Investig Magn Reson Imaging.  2019 Dec;23(4):296-315. 10.13104/imri.2019.23.4.296.

Guidelines for Cardiovascular Magnetic Resonance Imaging from Korean Society of Cardiovascular Imaging (KOSCI) - Part 1: Standardized Protocol

• Jo Y
• Kim J
• Park CH
• Lee JW
• Hur JH
• Yang DH
• Lee BY
• Im DJ
• Hong SJ
• Kim EY
• Park EA
• Kim PK
• Yong HS

• KMID: 2468048
• DOI: http://doi.org/10.13104/imri.2019.23.4.296

Abstract

Cardiac magnetic resonance (CMR) imaging is widely used in many areas of cardiovascular disease assessment. This is a practical, standard CMR protocol for beginners that is designed to be easy to follow and implement. This protocol guideline is based on previously reported CMR guidelines and includes sequence terminology used by vendors, essential MR physics, imaging planes, field strength considerations, MRI-conditional devices, drugs for stress tests, various CMR modules, and disease/symptom-based protocols based on a survey of cardiologists and various appropriate-use criteria. It will be of considerable help in planning and implementing tests. In addressing CMR usage and creating this protocol guideline, we particularly tried to include useful tips to overcome various practical issues and improve CMR imaging. We hope that this document will continue to standardize and simplify a patient-based approach to clinical CMR and contribute to the promotion of public health.

Keyword

Heart; Cardiovascular; Magnetic resonance imaging; Protocol; Guideline

MeSH Terms

Cardiovascular Diseases
Commerce
Exercise Test
Heart
Hope
Magnetic Resonance Imaging*
Public Health

Figure

• 

  Fig. 1 Spin echo sequence. RF = radio frequency; TE = time of echo; TR = time of repetition

• 

  Fig. 2 Fast spin echo sequence.

• 

  Fig. 3 Spoiled gradient echo sequence.

• 

  Fig. 4 Balanced steady-state free precession.

• 

  Fig. 5 Preparation pulses. (a) Inversion recovery pulse (IR). (b) Saturation recovery pulse.

• 

  Fig. 6 Magnetic susceptibility artifact by cardiac implantable electronic device. Cine image (a) and LGE image (b) show significant magnetic susceptibility artifact caused by cardiac implantable electronic device. LGE = late gadolinium enhancement

• 

  Fig. 7 Banding artifact. (a) Cine image of 2-chamber right ventricle view shows severe banding artifact which hampers appropriate interpretation. (b) After cardiac shimming and TR adjustment, image quality is improved without banding artifact.

• 

  Fig. 8 First pass perfusion sequence. ECG = electrocardiogram; SR = saturation; TSR = SR time

• 

  Fig. 9 Dark rim artifact during perfusion magnetic resonance imaging. Subendocardial dark rims are seen at basal septum on both stress (a) and rest (b) perfusion images.

• 

  Fig. 10 LGE sequences. Sequences of LGE with magnitude IR (a) and phase-sensitive inversion-recovery (b). FA = flip angle; TD = trigger delay; TI = inversion time

• 

  Fig. 11 Better image quality of single shot LGE in patient with poor breath holding. LGE image with two-dimensional segmented inversion recovery gradient-echo (a) in patient with poor breath holding shows poor image quality with significant motion artifact. Single shot LGE (b) shows much improved image quality with less motion artifact.

• 

  Fig. 12 VENC effect on phase-contrast flow imaging. Very low VENC factor (a, VENC factor = 90 cm/s) causes aliasing on phase contrast flow image of ascending aorta. Usual peak of ascending aorta is 100-160 cm/s (b, VENC factor = 130 cm/s; c, VENC factor = 160 cm/s). Very high VENC factor (d, VENC factor = 190 cm/s) causes noise and inaccurate measurement. VENC = velocity encoding sensitivity

• 

  Fig. 13 T1 mapping sequences. T1 mapping sequences with MOLLI (a) and SASHA (b). MOLLI = modified look-locker inversion recovery; SASHA = saturation recovery single-shot acquisition

• 

  Fig. 14 Native T1 map and post T1 map. Native T1 map image (a) acquired prior to contrast injection provides pixel-wise absolute native T1 values. Post T1 map image (b) acquired after administration of contrast agent provides pixel-wise post T1 values. Using native T1 values and post T1 values of myocardium and blood cavity and hematocrit value, extracellular volume fraction of myocardium could be calculated.

