Background
Methodology
Special considerations for imaging pediatric patients
Sedation and general anesthesia
CMR in specific disease states
Dilated cardiomyopathy and post-chemotherapy cardiomyopathy
Goals of examination
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Short-axis stack | LV volumes, mass, and EF RV volumes, mass (short axis only), and EF Regional wall motion Intracardiac thrombus |
LV long axis views | ||
Axial stack | RV volumes, and EF Intracardiac thrombus | |
Late gadolinium enhancement | Short-axis stack LV long-axis views RV-specific views | Focal fibrosis Prognostic stratification |
Additional case-specific or comprehensive imaging | ||
Cine bSSFP | Short-axis or axial stack | LA volume |
T2 signal intensity ratio | Short-axis stack LV long-axis views RV-specific views | Inflammation (edema) |
Early gadolinium enhancement | Short-axis stack LV long-axis views RV-specific views | Inflammation (hyperemia) |
T1-mapping pre- and post-gadolinium contrast | Short-axis view LV 4-chamber view | Inflammation Diffuse myocardial fibrosis Extracellular volume |
Phase contrast flow mapping | Transmitral flow plane | LV diastolic function |
Myocardial tagging | Short-axis views LV 4-chamber view | Myocardial strain (Alternative to use feature tracking for post-processing cine bSSFP sequences) |
First-pass perfusion | Short-axis views LV 4-chamber view | Myocardial perfusion |
Limitations and pitfalls
Newer techniques
Left ventricular non-compaction
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Short-axis stack | LV volumes, mass, and EF RV volumes, mass, and EF Calculation of NC:C ratio (as noted in text) |
LV long-axis views | ||
Additional case-specific or comprehensive imaging | ||
T1-mapping pre- and post-gadolinium contrast | Short-axis view LV 4-chamber view | Fibrosis Extracellular volume |
Late gadolinium enhancement | Short-axis stack LV long-axis views RV-specific views | Fibrosis |
First-pass perfusion | Short-axis views LV 4-chamber view | Myocardial perfusion |
Goals of examination for LVNC
Limitations and pitfalls
Newer techniques for LVNC
Arrhythmogenic right ventricular cardiomyopathy
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Regional RV akinesia or dyskinesia or dyssynchronous RV contraction and 1 of the following:
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RV end-diastolic volume/body surface area (BSA) ≥ 110 mL/m2 (male) or ≥ 100 mL/m2 (female)
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RV ejection fraction (RVEF) ≤ 40%Minor
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Regional RV akinesia or dyskinesia or dyssynchronous RV contraction and 1 of the following:
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RV end-diastolic volume/BSA ≥ 100 to < 110 mL/m2 (male) or ≥ 90 to < 100 mL/m2 (female)
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RV ejection fraction (RVEF) > 40 to ≤ 45%
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Goals of examination for ARVC
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Short-axis stack | LV volumes, mass, and EF RV volumes and EF |
LV long-axis views | Regional wall motion abnormalities | |
Axial stack | RV regional wall motion abnormality and RV aneurysm RV volumes and EF | |
2 Chamber RV view RVOT sagittal view | RV regional wall motion abnormality and RV aneurysm | |
Additional case-specific or comprehensive imaging | ||
T1-weighted imaging with and without fat saturation | Axial stack covering RV Short-axis stack | Fatty infiltration, although this is not part of the ARVC Task Force criteria |
Late gadolinium enhancement | Short-axis stack LV long-axis views RV-specific views | Focal fibrosis, but also not part of diagnostic criteria |
Limitations and pitfalls
Newer techniques for ARVC
Hypertrophic cardiomyopathy
Goals of examination for HCM
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Short-axis stack | LV volumes, mass, and EF RV volumes, mass, and EF |
LV 2-chamber view LV 4-chamber view | ||
LV 3-chamber view (LVOT view) | LVOT obstruction and presence of systolic anterior motion of the mitral valve chordae and leaflets | |
Late gadolinium enhancement | Short-axis stack LV long-axis views RV-specific views | Extent of LGE via summation of short axis slices for calculation of percent myocardium with LGE; 2- and 4-chamber images for correlative data to rule out artifact |
