ArticlePDF AvailableLiterature Review

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

Authors:

Abstract

Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due to recent technical developments. CMR can give physicians information that cannot be found with other imaging modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean Society of Cardiology and the Korean Society of Radiology.
659
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
PREFACE
Cardiac magnetic resonance (CMR) imaging is now widely
used in several fields of cardiovascular disease due to
recent technical developments. For each clinical situation,
physicians must choose the best imaging modality among
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
Yeonyee E. Yoon, MD1*, Yoo Jin Hong, MD2*, Hyung-Kwan Kim, MD3, Jeong A Kim, MD4,
Jin Oh Na, MD5, Dong Hyun Yang, MD6, Young Jin Kim, MD, PhD2, Eui-Young Choi, MD, PhD7
1Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam 463-707, Korea; 2Department of
Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul 120-752, Korea; 3Division of Cardiology, Department of Internal
Medicine, Cardiovascular Center, Seoul National University College of Medicine, Seoul National University Hospital, Seoul 110-744, Korea;
4Department of Radiology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang 411-706, Korea; 5Cardiovascular Center, Korea
University Guro Hospital, Korea University College of Medicine, Seoul 152-703, Korea; 6Department of Radiology, Asan Medical Center, University
of Ulsan College of Medicine, Seoul 138-736, Korea; 7Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine,
Seoul 135-720, Korea
Cardiac magnetic resonance (CMR) imaging is now widely used in several fields of cardiovascular disease assessment due
to recent technical developments. CMR can give physicians information that cannot be found with other imaging
modalities. However, there is no guideline which is suitable for Korean people for the use of CMR. Therefore, we have
prepared a Korean guideline for the appropriate utilization of CMR to guide Korean physicians, imaging specialists, medical
associates and patients to improve the overall medical system performances. By addressing CMR usage and creating these
guidelines we hope to contribute towards the promotion of public health. This guideline is a joint report of the Korean
Society of Cardiology and the Korean Society of Radiology.
Index terms: Guideline; Appropriateness criteria; Magnetic resonance imaging; Heart; Evidence-based medicine
Korean J Radiol 2014;15(6):659-688
echocardiography, cardiac computed tomography (CT),
CMR or nuclear imaging. However, while each imaging
modality has individual strengths in specific fields, previous
studies have just focused on each modality’s feasibility
and strength separately. Regarding CMR, some guidelines
for appropriate utilization have been published especially
http://dx.doi.org/10.3348/kjr.2014.15.6.659
pISSN 1229-6929 · eISSN 2005-8330
Review Article | Cardiovascular Imaging
Received September 11, 2014; accepted after revision September 25, 2014.
This guideline was developed through collaboration between the Korean Society of Cardiology and the Korean Society of Radiology and
has been published jointly by invitation and consent in both the Korean Circulation Journal and the Korean Journal of Radiology.
This work was supported by the Guideline Development Fund of the Korean Society of Cardiology, the Korean Society of Radiology, and
Korean Society of Cardiovascular Imaging.
*Two authors equally contributed.
Correspondence to
Young Jin Kim, MD, PhD, Department of Radiology, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-
gu, Seoul 120-752, Korea. Tel: (822) 2228-7400Fax: (822) 393-3035 E-mail: dryj@yuhs.ac; and
Eui-Young Choi, MD, PhD, Division of Cardiology, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro,
Gangnam-gu, Seoul 135-720, Korea. Tel: (822) 2019-3310Fax: (822) 2019-2314 E-mail: choi0928@yuhs.ac
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://
creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium,
provided the original work is properly cited.
660
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
From national databases, 51 articles from the National
Guideline Clearing House of the United States, 2 from the
Scottish Intercollegiate Guidelines Network and 16 from
the National Institute for Health and Care Excellence of
the United Kingdom were reviewed. In addition, 54 articles
from PubMed, 40 articles from the Cochrane Library, and
55 articles from Embase were reviewed. Only publications
and guidelines from January 2000 to June 2013 were
selected and reviewed. When guidelines had been revised,
the most recent version of the guideline was selected for
review. Guidelines that did not give detailed data on the
utilization of CMR in relation to overall disease treatment
or guidelines that were established by expert consensus
without being supported by objective evidence were
excluded. Six pre-existing guidelines were finally selected
for guideline adaptation. To evaluate the quality of pre-
existing guidelines selected for guideline adaptation, 4
of the Writing Committee members graded each guideline
according to the Korean Appraisal of Guidelines for Research
& Evaluation II (K-AGREE II). An evaluation of pre-
existing guidelines was made with the Korean Appraisal of
Guidelines for Research & Evaluation (K-AGREE) which was
developed as a Korean version of AGREE 2.0 by the Clinical
Practice Guideline Executive Committee of the KAMS. Four
members of the Writing Committee evaluated the 6 selected
pre-existing guidelines and a reevaluation was done of
any category with a difference of more than 2 points (1-
7). A standardized score was found for each section and
compared. Three guidelines that had standardized scores
for rigour of development category greater than 50% were
finally chosen. However, these were guidelines for the
diagnosis and treatment of specific diseases and as such,
the guidelines for the utilization of CMR were limited to
those specific medical conditions. Thus, 2 guidelines that
had high standardized scores were selected additionally
out of 3 guidelines regarding the indications of CMR. Tables
for the K-AGREE evaluation results and guideline matrixes
are given in the Supplement (in the online-only Data
Supplement). Among the 5 guidelines selected for guideline
adaptation, some did not present the level of evidence. As
the level of evidence in some of the guidelines was thought
to possibly be changed with more recent studies, additional
papers were searched for each question. PubMed and
Embase were used to search for supportive evidence and
the searching parameters were restricted to publications
between 2000 and 2013, studies done on humans only, and
studies published in English. After developing appropriate
in Canada (1) or Europe (2, 3). However, ethnicity,
socioeconomic status, clinical practice environment, and
the medical insurance system are different from country
to country. To overcome ethnic differences, the Asian
Society of Cardiovascular Imaging (ASCI) published practice
guidelines for CMR utilization in 2010 (4). Even with this
effort, differences in socioeconomic status and the medical
insurance system have still not been fully overcome. In
addition, more evidence has been collected from when the
last guideline was published 4 years ago. Therefore, here,
we have prepared a Korean guideline for the appropriate
utilization of CMR to guide Korean physicians, imaging
specialists, medical associates and patients so that the best
possible practice of CMR is done.
Methods for Establishing the 2014 Korean
Guidelines for Appropriate Utilization of CMR
The guidelines presented here were conjointly established
by the Korean Society of Cardiology (KSC) and the Korean
Society of Radiology (KSR). The two Societies decided to
do a guideline adaptation of pre-existing guidelines and
guideline development was based on the (Adaptation
Process for Developing Korean Clinical Practice Guidelines)
published by the Ministry of Health and Welfare in November
2011. The Clinical Practice Guideline Executive Committee
of the Korean Academy of Medical Sciences (KAMS) was
consulted for guideline development methods and a library
search expert participated during the development of
the 2014 Korean Guidelines. The Writing Committee was
comprised of 4 members appointed by the Cardiovascular
Imaging Research Group of the KSC and 4 members
appointed by the Korean Society of Cardiovascular Imaging
of the KSR. The Delphi method was used to develop and
establish guidelines in consensus. The Rating Committee for
the Delphi consensus process was comprised of 20 panelists
who were appointed by the KSR and the KSC. The Writing
Committee made a first draft of the Korean CMR guidelines
by consolidating pre-existing guidelines and related
research study results selected for guideline adaptation and
the Committee then prepared a questionnaire based on this
first draft. The final guidelines were established with the
outcomes found by panels of the Rating Committee through
three rounds of the Delphi consensus process. For the
development of the 2014 Korean guidelines, we reviewed
pre-existing utilization guidelines from US (5), Canada (1),
Europe (2, 3), and Asia (4), which were written in English.
661
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
searching formulas for each question, a review was done
of the search results and evidential studies were selected
for each related question. When a more recent systematic
review or a meta-analysis study was found, papers
previously published with lower levels of evidence were
excluded along with case reports. Search formulas for each
category are given in the Supplement (in the online-only
Data Supplement).
The levels of evidence given in this guideline are stratified
into 3 grades and are based on the levels of evidence for
prognosis and diagnosis published by the Oxford Centre for
Evidence-Based Medicine in 2011. A level of evidence, of
either A, B, or C, is provided for each recommendation. The
following table lists (Tables 1, 2) the levels of evidence and
how the evidence was graded.
The appropriateness criteria was adapted from the 2010
American Heart Association cardiac CT appropriateness
criteria and defined with three ratings: appropriate,
uncertain, and inappropriate (Table 3). Throughout the
guidelines, the criteria is marked with A (Appropriate), U
(Uncertain), or I (Inappropriate) (8).
The questionnaire was based on a first draft of the Korean
guidelines and had 4 sections with a total of 52 questions.
A survey was conducted a total of 3 times, and for each
question, the appropriateness of CMR utilization was graded
with a response scale; 1–3 points defining the use of CMR
as inappropriate, 4–6 points as uncertain, and 7–9 points as
appropriate. When more than 70% of the panelists agreed
on a grade, the panel was considered to have reached
consensus for that particular section. The report form for
the Delphi consensus included appropriateness criteria from
other guidelines for each category, levels of evidence based
on searched literature, the response scale (9-point scale),
sections available for panelists to write in other comments,
and a reference list for each question. In following
consensus rounds, questions for which agreement had not
been reached had both their median score from the previous
round and the score given in the previous round by the
answering panelist listed. Response sections of questions for
which agreement had been reached in previous rounds were
covered in the questionnaires in the following rounds. No
modifications were made to questions for which agreement
had not been reached in the previous round and no other
comments were written down on the questionnaires by any
of the panelists. Of a total of 52 questions, a consensus was
reached on 47 questions in the first survey, 4 questions in
the second survey, and 1 remaining question on the third
survey. The response rate for each round was 100%. The
results of the Delphi voting are included in the Supplement
(in the online-only Data Supplement).
A total of 10 members, consisting of 1 member of
the Clinical Practice Guideline Executive Committee of
the KAMS, 3 of the KSC, 3 of the Korean Pediatric Heart
Association, and 3 of the KSR, reviewed the guidelines
selected by consensus, which were later verified at an
independent audit forum. The development of the current
Table 1. Definition of Levels of Evidence
Level of Evidence Definition
ALevel 1 study, two or more Level 2 studies
BOne Level 2 study, two or more Level 3 studies
COne Level 3 study, Level 4 or 5 study
Table 2. Definition of Levels of Study
Level of Study Definition
1Systematic review, meta-analysis
2Individual cross sectional studies with consistently applied reference standard and blinding/Inception cohort studies
3Non-consecutive studies, or studies without consistently applied reference standards/Cohort study or control arm of
randomized trial
4Case-control studies, or poor or non-independent reference standard/Case-series or case-control studies, or poor
quality prognostic cohort study
5Mechanism-based reasoning
Table 3. Definition of Appropriateness Criteria
Appropriateness Criteria (Score) Definition
A-Appropriate (7–9) Test is generally acceptable and a reasonable approach for the listed indication.
U-Uncertain (4–6)
Test may be generally acceptable and may be a reasonable approach for the indication.
Uncertainty also implies that more patient evaluation or patient information is needed to classify
the indication definitively.
I-Inappropriate (1–3) Test is not generally acceptable and is not a reasonable approach for the indication.
662
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
guidelines was funded by the KSC and KSR. However, the
activities of the Writing Committee, the Rating Committee
for the Delphi consensus and the Reviewing Committee
that reviewed and verified the selected recommendations
were independent of one another and none of the three
Committees were influenced by any of the Societies funding
the guideline development.
These recommendations should be revised every 3–5
years, depending on the development of magnetic resonance
imaging (MRI) technology, changes in the healthcare
environment, and further accumulation of evidence
associated with CMR.
Contents
Detection of Coronary Artery Disease (CAD):
Symptomatic
Clinical Scenario 1: Evaluation of Chest Pain Syndrome
There are several approaches to detect coronary artery
disease (CAD) using CMR. These include direct visualization
of coronary arteries using MR coronary angiography, and
visualization of the effects of induced ischemia using stress
CMR imaging. Stress CMR imaging can be performed with
2 different techniques: 1) dynamic first-pass perfusion
imaging, which assesses inducible perfusion defects,
indicative of impaired perfusion reserves; and 2) stress-
inducible wall motion abnormalities imaging, which
evaluates the impairment of regional endocardial excursion
and myocardial thickening, also indicative of underlying
ischemia.
Myocardial Perfusion Imaging
Cardiac magnetic resonance perfusion imaging is
performed using a T1-weighted sequence to visualize
the first passage of a gadolinium based contrast agent
in transit through the heart. Following the intravenous
injection, the contrast is detected against a background
of nulled myocardium with rapid enhancement with and
without vasodilation stress. Signal intensity correlates with
contrast concentration, and analysis can be performed in a
quantitative, semi-quantitative, or qualitative fashion. Visual
interpretation is usually performed to identify dark areas of
hypoperfusion relative to normally perfused segments. Semi-
quantification can be performed by measuring the upslope
of myocardial signal increase (9). Deconvolution analysis
allowing for the input function from the left ventricular (LV)
blood pool signal curve can be used to generate regional
values for the quantitative perfusion index and myocardial
perfusion reserve (10).
Validation of CMR perfusion imaging in humans has
been performed in a number of clinical studies employing
a variety of contrast agents, analysis techniques, and
reference standards (11-15). A meta-analysis of CMR
perfusion studies demonstrated a sensitivity of 91% and
a specificity of 81% for the diagnosis of CAD with ≥ 50%
diameter stenosis using catheter-based X-ray coronary
angiography (XCA) as a reference standard (16). The
Magnetic Resonance Imaging for Myocardial Perfusion
Assessment in Coronary Artery Disease Trial (MR-IMPACT)
study of 241 patients compared the diagnostic performance
of CMR perfusion imaging and single photon emission
computed tomography (SPECT) and reported a similar
overall accuracy (14). In a subsequent larger multicenter
trial, MR-IMPACT II, of 533 patients, comparing CMR
perfusion to SPECT suggests a higher sensitivity (75% vs.
52%, respectively) and lower specificity of CMR perfusion
(59% vs. 72%, respectively) (15). When the investigators
performed receiver operator characteristics curve analysis,
the diagnostic performance estimated as area under the
curve of CMR perfusion is superior to SPECT (17). However,
there was a trend towards slightly lower sensitivity and
specificity in the MR-IMPACT II study compared to the MR-
IMPACT I study (75% vs. 85%, respectively; 59% vs. 67%,
respectively). This might be related to the larger number
of sites participating in the MR-IMPACT II study, in which
less experienced centers might have contributed more to
the database. Although CMR perfusion is currently thought
to be an alternative to SPECT to detect perfusion deficit in
CAD, appropriate physician and staff training and a facility
capable of performing the stress test are required.
Stress Imaging of Ventricular Function
Cardiac magnetic resonance can detect myocardial
ischemia using exercise and pharmacological stressors
with an accuracy comparable to nuclear imaging and
echocardiography (18-24). A meta-analysis of stress-
functional CMR studies demonstrated a sensitivity of 83%
and a specificity of 86% for the demonstration of CAD
with ≥ 50% diameter stenosis using catheter-based XCA
(16). Since physical exercise is difficult to perform within
the magnet bore and often induces motion artifacts,
pharmacological stress is more commonly used. Dobutamine
with and without atropine is the most common stressor
663
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
used for assessment of inducible wall motion abnormalities
(18-22, 24, 25). Breath-hold gradient echo or steady state
free precession (SSFP) cines are used to examine regional
wall function throughout the LV before and during stress
as the dose of dobutamine is increased in a similar manner
to dobutamine stress echocardiography. Dobutamine
stress CMR has a high accuracy for detecting ischemia,
related in part to excellent LV endocardial visualization
throughout dobutamine/atropine stress protocols (20).
