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. Author manuscript; available in PMC: 2014 Aug 1.
Published in final edited form as: Curr Treat Options Cardiovasc Med. 2013 Aug;15(4):373–386. doi: 10.1007/s11936-013-0253-6

The Role of Cardiovascular Magnetic Resonance (CMR) and Computed Tomography (CCT) in Facilitating Heart Failure Management

R Brandon Stacey 1, W Gregory Hundley 1,2
PMCID: PMC3767383  NIHMSID: NIHMS501098  PMID: 23817725

Opinion Statement

Cardiovascular magnetic resonance (CMR) and cardiac computed tomography (CCT) offer advantages for detecting left or right ventricular dysfunction in patients with or suspected of heart failure. CMR does not expose patients to ionizing radiation, and thus is well-suited for functional assessments and serial studies. CCT provides high spatial resolution, making it useful for the identification of coronary arteriosclerosis associated with ischemic cardiomyopathy. In this review, the clinical applications of CMR and CCT are individually discussed, with comparisons made between them to examine the strengths of each modality. The major techniques for each modality are outlined, as well as their uses for the evaluation of cardiomyopathy in heart failure patients with reduced left ventricular ejection fraction, preserved left ventricular ejection fraction, and valvular heart disease. Finally, we review the utility of CMR and CCT in determining which patients will benefit from cardiac resynchronization therapy.

Keywords: Cardiovascular Magnetic Resonance, Cardiac Computed Tomography, Heart Failure, Cardiomyopathy, Valvular Heart Disease

Introduction

Heart failure, a clinical syndrome that results from a structural or functional cardiac disorder which prevents the ventricles from either filling with or ejecting blood, represents the most common Medicare diagnosis-related group in individuals over the age of 65 years [1]. Dyspnea and fatigue limit exercise tolerance and fluid retention, which promotes pulmonary congestion or peripheral edema, and represent the primary manifestations that impair the functional capacity as well as the quality of life of those with heart failure [2]. Cardiovascular magnetic resonance (CMR) and cardiac computed tomography (CCT) have recently emerged as tomographic imaging modalities with high utility for assessing patients with or suspected of heart failure [3]. The ability of these modalities to collect information related to the etiology of left ventricular (LV) dysfunction facilitates the diagnosis and management of patients with heart failure [3]. In this article, we review the clinical applications of CMR and CCT for the assessment and evaluation of LV dysfunction in patients with heart failure.

Techniques

Cardiovascular Magnetic Resonance (CMR)

Cardiovascular magnetic resonance is a versatile imaging modality. In one examination, one can assess an organ’s structure, function, perfusion, or metabolism. All of these assessments can be accomplished without an interventional procedure, the administration of intravenous contrast materials, or exposure to ionizing radiation. Each of these aspects of CMR is particularly useful for assessing patients with heart failure.

Determination of cardiac structure is useful for classifying types of heart failure, whether they be related to a dilated or hypertrophic cardiomyopathy. Most commonly, identifying cardiac structure is accomplished using black-blood imaging, a technique that defines cardiac and vascular anatomy by nulling the signal from the blood to create a dark chamber cavity (Figure 1) [4]. Black-blood imaging may be weighted more toward T1 or T2 recovery [5]. T1-weighted black blood imaging displays fat as a higher signal, which can be useful for identifying fat infiltration of the right ventricular (RV) free wall in patients suspected of arrhythmogenic RV cardiomyopathy. T2-weighted black blood imaging can be used to identify acute myocardial edema that is present in myocardial inflammation associated with infarction or myocarditis (Figure 1). On these images, excess myocardial water is displayed as higher signal intensity.

Figure 1.

Figure 1

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Dark blood T2-weighted short axis view of the left and right ventricles. On the image, the left and right ventricular cavities are shown with dark signal intensity. As noted by the arrows, there is increased signal intensity within the lateral wall of the left ventricle in a patient with confirmed regional myocarditis.