Additional case-specific or comprehensive imaging | ||
T1-weighted imaging pre- and post-gadolinium | Short-axis stack LV long-axis views | Diffuse fibrosis Extracellular volume |
Tagged images (SPAMM or C-SPAMM) or feature tracking | Short-axis, LV long-axis | Myocardial deformation |
Limitations and pitfalls
Newer techniques for HCM
Myocarditis
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Short-axis stack | LV volumes, mass, and EF RV volumes, mass, and EF Regional wall motion abnormalities |
LV long-axis views | ||
T2 edema-weighted imaging (e.g., STIR) | Short-axis stack LV 2-chamber view LV 4-chamber view | Focal myocardial edema Pericardial effusion |
T1 mapping (native) | Short-axis stack | Focal and diffuse myocardial edema, but also detects hyperemia or fibrosis |
T2 mapping (pre-contrast) | Short-axis stack | Myocardial edema |
≥ 15 min post-contrast T1 mapping | Mid-cavity, apical and basal short-axis views | Extracellular volume |
Late gadolinium enhancement | Short-axis stack LV long-axis views RV-specific views | Myocardial or pericardial hyperenhancement |
Goals of examination
Limitations and pitfalls
Newer techniques
Kawasaki disease and systemic vasculitis
Goals of examination
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
2D Cine bSSFP | Short-axis stack | LV volumes, mass, and EF RV volumes, mass, and EF Regional wall motion |
LV long axis views | ||
3D bSSFP respiratory-gated and ECG-triggered whole heart sequencea | 3D Volume | Coronary artery assessment for aneurysm formation |
Non-ECG gated 3D magnetic resonance contrast angiography | 3D Volume | Extracardiac vascular lumen imaging for detection of aneurysm formation |
Late gadolinium enhancement | Short-axis stack LV long-axis views RV-specific views | Myocardial scarring |
Additional case-specific or comprehensive imaging | ||
Coronary or large vessel wall enhancement in patients with systemic arterial inflammation | ||
T1 mapping | Short-axis stack | Acute myocardial inflammation (edema) or fibrosis |
T2 signal intensity ratio OR T2 mapping | Short-axis stack | Acute myocardial inflammation (edema) |
Rest and stress myocardial perfusion | Short-axis stack | Suspected coronary stenosis including microvascular disease of the myocardium |
Phase contrast flow | As indicated | KD-related decreased ventricular output or valve insufficiency |
Limitations and pitfalls
Newer techniques
Coronavirus disease-2019 (COVID-19)
Goals of examination
Limitations and pitfalls
Cardiac tumors
Goals of examination
Sequence | imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Axial and oblique planes across the tumor | Tumor size and location Assessment for potential interference with blood flow or valve function |
Short-axis stack LVOT and RVOT long-axis | Assessment for potential interference with blood flow, valve function, or ventricular function | |
T1-weighted spin echo with and without fat suppression | Across the tumor and uninvolved myocardium | Tumor characterization |
T2-weighted spin echo with fat suppression | Same plane and coverage as T1-weighted sequence | Tumor characterization |
First-pass perfusion | Short-axis 4-chamber | Myocardial and tumor perfusion |
Late gadolinium enhancement | Across the tumor and uninvolved myocardium | Fibrosis |
Additional late gadolinium enhancement imaging 20–30 min post-contrast | As indicated across the tumor and uninvolved myocardium | Strong hyperenhancement may be present in certain cases of large fibromas |
Post-contrast late gadolinium enhancement with long inversion time (600 ms) | As indicated across the tumor and uninvolved myocardium | Suspicion of thrombus |
Additional case-specific or comprehensive imaging | ||
Coronary artery imaging | Coronary artery relationship to tumor | |
Velocity encoded phase contrast flow | Tumor-related obstruction to blood flow and valvular regurgitation | |
Magnetic resonance contrast angiography | Extracardiac vascular anatomy |
Tumor type | Location | bSSFP | T1 | T1 + Fat sat | T2 | FPP | LGE | Other |
---|---|---|---|---|---|---|---|---|
Fibroma | Intramyocardial, ventricular septum or free wall | – | ± | ± | ± | No | + + (well-defined border ± dark core) | Can be in an atypical location (e.g., atria) |