Thus, dobutamine CMR appears to be valuable for patients
who are unsuitable for dobutamine echocardiography (19).
Dobutamine stress CMR exhibits major complications (i.e.,
the development of sustained ventricular tachycardia) in
less than 0.1% of subjects, findings that are similar to
those observed with dobutamine stress echocardiography
(26).
Other CMR techniques have been used to assess CAD
with dobutamine. Tagging methods have shown increased
sensitivity for CAD diagnosis (27). Strain quantification
using strain-encoded CMR allows early detection of inducible
ischemia during intermediate stage (28). Real-time CMR
may be used to monitor wall motion and may eliminate
the need for breath-holding (24). However, further studies
are required to determine the clinical role of these imaging
techniques.
MR Coronary Angiography
MR coronary angiography is technically more challenging
than MR angiography of other vascular beds due to
the small caliber, tortuosity, and complex motion of
the coronary arteries during the cardiac cycles, and
the surrounding signal from adjacent epicardial fat and
myocardium. To overcome these obstacles, several CMR
approaches are employed. Cardiac triggering (e.g., vector
electrocardiogram [ECG]) is used to account for intrinsic
cardiac motion. Although breath-holding can be used to
suppress respiratory motion, it has limited applicability of
MR coronary angiography. Navigator echo method can be
used for respiratory gating and enables free-breathing MR
coronary angiography. Bright blood technique (segmented
gradient echo and SSFP) is commonly used without a
contrast agent, and pre-pulses (e.g., fat saturation, T2
preparation) are used to enhance the contrast-to-noise
ratio of the coronary arterial blood. Recently, target-volume
approach has been largely replaced by the whole-heart MR
coronary angiography which allows visualization of all major
coronary arteries with a single axial three-dimensional (3D)
acquisition in a similar manner to that for CT coronary
angiography.
Several studies evaluated the diagnostic performance of
MR coronary angiography for detecting significant CAD (29-
34). A prospective multicenter, free-breathing, 3D volume-
targeted MR coronary angiography study demonstrated a
very high sensitivity (100%) and a modestly high specificity
(85%) with a very high negative predictive value (100%)
of MR coronary angiography for the identification of left
main and multi-vessel CAD (29). In a recent prospective
multicenter study, SSFP whole-heart MR coronary
angiography demonstrated a high sensitivity (88%) and
moderate specificity (72%) with a high negative predictive
value (88%) in the detection of significant CAD (31).
Clinical utilization of MR coronary angiography has been
limited for the detection of CAD, mainly due to low spatial
resolution and long imaging time. However, substantial
progress in imaging hardware and techniques has been made
during past decades. The introduction of 32-channel cardiac
coils permits use of higher parallel imaging acceleration
factors and substantially reduces the imaging time of MR
coronary angiography within 10 minutes (35). The higher
field, 3-T system provides better signal and contrast values
relative to the 1.5-T system, and thus, may improve the
detection of CAD with MR coronary angiography (32). A
recent comparison study of 3-T MR coronary angiography
with 32-channel cardiac coils and 64-slice CT demonstrated
similar diagnostic accuracy between the two techniques
(33). However, to date, data regarding the clinical utility
of MR coronary angiography for the evaluation of CAD
are based on high-risk populations referred for catheter-
based XCA. And, importantly, the majority of MR coronary
angiography data has been generated in only a few highly
specialized centers.
CMR for Prognosis Assessment
Prognostic data are now available using both vasodilator
and dobutamine stress functional CMR methods (36-39).
In a recent meta-analysis, the annualized event rates for
composite outcome of cardiovascular death and myocardial
infarction were 4.9% for positive versus 0.8% for a negative
stress CMR (39). Another meta-analysis demonstrated a
high negative predictive value of 98% for cardiac death and
myocardial infarction of negative stress CMR, and showed
a similar ability to identify low-risk patients with known or
suspected CAD (38). In patients with suspected or known
CAD, stress CMR has excellent prognostic value and may
664
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
help guide risk stratification. However, data on prognostic
value of MR coronary angiography is limited. Only a recent
single study, including 207 patients with suspected CAD,
reported that significant stenosis detected by MR coronary
angiography can be used to identify patients at high risk
for subsequent adverse cardiac events, whereas normal MR
coronary angiography results are associated with a very low
event rate (40).
Detection of CAD: symptomatic
Evaluation of chest pain syndrome (protocols may
include vasodilator perfusion CMR, dobutamine stress
function CMR, and/or MR coronary angiography)
1. Low pre-test probability of CAD/ECG interpretable
AND able to exercise (Level of evidence: A,
Appropriateness criteria: I)
2. Intermediate pre-test probability of CAD/ECG
interpretable AND able to exercise (Level of evidence:
A, Appropriateness criteria: U)
3. Intermediate pre-test probability of CAD/ECG
interpretable AND able to exercise (Level of evidence:
A, Appropriateness criteria: A)
4. High pre-test probability of CAD (Level of evidence: A,
Appropriateness criteria: U)
Clinical Scenario 2: Evaluation of Coronary Artery
Anomaly (Use of MR Coronary Angiography)
Coronary artery anomalies are a diverse group of congenital
disorders with manifestations and pathophysiological
mechanisms that are highly variable. Although the
majority of coronary artery anomalies are not thought to
be hemodynamically significant, anomalous origination of
a coronary artery from the opposite sinus with subsequent
passage between the aorta and pulmonary artery is a well-
recognized cause of myocardial ischemia and sudden cardiac
death in young individuals (41). Traditionally, catheter-
based XCA has been used to identify these anomalies.
However, XCA only provides a two-dimensional (2D) view,
thus the complex 3D course of the anomalous vessel,
especially in respect to the aorta and pulmonary artery,
may be difficult to discern. Furthermore, the presence of
an anomalous vessel is sometimes only suspected even
after an invasive angiography, because of an unsuccessful
engagement and visualization of the coronary artery. CT
coronary angiography and MR coronary angiography are
alternatives to XCA, which are noninvasive and have the
multi-planar capability of providing 3D images. MR coronary
angiography has several significant advantages over XCA
and CT coronary angiography for diagnosing coronary
artery anomalies: MR coronary angiography does not
expose patients to ionizing radiation and can be performed
without administration of contrast agents at 1.5-T. This is
an important consideration especially in adolescents and
younger adults with suspected anomalous CAD. Both 2D
breath-hold and targeted 3D or free-breathing navigator
whole-heart MR coronary angiographic methods have been
used with similar excellent results. However, 3D whole-heart
MR coronary angiography with a single axial 3D acquisition
has become the method of choice for MR coronary imaging,
and is thought to have marked utility relative to the 2D
projection technique in the assessment of coronary artery
anomalies (42-47).
Evaluation of intracardiac structures (use of MR
coronary angiography)
1. Evaluation of suspected coronary anomalies (Level of
evidence: B, Appropriateness criteria: A)
Clinical Scenario 3: Acute Chest Pain
The use of CMR in the emergency department may allow
for a more rapid and comprehensive evaluation of patients.
The unique advantage of CMR imaging is that it can
provide information on myocardial function, perfusion, and
infarction in a single scanning session. However, to date,
there is a paucity of data regarding the utility of CMR in
the triage of acute chest pain patients. By combining the
assessment of the left ventricular function, adenosine stress
perfusion, and late gadolinium enhancement (LGE) imaging,
CMR demonstrated a sensitivity of 96% and a specificity of
83% for the detection of significant stenosis in 68 patients
with non-ST-segment elevation myocardial infarction (48).
Otherwise, there have only been 2 small single-center
observational trials in patients with acute chest pain and
an inconclusive evaluation in the emergency department.
CMR including the LV function, resting perfusion, and LGE
imaging was performed in 161 patients with acute chest
pain and showed a sensitivity of 84% and a specificity of
85%, respectively (49). In a smaller study with 62 patients,
the addition of the T2-weighted sequence for the detection
of myocardial edema improved the specificity and positive
predictive value for acute coronary syndrome to 96% and
85% (50). Management of intermediate-risk patients with
665
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
possible acute coronary syndrome in an observational unit
with CMR may reduce medical costs during the index visit
and subsequent to discharge over the first year (51). The
reduction in costs even after discharge is thought to be
associated with fewer coronary artery revascularizations,
fewer hospital readmissions, and fewer cases of recurrent
cardiac testing (52). However, as with the diagnostic
accuracy literature for CMR, studies in this area are
primarily single-center reports that describe the findings
of experienced observers in a small number of patients.
Thus, at present, the level of evidence is low, and larger
multicenter investigations should further build on these
results.
Acute chest pain (protocols may include vasodilator
perfusion CMR or dobutamine stress function CMR)
1. Low pre-test probability of CAD/No ECG changes and
serial cardiac enzyme negative (Level of evidence: A,
Appropriateness criteria: U)
2. Intermediate pre-test probability of CAD/No ECG
changes and serial cardiac enzyme negative (Level of
evidence: A, Appropriateness criteria: U)
3. High pre-test probability of CAD/No ECG changes and
serial cardiac enzyme negative (Level of evidence: A,
Appropriateness criteria: U)
4. High pre-test probability of CAD/ECG–ST-segment
elevation and/or positive cardiac enzymes (Level of
evidence: A, Appropriateness criteria: I)
Clinical Scenario 4: Detection of CAD with Prior Test
Results
An important decision facing clinicians is whether
a noninvasive cardiac imaging result warrants
revascularization or whether medical management is most
appropriate. Current guidelines recommend proof of ischemia
prior to elective revascularization (53-55). However, the
severity of coronary stenosis assessed by catheter-based
XCA or CT coronary angiography does not correlate well
with functional significance assessed by the fractional flow
reserve (FFR) (56). The relevance of this discrepancy has
been highlighted by results of the Fractional Flow Reserve
versus Angiography for Multivessel Evaluation (FAME) trial,
which demonstrated improved cardiac outcome when FFR
measurements were taken during coronary intervention
for multi-vessel disease (57, 58). These results show the
importance of assessing the functional significance of CAD
in addition to anatomic evaluation, supporting the use of
noninvasive testing for guiding revascularization.
Stress CMR, either with vasodilator or dobutamine stress,
has been shown to have high diagnostic accuracy for the
detection of significant CAD (13-16, 59). Several studies
have compared stress CMR perfusion imaging with the
invasive reference standard, FFR, and have demonstrated
good correlation between stress CMR perfusion imaging
and FFR (60-63). In a single center study by Watkins et al.
(62), 103 patients with suspected angina underwent stress
CMR perfusion imaging and catheter-based XCA and FFR was
measured in all major patent epicardial coronary arteries.
Stress CMR perfusion imaging can detect functionally
significant CAD defined as FFR < 0.75 with excellent
sensitivity (91%), specificity (94%), and positive and
negative predictive values (91% and 94%, respectively).
In a recent study by Groothuis et al. (64), the addition of
stress CMR perfusion imaging to CT coronary angiography
significantly improved specificity and overall diagnostic
accuracy for the detection of significant CAD as defined
by catheter-based XCA with conditional FFR measurement.
Thus, in clinical practice, stress CMR can subsequently be
used to assess the hemodynamic significance of CAD and to
direct revascularization.
Stress CMR provides excellent prognostic stratification of
patients with known or suspected CAD with a high negative
predictive value for adverse cardiac events (38, 39). Further,
it has a number of advantages over the other noninvasive
techniques, including high spatial and temporal resolution,
no exposure to ionizing radiation, no attenuation or scatter
artifacts, and no image orientation constraints. However, it
is currently difficult to conclude that using ischemic burden
to guide the decision for revascularization with stress CMR
is superior compared to other noninvasive tests. Although
a few previous studies have reported a higher diagnostic
accuracy of stress CMR in comparison to myocardial SPECT,
the majority of studies have compared diagnostic accuracy
for the detection of significant CAD, using catheter-based
XCA as the reference standard (13-15, 17, 65). It needs to
be confirmed whether stress CMR guided revascularization
truly achieves a therapeutic reduction in ischemia or truly
improves outcomes.
Combining stress perfusion and wall motion assessment
with LGE and/or coronary artery anatomy may further
increase the diagnostic and prognostic power of stress
CMR. In a large prospective study entitled Cardiovascular
Magnetic Resonance and Single-photon Emission Computed
666
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
Tomography for Diagnosis of Coronary Heart Disease (CE-
MARC), multiparametric CMR including LV function, stress
perfusion, LGE, and MR coronary angiography, demonstrated
superior diagnostic accuracy compared to SPECT (13).
However, further studies are necessary to determine whether
LGE or MR coronary angiography provides incremental
information to stress CMR in the decision making process
for revascularization.
Detection of CAD: with prior test results (protocols
may include vasodilator perfusion CMR or dobutamine
stress function CMR)
1. Normal prior stress test (exercise, nuclear, echo,
MRI)/high CHD risk (Framingham)/within 1
year of prior stress test (Level of evidence: A,
Appropriateness criteria: I)
2. Equivocal stress test (exercise, stress SPECT, or stress
echo)/intermediate CHD risk (Framingham) (Level of
evidence: A, Appropriateness criteria: U)
3. Coronary angiography (catheterization or CT)/
stenosis of unclear significance (Level of evidence: C,
Appropriateness criteria: A)
Clinical Scenario 5: Evaluation of CAD in Patients
with Post Percutaneous Coronary Intervention (PCI) or
Coronary Artery Bypass Grafting (CABG)
Several studies had reported that 10% of postoperative
grafts had been occluded either during or immediately
after coronary artery bypass grafting (CABG). Moreover, in
a 10 year follow-up study after the surgery, 59% of vein
grafts and 17% of artery grafts had been occluded (66-
68). Therefore, reliable diagnostic methods for patency
assessment are needed after CABG. Cardiac CT and CMR are
noninvasive methods geared toward this end. Some studies
have shown that high-resolution MR angiography provides
fair diagnostic accuracy in evaluating the severity of vein
graft stenosis comparing with invasive coronary angiography
in patients with recurrent chest pain or in asymptomatic
patients after bypass surgery (69, 70). However, until now,
most studies used cardiac CT to assess graft vessel patency
after CABG and only a small number of studies utilized CMR
for this purpose. Therefore, further studies on CMR in this
capacity are warranted.
Regular clinical evaluation of stent restenosis is
recommended in patients who have undergone percutaneous
coronary intervention (PCI) with stent placement (55).
Although several studies had suggested that CMR imaging
of coronary stents is a safe and promising non-invasive
method that assessing patency of the coronary stents
(71-73), the use of MR coronary angiography for this
purpose is limited by low-signal artifacts that occur at the
stenting site and direct evaluation of in-stent restenosis
is not possible. Therefore, MR coronary angiography is not
recommended as an appropriate method for the routine
evaluation of in-stent restenosis. Also, the indirect
approach of inferring the degree of stenosis through the
presence of distal flow turbulence has been known to have
little credibility (74, 75).
