Special Radiological

Procedures

lecture 8
Cardiac MRI
By
MSc. Zeyad Tareq Al-Dulaimi
3rd.Stage
2023-2024
Indications

1. For the assessment of ischemic heart disease

a. Assessment viability prior to treatment (e.g. revascularization)
b. Assessment of location and extent of infarct
2. For the assessment of cardiac masses
3. For the assessment of cardiomyopathies
4. For the assessment of valvular disease
5. For the assessment of congenital heart disease
6. For the assessment of cardiac function

Contraindications

1. Non-MRI-compatible pacemaker

2. Non-MRI compatible implants/foreign bodies

3. Claustrophobia

Patient Preparation

1. Avoid caffeine for 24 h

2. Ask the patient to remove all metallic items

3. explain of the procedure to the patient

4. IV cannula in right antecubital vein

5. Shave the request area previous positioning ECG electrodes if the chest is
covered with hair, a gel used for ECG electrodes to high electrical conductivity.

1
 Cardiac MRI technique
1. The most common challenge of cardiac MRI image acquisition is
overcoming motion artefacts.
2. Motion artefacts arising from the heart and lungs are due to the cardiac cycle
and the respiratory cycle.
3. Respiratory motion can be eliminated by breath holding or respiratory
navigator technique.
4. Artefacts from cardiac motion however can only be eliminated by ECG
gating.
5. ECG gating acquires data during diastole when the heart is at rest.

2
Respiratory artefact reduction

Respiratory motion can be eliminated by breath holding or respiratory

navigator technique.

1. Breath holding technique

Cardiac scans are normally performed under expiration. This is because during
inspiration there is an increased tendency of the diaphragm to move and cause
changes in anatomical positioning.

It is therefore very important to give proper training to the patients before

placing them into the scanner.

1. Instruct the patient to breathe in, but not too deeply

2. Instruct the patient to breathe out and then stop breathing

3. Ask the patient to breathe normally after the scan (usually under 20s)

*It is important that the patient inhale and exhale approximately the same
amount of air during each breath-hold as the position of the diaphragm is
an important factor in ensuring an anatomical same position

3
Navigator technique
Navigator technique is used for patients who are unable to hold their breath.
During free breathing the motion of the diaphragm changes the position of the
heart, greater vessels and liver causing inconsistent image quality.The
navigation box detects the position of the diaphragm during each slice
acquisition and imaging only occurs when the diaphragm falls within the
acceptance window.

ECG gating
Artefacts from cardiac motion however can only be eliminated by ECG gating.
This can be done with either prospective or retrospective triggering.
1. Prospective Triggering
This technique is most commonly used for single slice or multi-slice single-
phase cardiac cycle.
Prospective triggering avoids cardiac motion artefact by acquiring images
when the heart is at rest during mid-diastole.
2. Retrospective Triggering
This method involves continuous acquisition of data to produce images from
all phases of the cardiac cycle to construct a cine movie that can be used for the
assessment of cardiac function and undertake cardiac chamber quantification.

Retrospective ECG-gated reconstruction in patient with sinus rhythm (68 beats per minute), imaged with tube current
modulation. White boxes indicate segment of R-R interval from which information will be used to reconstruct axial
images. Bold white lines indicate time period of maximum tube current. In this patient, time used for image
reconstruction starts at 65% of R- R interval and is well within time of tube current maximum. Tube current modulation
should be used in patients with low and regular heart rates.

4
Positioning the ECG electrodes in a Siemens scanner

The wireless ECG sensor has a monitoring capability based on 3 electrodes:

1. Position the first electrode (green) approximately 1 cm left of the xiphoid.

2. Position the second (white) and third (red) electrode to form a triangle around
the nipple. The distance between the electrodes should be approximately 15
cm.

Figure (1). ECG electrodes

Cardiac MRI Protocols

1. Auto Detect Table Position

2. Multi Plane Localizer: axial, coronal, sagittal slices

3. Axial Dark Blood Haste Localizer

4. Two, three, and four Chambers Localizer

5. Short Axis Localizer

6. Two, three, and four Chambers Cine

7. Short axis cine

5
8. Dark blood HASTE

9. Dynamic

10. TI_scout: Determine optimal TI for nulling of normal myocardium.

11. Two, three, and four Chambers Delayed

12. Short Axis Delayed

Early gadolinium enhancement

Images directly following administration of gadolinium to detect intracardiac

thrombus or microvascular obstruction.

Late gadolinium enhancement

Images 10–20 min following administration of gadolinium in the standard

cardiac planes. Patterns of enhancement/hyperenhancement are characteristic
for myocardial infarction, and for myocardial fibrosis

After at least 10 min the washout of the contrast in the normal myocardium is
almost complete, while there is still a high concentration of gadolinium in the
infarcted myocardium.

This high concentration of contrast gives high signal intensity

(hyperenhancement=white), on T1‑weighted imaging.

Chronic infarction is characterized by collagenous scars(fibrosis) with

increased interstitial space between the collagenous fibers. The washout of
gadolinium is reduced, resulting in an increased contrast concentration causing
hyperenhancement of the chronic infarct area.

Thank you