In addition to assessing cardiac structure, CMR can be used to assess cardiac function. This is accomplished using cine white blood imaging techniques in which the motion of the blood through the heart provides contrast with the cavity and endocardial surface (Figure 2). In general, one of two imaging sequences is used: spoiled gradient echo (GRE) imaging or steady state free precession (SSFP) imaging [6]. In SSFP images, only fluid and fat have high signals, which improves the delineation of the endocardial surface [7]. The only drawback of SSFP relative to GRE is that turbulent flow may not be well visualized [3]. Inability to visualize turbulent flow becomes problematic when patients with heart failure exhibit abnormal flow vortices associated with valvular stenosis or regurgitation [3]. When these clinical situations are suspected, the GRE sequence is often implemented.

Figure 2.

Figure 2

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End-diastolic frame from a cine white blood imaging sequence acquired within the 4 chamber plane. On these images, the cavitary blood appears white and the left ventricular myocardium appears gray. As shown by the arrows, there is noncompacted LV myocardium involving the apical segments of the left ventricle. This individual exhibited a reduced left ventricular ejection fraction due to noncompaction cardiomyopathy. This cine white blood imaging technique is useful for identifying both global (left ventricular ejection fraction and volumes) and regional left ventricular systolic function.

Left ventricular systolic and diastolic function can be readily assessed using these white blood imaging methods. Using 3-dimensional acquisitions and incorporating Simpson’s rule analysis techniques, CMR can assess end-diastolic and end-systolic LV volumes with high precision [8], and from these volume measurements, the LV ejection fraction (LVEF) can be calculated. When compared to 2-dimensional echocardiographic methods, the accuracy of CMR allows for 2- to 7-fold reductions in sample size estimates when LV volumes, EF, and mass are planned as primary outcomes in clinical trials [9].

Right heart chamber sizes, volumes, EF, and regional wall motion abnormalities can also be assessed with CMR. Both axial and sagital cine image acquisitions of the right heart are useful for excluding major and minor criteria associated with RV cardiomyopathy (Figure 3).

Figure 3.

Figure 3

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Four chamber view of the heart in a patient with arrhythmogenic right ventricular (RV) cardiomyopathy. The arrows denote RV aneurisms that represent a major criteria for establishing this diagnosis.

In addition to “global” measures of left or right ventricular volumes and EF, CMR can quantify regional changes in cardiac function including measures of myocardial strain. Strain analysis can be performed with CMR using several approaches [10-16]. Traditionally, many of these methods have incorporated tissue tagging, but more recently, feature tracking techniques have been developed that enable measurement of myocardial strain without needing to acquire additional images with tags (which increases the duration of the procedure) [17]. Additionally, LV diastolic function can be measured using assessments of strain rate [18].

Phase contrast GRE imaging is a form of GRE that is used to evaluate blood flow [19]. It involves creating a gradient, which induces a phase shift that is proportional to the velocity in the direction of the gradient [20]. On these images, the gray scale of the pixels in the image encodes for velocity and flow can be calculated by multiplying mean velocity by the area [20]. This technique is very accurate in measuring blood flow including cardiac and valvular output, regurgitant volume and regurgitant fraction [21].

CMR techniques are available to assess myocardial perfusion [22]. When implemented during pharmacologic stress, these perfusion methods can readily identify myocardial ischemia. Most perfusion techniques coordinate image acquisition around the first pass of gadolinium contrast through the heart. As contrast arrives within the LV myocardium, a decrease in contrast relative to the remaining myocardium causes a low signal intensity to occur on the image and indicates inducible ischemia that most often is associated with an epicardial coronary arterial luminal narrowing of >50% (Figure 4).

Figure 4.

Figure 4

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T1-weighted first-pass gadolinium enhanced short axis view of the left and right ventricle. The left ventricular cavity appears bright, and the surrounding myocardium appears gray. As shown by the arrow, there is a region of low signal intensity in the inferior wall consistent with inducible myocardial ischemia after the administration of intravenous adenosine. This individual exhibited an 80% coronary arterial luminal narrowing in the right coronary artery on contrast coronary angiography.

In addition to first-pass gadolinium stress perfusion techniques to identify ischemia, the LV myocardium can be imaged 10 minutes after contrast using a technique termed delayed enhancement imaging [23]. In this technique, scar tissue or areas of inflammation retain gadolinium within the extra-myocellular space. The retained gadolinium reduces the T1 (longitudinal) relaxation time such that on gradient echo inversion recovery images, healthy myocardium appears black and fibrosis related to prior myocardial infarction (MI) or residual viral infection appears white. As a result, this technique is useful for identifying prior infarcts in the setting of ischemic heart disease (Figure 5A).