Evaluation of CAD: post PCI or CABG
Evaluation of chest pain syndrome (use of MR coronary
angiography)
1. Evaluation of bypass grafts (Level of evidence: C,
Appropriateness criteria: U)
2. History of percutaneous revascularization with stents
(Level of evidence: C, Appropriateness criteria: I)
Asymptomatic (use of MR coronary angiography)
1. Evaluation of bypass grafts and coronary anatomy
(Level of evidence: C, Appropriateness criteria: I)
2. Evaluation for in-stent restenosis and coronary
anatomy after PCI (Level of evidence: C,
Appropriateness criteria: I)
Clinical Scenario 6: CAD Risk Assessment: Preoperative
Evaluation
The decision to conduct a preoperative cardiac evaluation
is made based on the surgery-specific cardiac risk and
patients scheduled for low-risk surgery can proceed to
the surgery without further testing. However, when an
intermediate- to high-risk surgery is scheduled, for which
the risk of a myocardial infarction or cardiac mortality is
around 5%, additional cardiac evaluation may be necessary
(76-80). Additional heart tests are required when three
or more clinical risk factors are present or when patient’s
functional capacity is poor. Because there is an increased
risk associated with surgery, a noninvasive cardiac stress
test is recommended before surgery (76, 77, 81).
As a noninvasive preoperative cardiac testing method,
CMR has the advantages of providing superior spatial
and temporal resolution without exposure to harmful
radiation in contrast to cardiac CT or myocardial perfusion
scintigraphy, and of having more precision in cardiac
667
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
evaluation than echocardiography in case with a poor
acoustic window. Therefore, CMR has recently been used
more frequently in clinical practice as a preoperative
test for myocardial viability and perfusion, valvular heart
disease, cardiomyopathy, and congenital heart disease
(82). In particular, in patients who showed a negative
stress perfusion CMR examination, the probability of
not experiencing cardiac death or a nonfatal myocardial
infarction for at least 3 years is as high as 99.2%,
indicating a very low likelihood of future cardiovascular
disease (37). Additionally, in meta-analysis of 21 studies
that observed a total of 1233 subjects, stress perfusion CMR
examination scored high on its ability to assess obstructive
CAD with a sensitivity of 84% (range, 44–93%) and a
specificity of 80% (range, 60–100%); therefore, CMR is
thought to be very useful in the preoperative assessment of
CAD (37, 83). Furthermore, CMR is known for its excellence
in assessing the LV ejection fraction and LV volume, which
predicts the occurrence of postoperative heart failure.
However, a disadvantage that must be mentioned is the
difficulty of performing a CMR examination in patients with
an artificial pacemaker, implantable defibrillator, or insulin
pump. Thus, the patient’s condition should be taken into
account when performing CMR.
CAD risk assessment: preoperative evaluation
(protocols may include vasodilator perfusion CMR or
dobutamine stress function CMR)
1. Low-risk non-cardiac surgery in patients with
intermediate perioperative risk predictors (Level of
evidence: C, Appropriateness criteria: I)
2. Intermediate or high risk non-cardiac surgery
in patients with intermediate perioperative risk
predictors (Level of evidence: C, Appropriateness
criteria: U)
3. CAD evaluation before valve surgery (Level of
evidence: C, Appropriateness criteria: U)
Clinical Scenario 7: Evaluation of CAD: in Pediatric
Patients with Kawasaki Disease
Echocardiography is the bedside technique of choice
during the acute phase of the disease. CMR can be a
valuable tool especially in children and adolescents, where
sometimes echocardiography fails to detect coronary
abnormalities and it has also the advantage of simultaneous
perfusion, function and viability evaluation. If CMR is not
available, a combination of echocardiography and SPECT
gives an overview of anatomy, function and perfusion.
Cardiac CT is of limited value for follow-up because
of radiation and the misleading data due to coronary
calcifications. Catheter-based XCA is kept mainly for cases
where an invasive procedure should be performed (84).
Mavrogeni et al. (85, 86) compared the results of MR
coronary angiography with XCA in a pediatric population
(87). In the 6 patients, aneurysms of the coronary arteries
were identified, while coronary ectasia alone was present
in the remaining seven patients. MR coronary angiography
and XCA diagnosis of coronary artery aneurysm (CAA)
agreed completely. Maximal aneurysm diameter and length
and ectasia diameter by MRA and XCA were similar. No
stenotic lesion was identified by either technique. Another
prospective study compared MR coronary angiography and
XCA findings in patients with CAAs. There was complete
agreement between MR coronary angiography and XCA in
the detection of CAA (n = 11), coronary artery stenoses (n
= 2), and coronary occlusions (n = 2). Excellent agreement
was found between the 2 techniques for detection of CAA
maximal diameter (mean difference = 0.4 ± 0.6 mm) and
length (mean difference = 1.4 ± 1.6 mm). The 2 methods
showed very similar results for proximal coronary artery
diameter and CAA distance from the ostia (88).
Evaluation of CAD: in pediatric patients with
Kawasaki disease (use of MR coronary angiography)
Asymptomatic
1. No previous definitive test (catheterbased XCA, MR
coronary angiography, or CT coronary angiography)
available (Level of evidence: B, Appropriateness
criteria: U)
2. Previous tests (catheter-based XCA, MR coronary
angiography, or CT coronary angiography)
documented coronary aneurysm/stenosis, for follow-
up (Level of evidence: B, Appropriateness criteria: A)
Symptomatic
1. No previous definitive test (catheterbased XCA, MR
coronary angiography, or CT coronary angiography)
available (Level of evidence: B, Appropriateness
criteria: A)
2. Previous tests (catheter-based XCA, MR coronary
angiography, or CT coronary angiography)
documented coronary aneurysm/stenosis, for follow-
up (Level of evidence: B, Appropriateness criteria: A)
668
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
Clinical Scenario 8: Detection of CAD: Asymptomatic
Regarding role of CMR for detecting occult CAD, no
well controlled studies have been reported. Especially, no
efficacy data have been reported regarding “screening” MR
coronary angiography in high-risk populations. Although
other imaging modalities such as coronary calcium scoring
has some evidences for risk stratifications in asymptomatic
populations, CMR based stress perfusion study or MR
coronary angiography based CAD detection need evidence
to get any appropriateness levels. Therefore in this category
of patients, performing CMR is not generally recommended
in low- or intermediate-risk populations. Regarding in high
risk asymptomatic populations, experts’ recommendations
from ASCI provide uncertain level with scoring 6, which
means it may be a “reasonable approach” (4, 89).
Detection of CAD: asymptomatic (protocols may
include vasodilator perfusion CMR, dobutamine stress
function CMR, and/or MR coronary angiography)
1. Low CHD risk (Framingham) (Level of evidence: A,
Appropriateness criteria: I)
2. Moderate CHD risk (Framingham) (Level of evidence:
A, Appropriateness criteria: U)
3. High CHD risk (Framingham) (Level of evidence: A,
Appropriateness criteria: U)
Clinical Scenario 9: Detection of Myocardial Scar and
Viability in Ischemic Heart Disease
In patients with ischemic heart disease, discrimination
of unviable necrotic areas from a viable area such as a
stunned myocardium is important in the prediction of the
potential recoverability of myocardial contractility and
in the planning of future treatment directions. Contrast-
enhanced CMR that uses gadolinium has been reported
to be useful in the evaluation of myocardial viability
by many studies. Contrast-enhanced CMR can also be
performed on myocardial infarction patients before coronary
artery revascularization to predict the post-procedural
reversibility of myocardial contractility (90, 91). A recent
meta-analysis that evaluated the ability of LGE CMR to
discern stunned myocardium that may be reversible in
patients with myocardial infarction scheduled for coronary
revascularization reported sensitivity of 87%, a specificity
of 68%, a positive predictive value of 83%, and a negative
predictive value of 72%, for an overall diagnostic accuracy
of 82% in those surveyed. The dobutamine stress CMR
technique was also evaluated and was found a sensitivity
of 67%, a specificity of 81%, a positive predictive value of
82%, a negative predictive value of 63%, and an overall
diagnostic accuracy of 74%. Therefore, CMR was founded
to be useful in the evaluation of myocardial viability (92).
Furthermore, in a meta-analysis of 4438 CAD patients, when
the CMR examination detected LGE lesions, patients had
a 2.65 (95% confidence interval [CI], 1.98–3.56) greater
risk of developing major cardiovascular events (MACE),
and a relationship to the size of the LGE in the lesion
was found with every 10% of the LV affected leading to a
56% (95% CI, 1.39–1.75) increase in MACE development.
These reports support the useful prognostic value of CMR in
predicting MACE in patients with prior myocardial infarction
(93). Thus, based on reports of its usefulness in patients
scheduled for coronary revascularization, CMR has become
a recognized pre-procedural assessment method of the
viability of cardiac function recovery.
Many studies have reported that dobutamine stress CMR
and LGE CMR are important in the evaluation of myocardial
viability. In particular, Romero et al. (94) reported in a
meta-analysis of 24 studies including 698 patients, that LGE
CMR scored high with a sensitivity and negative predictive
value of 95% and 90%, respectively, and that dobutamine
stress CMR scored 91% and 93% on specificity and positive
predictive value, respectively. They therefore concluded
that a more accurate prediction of cardiac function after
coronary revascularization can be achieved by analyzing the
results of several studies (94-96).
Late gadolinium enhancement CMR was also compared
to other noninvasive tests for myocardial viability, such as
dobutamine stress echocardiography and SPECT. First, when
comparing SPECT to CMR, while there was no significant
difference in each method’s ability to detect myocardial
transmural necrosis or normal myocardium, LGE CMR was
superior to SPECT in the detection of subendocardial
infarction owing to its superior spatial resolution (97-99).
In addition, a recent prospective study has shown that
CMR has a sensitivity of 86.5% and a specificity of 83.4%
in the detection of CAD, which are superior to the 66.5%
sensitivity and 82.6% specificity reported for SPECT (13).
Likewise, CMR appears to be superior to dobutamine stress
echocardiography, which is known to have a similar overall
accuracy to that of SPECT on the basis of a meta-analysis
that compiled 11 studies and reported a sensitivity of
79% and specificity of 87% (100). Taken together, these
results indicate that stress CMR has a special significance
669
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
for patients who tested negative for low to moderate risk
of CAD and for patients who tested positive for a high risk
of CAD. CMR has therefore been shown to be effective for
patients who tested as being moderately at risk by other
noninvasive examination methods (16).
As previously described, it is known that LGE CMR is a
good method for evaluating the size of myocardial necrosis
prior to coronary revascularization and for determining
whether or not myocardial necrosis after coronary
revascularization is likely to occur and to what extent.
When observing patients scheduled for PCI, an increase
in post-procedural troponin I level has been reported
to show a strong positive correlation to the area of new
myocardial enhancement as detected by LGE CMR. Moreover,
in patients with an elevated level of creatinine kinase-MB,
which indicates necrosis of the myocardium, LGE could be
observed in structurally associated parts, indicating that
it is possible to check for incidence of immediate post-
procedural myocardial infarction (101). Based on their
research studies on acute ST elevated myocardial infarction
patients, Eitel et al. (101, 102) concluded that the
myocardial salvage index measured by CMR is related to the
incidence of long-term MACE such as cardiac death and that
it is therefore an important independent prognostic factor.
Thus, it is believed that the implementation of CMR after
coronary revascularization procedures can help assess the
incidence of myocardial injury and that CMR can find further
application as an indicator of patient prognosis (103).
Detection of myocardial scar and viability (protocols
may include LGE evaluation or dobutamine stress
function CMR)
1. To determine the location and extent of myocardial
necrosis including ‘no reflow’ regions/post-
acute myocardial infarction (Level of evidence: A,
Appropriateness criteria: A)
2. To detect post PCI myocardial necrosis (Level of
evidence: A, Appropriateness criteria: A)
3. To determine viability prior to revascularization/
establish likelihood of recovery of function with
revascularization (PCI or CABG) or medical therapy
(Level of evidence: A, Appropriateness criteria: A)
4. To determine viability prior to revascularization/
viability assessment by SPECT or dobutamine echo
has provided “equivocal or indeterminate” results
(Level of evidence: A, Appropriateness criteria: A)
Structure and Myocardial Functional Evaluation in
Patients with Risk of Heart Failure or Overt Heart Failure
Clinical Scenario 10: Evaluation in Patients with Risk of
Heart Failure or Overt Heart Failure (General)
The main symptoms of heart failure include shortness of
breath, fatigue, and exercise intolerance, resulting from
variable combinations of fluid retention in the body and
significant decline in tissue perfusion (104). Physical
examination in heart failure patients can reveal cardiac
murmur, jugular venous engorgement, pedal edema,
crackles, and/or cold extremities, depending on the heart
failure severity (104). Heart failure is characterized by an
abnormality of cardiac structure and/or function, leading
to the impairment of the heart ability to meet the oxygen
requirements of the tissues (104). Therefore, any cardiac
diseases at the terminal stages can clinically cause heart
failure. Although the definition of heart failure seems to be
straightforward, its diagnosis is not always easy to make.
Many heart failure symptoms are nonspecific or even vague
and therefore, of limited diagnostic value (105, 106).
Heart failure can be caused by the abnormal function of
the myocardium, valves, and/or pericardium and even their
combinations, but the exact etiology cannot be clearly
differentiated with only history taking and/or physical
examination (105, 106). Also, the majority of heart failure
patients become symptomatic with the development of
myocardial dysfunction, which can be observed with a
diverse spectrum of clinical states. Myocardial dysfunction
can range from severely decreased ventricular systolic
dysfunction with or without ventricular dilation to preserved
ventricular systolic function (as assessed by ejection
fraction) with normal ventricular size, both of which are 2
important types of heart failure, that is heart failure with
reduced ejection fraction and heart failure with preserved
ejection fraction, respectively (104). Thus, assessment of
the systolic as well as the diastolic function of the ventricle
plays a central role in the diagnostic process of heart
failure. Echocardiography is a well-known and established
technique for assessing anatomical structure and function
(systolic and diastolic) of the ventricle and this is one of
the important reasons why echocardiography has taken a
main position in the evaluation of heart failure. In fact,
echocardiography has been widely employed to assess
changes in ventricular size or volume, shape and function
in many clinical trials (107-111). In this respect, there is
no doubt that echocardiography is the first-line imaging
670
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
modality for the evaluation of heart failure patients.
Nevertheless, echocardiography suffers from a wide inter-
observer variation in measurements of size and function,
and furthermore, is vulnerable to image quality that is
variable from patient to patient (108). In comparison, the
image quality of CMR is not a main concern for analysis, and
due to its inherent characteristics, post-processing does not
require any geometric assumptions for ventricular volume
quantification (112). This is of particular importance in
the evaluation of heart failure patients, given that many
heart failure patients experience geometric changes in their
ventricles with a large regional variation in contractility,
which can predispose to errors in measurements of volume
and ejection fraction by echocardiography. In addition, due
to its high accuracy and reproducibility, CMR is believed
to be the best reference standard imaging modality for
the noninvasive, in vivo assessment of ventricular volume,
mass, and function (112-116). CMR also allows for accurate,
serial, longitudinal assessment of changes in ventricular
size and function after therapeutic interventions on an
individual patient basis. Therefore, sample sizes for any
study can be far reduced with the use of CMR rather
than echocardiography in the longitudinal assessment of
ventricular volumes, mass and function (117).
