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Stress perfusion CMR – a report of an initial Romanian experience Cover

Stress perfusion CMR – a report of an initial Romanian experience

Romanian Journal of Cardiology
Volume 31 (2021): Issue 1 (March 2021)
By: Sebastian Onciul,  Oana Popa,  Radu Nicolaescu,  Vlad Bataila,  Lucian Calmac,  Cosmin Mihai,  Mugur Marinescu,  Radu Dan Andrei,  Alexandru Deaconu,  Stefan Bogdan,  Raluca Ciomag,  Nicoleta Popa-Fotea,  Sorin Popescu,  Stefan Radu,  Claudia Nica,  Bogdan Baciu,  Oana Gheorghe Fronea,  Maria Florescu,  Radu Sascau,  Cristian Statescu,  Alexandru Scafa,  Maria Dorobantu and  Razvan Capsa  
Open Access
|Apr 2022

Figures & Tables

Figure 1

Schematic depiction of our standard stress perfusion CMR protocol.
Schematic depiction of our standard stress perfusion CMR protocol.

Figure 2

Short-axis mid-ventricular slices acquired during stress and rest, showing the splenic switch-off phenomenon, defined as a visible decrease in splenic signal intensity during adenosine stress as compared to rest (yellow arrow). During adenosine-induced hypotension, the splenic blood flow is reduced presumably due reactive sympathetic vasoconstriction. During stress, a perfusion defect is seen on the lateral wall (red arrow). This defect is no longer seen on rest perfusion acquisition. The yellow arrowhead indicates a dark-rim artifact which is the most common artifact seen in stress perfusion CMR.
Short-axis mid-ventricular slices acquired during stress and rest, showing the splenic switch-off phenomenon, defined as a visible decrease in splenic signal intensity during adenosine stress as compared to rest (yellow arrow). During adenosine-induced hypotension, the splenic blood flow is reduced presumably due reactive sympathetic vasoconstriction. During stress, a perfusion defect is seen on the lateral wall (red arrow). This defect is no longer seen on rest perfusion acquisition. The yellow arrowhead indicates a dark-rim artifact which is the most common artifact seen in stress perfusion CMR.

Figure 3

The final diagnosis after stress perfusion cardiovascular magnetic resonance.
The final diagnosis after stress perfusion cardiovascular magnetic resonance.

Figure 4

Stress Perfusion CMR in a 61-year-old patient with intermediate lesions on invasive coronary angiography, without a clinical history of myocardial infarction. Perfusion imaging acquired during adequate vasodilator stress (upper row) show a large perfusion defect in the right coronary (RCA) territory (basal infero-septum, inferior and infero-lateral walls, mid inferior and infero-lateral walls and apical inferior segment) (yellow arrowhead). The rest acquisition (middle row) shows no evidence of perfusion defect. Late Gadolinium imaging (lower row) shows a small subendocardial scar (hyperenhancement) in the RCA territory (red arrowheads). Of note, the stress perfusion defect extends well beyond the myocardial scar.
Stress Perfusion CMR in a 61-year-old patient with intermediate lesions on invasive coronary angiography, without a clinical history of myocardial infarction. Perfusion imaging acquired during adequate vasodilator stress (upper row) show a large perfusion defect in the right coronary (RCA) territory (basal infero-septum, inferior and infero-lateral walls, mid inferior and infero-lateral walls and apical inferior segment) (yellow arrowhead). The rest acquisition (middle row) shows no evidence of perfusion defect. Late Gadolinium imaging (lower row) shows a small subendocardial scar (hyperenhancement) in the RCA territory (red arrowheads). Of note, the stress perfusion defect extends well beyond the myocardial scar.

Figure 5

Stress perfusion CMR in a 70-year-old patient with a history of complex PCIs. His initial culprit lesion was a severe left main stenosis for which he was revascularized with a 2-stent technique. After one year, the stent on circumflex artery (Cx) had a severe ostial restenosis with chronic occlusion of the large ramus intermedius (RI). The Cx lesion was dilated with a DES but the RI could not be opened. Basal, mid and apical short axis slices acquired during maximal vasodilatory stress showing a perfusion defect in 3 myocardial segments: basal anterior, mid lateral and apical lateral wall respectively (yellow arrows). The topography of hypoperfused myocardium is compatible with the territory of the occluded intermediate ramus.
Stress perfusion CMR in a 70-year-old patient with a history of complex PCIs. His initial culprit lesion was a severe left main stenosis for which he was revascularized with a 2-stent technique. After one year, the stent on circumflex artery (Cx) had a severe ostial restenosis with chronic occlusion of the large ramus intermedius (RI). The Cx lesion was dilated with a DES but the RI could not be opened. Basal, mid and apical short axis slices acquired during maximal vasodilatory stress showing a perfusion defect in 3 myocardial segments: basal anterior, mid lateral and apical lateral wall respectively (yellow arrows). The topography of hypoperfused myocardium is compatible with the territory of the occluded intermediate ramus.