Reference

1. Yoon YE, Hong YJ, Kim HK, et al. 2014 Korean guidelines for appropriate utilization of cardiovascular magnetic resonance imaging: a joint report of the Korean Society of Cardiology and the Korean Society of Radiology. Korean J Radiol. 2014; 15:659–688.

2. ASCI CCT and CMR Guideline Working Group. Chan CW, Choi BW, et al. ASCI 2010 standardized practice protocol for cardiac magnetic resonance imaging: a report of the Asian society of cardiovascular imaging cardiac computed tomography and cardiac magnetic resonance imaging guideline working group. Int J Cardiovasc Imaging. 2010; 26:187–202.

3. Kramer CM, Barkhausen J, Flamm SD, Kim RJ, Nagel E. Society for Cardiovascular Magnetic Resonance Board of Trustees Task Force on Standardized Protocols. Standardized cardiovascular magnetic resonance (CMR) protocols 2013 update. J Cardiovasc Magn Reson. 2013; 15:91.

4. Woodard PK, Bluemke DA, Cascade PN, et al. ACR practice guideline for the performance and interpretation of cardiac magnetic resonance imaging (MRI). J Am Coll Radiol. 2006; 3:665–676.

5. Kramer CM, Barkhausen J, Flamm SD, Kim RJ, Nagel E. Society for Cardiovascular Magnetic Resonance Board of Trustees Task Force on Standardized Protocols. Standardized cardiovascular magnetic resonance imaging (CMR) protocols, society for cardiovascular magnetic resonance: board of trustees task force on standardized protocols. J Cardiovasc Magn Reson. 2008; 10:35.

6. Fratz S, Chung T, Greil GF, et al. Guidelines and protocols for cardiovascular magnetic resonance in children and adults with congenital heart disease: SCMR expert consensus group on congenital heart disease. J Cardiovasc Magn Reson. 2013; 15:51.

7. ASCI Practice Guideline Working Group. Beck KS, Kim JA, et al. 2017 multimodality appropriate use criteria for noninvasive cardiac imaging: expert consensus of the Asian Society of Cardiovascular Imaging. Korean J Radiol. 2017; 18:871–880.

8. Friedrich MG, Larose E, Patton D, et al. Canadian Society for Cardiovascular Magnetic Resonance (CanSCMR) recommendations for cardiovascular magnetic resonance image analysis and reporting. Can J Cardiol. 2013; 29:260–265.

9. Hundley WG, Bluemke D, Bogaert JG, et al. Society for Cardiovascular Magnetic Resonance guidelines for reporting cardiovascular magnetic resonance examinations. J Cardiovasc Magn Reson. 2009; 11:5.

10. Levine GN, Gomes AS, Arai AE, et al. Safety of magnetic resonance imaging in patients with cardiovascular devices: an American Heart Association scientific statement from the Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology, and the Council on Cardiovascular Radiology and Intervention: endorsed by the American College of Cardiology Foundation, the North American Society for Cardiac Imaging, and the Society for Cardiovascular Magnetic Resonance. Circulation. 2007; 116:2878–2891.

11. Ridgway JP. Cardiovascular magnetic resonance physics for clinicians: part I. J Cardiovasc Magn Reson. 2010; 12:71.

12. Biglands JD, Radjenovic A, Ridgway JP. Cardiovascular magnetic resonance physics for clinicians: Part II. J Cardiovasc Magn Reson. 2012; 14:66.

13. Ferreira PF, Gatehouse PD, Mohiaddin RH, Firmin DN. Cardiovascular magnetic resonance artefacts. J Cardiovasc Magn Reson. 2013; 15:41.

14. Huang SY, Seethamraju RT, Patel P, Hahn PF, Kirsch JE, Guimaraes AR. Body MR imaging: artifacts, k-Space, and solutions. Radiographics. 2015; 35:1439–1460.

15. Saloner D, Liu J, Haraldsson H. MR physics in practice: how to optimize acquisition quality and time for cardiac MR imaging. Magn Reson Imaging Clin N Am. 2015; 23:1–6.

16. Ibrahim el-SH. Imaging sequences in cardiovascular magnetic resonance: current role, evolving applications, and technical challenges. Int J Cardiovasc Imaging. 2012; 28:2027–2047.

17. Sena L. Cardiac MR imaging: from physics to protocols. Pediatr Radiol. 2008; 38 Suppl 2:S185–S191.

18. Ginat DT, Fong MW, Tuttle DJ, Hobbs SK, Vyas RC. Cardiac imaging: part 1, MR pulse sequences, imaging planes, and basic anatomy. AJR Am J Roentgenol. 2011; 197:808–815.