Figure 5.

Figure 5

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Characteristic patterns of late enhancement in specific cardiomyopathies. (A) Ischemic cardiomyopathy: regional thinning with 50% transmural scar in lateral wall and 100% transmural scar in inferoseptal wall. (B) Idiopathic dilated cardiomyopathy: midwall late enhancement in the basal septum. (C) HCM: patchy late enhancement within septum. (D) Myocarditis: epicardial-zone late enhancement in inferolateral and anteroseptal walls. (E) Sarcoidosis: dense epicardial-zone late enhancement. (F) Amyloidosis: diffuse late enhancement progressing from subendocardium to epicardium (pattern may also be seen in uremic cardiomyopathy and post heart transplantation). Reprinted from Cardiology Clinics, Volume 25(1), White JA et al., The role of cardiovascular MRI in heart failure and the cardiomyopathies, Pages 71-95, Copyright 2007, with permission from Elsevier

Cardiac Computed Tomography

Over the past ten years, the implementation of gating algorithms has enabled the acquisition of high spatial resolution images of the heart. These high resolution images allow for the precise definition of coronary arterial anatomy including the determination of coronary arterial plaque presence, type, and severity of intraluminal obstruction [24-28]. The precision by which abnormalities of coronary artery anatomy can be defined facilitates identification of coronary arteriosclerosis that is associated with ischemic cardiomyopathy (Figure 6).

Figure 6.

Figure 6

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Contrast-enhanced computed tomography image of the coronary arteries of an individual with an ischemic cardiomyopathy. Higher signal intensity within the lumen of the coronary arteries appears bright. As shown by the arrow, there is reduced contrast in the vicinity of an 80% coronary arterial luminal narrowing in the left anterior descending coronary artery.

CCT can also be used to assess cardiac perfusion and delayed enhancement [29, 30]. Semi-quantitative per-segment analysis can be performed by simultaneous comparison of short-axis images obtained before and after intravenous vasodilator stress. To assess delayed enhancement with CCT, non-contrasted images are obtained ten minutes after a large contrast bolus (100-150 mL) or can be performed seven minutes after resting perfusion images.

Left ventricular volumes and systolic function are estimated with CCT using the Simpson’s method [31, 32]. Left or right ventricular volumes may be measured by assessing the Hounsfield units to accurately delineate the LV end-diastolic and end-systolic volume. This technique has the added advantage of quickly and reliably separating the blood pool from the papillary muscles. Cardiovascular CT derived measures of LV volumes and EF correlate well with CMR (r = 0.97) [31]; also, these techniques can be used to measure RV size and systolic function [31]. There are two limitations to measuring LV or RV volumes and EF with CCT. First, the temporal resolution of the images (~70 ms) may be insufficient to identify end systole. Second, since the methods utilize retrospective gating, the exposure to ionizing radiation increases.

The Evaluation of Cardiomyopathy

Heart Failure with a Reduced Left Ventricular Ejection Fraction

In those with reduced LVEF, it is important to identify ischemic heart disease. To this end, CMR and CCT often accomplish this identification using different processes. With CMR, the most common method is through the performance of a pharmacologic stress test with either a vasodilator (adenosine, regadenoson, or persantine) or a positive inotrope such as dobutamine [33]. Using either pharmacologic infusion protocol (vasodilator or inotrope), LV wall motion, stress and rest myocardial perfusion, and delayed gadolinium enhanced images are collected. In recent meta-analyses as well as large cohort studies of 500 to 1500 participants, the overall sensitivity and specificity of these stress modalities range from 83% to 95% for detecting >50% coronary arterial luminal narrowings [34].

In addition to diagnosing ischemia, CMR stress results can provide accurate estimates of cardiovascular prognosis [35, 36], and forecast the results of technically successful coronary artery revascularization procedures [37]. As an example, Steel, et al. demonstrated the prognostic utility of stress CMR myocardial perfusion and late gadolinium enhancement in 254 patients. The absence of a CMR-related perfusion defect or evidence of late gadolinium enhancement conferred a 98.1% negative annual event rate for cardiac death and MI within 17 months after the stress procedure [38]. In patients with chronic ischemic heart disease, those exhibiting greater than 50% transmural hyper-enhancement with late gadolinium imaging exhibit little evidence of recovery of systolic thickening after coronary arterial revascularization procedures [37].