Identification of heart failure etiology should be a
fundamental question addressed before a final decision
is reached on therapeutic plans. Although structure and
function are the two main targets for heart failure imaging,
CMR can provide clues to underling abnormalities leading
to heart failure (118, 119). CMR is highly accurate and
reproducible in ventricular volume and ejection fraction
measurements, as commented above. On top of that,
myocardial perfusion, viability, and fibrosis imaging
(using the LGE technique) by CMR can help identify heart
failure etiology and predict prognosis (119, 120). In
addition, LV mass quantification by CMR predicts prognosis
in heart failure patients (121, 122). Among a variety
of CMR techniques, LGE CMR provides a non-invasive
imaging approach to determine the underlying etiology
of heart failure by allowing for a direct interrogation of
the myopathic process (118). Differentiation between
ischemic and non-ischemic etiology is a basic step for
heart failure assessment because this classification exerts
a significant effect on patient management decision
and patient prognosis (123). LGE CMR can help, in many
cases, differentiation of the 2 conditions based on the LGE
pattern. Ischemic LGE pattern is characterized by a 100%
involvement of the subendocardium, i.e., subendocardial
or transmural, and should be found in a region consistent
with a perfusion territory of an epicardial coronary artery
(124). In contrast, a non-ischemic LGE pattern usually
spares the subendocardium, i.e., mid-wall or epicardial,
and/or is inconsistent with a perfusion territory subtended
by one coronary artery (124). LGE CMR is also helpful
for the diagnosis of any specific type of non-ischemic
cardiomyopathy causing heart failure, which can be finally
achieved by analyzing the location and pattern of LGE. For
example, asymmetric septal hypertrophic cardiomyopathy
(HCM) is characterized by LGE of both junctions of the right
ventricular (RV) and interventricular septum in the mid-
wall (125), whereas apical LGE is frequently found in apical
HCM (126). Mid-wall and epicardial LGE in the inferolateral
segments can be found in patients with Anderson-Fabry
disease (127), whereas LGE found in cardiac sarcoidosis
can be variable. But subepicardial or midwall involvement,
especially in basal septum, is unique findings of cardiac
sarcoidosis (25). Cardiac amyloidosis has a typical LGE
pattern, i.e., subendocardial, diffuse ring enhancement,
with difficulty in determining optimal inversion time
to null normal myocardium due to of its characteristic
diffuse myocardial involvement (128). Myocarditis can be
diagnosed with LGE CMR and T2 edema imaging (129, 130).
Assessment of transmurality of LGE is a good surrogate
marker for prognosis prediction (129). Combined CMR
assessment of LGE extent and CMR-based LV ejection
fraction is reported to be of prognostic value in heart
failure patients (131).
Approximately 50% of deaths in heart failure patients
occur suddenly and unexpectedly. Thus, prevention of these
unexpected events is another important target for heart
failure management. Implantable cardioverter-defibrillator
(ICD) therapy is a life-saving strategy in heart failure
patients with severely decreased LV ejection fraction.
Recent studies showed that assessment of myocardial
scarring by LGE CMR can improve risk stratification in heart
failure patients who are considered potential candidates for
ICD therapy (132, 133). Gao et al. (134) also demonstrated
that assessment of the total scar by LGE CMR can predict
an arrhythmic event. Despite no CMR criteria suggested by
the heart failure guideline published in 2012 (104), CMR-
based ICD therapy seems to hold promise in the prediction
of patients who may benefit from ICD therapy. The same
strategy can be true for determining potential candidates
of cardiac resynchronization therapy (CRT) or for planning
671
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
CRT procedures (135-137), but this has yet to be confirmed
with more data.
Although some case series have reported the safety and
effectiveness of the CMR-based approach in heart failure
patients with ICD (138, 139), this is not generally accepted
in the current era, and great care should be exercised before
it is adopted into daily clinical practice. Generally, CMR is
not recommended in patients with ICD or CRT devices.
Evaluation in patients with risk of heart failure
or overt heart failure (general) (protocols may
include LV/RV mass and volumes, MR angiography,
quantification of valvular disease, and LGE
evaluation)
1. Evaluation of LV function following myocardial
infarction OR in heart failure patients (Level of
evidence: A, Appropriateness criteria: A)
2. Evaluation of LV function following myocardial
infarction OR in heart failure patients/patients with
technically limited images from echocardiogram
(Level of evidence: A, Appropriateness criteria: A)
3. Quantification of LV function/discordant information
that is clinically significant from prior tests (Level of
evidence: A, Appropriateness criteria: A)
4. Evaluation in patients with new onset heart failure to
assess etiology (Level of evidence: A, Appropriateness
criteria: A)
5. Initial evaluation of structure and function for newly
suspected or potential heart failure (also including
malignancy on current or planned cardiotoxic
therapy, survived patients with suspected ventricular
dysfunction after chemotherapy, and no prior imaging
evaluation/familial or genetic cardiomyopathy in
first-degree relative, known congenital heart disease
with suspected ventricular dysfunction, acute
myocardial infarction during initial hospitalization)
(Level of evidence: A, Appropriateness criteria: A)
6. Evaluation to determine patient candidacy of ICD
therapy (ejection fraction and/or other structural
information) (Level of evidence: A, Appropriateness
criteria: A)
7. Initial evaluation to determine patient candidacy
of CRT or procedural planning (ejection fraction,
fibrosis, scarring, coronary vein variation, and
intracavitary thrombus) (Level of evidence: A,
Appropriateness criteria: A)
8. Cardiac function follow-up after ICD or CRT (Level of
evidence: C, Appropriateness criteria: I)
Clinical Scenario 11: Patients with Congenital Heart
Disease
Cardiac magnetic resonance is very useful in the
evaluation of congenital heart disease because complete
contiguous data sets from cardiac base to apex can give
complete descriptions of cardiac and extra-cardiac anatomy
of both simple and complex congenital heart disease
very effectively. Unlike cardiac CT, ionizing radiation
exposure is not an issue for CMR, allowing for repeated or
sequential evaluation of children and young adults without
radiation concern. Nevertheless, CMR is limited in critically-
ill patients, especially in acute settings or in patients
who cannot cooperate with the medical team, especially
neonates and infants. Therefore, CMR is in most cases used
as an adjunct approach to echocardiography. Thus, review
of echocardiographic images can aid in the appropriate
selection of CMR sequences that are likely to give answers
to unresolved questions. Although CMR is less operator-
dependent when compared to echocardiography, a thorough
understanding of the anatomical and functional aspects of
any given congenital heart disease is absolutely necessary
for a complete interrogation of that particular congenital
heart disease patient. A comprehensive evaluation of
cardiac and extra-cardiac anatomic structures can be imaged
as well, which makes CMR clinically useful in complex
congenital heart disease patients.
Anomalies of Coronary Circulation
Although CT coronary angiography offers much clearer
anatomical information, the origin and proximal course of
the coronary arteries can still be relatively well investigated
by MR coronary angiography (45). For patients who have
difficulty in holding their breath, real-time coronary
imaging using diaphragm navigators can be used to
minimize image blurring (42). MR coronary angiography is
also useful in the identification of inflammatory changes in
the coronary artery, such as changes that would occur with
Kawasaki disease (87).
Anomalies of Great Vessels (Anomalies of Aorta and
Pulmonary Artery)
MR angiography is also very effective for a complete
evaluation of the great vessels. Coarctation of the aorta is
672
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
one representative disease. Transthoracic echocardiography
using the 2D and Doppler technique is in many cases
enough to diagnose and evaluate hemodynamic severity,
but some difficulties can be encountered. Under these
situations, CMR can provide diverse and extensive
information regarding the severity and extent of stenosis,
collateral circulation, and morphologic changes in the
ascending aorta, and associated anomalies in the aortic
valve. CMR is also a good imaging modality after surgical
correction or angioplasty (140-142). Contrast-enhanced 3D
MR angiography can show abnormal sources of pulmonary
blood supply from the major aorta associated with
pulmonary stenosis or atresia, though CT angiography is
more sensitive at detecting small vessels connected to the
pulmonary vessels (143, 144).
Due to the ability of CMR to reliably assess the entire
aorta and its major branches, aortic disease accompanied
by systemic diseases like Marfan syndrome or Ehler-Danlos
syndrome can be accurately investigated. In addition,
CMR can detect in the preclinical stage abnormal aortic
elastic properties in affected patients before aortic dilation
clinically manifests (145, 146).
Assessment of Cardiac Chambers and Valves
Cardiac magnetic resonance is an excellent technique
for defining the morphologic features of ventricles
(147). Thus, it is easy to determine which ventricle the
morphological RV is and which ventricle the morphological
LV is with comprehensive CMR assessment. For this purpose,
detailed knowledge of the LV and RV is a prerequisite;
the morphological RV is characterized by multiple coarse
trabeculations including the moderator band, and is always
connected to the tricuspid valve that is located more
apically without exception in relation to the mitral valve.
Thus, complex congenital heart disease like transposition
of the great arteries or congenitally corrected transposition
of the great arteries can be accurately assessed (148,
149). In addition, CMR is also very valuable in terms of
postoperative follow-up of these patients (149, 150). CMR
can easily detect the presence of an intra-cardiac shunt like
a ventricular septal defect (VSD) or atrial septal defect (ASD)
with jets localization and shunt quantification (151-154).
It is in no doubt that echocardiography is the first line
of investigation for patients with valve diseases including
congenital valve lesions (155). However, CMR can provide
additional information to that offered by echocardiography,
especially in patients with poor echocardiographic windows
and patients with right-sided valve diseases. Thanks
to its high spatial resolution and signal-to-noise ratio,
morphologic or pathological changes in cardiac valves of
interest can be assessed. In addition, phase contrast imaging
allows for the accurate quantification of regurgitant volume.
This can be specifically applied to patients with significant
pulmonary regurgitation. The ability of CMR to quantitate
regurgitant volume is particularly valuable for the sequential
monitoring of pulmonary regurgitation severity in patients
with tetralogy of Fallot who have undergone RV outflow
tract patch surgery (156, 157). Sequential evaluation of
regurgitant volume along with RV volume changes can help
decide the optimal timing of pulmonary valve replacement
(158, 159). LGE CMR may contribute to risk stratification,
as well (160). However, in patients with a repaired tetralogy
of Fallot, other factors should be assessed including
tricuspid regurgitation, any residual VSD, branch pulmonary
stenosis, aortic regurgitation and LV dysfunction (157).
Therefore, a thorough evaluation of the left- and right-
sided ventricles and valves with an extension to branch
pulmonary arteries and the ascending aorta should be made
to manage patients with a repaired tetralogy of Fallot.
Another important disease for which CMR can make great
contributions to assessment is the Ebstein anomaly and the
associated tricuspid regurgitation (161). Obtaining a stack
of trans-axial cines is recommended, as well as horizontal
four-chamber cines for complete visualization of the
relationship between the right atrium and RV in patients
with the Ebstein anomaly. A combination of these cine
images is necessary for accurate and reproducible volume
measurements of the functional RV in these patients,
which is not easy to perform using short-axis cines (162).
Tricuspid regurgitation is frequently accompanied and the
quantification of its severity using phase contrast imaging
is also an important integrated part of CMR evaluation in
these patients. An ASD or patent foramen ovale is present
in up to 50% of patients and should be sought with an
atrial short-axis cine stack, although echocardiography is
preferable to CMR for this purpose. Shunt volume can be
quantified by phase-contrast imaging.
Postoperative Follow-Up of Congenital Heart Disease
Patients
Echocardiography is usually employed for the serial
monitoring of congenital heart disease patients after
surgery or the trans-catheter technique. In most cases,
echocardiography is more than adequate, but in some cases,
673
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
accurate RV/LV volumes or regurgitant volume quantification
is clinically important in deciding the optimal management.
CMR can provide more accurate and reproducible ventricular
volumes and function measurements than echocardiography
(114, 163). This is especially true for the RV (164, 165),
which is frequently involved and stressed by the repair
of CHD (165). The sequential evaluation of pulmonary
regurgitation and its effects on LV and RV functions should
be comprehensively evaluated by CMR for effective patient
management (166-168). The same strategy can be applied
to patients with transposition of the great arteries who
have undergone atrial and arterial switch operations, and
patients with Fontan operations (149, 169-172).
In congenital heart disease (protocols may
include LV/RV mass and volumes, MR angiography,
quantification of valvular disease, and LGE
evaluation)
1. Assessment about structure and hemodynamics
of congenital heart disease including anomalies
of coronary circulation, great vessels, and cardiac
chambers and valves (Level of evidence: A,
Appropriateness criteria: A)
2. Assessment of post-operative structure and
hemodynamics of congenital heart disease including
ventricular, great arterial and valvular function
and anatomy evaluation (Level of evidence: A,
Appropriateness criteria: A)
Clinical Scenario 12: Patients with Valvular Heart Disease
Direct visualization of valvular anatomy and the
cardiac chambers, and its hemodynamic consequences
have been possible since the advent of 2D and Doppler
echocardiography. There has been no doubt at all that
echocardiography is the standard tool for the initial
assessment and longitudinal follow-up of patients with
valvular heart disease irrespective of native or prosthetic
valves. Therefore, the role of CMR is strictly limited in the
field of valvular heart disease in daily clinical practice.
However, over the last 20 years, CMR has made remarkable
improvements in its image quality, scan time, and even
hemodynamic assessment and, as a result, it has emerged as
an alternative noninvasive imaging modality that is without
ionizing radiation exposure in patients with valvular
diseases. Thanks to its excellent signal-to-noise ratio and
good spatial resolution, CMR can provide beautiful images
of the valve anatomy and can thus also provide valuable
insight into the mechanisms of valvular lesions. Regurgitant
or stenotic flow jets are well visualized on cine imaging
without any contrast agent. However, jet size or density
should not be used for qualitative evaluation of the severity
of valvular disease. The visibility extent of any jet observed
in cine CMR imaging does depend on the CMR setting of
specific sequences. While CMR can quantify the severity of
stenotic or regurgitant valve lesions via the phase contrast
imaging technique, velocities can be underestimated if the
scan slice is not optimally aligned to regurgitant or stenotic
jets. In the evaluation of patients with valvular disease, the
advantage of CMR is in its power to reveal consequences
of the valvular lesion, including the effects on LV or RV
volumes, systolic function and left atrial or right atrial
volumes. More fascinating is the fact that all of these
examinations can be performed without administration of
contrast agents, and thus can be conducted in patients
with renal failure without fear of nephrogenic systemic
fibrosis. The SSFP cine pulse sequence is the most widely
used CMR technique for investigating valve anatomy and
motion. This pulse sequence is well known to have excellent
blood-to-myocardium contrast and a high intrinsic signal-
to-noise ratio (173). With this technique, CMR can create
tomographic images at any plane and at any level. Phase
contrast imaging is used for velocity measurements and can
be considered in patients whose echocardiographic images
are inconclusive or inadequate for reliable evaluation.
However, because temporal resolution of phase contrast
imaging is much lower than Doppler echocardiography, we
should consider a chance that the peak velocity will be
underestimated.
One thing that should be kept in mind is that almost
all CMR validation studies in relation to valvular heart
disease were performed with echocardiography as the gold
standard and only in a small number of patients (174-
180). Nevertheless, the peak antegrade velocity, pressure
gradient, and stenotic valve area can be accurately
calculated with CMR in patients with valve stenosis. In
addition, the regurgitant valve area, regurgitant volume
and regurgitant fraction can be assessed in patients with
valvular regurgitation. Like Doppler echocardiography,
however, a misalignment of more than 20 degrees between
the phase direction and the blood flow direction makes
velocity measurements with CMR inaccurate (180).