19. Nael K, Fenchel M, Saleh R, Finn JP. Cardiac MR imaging: new advances and role of 3T. Magn Reson Imaging Clin N Am. 2007; 15:291–300.

20. Gimbel JR. Magnetic resonance imaging of implantable cardiac rhythm devices at 3.0 tesla. Pacing Clin Electrophysiol. 2008; 31:795–801.

21. Rajiah P, Bolen MA. Cardiovascular MR imaging at 3 T: opportunities, challenges, and solutions. Radiographics. 2014; 34:1612–1635.

22. Mangion K, Clerfond G, McComb C, et al. Myocardial strain in healthy adults across a broad age range as revealed by cardiac magnetic resonance imaging at 1.5 and 3.0T: Associations of myocardial strain with myocardial region, age, and sex. J Magn Reson Imaging. 2016; 44:1197–1205.

23. Oshinski JN, Delfino JG, Sharma P, Gharib AM, Pettigrew RI. Cardiovascular magnetic resonance at 3.0 T: current state of the art. J Cardiovasc Magn Reson. 2010; 12:55.

24. Lim J, Park EA, Song YS, Lee W. Single-dose gadoterate meglumine for 3T late gadolinium enhancement MRI for the assessment of chronic myocardial infarction: intra-individual comparison with conventional double-dose 1.5T MRI. Korean J Radiol. 2018; 19:372–380.

25. Min JY, Ko SM, Song IY, Yi JG, Hwang HK, Shin JK. Comparison of the diagnostic accuracies of 1.5T and 3T stress myocardial perfusion cardiovascular magnetic resonance for detecting significant coronary artery disease. Korean J Radiol. 2018; 19:1007–1020.

26. Roguin A, Schwitter J, Vahlhaus C, et al. Magnetic resonance imaging in individuals with cardiovascular implantable electronic devices. Europace. 2008; 10:336–346.

27. Sierra M, Machado C. Magnetic resonance imaging in patients with implantable cardiac devices. Rev Cardiovasc Med. 2008; 9:232–238.

28. Burke PT, Ghanbari H, Alexander PB, Shaw MK, Daccarett M, Machado C. A protocol for patients with cardiovascular implantable devices undergoing magnetic resonance imaging (MRI): should defibrillation threshold testing be performed post-(MRI). J Interv Card Electrophysiol. 2010; 28:59–66.

29. Halshtok O, Goitein O, Abu Sham'a R, Granit H, Glikson M, Konen E. Pacemakers and magnetic resonance imaging: no longer an absolute contraindication when scanned correctly. Isr Med Assoc J. 2010; 12:391–395.

30. Cronin EM, Wilkoff BL. Magnetic resonance imaging conditional pacemakers: rationale, development and future directions. Indian Pacing Electrophysiol J. 2012; 12:204–212.

31. Miller JD, Nazarian S, Halperin HR. Implantable electronic cardiac devices and compatibility with magnetic resonance imaging. J Am Coll Cardiol. 2016; 68:1590–1598.

32. Shulman RM, Hunt B. Cardiac implanted electronic devices and MRI safety in 2018-the state of play. Eur Radiol. 2018; 28:4062–4065.

33. Hsu C, Parker G, Puranik R. Implantable devices and magnetic resonance imaging. Heart Lung Circ. 2012; 21:358–363.

34. Strach K, Meyer C, Schild H, Sommer T. Cardiac stress MR imaging with dobutamine. Eur Radiol. 2006; 16:2728–2738.

35. Ordovas KG, Higgins CB. Delayed contrast enhancement on MR images of myocardium: past, present, future. Radiology. 2011; 261:358–374.

36. Kim PK, Hong YJ, Im DJ, et al. Myocardial T1 and T2 mapping: techniques and clinical applications. Korean J Radiol. 2017; 18:113–131.

37. Hamdy A, Ishida M, Sakuma H. Cardiac MR assessment of coronary arteries. Cardiovasc Imaging Asia. 2017; 1:49–59.

38. Montant P, Sigovan M, Revel D, Douek P. MR imaging assessment of myocardial edema with T2 mapping. Diagn Interv Imaging. 2015; 96:885–890.

39. Kim HW, Van Assche L, Jennings RB, et al. Relationship of T2-weighted MRI myocardial hyperintensity and the ischemic area-at-risk. Circ Res. 2015; 117:254–265.

40. Srichai MB, Lim RP, Wong S, Lee VS. Cardiovascular applications of phase-contrast MRI. AJR Am J Roentgenol. 2009; 192:662–675.