Rhabdomyoma | Intramyocardial or intracavitary, attached to myocardium, often multiple tumors | ± | ± | ± | + | No | –– | |
Malignant | Infiltrativeb | ± | ± | Variable | ± (if + then heterogenous appearance) | Known malignancy, pericardial effusion | ||
Vascularc | Variable | ± | – | – | + (variable) | Strong | + (variable and heterogenous) | Consider malignant tumor |
Thrombus | Mural or intraluminal | – | – | – | – | No | –– | LGE sequence, long inversion time |
Myxoma | Typically left atrium but can be in any chamber | ± | ± | ± | + | No | ± | Irregular, pedunculated, mobile |
Fibroelastoma | Pedunculated, mobile endocardial or valvular mass | – | – | – | – | No | ||
Pleuropericardial cyst | Right cardiophrenic angle | + + | – | – | + + | No | – | Smooth-walled and well-defined |
Purkinje cell tumor | Ventricular myocardium | + + | –– | – | No | Ventricular arrhythmia | ||
Teratoma | Intrapericardial (usually compressing SVC and/or right atrium) | ± | No | Multilocular bosselated mass with solid and cystic areas | ||||
Lipoma | Any chamber | – | + + | –– | ± | No | – |
Limitations and pitfalls
Pericardial disease
Sequence | Imaging plane | Indication |
---|---|---|
Spin echo CMR or cine bSSFP | Axial | Pericardial thickness, fluid extent, localization |
Cine bSSFP | Short-axis views | Ventricular and atrial size and shape, ventricular function |
LV long-axis views RV-specific views | ||
Cine CMR with tagging | Short-axis stack LV 4-chamber view | Screen for fusion of pericardium and myocardium in constriction |
Real-time free-breathing bSSFP | Short axis | Ventricular coupling: ventricular septal shape motion pattern with respiration in constriction |
T1- or T2-weighted with post Gadolinium spin echo or cine SSFP | Axial | Pericardial layer or fluid characterization |
Late gadolinium enhancement | Axial | Distinguish fat vs. fibrosis vs. inflammation |
Velocity encoded phase contrast flow | 4-chamber view | Abnormal atrioventricular valve filling in constrictive pericarditis |
Pericardial effusion
Goals of examination
Constrictive pericarditis
Goals of examination for constrictive pericarditis
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Pericardial thickness 2 mm or less: normal
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Pericardial thickness greater than 4 mm: suggestive of pericardial constriction in patients with appropriate clinical presentation
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Pericardial thickness greater than 5–6 mm: high specificity for constriction.
Acute pericarditis
Goals of examination for acute pericarditis
Limitations and pitfalls of pericardial CMR
Pulmonary hypertension
Goals of examination
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Axial, vertical, and horizontal long axes of the RV | RV volumes, mass, and EF Assessment of pulmonary artery anatomy and pulsatility |
Short-axis stack | LV volumes, mass, and EF RV volumes, mass, and EF | |
Phase contrast flow | Ascending aorta, main pulmonary artery, and branch pulmonary arteries | Pulmonary regurgitation Differential pulmonary blood flow Qp:Qs measurement in context of a suspected shunt |
Additional case-specific or comprehensive imaging | ||
Phase contrast flow | Pulmonary veins | Aortopulmonary collateral flow measurement |
Magnetic resonance contrast angiography | 3D volume | Indicated as part of first study Pulmonary artery anatomy Pulmonary vein anatomy |
Late gadolinium enhancement | Short-axis stack LV long-axis views RV-specific views | Myocardial scarring |
3D bSSFP imaging | 3D volume | Intracardiac anatomy |
4D flow imaging | Pulmonary arteries RV inflow | Assessment of pulmonary arterial pressures Wall shear stress RV diastolic function |
Limitations and pitfalls
Newer techniques
Heart transplantation
Goals of examination
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Short-axis stack LV long-axis views | LV volumes, mass, and EF RV volumes, mass, and EF Regional wall thickness and motion |
T2 imaging and/or mapping | 1–3 short-axis views | Myocardial edema |
T1 mapping (native, pre-contrast) | 1–3 short-axis views | Myocardial characterization |
Early gadolinium enhancement | Short-axis view | Hyperemia |