Reproducibility of LV and RV volume quantification is one
of the most important strengths of CMR. Any significant
674
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
valvular regurgitation can cause LV or RV volume overload
and can finally precipitate the LV or RV to remodel and
change geometry. LV and RV volumes can be accurately
measured with CMR without any assumption of ventricular
geometry. This is especially useful for right-sided valve
regurgitation, because echocardiography cannot accurately
assess RV volume and ejection fraction due to its complex
geometry and shape. In particular, pulmonary regurgitation,
a major late complication after surgical correction of
tetralogy of Fallot, has been frequently assessed using CMR-
based RV volume measurements (156, 164, 181, 182) and
now CMR is generally accepted as the gold standard method
for in vivo RV assessment (183, 184). Also, although CMR is
safe in patients with prosthetic valves at 1.5-T, the metal
contained within prosthetic valves generates artifacts
and signal loss, and thus CMR validation in patients with
prosthetic valves is very limited (185-187). Thus, as of now,
the clinical use of CMR in valvular heart disease is limited.
In this respect, the use of CMR in valve diseases is currently
recommended only for patients with technically challenging
echocardiographic images.
In valvular heart disease (protocols may include LV/
RV mass and volumes, MR angiography, quantification
of valvular disease, and LGE evaluation)
1. Characterization of native and prosthetic cardiac
valves–including planimetry of stenotic disease and
quantification of regurgitant disease/patients with
technically limited images from transthoracic or
transesophageal echocardiography (Level of evidence:
A, Appropriateness criteria: A)
Clinical Scenario 13: Patients with Suspected or Diagnosed
Myocardial Disease
Myocardial diseases are one of the most important disease
entities in the field of cardiology. They are usually classified
into 2 categories, namely cardiomyopathy and myocarditis.
Cardiomyopathy
Cardiomyopathy is classified into 5 different categories,
although there are definitely situations in which the
suggested classification system cannot fully address some
of the myopathic phenotypes. Unlike HCM and dilated
cardiomyopathy (DCM), arrhythmogenic right ventricular
dysplasia/cardiomyopathy (ARVD/C) is diagnosed on a
histologic basis and characterized by progressive fibrofatty
replacement in the RV, resulting in morphological and
functional changes of the RV. ARVD/C can sometimes
involve the LV and clinically manifests as a DCM phenotype,
but this is not always true.
Recently, the role of CMR has been significantly
increased in the diagnosis of ARVD/C. Generally, the
diagnosis of ARVD/C depends on the demonstration
of structural, functional, ECG abnormalities, and their
combinations. According to the original task force criteria,
RV morphological and functional abnormalities were
predominantly estimated by echocardiography. However,
though useful, echocardiography is not the best approach
for assessing morphological and functional changes in the
RV. CMR is the gold standard for this purpose and thus, the
revised task force criteria encompassed the CMR-derived
definition of RV morphological and functional abnormalities
including RV regional wall motion abnormalities, correct
quantification of RV volumes, aneurysm/trabecular disarray,
and increased myocardial signal suggestive of fatty
replacement (188). However, the role of LGE CMR has not
been mentioned in this new proposed criteria (188). CMR
can allow for early detection of patients with genotype (+),
but with phenotype (-) (189). In addition to its diagnostic
role, CMR including LGE imaging can play a prognostic role
in ARVD/C patients (190, 191). However, given that the
normal variants of the RV are usually greater than those
found in the LV, great caution should be exercised in the
interpretation of RV findings found in CMR.
As described in the heart failure section, CMR can be
very helpful in the differential diagnosis or evaluation of
specific cardiomyopathies, especially thanks to the advent
of LGE imaging. Aside from ischemia-induced myocardial
disease, the LGE pattern of non-ischemic cardiomyopathies
usually spares the subendocardium, i.e., mid-wall or
epicardial, and/or is inconsistent with a perfusion territory
subtended by one coronary artery (124). The LGE pattern
depends on the type of cardiomyopathy, though it is not
always or totally differential (124). For example, it has
been reported that cardiac amyloidosis has a typical LGE
pattern, i.e., subendocardial, diffuse ring enhancement,
with difficulty in determining optimal inversion time to
null normal myocardium due to its characteristic diffuse
involvement (128, 192), although the precise pattern
of LGE in cardiac amyloidosis has been reported to be
more variable in recent studies than what was previously
believed (193, 194). However, LGE CMR is expected to
facilitate the easy detection of cardiac involvement in
675
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
patients with sarcoidosis, and to be used in monitoring
treatment responses because the degree of LGE is reduced
with successful treatment of steroid therapy, suggesting the
possibility that it may be used as a therapeutic surrogate
marker (195). Trastuzumab-induced cardiomyopathy is
characterized by LGE of the lateral wall of the LV within
the mid myocardial portion (196), but this finding requires
further data. LV noncompaction cardiomyopathy has been
increasingly recognized along with the revolutionary
evolution of cardiac imaging techniques. LV noncompaction
cardiomyopathy is characterized by 2 factors; prominent LV
trabeculae and deep inter-trabecular recesses (197). Since
this cardiomyopathy can be diagnosed by LV morphologic
features, the role of CMR has been increasingly important
with its unprecedented high signal-to-noise ratio. A ratio
of noncompacted/compacted myocardium of more than
2.3 in diastole was suggested for the CMR diagnosis of
this disease entity (198). CMR also precisely interrogates
the transition zone between affected and non-affected
LV segments due to its good spatial resolution. Stress-
induced cardiomyopathy was recently incorporated into
cardiomyopathy classification, which is usually characterized
by transient regional LV systolic dysfunction in the absence
of obstructive epicardial coronary disease on coronary
angiography. In most cases, the LV apex is involved, but
sometimes the mid-ventricle or basal ventricle alone can be
affected. Although echocardiography is usually enough for
the diagnosis of stress-induced cardiomyopathy, CMR seems
to be a promising imaging modality for confirming regional
wall motion abnormality and for differentiating this (no LGE
is present in most cases) from acute myocardial infarction
or myocarditis (LGE is frequently present) based on the
presence or absence of LGE (199-201).
Myocarditis
Myocarditis is another important myocardial disease
of which a diagnosis is not easy to make. The gold
standard method of diagnosis is histologic confirmation
of myocardial inflammation, which is sometimes difficult
and limited by the patchy involvement of the inflammatory
process. Myocardial biopsy carries some risk, as well. The
unique ability of CMR to visualize myocardial tissue changes
is the reason for CMR being increasingly employed in the
diagnostic process of myocarditis (202, 203). Anticipated
tissue pathological changes in acute myocarditis include
intracellular/interstitial edema, hyperemia, capillary
leakage, and cellular necrosis with fibrosis, all of which
can be easily found with a variety of CMR techniques like
T2 edema imaging and LGE or the early enhancement
technique. CMR can show increases in myocardial signals
on T2-weighted and LGE images in acute myocarditis (129,
130).
For the accurate diagnosis of cardiomyopathy etiology,
the role of CMR is increasingly recognized and emphasized.
There is no doubt that the gold standard method for
etiological diagnosis is histological confirmation and the
first-line imaging modality in patients under suspicion
for myocardial disease is echocardiography. However, a
comprehensive CMR protocol including cine, LGE, and
sometimes perfusion techniques can provide etiological
diagnosis and prognostic implications.
In suspected or diagnosed myocardial disease
(protocols may include LV/RV mass and volumes, MR
angiography, quantification of valvular disease, and
LGE evaluation)
1. Evaluation for ARVD/C patients presenting with
syncope or ventricular arrhythmia (Level of evidence:
A, Appropriateness criteria: A)
2. Evaluation of myocarditis or myocardial infarction
with normal coronary arteries/positive cardiac
enzymes without obstructive atherosclerosis on
angiography (Level of evidence: A, Appropriateness
criteria: A)
3. Evaluation of specific cardiomyopathies (infiltrative
[amyloid, sarcoid, etc.] or due to cardiotoxic
therapies) (Level of evidence: A, Appropriateness
criteria: A)
Clinical Scenario 14: Evaluation in Patients with HCM
Hypertrophic cardiomyopathy is the most common
genetic cardiovascular disorder that is characterized by
sarcomere gene mutation (204). Accurate diagnosis of HCM
is crucial because HCM patients must alter their life-style
to prevent unexpected dismal events. Family screening
should be done, as well. Transthoracic echocardiography
is the most commonly used imaging modality for the
diagnosis of HCM by identification of LV hypertrophy and
systolic anterior motion of the mitral valve with associated
LV outflow tract dynamic obstruction. CMR, thanks to its
high signal-to-noise ratio and good spatial resolution,
has established its role in the diagnosis of HCM, because
phenotypic expressions of HCM are diverse and complex,
676
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
and thus transthoracic echocardiography sometimes
misses the hypertrophic segments, especially in the apex,
posteroseptum and lateral free wall, difficult areas to
evaluate with transthoracic echocardiography due to its low
lateral spatial resolution (205-208). The LV apex is notably
much more difficult to evaluate with echocardiography
due in part to its proximity to the echocardiographic
probe. Thus, diagnosis of apical HCM may be underreported
using transthoracic echocardiography (207). In addition,
the detection of apical aneurysm is problematic with
transthoracic echocardiography. However, a more sensitive
discovery of apical aneurysm in HCM is clinically relevant,
given that its prevalence is not low and that its presence
is associated with cardiovascular morbidity and mortality
(209, 210). In this respect, cine CMR can provide more
accurate information about the LV hypertrophic pattern and
the presence or absence of apical aneurysm in HCM patients
whose echocardiographic images are technically suboptimal
and nondiagnostic. The phenotypic heterogeneity of HCM
sometimes involves morphologic abnormalities of the RV,
which can be assessed with cine CMR more accurately than
with transthoracic echocardiography, although the clinical
or prognostic significance of RV involvement in HCM is yet
to be determined (211).
Late gadolinium enhancement CMR can provide a unique
opportunity for patients with unexplained LV hypertrophy
(212). LGE in HCM is predominantly located at the anterior
and posterior insertion points of the RV into the septum
with a typical non-subendocardial pattern (212). However,
LGE can be found in different locations, not confined
to hypertrophic segments (126). Myocardial fibrosis is
generally accepted as the main pathohistological feature
of HCM, which can be accurately assessed with LGE CMR
(213-215). CMR-determined myocardial fibrosis has been
repeatedly reported to be closely associated with a grave
prognosis in HCM patients and has advantages over
traditional risk factors for future sudden death (209, 216-
221). Also, the extent of LGE is reported to be linked to
progressive ventricular remodeling (222). Given the strong
association between the presence of LGE and ventricular
tachyarrhythmia on Holter monitoring (209, 220, 223), it is
conceivable that LGE in HCM can be a potential arbitrator
of ventricular tachyarrhythmia. Although LGE CMR looks
promising, there still seems to be insufficient data for
inserting ICDs in HCM patients based only on LGE CMR
findings, given the technical and methodological issues of
LGE assessment (224).
Hypertrophic cardiomyopathy is a genetic disease
with an autosomal dominant trait, and thus first-degree
relatives have a 50% chance of being gene carriers.
Although genotyping is the best way to detect possible
future clinical manifestations of HCM, it is limited by high
cost and the variable penetrance of the disease. Another
problem is that approximately 40% of HCM patients are
genetically negative. Therefore, the most realistic screening
modalities that can be applied clinically are the ECG and
echocardiogram. However, some CMR findings have recently
been found to suggest early imaging manifestations of HCM
including myocardial crypts (225, 226), elongated mitral
valve leaflets (227), and the presence of LGE suggesting
HCM (228). All of these findings should be confirmed in
future CMR studies, but if combined with genetic testing,
these CMR evaluations have the potential to identify HCM
at an early stage of the disease. Current and emerging
recommendations of CMR are summarized in the following
table.
Evaluation in HCM
1. In HCM patients with inconclusive or inadequate
echocardiography (Level of evidence: A,
Appropriateness criteria: A)
2. To define apical hypertrophy and/or aneurysm if
echocardiography is inconclusive (Level of evidence:
A, Appropriateness criteria: A)
3. In selected patients with known HCM, when sudden
cardiac death risk stratification is inconclusive after
documentation of the conventional risk factors/use of
LGE evaluation (Level of evidence: A, Appropriateness
criteria: A)
Miscellaneous Disease
Clinical Scenario 15: Evaluation of Cardiac Mass
(Suspected Tumor or Thrombus)/Use of Contrast for
Perfusion and Enhancement
Intracardiac mass is not uncommonly seen in clinical
situations with the thrombus being the most common
intracardiac mass. Notably, a left atrial thrombus in patients
with atrial fibrillation and a LV thrombus in patients with
severe LV systolic dysfunction due to myocardial infarction
or underlying cardiomyopathy are frequently discovered.
Several previous studies show that the detection rate
of an intracardiac thrombus especially the LV thrombus
677
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
using LGE imaging with varying degrees of inversion time
is better than that of conventional echocardiography or
contrast echocardiography (229-231). The intramural type
of LV thrombus is especially best detected by contrast CMR
(232). Regarding intracardiac tumors, the most important
information provided by CMR is extent of tumor and its
relationship with adjacent structures. Although malignant
tumors are rare, tissue characterization of a tumor would
reveal the nature of the tumor. Myxoma is the most common
intracardiac tumor and CMR findings of cardiac myxoma
show increased signal intensity in T2-weighted images
but the signal composition is usually heterogeneous. The
differential diagnosis of a high signal intensity lesion on
T1-weighted images includes lipoma, tumor with recent
hemorrhage, and melanoma (due to the effects of melanin).
For the accurate differentiation in this situation, fat
saturation technique provides additional information. A
lesion with low signal intensity on T1-weighted images may
represent a cyst, a signal void in a vascular malformation,
a calcified lesion or the presence of air. As water content
typically shows high signal intensity on T2-weighted
images, intracardiac or pericardial cyst provides high signal
intensity. In addition, myxoma, lipoma or metastatic tumor
can also be shown to have high signal intensity on T2-
weighted images. So, for further differentiation, perfusion
imaging, early and late gadolinium enhancement imagings
are usually needed. In the early phase, after injection at
1–2 minutes, necrotic areas in malignant tumors show
up as dark areas surrounded by enhancement elsewhere.
In the later phase, malignant tumors typically show
contrast enhancement indicating tissue vascularity. Such
enhancement pattern is usually absent in cystic lesions
and most benign tumors except for myxomas (2, 3). For
the differentiation from myxoma, its location and presence
of stalk would provide important information. Adjacent
tissue infiltration is best estimated by CMR using first pass
perfusion imaging and the LGE technique (233-235).
Evaluation of cardiac mass (suspected tumor
or thrombus)/use of contrast for perfusion and
enhancement (Level of evidence: A, Appropriateness
criteria: A)
Clinical Scenario 16: Evaluation of Pericardium
Cardiac magnetic resonance can provide information about
the accurate amount of pericardial effusion and pericardial
thickness (236, 237). Using LGE with fat saturation
techniques, the degree of pericardial inflammation can
be assumed in patients with constrictive pericarditis.
Therefore it can predict the effectiveness of intensive
anti-inflammatory medications before a pericardiectomy
(238). Pericardial tumors are also detected and their tissue
characterization is also possible with good reliability. The
absence of the pericardium can be suspected by a leftward
shift of the long axis LV. Any protrusion of any portion of
the heart can suggest pericardial absence (239).