Non-ischemic Cardiomyopathy

Over the last seven years, the role of CMR in evaluating patients with cardiomyopathies and heart failure with reduced LVEF has been expanded through the use of both delayed enhancement as well as T2 and T2* techniques for characterizing myocardial tissue. Using these tissue characterization capabilities, CMR is able to identify abnormalities of these tissue characteristics which are either highly suggestive or diagnostic of various etiologies of LV dysfunction.

For example, using the delayed enhancement technique, patients with evidence of myocarditis will demonstrate delayed enhancement that occurs along the epicardial surface of the LV myocardium in the regions of the visceral pericardium [39-41]. These epicardial patches of delayed hyper-enhancement (Figure 5D) help to also identify the cause of chest pain in patients presenting with LV dysfunction and a history consistent with myocarditis. Moreover, utilizing either T2-weighted images or T2 mapping processes, one can identify evidence of increased myocardial water associated with active inflammation and active myocarditis [41].

In those exposed to viral etiologies of their myocardial inflammation [41], delayed enhancement patterns consistent with mid-wall hyper-enhancement have also been appreciated in patients with dilated cardiomyopathies and residual fibrosis after treatment of their disease [41, 39]. Recent study results suggest that this mid-wall fibrosis that occurs chronically after treatment for a viral infection may be associated with adverse cardiac prognosis.

Infiltrative processes associated with systemic amyloidosis or sarcoidosis also create patterns of delayed hyper-enhancement suggestive of the disease [42, 40, 43]. In patients with cardiac amyloid involvement, a characteristic sub-endocardial diffusely based delayed hyper-enhancement pattern is often appreciated (Figure 5F) [40]. In addition, identifying a point in which the myocardium can be appropriately “nulled” is difficult to achieve in patients with systemic amyloidosis. In individuals with sarcoid myocarditis, patchy accumulations of delayed enhancement are often observed, and in patients with active progressive sarcoid, these can continuously evolve over time (Figure 5E) [42, 43]. As shown in Figure 5, there are multiple patterns of delayed hyper-enhancement that can indicate the etiology of LV dysfunction in patients with non-ischemic cardiomyopathies [44].

It is important to note that in addition to delayed enhancement patterns, T2* evaluations are useful in assessing iron accumulation in patients with conditions such as hemochromatosis [45-47]. In this condition, a series of images is often collected in short axis views and the relationship between signal intensity and various echo times can produce a T2* value within the myocardium indicative of intramyocardial iron. Those individuals with T2* values less than 20 milliseconds often exhibit accumulations of myocardial iron warranting further therapy.

Cardiovascular MR also has the ability to provide detailed images of cardiac morphology. Another situation where CMR is useful is noncompaction cardiomyopathy (Figure 2) [48]. Several small studies have demonstrated that CMR can reliably demonstrate LV trabeculations more clearly than echocardiography [49]. In limited comparisons between echocardiography and CMR, several studies have suggested different criteria [50, 48]. However, more defined criteria are being investigated to avoid the confusion between imaging modalities. Cardiovascular CT can also image trabeculations, but due to increased radiation doses, most often only end-diastolic images are obtained. Cardiovascular MR can demonstrate both end-systolic and end-diastolic noncompacted:compacted ratios [51]. By accurately identifying patients with potential noncompaction cardiomyopathy, clinicians can make more informed decisions about whether anti-coagulation is appropriate (Figure 2).

Heart Failure and Preserved Left Ventricular Ejection Fraction

CMR provides important information in evaluating for potential hypertrophic cardiomyopathy. CMR can accurately assess wall thickness and location of asymmetric hypertrophy. This is particularly useful when assessing patients with the apical form of hypertrophic cardiomyopathy. In these situations, transthoracic echocardiography can often foreshorten the LV apex so that this condition would be missed. With CMR or CCT, identification of apical hypertrophic cardiomyopathy is readily obtained. A LV end-diastolic wall thickness of >15 mm or a LV end-diastolic wall thickness ratio of apical versus basal thickness >1.3 is diagnostic of the condition. When echocardiography is inconclusive, phase contrast imaging can accurately measure velocities to evaluate dynamic outflow tract obstruction [52]. Delayed enhancement can provide prognostic information related to risk of sudden cardiac death. In addition, it can indicate the presence of basal myocardial crypts and anterior mitral leaflet lengthening, two novel indicators to evaluate for subclinical disease [53, 54].