Late gadolinium enhancement | Short-axis stack Long-axis views | Myocardial inflammation or fibrosis |
T1 mapping (post-contrast) | 1–3 short-axis views LV long-axis view(s) | Myocardial characterization |
Additional case-specific or comprehensive imaging | ||
Myocardial perfusion (with regadenoson stress using 1/4 of total gadolinium dosea) | 1–3 short-axis views LV long-axis view(s) | Coronary artery evaluation |
Myocardial perfusion (at rest using 1/4 of total gadolinium dose, followed by administration of remainder of gadolinium contrasta) | 1–3 short-axis views LV long-axis view(s) | Coronary artery evaluation |
Dynamic magnetic resonance angiography | Persistent superior cavopulmonary anastomosis assessment | |
Respiratory navigator-gated, ECG-triggered magnetic resonance contrast angiography | Venous or arterial evaluation | |
Phase contrast flow | Ascending aorta Main pulmonary artery (if indicated) Atrioventricular valves (if indicated) | Valve dysfunction |
Black blood imaging (especially with metallic artifact) | Axial stack | Venous or arterial evaluation |
Cardiac function
Myocardial characterization
Coronary artery evaluation
Valve disease
Venous or arterial evaluation
Limitations and pitfalls
Newer techniques
Aortopathy and connective tissue disease (CTD)
Goals of examination
Sequence | Imaging plane | Indication |
---|---|---|
Standard imaging | ||
Cine bSSFP | Parallel to the LVOT in orthogonal planes, short axis of the aortic root, Short-axis of the largest diameter of the ascending aorta, sagittal oblique in long axis of the aortic arch (“candy cane”) | Aortic valve morphology, measurement of aortic root and ascending aorta, and assessment of aortic arch anatomy |
Contrast-enhanced magnetic resonance angiography | 3D volume, extend field of view superiorly to angle of the jaw | Extracardiac vascular anatomy for aneurysm formation and vertebral tortuosity |
3D bSSFP, GRE or mDIXON FSE respiratory navigator-gated and ECG-triggered whole heart sequencea | 3D volume | Extracardiac vascular assessment for aneurysm formation, measurement of aortic root |
Phase contrast flow | Ascending aorta Descending aorta | Flow velocity and pattern |
Additional case-specific or comprehensive imaging | ||
Cine bSSFP | Ventricular short-axis or axial (transverse) stack | LV volumes, mass, and EF RV volumes, mass, and EF |
Cine bSSFP | Extend field of view to include head, neck, abdomen, and pelvis | Loeys-Dietz syndrome |
Proton-density-weighted FSE black blood imaging | Sagittal oblique in long axis of the aortic arch (“candy cane”) | Vascular anatomy |
Cine bSSFP | Short and long axis of the region of interest | Concern for dissection or interarterial thrombus |
Measurement guidelines
Limitations and pitfalls
Newer techniques
Structured CMR reporting in pediatric patients
Administrative | |
Recommended | Site of service Scanner field strength and model Procedure date and time Referring physician Referring clinical information, including indication(s) |
Optional | Laboratory accreditation status |
Patient demographics | |
Recommended | Unique patient identification number Date of birth Gender Height, weight, and body surface area |
Optional | Race and ethnicity Heart rate Blood pressure Renal function assessment |
Study performance | |
Recommended | Description of the study, including sequences Contrast agent, if any Sedation or anesthesia, if any Significant study limitations, if any Adverse events, if any |
Optional | Personnel involved in the procedure |
Structured cardiovascular findings | |
Recommended | Segmental diagnoses Ventricular volume, function, and mass assessment Regional wall motion assessment, if appropriate Late gadolinium enhancement, if appropriate |
Optional/as applicable | Significant non-cardiovascular findings, if any Key images |
Measurements | |
Recommended | Biventricular volume, function, and left ventricular mass measurements |
Optional/as applicable | Phase contrast flow measurements of the ascending aorta, main and branch pulmonary arteries Aortic measurements (with normal range as available) |
Summary of findings | |
Recommended | Abnormal findings Pertinent negative findings Comparison with previous studies, if appropriate |
Optional | Differential diagnoses Recommendations for further imaging |