Evaluation of pericardium (pericardial mass, constrictive
pericarditis) (Level of evidence: B, Appropriateness
criteria: A)
Clinical Scenario 17: Evaluation for Aortic Dissection
MR angiography has been accepted as a good modality
for detecting a dissection flap and entry tear site.
Transesophageal echocardiography or CT scans are widely
used modalities. However the aortic arch is a weak point
with transesophageal echocardiography and CT scans
need iodine contrast agents and radiation. A previous
study shows that cardiac CT or CMR have advantages over
transthoracic echocardiography. In a meta-analysis of 1139
patients, the pooled sensitivity (98–100%) and specificity
(95–98%) were comparable between these imaging
techniques. The pooled positive likelihood ratio appeared
to be higher for CMR (positive likelihood ratio, 25.3; 95%
CI [11.1–57.1]) than for transesophageal echocardiography
(14.1; 6.0–33.2) or helical CT (13.9; 4.2–46.0) (240).
Evaluation for aortic dissection (Level of evidence: A,
Appropriateness criteria: A)
Clinical Scenario 18: Evaluation of Pulmonary Veins
Prior to Radiofrequency Ablation for Atrial Fibrillation/
Left Atrial and Pulmonary Venous Anatomy Including
Dimensions of Veins for Mapping Purposes
An accurate anatomic view of the left atrium and
pulmonary veins is essential before radiofrequency ablation
of pulmonary veins in patients with atrial fibrillation.
Currently cardiac CT provides excellent images to guide
catheter-based pulmonic vein isolation, and CMR can also
provide excellent imaging views about anatomical variants
of the pulmonic vein (241-243). Some studies have reported
678
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
that diverse variations of the pulmonic vein exist and these
have been well correlated with cardiac CT and CMR (241).
Evaluation of pulmonary veins prior to radiofrequency
ablation for atrial fibrillation/left atrial and
pulmonary venous anatomy including dimensions of
veins for mapping purposes (Level of evidence: B,
Appropriateness criteria: A)
Clinical Scenario 19: Anatomic Assessment before
Percutaneous Device Closure of ASD or VSD/Anatomic
Assessment before Percutaneous Aortic Valve Replacement
The accurate measurement of ASD shape and size is
essential in the selection of an appropriate device. Accurate
classification of the ASD type, non-invasive measurement
of Qp/Qs (pulmonary flow/systemic flow ratio), and
detection of concomitant congenital anomaly are extremely
important and can be reliably done by CMR. Several
studies have shown that CMR based ASD correlated well to
transesophageal echocardiography based on defects size. En
face CMR with an optimized imaging plane can determine
ASD flow, size, and morphology (244, 245). Thomson et al.
(246) reported that CMR provided information incremental
to comprehensive standard evaluation that altered clinical
management in 20% of patients. Recently, the catheter-
based percutaneous aortic valve replacement has been
introduced and the number of this procedure being
performed has increased markedly. While transesophageal
echocardiography and cardiac CT are known to provide
excellent anatomical and functional images of the left
ventricular outflow tract, the relationship to the coronary
ostium, and the severity of calcification, CMR has been
reported to provide good information albeit with a tendency
to have larger values than transthoracic echocardiography
for all measurements (247).
Anatomic assessment before percutaneous device
closure of ASD or VSD/anatomic assessment before
percutaneous aortic valve replacement (Level of
evidence: B, Appropriateness criteria: A)
Acknowledgments
Rating Panel: Dae-Hee Kim, Kye Hun Kim, Sung-A Chang,
Seong-Mi Park, Hyuk-Jae Chang, Wook Jin Chung, Hae-
Ok Jung, Sang-Chol Lee, Jong-Won Ha, Jun Kwan, Eun Joo
Kang, Joon-Won Kang, Sung Min Ko, Hyon Joo Kwag, Yon Mi
Sung, Whal Lee, Ki-Seuk Choo, Sang Il Choi, Jung Im Jung,
Heon Lee
Consultation Panel: Euisoo Shin, Ein-Soon Shin
Review Panel: Seung-Pyo Lee, Il-Suk Sohn, Ho-Joong
Yoon, Jae Seung Seo, Jong-Min Lee, Byoung Wook Choi,
Chung Il Noh, Lucy Young Min Eun, Gi Beom Kim, Ein-Soon
Shin
Steering Committee: Yong-Jin Kim, Sang-Chol Lee, Tae
Hoon Kim, Yeon Hyeon Choe, Dae-Won Sohn
Supplementary Materials
The online-only Data Supplement is available with this
article at http://dx.doi.org/10.3348/kjr.2014.15.6.659.
REFERENCES
1. Beanlands RS, Chow BJ, Dick A, Friedrich MG, Gulenchyn KY,
Kiess M, et al. CCS/CAR/CANM/CNCS/CanSCMR joint position
statement on advanced noninvasive cardiac imaging using
positron emission tomography, magnetic resonance imaging
and multidetector computed tomographic angiography in
the diagnosis and evaluation of ischemic heart disease--
executive summary. Can J Cardiol 2007;23:107-119
2. Pennell DJ, Sechtem UP, Higgins CB, Manning WJ,
Pohost GM, Rademakers FE, et al. Clinical indications for
cardiovascular magnetic resonance (CMR): Consensus Panel
report. Eur Heart J 2004;25:1940-1965
3. Pennell DJ, Sechtem UP, Higgins CB, Manning WJ,
Pohost GM, Rademakers FE, et al. Clinical indications for
cardiovascular magnetic resonance (CMR): Consensus Panel
report. J Cardiovasc Magn Reson 2004;6:727-765
4. ASCI CCT and CMR Guideline Working Group, Kitagawa
K, Choi BW, Chan C, Jinzaki M, Tsai IC, et al. ASCI 2010
appropriateness criteria 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 Suppl 2:173-186
5. Hendel RC, Patel MR, Kramer CM, Poon M, Hendel RC,
Carr JC, et al. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/
SIR 2006 appropriateness criteria for cardiac computed
tomography and cardiac magnetic resonance imaging: a
report of the American College of Cardiology Foundation
Quality Strategic Directions Committee Appropriateness
Criteria Working Group, American College of Radiology,
Society of Cardiovascular Computed Tomography, Society
for Cardiovascular Magnetic Resonance, American Society
of Nuclear Cardiology, North American Society for Cardiac
Imaging, Society for Cardiovascular Angiography and
Interventions, and Society of Interventional Radiology. J Am
679
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
Coll Cardiol 2006;48:1475-1497
6. Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link
MS, et al. 2011 ACCF/AHA guideline for the diagnosis
and treatment of hypertrophic cardiomyopathy: executive
summary: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on
Practice Guidelines. Circulation 2011;124:2761-2796
7. Patel MR, White RD, Abbara S, Bluemke DA, Herfkens RJ,
Picard M, et al. 2013 ACCF/ACR/ASE/ASNC/SCCT/SCMR
appropriate utilization of cardiovascular imaging in heart
failure: a joint report of the American College of Radiology
Appropriateness Criteria Committee and the American College
of Cardiology Foundation Appropriate Use Criteria Task Force.
J Am Coll Cardiol 2013;61:2207-2231
8. Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara
P, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/
SCMR 2010 appropriate use criteria for cardiac computed
tomography. A report of the American College of Cardiology
Foundation Appropriate Use Criteria Task Force, the Society of
Cardiovascular Computed Tomography, the American College
of Radiology, the American Heart Association, the American
Society of Echocardiography, the American Society of Nuclear
Cardiology, the North American Society for Cardiovascular
Imaging, the Society for Cardiovascular Angiography and
Interventions, and the Society for Cardiovascular Magnetic
Resonance. J Am Coll Cardiol 2010;56:1864-1894
9. Wilke N, Jerosch-Herold M, Wang Y, Huang Y, Christensen BV,
Stillman AE, et al. Myocardial perfusion reserve: assessment
with multisection, quantitative, first-pass MR imaging.
Radiology 1997;204:373-384
10. Schwitter J, Nanz D, Kneifel S, Bertschinger K, Büchi
M, Knüsel PR, et al. Assessment of myocardial perfusion
in coronary artery disease by magnetic resonance: a
comparison with positron emission tomography and coronary
angiography. Circulation 2001;103:2230-2235
11. Giang TH, Nanz D, Coulden R, Friedrich M, Graves M, Al-
Saadi N, et al. Detection of coronary artery disease by
magnetic resonance myocardial perfusion imaging with
various contrast medium doses: first European multi-centre
experience. Eur Heart J 2004;25:1657-1665
12. Pilz G, Bernhardt P, Klos M, Ali E, Wild M, Höfling B.
Clinical implication of adenosine-stress cardiac magnetic
resonance imaging as potential gatekeeper prior to invasive
examination in patients with AHA/ACC class II indication for
coronary angiography. Clin Res Cardiol 2006;95:531-538
13. Greenwood JP, Maredia N, Younger JF, Brown JM, Nixon J,
Everett CC, et al. Cardiovascular magnetic resonance and
single-photon emission computed tomography for diagnosis
of coronary heart disease (CE-MARC): a prospective trial.
Lancet 2012;379:453-460
14. Schwitter J, Wacker CM, van Rossum AC, Lombardi M, Al-
Saadi N, Ahlstrom H, et al. MR-IMPACT: comparison of
perfusion-cardiac magnetic resonance with single-photon
emission computed tomography for the detection of coronary
artery disease in a multicentre, multivendor, randomized
trial. Eur Heart J 2008;29:480-489
15. Schwitter J, Wacker CM, Wilke N, Al-Saadi N, Sauer E, Huettle
K, et al. MR-IMPACT II: Magnetic Resonance Imaging for
Myocardial Perfusion Assessment in Coronary artery disease
Trial: perfusion-cardiac magnetic resonance vs. single-photon
emission computed tomography for the detection of coronary
artery disease: a comparative multicentre, multivendor trial.
Eur Heart J 2013;34:775-781
16. Nandalur KR, Dwamena BA, Choudhri AF, Nandalur MR,
Carlos RC. Diagnostic performance of stress cardiac magnetic
resonance imaging in the detection of coronary artery
disease: a meta-analysis. J Am Coll Cardiol 2007;50:1343-
1353
17. Schwitter J, Wacker CM, Wilke N, Al-Saadi N, Sauer E, Huettle
K, et al. Superior diagnostic performance of perfusion-
cardiovascular magnetic resonance versus SPECT to detect
coronary artery disease: the secondary endpoints of the
multicenter multivendor MR-IMPACT II (Magnetic Resonance
Imaging for Myocardial Perfusion Assessment in Coronary
Artery Disease Trial). J Cardiovasc Magn Reson 2012;14:61
18. Paetsch I, Jahnke C, Ferrari VA, Rademakers FE, Pellikka PA,
Hundley WG, et al. Determination of interobserver variability
for identifying inducible left ventricular wall motion
abnormalities during dobutamine stress magnetic resonance
imaging. Eur Heart J 2006;27:1459-1464
19. Hundley WG, Hamilton CA, Thomas MS, Herrington DM, Salido
TB, Kitzman DW, et al. Utility of fast cine magnetic resonance
imaging and display for the detection of myocardial ischemia
in patients not well suited for second harmonic stress
echocardiography. Circulation 1999;100:1697-1702
20. Nagel E, Lehmkuhl HB, Bocksch W, Klein C, Vogel U, Frantz E,
et al. Noninvasive diagnosis of ischemia-induced wall motion
abnormalities with the use of high-dose dobutamine stress
MRI: comparison with dobutamine stress echocardiography.
Circulation 1999;99:763-770
21. Paetsch I, Jahnke C, Wahl A, Gebker R, Neuss M, Fleck E, et
al. Comparison of dobutamine stress magnetic resonance,
adenosine stress magnetic resonance, and adenosine stress
magnetic resonance perfusion. Circulation 2004;110:835-842
22. Pennell DJ, Underwood SR, Manzara CC, Swanton RH,
Walker JM, Ell PJ, et al. Magnetic resonance imaging during
dobutamine stress in coronary artery disease. Am J Cardiol
1992;70:34-40
23. Rerkpattanapipat P, Gandhi SK, Darty SN, Williams RT, Davis
AD, Mazur W, et al. Feasibility to detect severe coronary
artery stenoses with upright treadmill exercise magnetic
resonance imaging. Am J Cardiol 2003;92:603-606
24. Schalla S, Klein C, Paetsch I, Lehmkuhl H, Bornstedt A,
Schnackenburg B, et al. Real-time MR image acquisition
during high-dose dobutamine hydrochloride stress for
detecting left ventricular wall-motion abnormalities
in patients with coronary arterial disease. Radiology
2002;224:845-851
25. Patel MR, Cawley PJ, Heitner JF, Klem I, Parker MA, Jaroudi
WA, et al. Detection of myocardial damage in patients with
sarcoidosis. Circulation 2009;120:1969-1977
26. Wahl A, Paetsch I, Gollesch A, Roethemeyer S, Foell
680
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
D, Gebker R, et al. Safety and feasibility of high-dose
dobutamine-atropine stress cardiovascular magnetic
resonance for diagnosis of myocardial ischaemia: experience
in 1000 consecutive cases. Eur Heart J 2004;25:1230-1236
27. Kuijpers D, Ho KY, van Dijkman PR, Vliegenthart R, Oudkerk
M. Dobutamine cardiovascular magnetic resonance for the
detection of myocardial ischemia with the use of myocardial
tagging. Circulation 2003;107:1592-1597
28. Korosoglou G, Lehrke S, Wochele A, Hoerig B, Lossnitzer
D, Steen H, et al. Strain-encoded CMR for the detection
of inducible ischemia during intermediate stress. JACC
Cardiovasc Imaging 2010;3:361-371
29. Kim WY, Danias PG, Stuber M, Flamm SD, Plein S, Nagel E,
et al. Coronary magnetic resonance angiography for the
detection of coronary stenoses. N Engl J Med 2001;345:1863-
1869
30. Sakuma H, Ichikawa Y, Chino S, Hirano T, Makino K, Takeda
K. Detection of coronary artery stenosis with whole-heart
coronary magnetic resonance angiography. J Am Coll Cardiol
2006;48:1946-1950
31. Kato S, Kitagawa K, Ishida N, Ishida M, Nagata M, Ichikawa Y,
et al. Assessment of coronary artery disease using magnetic
resonance coronary angiography: a national multicenter trial.
J Am Coll Cardiol 2010;56:983-991
32. Yang Q, Li K, Liu X, Bi X, Liu Z, An J, et al. Contrast-enhanced
whole-heart coronary magnetic resonance angiography at
3.0-T: a comparative study with X-ray angiography in a single
center. J Am Coll Cardiol 2009;54:69-76
33. Hamdan A, Asbach P, Wellnhofer E, Klein C, Gebker R, Kelle
S, et al. A prospective study for comparison of MR and CT
imaging for detection of coronary artery stenosis. JACC
Cardiovasc Imaging 2011;4:50-61
34. Schuetz GM, Zacharopoulou NM, Schlattmann P, Dewey M.
Meta-analysis: noninvasive coronary angiography using
computed tomography versus magnetic resonance imaging.
Ann Intern Med 2010;152:167-177
35. Nagata M, Kato S, Kitagawa K, Ishida N, Nakajima H,
Nakamori S, et al. Diagnostic accuracy of 1.5-T unenhanced
whole-heart coronary MR angiography performed with
32-channel cardiac coils: initial single-center experience.