Valvular Heart Disease

Normally, aortic stenosis results in concentric hypertrophy, but in later stages, may result in a dilated cardiomyopathy. In situations where echocardiography is unable to assess aortic stenosis, CMR with phase contrast imaging can be used to define aortic value area and measure transvalvular gradient [55-58, 21].

Recently, the anatomic clarity of CCT has been used to facilitate management of patients with valvular heart disease. CCT can assess valve morphology, and measure aortic valve orifice area [59]. Increasingly, cardiac CT has an emerging role in the pre-procedural assessment for transcutaneous aortic valve replacements [60]. To assess aortic regurgitation, CCT can measure anatomic regurgitant orifice area [61], and further, it can provide LV volume assessments to help determine the significance of the valvular defect.

Cardiac Resynchronization Therapy

Once patients have developed severe LV dysfunction, a challenge related to their management involves determining which patients will benefit from cardiac resynchronization therapy. To date, echocardiographic measurements have not been overly helpful in identifying those individuals that will benefit above and beyond criteria obtained from 12-lead electrocardiography. Both CMR and CCT may have utility in this regard [62-64]. With either CMR or CCT, the identification of fibrotic scarred myocardium provides important information as to whether myocardial segments will improve contractility or develop synchronous contraction when a pacing lead is placed in close juxtaposition. Studies have indicated that placing pacing leads in regions with scarred myocardium will not facilitate the development of synchronous contraction [62, 64].

In addition, identifying coronary vein anatomy and correlating this coronary vein anatomy with regions of viable, non-fibrotic myocardium can be of use [65-67]. With CCT, images are obtained within seconds that provide accurate assessments of coronary venous anatomy that then can be co-registered with myocardial regions absent of scar to determine if coronary sinus lead placement will facilitate synchronous LV contraction (Figure 7) [65, 67].

Figure 7.

Figure 7

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3D volume rendered images from CCT to evaluate coronary veins. These high resolution images can be useful for guiding left ventricular pacing leads when considering patients with heart failure for resynchronization therapy. Reprinted from the European Journal of Radiology, Volume 81(11), Malago R et al., Non invasive cardiac vein mapping: role of multislice CT coronary angiography, Pages 3262-9, Copyright 2012, with permission from Elsevier

Conclusion

Both CMR and CCT provide useful information to help identify the etiology of LV dysfunction in patients with congestive heart failure. Cardiovascular MR provides robust functional assessments and lends itself to serial studies due to the lack of exposing patients to ionizing radiation. Cardiovascular CT provides high spatial resolution images for visualizing coronary arteries, plaques and stenoses to help identify ischemic cardiomyopathy, but is limited in functional assessment due to increased radiation dose. Both CMR and CCT can be used to visualize scar tissue from prior infarctions and evaluate for inducible ischemia. The image clarity associated with CMR measures of delayed enhancement and both T1, T2, and T2* mapping provides a unique opportunity to characterize myocardial tissue and thereby establish the etiology of nonischemic causes of cardiomyopathy in individuals with heart failure and preserved or reduced LVEF. Functional CMR and anatomic CCT assessments can be useful when assessing patients with valvular heart disease. In those individuals under evaluation for cardiac resynchronization strategies, CCT or CMR can provide high-quality images of the coronary veins to help plan coronary sinus lead placement, and CMR may help further guide lead placement by direct visualization of the scarred myocardium by delayed enhancement imaging.

Acknowledgment

Research supported in part by National Institute of Health grants R33 CA121296-02, R01 HL076438-02, R01 CA167821-01, P30 AG21332 and P30 CA012197.

Dr. W. George Hundley reported receiving grants from NIH and Bracco (grants R33 CA121296-02, R01 HL076438-02, R01 CA167821-01, P30 AG21332 and P30 CA012197).

Footnotes

Compliance with Ethics Guidelines

Conflict of Interest Dr. Richard Stacey reported no potential conflicts of interest relevant to this article.

Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

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