Figure 6

Stress perfusion CMR in a 60-year-old patient with intermediate lesions on invasive coronary angiography, with a dual chamber pacemaker implanted for intermittent AV block. During CMR examination, the pacemaker was set in DOO mode, 80 bpm. Basal, mid and apical short axis slices show the pacemaker right ventricular lead (yellow arrow) which does not induce any metallic artifacts. However, the pulse generator (red arrow), induces a significant artifact which precludes the optimal visualisation of the apical anterior segment only. Overall, the image quality permits reliable interpretation of the stress test.
Stress perfusion CMR in a 60-year-old patient with intermediate lesions on invasive coronary angiography, with a dual chamber pacemaker implanted for intermittent AV block. During CMR examination, the pacemaker was set in DOO mode, 80 bpm. Basal, mid and apical short axis slices show the pacemaker right ventricular lead (yellow arrow) which does not induce any metallic artifacts. However, the pulse generator (red arrow), induces a significant artifact which precludes the optimal visualisation of the apical anterior segment only. Overall, the image quality permits reliable interpretation of the stress test.

Clinical indications for which patients underwent stress perfusion CMR

Clinical indicationTotal (n=120)Positive testNegative test
Detection of ischaemia in patients with risk factors or atypical chest pain36 (30%)3 (8.33%)32 (88.88%)
Etiology of DCM4 (3.33%)1 (25%)3 (75%)
Detection of ischaemia in patients with history of MI or previous revascularisation51 (42.5%)11 (21.56%)40 (78,43%)
Detection of functional significance of intermediate lesions37 (30.83%)9 (24,32%)27 (72,97%)
Ventricular arrhytmia substrate detection5 (4.16%)05 (100%)

Clinical end electrocardiography data of the analyzed patients

Demographics (n=120)
Age, years57 ± 11
Men95 (79.1%)
BMI (kg/m2)28.9 ± 3.6
Outpatient referral48 (40%)
Cardiovascular risk factors (data available for 75 patients)
Hypertension53 (70.67%)
Hypercholesterolemia57 (76%)
Diabetes19 (25.33%)
Tobacco use33 (44%)
Median number of aggregated risk factors2
Cardiovascular history
Previous non-invasive ischaemia testing28 (23.33%)
Previous myocardial infarction51 (42.5%)
ICA before CMR77 (64.16%)
Number of affected vessels on ICA

  • 0

  • 1 vessel

  • 2 vessels

  • 3 vessels

  • 6 (7.79%)

  • 23 (29.87%)

  • 22 (28.57%)

  • 26 (33.76%)

History of PCI40 (33.3%)
History of CABG7 (5.83%)
ECG at the time of CMR
Sinus rhythm113 (94%)
Atrial fibrillation7 (6%)
Extrasystoles8 (6.66%)
Narrow QRS106 (88.33%)
LBBB5 (4.16%)
RBBB9 (7.5%)

Selected CMR findings

General CMR findings
Artifacts4 (3.33%)
Extracardiac findings34 (28,33%)
Efficient vasodilatory stress113 (94.16%)
Positive stress test21 (17.5%)
LV dimensions and function
LV motion abnormalities44 (36,66%)
LV EDV (ml)188.35 ± 59.09
LV EDVi (ml/m2)92,68 ± 29.13
LV ESV (ml)87.12 ± 55.34
LV SV100.78 ± 24.78
LV EF56.87 ± 13.52
LV myocardial mass (g/m2)56.74 ± 15.21
Tissue characterization
Oedema2 (1.66%)
Native T1 (ms)982.60 ± 151.20
ECV (%)25.71 ± 2.51
T2 (ms)46.06 ± 2.56
Characterization of focal scars
Scar present63 (52.5%)
Ischaemic scar49 (40.83%)
Non-ischaemic scar14(11.66%)
Number of scars

  • 1 scar

  • 2 scars

  • 3 scars

  • 49 (77.77%)

  • 11 (17.46%)

  • 3 (4.76%)

DOI: https://doi.org/10.47803/rjc.2021.31.1.52 | Journal eISSN: 2734-6382 | Journal ISSN: 1220-658X
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Language: English
Page range: 52 - 62
Published on: Apr 30, 2022
Published by: Romanian Society of Cardiology
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
cardiovascular magnetic resonance,
stress perfusion,
coronary artery disease,
non-invasive imaging
Related subjects:
Medicine,
Clinical medicine,
Internal medicine,
Cardiology,
Pediatrics and juvenile medicine,
Paediatric cardiology,
Surgery,
Cardiac surgery

© 2022 Sebastian Onciul, Oana Popa, Radu Nicolaescu, Vlad Bataila, Lucian Calmac, Cosmin Mihai, Mugur Marinescu, Radu Dan Andrei, Alexandru Deaconu, Stefan Bogdan, Raluca Ciomag, Nicoleta Popa-Fotea, Sorin Popescu, Stefan Radu, Claudia Nica, Bogdan Baciu, Oana Gheorghe Fronea, Maria Florescu, Radu Sascau, Cristian Statescu, Alexandru Scafa, Maria Dorobantu, Razvan Capsa, published by Romanian Society of Cardiology
This work is licensed under the Creative Commons Attribution 4.0 License.

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