Radiology 2011;259:384-392
36. Hundley WG, Morgan TM, Neagle CM, Hamilton CA,
Rerkpattanapipat P, Link KM. Magnetic resonance
imaging determination of cardiac prognosis. Circulation
2002;106:2328-2333
37. Jahnke C, Nagel E, Gebker R, Kokocinski T, Kelle S, Manka R,
et al. Prognostic value of cardiac magnetic resonance stress
tests: adenosine stress perfusion and dobutamine stress wall
motion imaging. Circulation 2007;115:1769-1776
38. Gargiulo P, Dellegrottaglie S, Bruzzese D, Savarese G, Scala
O, Ruggiero D, et al. The prognostic value of normal stress
cardiac magnetic resonance in patients with known or
suspected coronary artery disease: a meta-analysis. Circ
Cardiovasc Imaging 2013;6:574-582
39. Lipinski MJ, McVey CM, Berger JS, Kramer CM, Salerno M.
Prognostic value of stress cardiac magnetic resonance
imaging in patients with known or suspected coronary artery
disease: a systematic review and meta-analysis. J Am Coll
Cardiol 2013;62:826-838
40. Yoon YE, Kitagawa K, Kato S, Ishida M, Nakajima H, Kurita
T, et al. Prognostic value of coronary magnetic resonance
angiography for prediction of cardiac events in patients
with suspected coronary artery disease. J Am Coll Cardiol
2012;60:2316-2322
41. Cheitlin MD, De Castro CM, McAllister HA. Sudden death
as a complication of anomalous left coronary origin from
the anterior sinus of Valsalva, A not-so-minor congenital
anomaly. Circulation 1974;50:780-787
42. Bunce NH, Lorenz CH, Keegan J, Lesser J, Reyes EM, Firmin
DN, et al. Coronary artery anomalies: assessment with free-
breathing three-dimensional coronary MR angiography.
Radiology 2003;227:201-208
43. Gharib AM, Ho VB, Rosing DR, Herzka DA, Stuber M, Arai
AE, et al. Coronary artery anomalies and variants: technical
feasibility of assessment with coronary MR angiography at 3 T.
Radiology 2008;247:220-227
44. McConnell MV, Ganz P, Selwyn AP, Li W, Edelman RR,
Manning WJ. Identification of anomalous coronary arteries
and their anatomic course by magnetic resonance coronary
angiography. Circulation 1995;92:3158-3162
45. Taylor AM, Thorne SA, Rubens MB, Jhooti P, Keegan J,
Gatehouse PD, et al. Coronary artery imaging in grown up
congenital heart disease: complementary role of magnetic
resonance and x-ray coronary angiography. Circulation
2000;101:1670-1678
46. Casolo G, Del Meglio J, Rega L, Manta R, Margheri M, Villari
N, et al. Detection and assessment of coronary artery
anomalies by three-dimensional magnetic resonance coronary
angiography. Int J Cardiol 2005;103:317-322
47. Clemente A, Del Borrello M, Greco P, Mannella P, Di Gregorio
F, Romano S, et al. Anomalous origin of the coronary arteries
in children: diagnostic role of three-dimensional coronary MR
angiography. Clin Imaging 2010;34:337-343
48. Plein S, Greenwood JP, Ridgway JP, Cranny G, Ball SG,
Sivananthan MU. Assessment of non-ST-segment elevation
acute coronary syndromes with cardiac magnetic resonance
imaging. J Am Coll Cardiol 2004;44:2173-2181
49. Kwong RY, Schussheim AE, Rekhraj S, Aletras AH, Geller N,
Davis J, et al. Detecting acute coronary syndrome in the
emergency department with cardiac magnetic resonance
imaging. Circulation 2003;107:531-537
50. Cury RC, Shash K, Nagurney JT, Rosito G, Shapiro MD,
Nomura CH, et al. Cardiac magnetic resonance with T2-
weighted imaging improves detection of patients with acute
coronary syndrome in the emergency department. Circulation
2008;118:837-844
51. Miller CD, Hwang W, Case D, Hoekstra JW, Lefebvre C,
Blumstein H, et al. Stress CMR imaging observation unit in
the emergency department reduces 1-year medical care costs
in patients with acute chest pain: a randomized study for
comparison with inpatient care. JACC Cardiovasc Imaging
2011;4:862-870
681
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
52. Miller CD, Case LD, Little WC, Mahler SA, Burke GL, Harper
EN, et al. Stress CMR reduces revascularization, hospital
readmission, and recurrent cardiac testing in intermediate-
risk patients with acute chest pain. JACC Cardiovasc Imaging
2013;6:785-794
53. Kern MJ, Lerman A, Bech JW, De Bruyne B, Eeckhout E,
Fearon WF, et al. Physiological assessment of coronary artery
disease in the cardiac catheterization laboratory: a scientific
statement from the American Heart Association Committee
on Diagnostic and Interventional Cardiac Catheterization,
Council on Clinical Cardiology. Circulation 2006;114:1321-
1341
54. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern
MJ, King SB 3rd, et al. ACC/AHA/SCAI 2005 guideline update
for percutaneous coronary intervention: a report of the
American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (ACC/AHA/SCAI Writing
Committee to Update 2001 Guidelines for Percutaneous
Coronary Intervention). Circulation 2006;113:e166-e286
55. Smith SC Jr, Feldman TE, Hirshfeld JW Jr, Jacobs AK, Kern
MJ, King SB 3rd, et al. ACC/AHA/SCAI 2005 guideline update
for percutaneous coronary intervention: a report of the
American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (ACC/AHA/SCAI Writing
Committee to Update the 2001 Guidelines for Percutaneous
Coronary Intervention). J Am Coll Cardiol 2006;47:e1-e121
56. Meijboom WB, Van Mieghem CA, van Pelt N, Weustink A,
Pugliese F, Mollet NR, et al. Comprehensive assessment of
coronary artery stenoses: computed tomography coronary
angiography versus conventional coronary angiography and
correlation with fractional flow reserve in patients with
stable angina. J Am Coll Cardiol 2008;52:636-643
57. Tonino PA, De Bruyne B, Pijls NH, Siebert U, Ikeno F, van’t
Veer M, et al. Fractional flow reserve versus angiography for
guiding percutaneous coronary intervention. N Engl J Med
2009;360:213-224
58. Pijls NH, Fearon WF, Tonino PA, Siebert U, Ikeno F,
Bornschein B, et al. Fractional flow reserve versus
angiography for guiding percutaneous coronary intervention
in patients with multivessel coronary artery disease: 2-year
follow-up of the FAME (Fractional Flow Reserve Versus
Angiography for Multivessel Evaluation) study. J Am Coll
Cardiol 2010;56:177-184
59. Hamon M, Fau G, Née G, Ehtisham J, Morello R, Hamon
M. Meta-analysis of the diagnostic performance of stress
perfusion cardiovascular magnetic resonance for detection of
coronary artery disease. J Cardiovasc Magn Reson 2010;12:29
60. Rieber J, Huber A, Erhard I, Mueller S, Schweyer M, Koenig
A, et al. Cardiac magnetic resonance perfusion imaging
for the functional assessment of coronary artery disease: a
comparison with coronary angiography and fractional flow
reserve. Eur Heart J 2006;27:1465-1471
61. Costa MA, Shoemaker S, Futamatsu H, Klassen C, Angiolillo
DJ, Nguyen M, et al. Quantitative magnetic resonance
perfusion imaging detects anatomic and physiologic coronary
artery disease as measured by coronary angiography and
fractional flow reserve. J Am Coll Cardiol 2007;50:514-522
62. Watkins S, McGeoch R, Lyne J, Steedman T, Good R,
McLaughlin MJ, et al. Validation of magnetic resonance
myocardial perfusion imaging with fractional flow reserve
for the detection of significant coronary heart disease.
Circulation 2009;120:2207-2213
63. Lockie T, Ishida M, Perera D, Chiribiri A, De Silva K, Kozerke
S, et al. High-resolution magnetic resonance myocardial
perfusion imaging at 3.0-Tesla to detect hemodynamically
significant coronary stenoses as determined by fractional
flow reserve. J Am Coll Cardiol 2011;57:70-75
64. Groothuis JG, Beek AM, Brinckman SL, Meijerink MR, van
den Oever ML, Hofman MB, et al. Combined non-invasive
functional and anatomical diagnostic work-up in clinical
practice: the magnetic resonance and computed tomography
in suspected coronary artery disease (MARCC) study. Eur
Heart J 2013;34:1990-1998
65. Jaarsma C, Leiner T, Bekkers SC, Crijns HJ, Wildberger JE,
Nagel E, et al. Diagnostic performance of noninvasive
myocardial perfusion imaging using single-photon emission
computed tomography, cardiac magnetic resonance, and
positron emission tomography imaging for the detection of
obstructive coronary artery disease: a meta-analysis. J Am
Coll Cardiol 2012;59:1719-1728
66. Bryan AJ, Angelini GD. The biology of saphenous vein graft
occlusion: etiology and strategies for prevention. Curr Opin
Cardiol 1994;9:641-649
67. Barner HB, Standeven JW, Reese J. Twelve-year experience
with internal mammary artery for coronary artery bypass. J
Thorac Cardiovasc Surg 1985;90:668-675
68. Cameron AA, Davis KB, Rogers WJ. Recurrence of angina after
coronary artery bypass surgery: predictors and prognosis
(CASS Registry). Coronary Artery Surgery Study. J Am Coll
Cardiol 1995;26:895-899
69. Langerak SE, Vliegen HW, de Roos A, Zwinderman AH, Jukema
JW, Kunz P, et al. Detection of vein graft disease using high-
resolution magnetic resonance angiography. Circulation
2002;105:328-333
70. Galjee MA, van Rossum AC, Doesburg T, van Eenige MJ,
Visser CA. Value of magnetic resonance imaging in assessing
patency and function of coronary artery bypass grafts. An
angiographically controlled study. Circulation 1996;93:660-
666
71. Duerinckx AJ, Atkinson D, Hurwitz R. Assessment of coronary
artery patency after stent placement using magnetic
resonance angiography. J Magn Reson Imaging 1998;8:896-
902
72. Sardanelli F, Zandrino F, Molinari G, Iozzelli A, Balbi M,
Barsotti A. MR evaluation of coronary stents with navigator
echo and breath-hold cine gradient-echo techniques. Eur
Radiol 2002;12:193-200
73. De Cobelli F, Cappio S, Vanzulli A, Del Maschio A. MRI
assessment of coronary stents. Rays 1999;24:140-148
74. Duerinckx AJ, Atkinson D, Hurwitz R, Mintorovitch J,
Whitney W. Coronary MR angiography after coronary stent
placement. AJR Am J Roentgenol 1995;165:662-664
682
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
75. De Cobelli F, Guidetti D, Vanzulli A, Mellone R, Chierchia S,
Del Maschio A. [Magnetic resonance angiography of coronary
arteries: assessment in patients with coronary stenosis and
control after stent positioning]. Radiol Med 1998;95:54-61
76. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof
E, Fleischmann KE, et al. ACC/AHA 2007 Guidelines on
Perioperative Cardiovascular Evaluation and Care for
Noncardiac Surgery: Executive Summary: A Report of the
American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Writing Committee to
Revise the 2002 Guidelines on Perioperative Cardiovascular
Evaluation for Noncardiac Surgery): Developed in
Collaboration With the American Society of Echocardiography,
American Society of Nuclear Cardiology, Heart Rhythm
Society, Society of Cardiovascular Anesthesiologists, Society
for Cardiovascular Angiography and Interventions, Society
for Vascular Medicine and Biology, and Society for Vascular
Surgery. Circulation 2007;116:1971-1996
77. Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof
EL, Fleischmann KE, et al. ACC/AHA 2007 guidelines
on perioperative cardiovascular evaluation and care for
noncardiac surgery: a report of the American College of
Cardiology/American Heart Association Task Force on
Practice Guidelines (Writing Committee to Revise the 2002
Guidelines on Perioperative Cardiovascular Evaluation for
Noncardiac Surgery) developed in collaboration with the
American Society of Echocardiography, American Society
of Nuclear Cardiology, Heart Rhythm Society, Society of
Cardiovascular Anesthesiologists, Society for Cardiovascular
Angiography and Interventions, Society for Vascular Medicine
and Biology, and Society for Vascular Surgery. J Am Coll
Cardiol 2007;50:e159-e241
78. Fleisher LA; American College of Cardiology/American Heart
Association. Cardiac risk stratification for noncardiac surgery:
update from the American College of Cardiology/American
Heart Association 2007 guidelines. Cleve Clin J Med 2009;76
Suppl 4:S9-S15
79. Freeman WK, Gibbons RJ. Perioperative cardiovascular
assessment of patients undergoing noncardiac surgery. Mayo
Clin Proc 2009;84:79-90
80. Holt NF. Perioperative cardiac risk reduction. Am Fam
Physician 2012;85:239-246
81. Nelson CL, Herndon JE, Mark DB, Pryor DB, Califf RM,
Hlatky MA. Relation of clinical and angiographic factors to
functional capacity as measured by the Duke Activity Status
Index. Am J Cardiol 1991;68:973-975
82. Fathala A, Hassan W. Role of multimodality cardiac imaging
in preoperative cardiovascular evaluation before noncardiac
surgery. Ann Card Anaesth 2011;14:134-145
83. Shah DJ, Kim HW, Kim RJ. Evaluation of ischemic heart
disease. Heart Fail Clin 2009;5:315-332, v
84. Mavrogeni S, Papadopoulos G, Karanasios E, Cokkinos DV.
How to image Kawasaki disease: a validation of different
imaging techniques. Int J Cardiol 2008;124:27-31
85. Mavrogeni S, Papadopoulos G, Douskou M, Kaklis S, Seimenis
I, Baras P, et al. Magnetic resonance angiography is
equivalent to X-ray coronary angiography for the evaluation
of coronary arteries in Kawasaki disease. J Am Coll Cardiol
2004;43:649-652
86. Mavrogeni S, Papadopoulos G, Douskou M, Kaklis S, Seimenis
I, Varlamis G, et al. Magnetic resonance angiography,
function and viability evaluation in patients with Kawasaki
disease. J Cardiovasc Magn Reson 2006;8:493-498
87. Greil GF, Stuber M, Botnar RM, Kissinger KV, Geva T,
Newburger JW, et al. Coronary magnetic resonance
angiography in adolescents and young adults with kawasaki
disease. Circulation 2002;105:908-911
88. Greil GF, Seeger A, Miller S, Claussen CD, Hofbeck M, Botnar
RM, et al. Coronary magnetic resonance angiography and
vessel wall imaging in children with Kawasaki disease.