41. Lotz J, Meier C, Leppert A, Galanski M. Cardiovascular flow measurement with phase-contrast MR imaging: basic facts and implementation. Radiographics. 2002; 22:651–671.

42. Verhaert D, Thavendiranathan P, Giri S, et al. Direct T2 quantification of myocardial edema in acute ischemic injury. JACC Cardiovasc Imaging. 2011; 4:269–278.

43. Goo HW. Comparison between three-dimensional navigator-gated whole-heart MRI and two-dimensional cine MRI in quantifying ventricular volumes. Korean J Radiol. 2018; 19:704–714.

44. Wang L, Chen Y, Zhang B, et al. Self-gated late gadolinium enhancement at 7T to image rats with reperfused acute myocardial infarction. Korean J Radiol. 2018; 19:247–255.

45. Karimi S, Pourmehdi M, Naderi M. Re: prediction of the left ventricular functional outcome by myocardial extracellular volume fraction measured using magnetic resonance imaging: methodological issue. Korean J Radiol. 2019; 20:1001–1002.

46. Cui C, Yin G, Lu M, et al. Retrospective electrocardiography-gated real-time cardiac cine MRI at 3T: comparison with conventional segmented cine MRI. Korean J Radiol. 2019; 20:114–125.

47. Sakuma H. Magnetic resonance imaging for ischemic heart disease. J Magn Reson Imaging. 2007; 26:3–13.

48. Childs H, Friedrich MG. Cardiovascular magnetic resonance imaging in myocarditis. Prog Cardiovasc Dis. 2011; 54:266–275.

49. Florian A, Jurcut R, Ginghina C, Bogaert J. Cardiac magnetic resonance imaging in ischemic heart disease: a clinical review. J Med Life. 2011; 4:330–345.

50. Nikolaou K, Alkadhi H, Bamberg F, Leschka S, Wintersperger BJ. MRI and CT in the diagnosis of coronary artery disease: indications and applications. Insights Imaging. 2011; 2:9–24.

51. Francone M. Role of cardiac magnetic resonance in the evaluation of dilated cardiomyopathy: diagnostic contribution and prognostic significance. ISRN Radiol. 2014; 2014:365404.

52. Tavano A, Maurel B, Gaubert JY, et al. MR imaging of arrhythmogenic right ventricular dysplasia: what the radiologist needs to know. Diagn Interv Imaging. 2015; 96:449–460.

53. von Knobelsdorff-Brenkenhoff F, Schulz-Menger J. Role of cardiovascular magnetic resonance in the guidelines of the European Society of Cardiology. J Cardiovasc Magn Reson. 2016; 18:6.

54. Pizzino F, Recupero A, Pugliatti P, Maffei S, Di Bella G. Re: multi-parameter CMR approach in acute myocarditis to improve diagnosis and prognostic stratification. Korean J Radiol. 2018; 19:366–367.

55. Chen Y, Zheng X, Jin H, et al. Role of myocardial extracellular volume fraction measured with magnetic resonance imaging in the prediction of left ventricular functional outcome after revascularization of chronic total occlusion of coronary arteries. Korean J Radiol. 2019; 20:83–93.

56. Lee HG, Shim J, Choi JI, Kim YH, Oh YW, Hwang SH. Use of cardiac computed tomography and magnetic resonance imaging in case management of atrial fibrillation with catheter ablation. Korean J Radiol. 2019; 20:695–708.

57. Lee JW, Jeong YJ, Lee G, et al. Predictive value of cardiac magnetic resonance imaging-derived myocardial strain for poor outcomes in patients with acute myocarditis. Korean J Radiol. 2017; 18:643–654.

58. Ahn H, Chun EJ, Lee HJ, et al. Multimodality imaging in patients with secondary hypertension: with a focus on appropriate imaging approaches depending on the etiologies. Korean J Radiol. 2018; 19:272–283.

59. Patel AR, Kramer CM. Role of cardiac magnetic resonance in the diagnosis and prognosis of nonischemic cardiomyopathy. JACC Cardiovasc Imaging. 2017; 10:1180–1193.

60. Peterzan MA, Rider OJ, Anderson LJ. The role of cardiovascular magnetic resonance imaging in heart failure. Card Fail Rev. 2016; 2:115–122.

61. Kim YJ, Yong HS, Kim SM, et al. Korean guidelines for the appropriate use of cardiac CT. Korean J Radiol. 2015; 16:251–285.

62. Saremi F, Grizzard JD, Kim RJ. Optimizing cardiac MR imaging: practical remedies for artifacts. Radiographics. 2008; 28:1161–1187.