Case of the week 08-16:Advanced late gadolinium enhancement optimisation

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Case of the week 08-16Advanced late gadolinium
enhancement optimisation

• History 48 Y/O male from Kuwait presented with
  dyspnea and palpitations. Holter shows 21 heart
  block episodes. PMH severe asthma.
• Echo LV impairment with regional wall motion
  abnormalities
• Angiography Normal. Patient referred for CMR
• Cine CMR Mild LV impairment, multiple subtle
  RWMAs
• LGE CMR Imaging optimization progressed through
  the following steps
• IR-FLASH - suspicion for endocardial LGE
• but blood pool brightsuggest waiting (blood
  pool darkens) and imaging
• in systole (to image when trabeculae are
  compressed together)
• 2. Switched to imaging in systole
• - But image blurry with IR-FLASH (long readout
  23x6ms 138ms so motion artefact)
• 3. Switched to IR-FISP imaging
• -Better The faster readout per line (3ms vs 6ms)
  can be used in a variety of ways.
• 4. Switched to IR-FISP in systole
• - Better Squashing trabeculae together (systole)
  and shorter readout (IR-FISP)
• 5. Pushing the envelope more of the above,
  but inevitably a longer breath-hold
• 25 lines readout (75ms) best image valve
  leaflets static and clearly seen
• 6. Cross cuts (othagonal plane imaging) to prove
  EMF
• Short axis and 2-chamber confirm findings

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Giovanne Quarta, Derek Hausenloy, Diana
Holdright, James Moon. The Heart Hospital, London
UK.
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Case of the week 08-16Tips and tricks LGE in
endomyocardial fibrosis 2 of 2
CMR diagnosis Probable endomyocardial fibrosis
consider filiarial disease, Churgg-Strauss. What
was the eosinophil count? Follow-up Eosinophils
normal Unfortunately patient returned to home
country before full investigation. CMR
perspective. Advanced practionners of CMR can get
the most out of LGE imaging by taking many
images and adjusting the acquisitions for both
for patient characteristics and the disease under
investigation. An SSFP readout is twice as fast
and frequently this permits increased
optimisation. See table below for our basic
imaging modifications for specific clinical
situations (using a Siemens Avanto scanner).
Patient characteristic Standard IR-FLASH Modified IR-FLASH Standard IR-FISP Modified IR-FISP
Normal Trigger 2 23 segments 20º flip angle 115-140 lines (14 heart beats) Trigger 2 65 segments 50-60º flip angle 130 lines (12 heart-beats)
HR lt800ms Trigger 3 Segments 19-21 Flip angle 22 º Trigger 3 or 4 Segments 45 Trigger 3 or 4 Segments 45
HR variable Trigger 3 (if possible) Trigger 3 or 4 Consider systolic scanning
For endoomyocardium Scan in systole acq window low as possible segments 30 Wait until blood pool down
Severe fluid ghosting Increase FOV, switch PE direction, use presaturation bands. Consider shorter scan or single shot.
Poor breath-hold Segments 65 or single shot 1 average