects at peak stress. This study successfully demonstrates in-room treadmill exercise CMR in healthy volunteers, but confirmation of feasibility in patients with heart disease is still needed.

MR-compatible treadmill for exercise stress cardiac magnetic resonance imaging.

This article describes an MR‐safe treadmill that enables cardiovascular exercise stress testing adjacent to the MRI system, facilitating cardiac MR imaging immediately following exercise stress. The treadmill was constructed of nonferromagnetic components utilizing a hydraulic power system. Computer control ensured precise execution of the standard Bruce treadmill protocol commonly used for cardiovascular exercise stress testing. The treadmill demonstrated no evidence of ferromagnetic attraction and did not affect image quality. Treadmill performance met design specifications both inside and outside the MRI environment. Ten healthy volunteers performed the Bruce protocol with the treadmill positioned adjacent to the MRI table. Upon reaching peak stress (98 ± 8% of age‐predicted maximum heart rate), the subjects lay down directly on the MRI table, a cardiac array coil was placed, an intravenous line connected, and stress cine and perfusion imaging performed. Cine imaging commenced on average within 24 ± 4 s and was completed within 40 ± 7 s of the end of exercise. Subject heart rates were 86 ± 9% of age‐predicted maximum heart rate at the start of imaging and 81 ± 9% of age‐predicted maximum heart rate upon completion of cine imaging. The MRI‐compatible treadmill was shown to operate safely and effectively in the MRI environment. Magn Reson Med, 2012.

A new approach to autocalibrated dynamic parallel imaging based on the Karhunen-Loeve transform: KL-TSENSE and KL-TGRAPPA.

TSENSE and TGRAPPA are autocalibrated parallel imaging techniques that can improve the temporal resolution and/or spatial resolution in dynamic magnetic resonance imaging applications. In its original form, TSENSE uses temporal low‐pass filtering of the undersampled frames to create the sensitivity map. TGRAPPA uses a sliding‐window moving average when finding the autocalibrating signals. Both filtering methods are suboptimal in the least‐squares sense and may give rise to mismatches between the undersampled k‐space raw data and the corresponding coil sensitivities. Such mismatches may result in aliasing artifacts when imaging patients with heavy breathing, as in real‐time imaging of wall motion by MRI following a treadmill exercise stress test. In this study, we demonstrate the use of an optimal linear filter, i.e., the Karhunen‐Loeve transform filter, to estimate the channel sensitivity for TSENSE and acquire the autocalibration signals for TGRAPPA. Phantom experiments show that the new reconstruction method has comparable signal‐to‐noise ratio performance to traditional TSENSE/TGRAPPA reconstruction. In vivo real‐time cardiac cine experiments performed in five healthy volunteers post‐exercise during rapid respiration show that the new method significantly reduces the chest wall aliasing artifacts caused by respiratory motion (P < 0.001). Magn Reson Med, 2011.

Magnetic field threshold for accurate electrocardiography in the MRI environment.

Although the electrocardiogram is known to be nondiagnostic within the bore of any high‐field magnet due to the magnetohydrodynamic effect, there are an increasing number of applications that require accurate electrocardiogram monitoring of a patient inside the MRI room but outside of the magnet bore. Magnetohydrodynamic effects on the ST segment of the electrocardiogram waveform were investigated in six subjects at magnetic field strengths ranging from 6.4 mT to 652 mT at the aortic midarch, and the electrocardiogram was found to be accurate at magnetic fields below 70 mT. This corresponds to a distance of 160 cm from the isocenter and 80 cm from the bore entrance for the 1.5‐T MRI system used in this study. These results can be translated to any MRI system, with knowledge of the fringe field. Accurate electrocardiogram monitoring is feasible in close proximity to the MRI magnet, such as during and after pharmacologic or exercise stress, or interventional or surgical procedures performed in the MRI room. Magn Reson Med, 2010.

Treadmill Stress Cardiac Magnetic Resonance Imaging: First In Vivo Demonstration of Exercise-Induced Apical Ballooning

![Figure][1] ![Figure][1] [Video 1][2] ![Figure][1] [Video 2][3] Left ventricular apical ballooning mimicking proximal left anterior descending coronary artery ischemia has been described in patients with acute coronary syndrome-like presentations but without obstructive

NON-INVASIVE IMAGING OF THE LOCALIZATION AND TIME COURSE OF CELL DEATH IN A CANINE MODEL OF ACUTE MYOCARDIAL INFARCTION AND REPERFUSION: DEMONSTRATION OF EARLY AND LATE PHASES OF REPERFUSION CELL DEATH

Methods: The left anterior descending artery (LAD) was occluded using a 3 mm PTCA balloon catheter (n = 12). A constant gadolinium (Gd) infusion was administered during MRI to assess MI. Regional myocardial signal enhancement and function were recorded every 10 min during 90 min of ischemia followed by 120 min of R, and again at 24 and 48 hr post R. A catheter was inserted into the coronary sinus to measure creatine kinase (CK) leak across the coronary circulation.