Pediatr Radiol 2007;37:666-673
89. Ferket BS, Genders TS, Colkesen EB, Visser JJ, Spronk S,
Steyerberg EW, et al. Systematic review of guidelines on
imaging of asymptomatic coronary artery disease. J Am Coll
Cardiol 2011;57:1591-1600
90. Choi KM, Kim RJ, Gubernikoff G, Vargas JD, Parker M, Judd
RM. Transmural extent of acute myocardial infarction predicts
long-term improvement in contractile function. Circulation
2001;104:1101-1107
91. Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, Simonetti O,
et al. The use of contrast-enhanced magnetic resonance
imaging to identify reversible myocardial dysfunction. N Engl
J Med 2000;343:1445-1453
92. Romero J, Kahan J, Kelesidis I, Makani H, Wever-Pinzon
O, Medina H, et al. CMR imaging for the evaluation of
myocardial stunning after acute myocardial infarction: a
meta-analysis of prospective trials. Eur Heart J Cardiovasc
Imaging 2013;14:1080-1091
93. Chan RH, Leung AA, Manning WJ. Prognostic utility of
late gadolinium enhancement cardiac magnetic resonance
imaging in coronary artery disease: a meta-analysis. J
Cardiovasc Magn Reson 2013;15 Suppl 1:O75
94. Romero J, Xue X, Gonzalez W, Garcia MJ. CMR imaging
assessing viability in patients with chronic ventricular
dysfunction due to coronary artery disease: a meta-analysis
of prospective trials. JACC Cardiovasc Imaging 2012;5:494-508
95. Trent RJ, Waiter GD, Hillis GS, McKiddie FI, Redpath
TW, Walton S. Dobutamine magnetic resonance imaging
as a predictor of myocardial functional recovery after
revascularisation. Heart 2000;83:40-46
96. Selvanayagam JB, Kardos A, Francis JM, Wiesmann F,
Petersen SE, Taggart DP, et al. Value of delayed-enhancement
cardiovascular magnetic resonance imaging in predicting
myocardial viability after surgical revascularization.
Circulation 2004;110:1535-1541
97. Wagner A, Mahrholdt H, Holly TA, Elliott MD, Regenfus M,
Parker M, et al. Contrast-enhanced MRI and routine single
photon emission computed tomography (SPECT) perfusion
imaging for detection of subendocardial myocardial infarcts:
an imaging study. Lancet 2003;361:374-379
98. Roes SD, Kaandorp TA, Marsan NA, Westenberg JJ, Dibbets-
Schneider P, Stokkel MP, et al. Agreement and disagreement
683
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
between contrast-enhanced magnetic resonance imaging and
nuclear imaging for assessment of myocardial viability. Eur J
Nucl Med Mol Imaging 2009;36:594-601
99. Crean A, Khan SN, Davies LC, Coulden R, Dutka DP.
Assessment of Myocardial Scar; Comparison Between F-FDG
PET, CMR and Tc-Sestamibi. Clin Med Cardiol 2009;3:69-76
100. Heijenbrok-Kal MH, Fleischmann KE, Hunink MG. Stress
echocardiography, stress single-photon-emission computed
tomography and electron beam computed tomography for
the assessment of coronary artery disease: a meta-analysis
of diagnostic performance. Am Heart J 2007;154:415-423
101. Eitel I, Desch S, de Waha S, Fuernau G, Gutberlet M, Schuler
G, et al. Long-term prognostic value of myocardial salvage
assessed by cardiovascular magnetic resonance in acute
reperfused myocardial infarction. Heart 2011;97:2038-2045
102. Eitel I, Desch S, Fuernau G, Hildebrand L, Gutberlet M,
Schuler G, et al. Prognostic significance and determinants
of myocardial salvage assessed by cardiovascular magnetic
resonance in acute reperfused myocardial infarction. J Am
Coll Cardiol 2010;55:2470-2479
103. Selvanayagam JB, Porto I, Channon K, Petersen SE, Francis
JM, Neubauer S, et al. Troponin elevation after percutaneous
coronary intervention directly represents the extent of
irreversible myocardial injury: insights from cardiovascular
magnetic resonance imaging. Circulation 2005;111:1027-1032
104. McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm
M, Dickstein K, et al. ESC Guidelines for the diagnosis and
treatment of acute and chronic heart failure 2012: The Task
Force for the Diagnosis and Treatment of Acute and Chronic
Heart Failure 2012 of the European Society of Cardiology.
Developed in collaboration with the Heart Failure Association
(HFA) of the ESC. Eur Heart J 2012;33:1787-1847
105. Fonseca C. Diagnosis of heart failure in primary care. Heart
Fail Rev 2006;11:95-107
106. Kelder JC, Cramer MJ, van Wijngaarden J, van Tooren R,
Mosterd A, Moons KG, et al. The diagnostic value of physical
examination and additional testing in primary care patients
with suspected heart failure. Circulation 2011;124:2865-2873
107. Assomull RG, Shakespeare C, Kalra PR, Lloyd G, Gulati A,
Strange J, et al. Role of cardiovascular magnetic resonance
as a gatekeeper to invasive coronary angiography in patients
presenting with heart failure of unknown etiology. Circulation
2011;124:1351-1360
108. Bellenger NG, Burgess MI, Ray SG, Lahiri A, Coats AJ, Cleland
JG, et al. Comparison of left ventricular ejection fraction and
volumes in heart failure by echocardiography, radionuclide
ventriculography and cardiovascular magnetic resonance; are
they interchangeable? Eur Heart J 2000;21:1387-1396
109. Bristow MR, Gilbert EM, Abraham WT, Adams KF, Fowler
MB, Hershberger RE, et al. Carvedilol produces dose-related
improvements in left ventricular function and survival in
subjects with chronic heart failure. MOCHA Investigators.
Circulation 1996;94:2807-2816
110. Capomolla S, Febo O, Gnemmi M, Riccardi G, Opasich C,
Caporotondi A, et al. Beta-blockade therapy in chronic
heart failure: diastolic function and mitral regurgitation
improvement by carvedilol. Am Heart J 2000;139:596-608
111. Doughty RN, Whalley GA, Walsh HA, Gamble GD, López-
Sendón J, Sharpe N; CAPRICORN Echo Substudy Investigators.
Effects of carvedilol on left ventricular remodeling after
acute myocardial infarction: the CAPRICORN Echo Substudy.
Circulation 2004;109:201-206
112. Alfakih K, Reid S, Jones T, Sivananthan M. Assessment of
ventricular function and mass by cardiac magnetic resonance
imaging. Eur Radiol 2004;14:1813-1822
113. Holman ER, Buller VG, de Roos A, van der Geest RJ, Baur
LH, van der Laarse A, et al. Detection and quantification of
dysfunctional myocardium by magnetic resonance imaging.
A new three-dimensional method for quantitative wall-
thickening analysis. Circulation 1997;95:924-931
114. Grothues F, Moon JC, Bellenger NG, Smith GS, Klein HU,
Pennell DJ. Interstudy reproducibility of right ventricular
volumes, function, and mass with cardiovascular magnetic
resonance. Am Heart J 2004;147:218-223
115. Grothues F, Smith GC, Moon JC, Bellenger NG, Collins P,
Klein HU, et al. Comparison of interstudy reproducibility of
cardiovascular magnetic resonance with two-dimensional
echocardiography in normal subjects and in patients with
heart failure or left ventricular hypertrophy. Am J Cardiol
2002;90:29-34
116. Jenkins C, Moir S, Chan J, Rakhit D, Haluska B, Marwick TH.
Left ventricular volume measurement with echocardiography:
a comparison of left ventricular opacification, three-
dimensional echocardiography, or both with magnetic
resonance imaging. Eur Heart J 2009;30:98-106
117. Bellenger NG, Davies LC, Francis JM, Coats AJ, Pennell DJ.
Reduction in sample size for studies of remodeling in heart
failure by the use of cardiovascular magnetic resonance. J
Cardiovasc Magn Reson 2000;2:271-278
118. Kim YJ, Kim RJ. The role of cardiac MR in new-onset heart
failure. Curr Cardiol Rep 2011;13:185-193
119. Valle-Muñoz A, Estornell-Erill J, Soriano-Navarro CJ, Nadal-
Barange M, Martinez-Alzamora N, Pomar-Domingo F, et al.
Late gadolinium enhancement-cardiovascular magnetic
resonance identifies coronary artery disease as the aetiology
of left ventricular dysfunction in acute new-onset congestive
heart failure. Eur J Echocardiogr 2009;10:968-974
120. Hamilton-Craig C, Strugnell WE, Raffel OC, Porto I, Walters
DL, Slaughter RE. CT angiography with cardiac MRI: non-
invasive functional and anatomical assessment for the
etiology in newly diagnosed heart failure. Int J Cardiovasc
Imaging 2012;28:1111-1122
121. Bluemke DA, Kronmal RA, Lima JA, Liu K, Olson J, Burke
GL, et al. The relationship of left ventricular mass and
geometry to incident cardiovascular events: the MESA (Multi-
Ethnic Study of Atherosclerosis) study. J Am Coll Cardiol
2008;52:2148-2155
122. Olivotto I, Maron MS, Autore C, Lesser JR, Rega L, Casolo
G, et al. Assessment and significance of left ventricular
mass by cardiovascular magnetic resonance in hypertrophic
cardiomyopathy. J Am Coll Cardiol 2008;52:559-566
123. Follath F, Cleland JG, Klein W, Murphy R. Etiology and
684
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
response to drug treatment in heart failure. J Am Coll Cardiol
1998;32:1167-1172
124. Mahrholdt H, Wagner A, Judd RM, Sechtem U, Kim RJ.
Delayed enhancement cardiovascular magnetic resonance
assessment of non-ischaemic cardiomyopathies. Eur Heart J
2005;26:1461-1474
125. Choudhury L, Mahrholdt H, Wagner A, Choi KM, Elliott
MD, Klocke FJ, et al. Myocardial scarring in asymptomatic
or mildly symptomatic patients with hypertrophic
cardiomyopathy. J Am Coll Cardiol 2002;40:2156-2164
126. Kim KH, Kim HK, Hwang IC, Lee SP, Park EA, Lee W, et al.
Myocardial scarring on cardiovascular magnetic resonance in
asymptomatic or minimally symptomatic patients with “pure”
apical hypertrophic cardiomyopathy. J Cardiovasc Magn Reson
2012;14:52
127. Moon JC, Sachdev B, Elkington AG, McKenna WJ, Mehta
A, Pennell DJ, et al. Gadolinium enhanced cardiovascular
magnetic resonance in Anderson-Fabry disease. Evidence for
a disease specific abnormality of the myocardial interstitium.
Eur Heart J 2003;24:2151-2155
128. Maceira AM, Joshi J, Prasad SK, Moon JC, Perugini E, Harding
I, et al. Cardiovascular magnetic resonance in cardiac
amyloidosis. Circulation 2005;111:186-193
129. Mahrholdt H, Goedecke C, Wagner A, Meinhardt G,
Athanasiadis A, Vogelsberg H, et al. Cardiovascular
magnetic resonance assessment of human myocarditis: a
comparison to histology and molecular pathology. Circulation
2004;109:1250-1258
130. Friedrich MG, Strohm O, Schulz-Menger J, Marciniak H, Luft
FC, Dietz R. Contrast media-enhanced magnetic resonance
imaging visualizes myocardial changes in the course of viral
myocarditis. Circulation 1998;97:1802-1809
131. Klem I, Shah DJ, White RD, Pennell DJ, van Rossum AC,
Regenfus M, et al. Prognostic value of routine cardiac
magnetic resonance assessment of left ventricular ejection
fraction and myocardial damage: an international,
multicenter study. Circ Cardiovasc Imaging 2011;4:610-619
132. Klem I, Weinsaft JW, Bahnson TD, Hegland D, Kim HW, Hayes
B, et al. Assessment of myocardial scarring improves risk
stratification in patients evaluated for cardiac defibrillator
implantation. J Am Coll Cardiol 2012;60:408-420
133. Joshi SB, Connelly KA, Jimenez-Juan L, Hansen M, Kirpalani
A, Dorian P, et al. Potential clinical impact of cardiovascular
magnetic resonance assessment of ejection fraction on
eligibility for cardioverter defibrillator implantation. J
Cardiovasc Magn Reson 2012;14:69
134. Gao P, Yee R, Gula L, Krahn AD, Skanes A, Leong-Sit P, et
al. Prediction of arrhythmic events in ischemic and dilated
cardiomyopathy patients referred for implantable cardiac
defibrillator: evaluation of multiple scar quantification
measures for late gadolinium enhancement magnetic
resonance imaging. Circ Cardiovasc Imaging 2012;5:448-456
135. Delgado V, van Bommel RJ, Bertini M, Borleffs CJ, Marsan
NA, Arnold CT, et al. Relative merits of left ventricular
dyssynchrony, left ventricular lead position, and myocardial
scar to predict long-term survival of ischemic heart failure
patients undergoing cardiac resynchronization therapy.
Circulation 2011;123:70-78
136. Leyva F, Foley PW. Current and future role of cardiovascular
magnetic resonance in cardiac resynchronization therapy.
Heart Fail Rev 2011;16:251-262
137. Leyva F, Foley PW, Chalil S, Ratib K, Smith RE, Prinzen F,
et al. Cardiac resynchronization therapy guided by late
gadolinium-enhancement cardiovascular magnetic resonance.
J Cardiovasc Magn Reson 2011;13:29
138. Dickfeld T, Tian J, Ahmad G, Jimenez A, Turgeman A, Kuk
R, et al. MRI-Guided ventricular tachycardia ablation:
integration of late gadolinium-enhanced 3D scar in patients
with implantable cardioverter-defibrillators. Circ Arrhythm
Electrophysiol 2011;4:172-184
139. Junttila MJ, Fishman JE, Lopera GA, Pattany PM, Velazquez
DL, Williams AR, et al. Safety of serial MRI in patients with
implantable cardioverter defibrillators. Heart 2011;97:1852-
1856
140. Chessa M, Carrozza M, Butera G, Piazza L, Negura DG,
Bussadori C, et al. Results and mid-long-term follow-up of
stent implantation for native and recurrent coarctation of
the aorta. Eur Heart J 2005;26:2728-2732
141. Hassan W, Awad M, Fawzy ME, Omrani AA, Malik S, Akhras
N, et al. Long-term effects of balloon angioplasty on left
ventricular hypertrophy in adolescent and adult patients
with native coarctation of the aorta. Up to 18 years follow-
up results. Catheter Cardiovasc Interv 2007;70:881-886
142. Bogaert J, Kuzo R, Dymarkowski S, Janssen L, Celis I, Budts
W, et al. Follow-up of patients with previous treatment
for coarctation of the thoracic aorta: comparison between
contrast-enhanced MR angiography and fast spin-echo MR
imaging. Eur Radiol 2000;10:1847-1854
143. Geva T, Greil GF, Marshall AC, Landzberg M, Powell AJ.
Gadolinium-enhanced 3-dimensional magnetic resonance
angiography of pulmonary blood supply in patients with
complex pulmonary stenosis or atresia: comparison with
x-ray angiography. Circulation 2002;106:473-478
144. Prasad SK, Soukias N, Hornung T, Khan M, Pennell DJ,
Gatzoulis MA, et al. Role of magnetic resonance angiography
in the diagnosis of major aortopulmonary collateral
arteries and partial anomalous pulmonary venous drainage.
Circulation 2004;109:207-214
145. Fattori R, Bacchi Reggiani L, Pepe G, Napoli G, Bnà C,
Celletti F, et al. Magnetic resonance imaging evaluation
of aortic elastic properties as early expression of Marfan
syndrome. J Cardiovasc Magn Reson 2000;2:251-256
146. Baumgartner D, Baumgartner C, Mátyás G, Steinmann B,
Löffler-Ragg J, Schermer E, et al. Diagnostic power of aortic
elastic properties in young patients with Marfan syndrome. J
Thorac Cardiovasc Surg 2005;129:730-739
147. Geva T, Vick GW 3rd, Wendt RE, Rokey R. Role of spin echo
and cine magnetic resonance imaging in presurgical planning
of heterotaxy syndrome. Comparison with echocardiography
and catheterization. Circulation 1994;90:348-356
148. Salehian O, Schwerzmann M, Merchant N, Webb GD, Siu SC,
Therrien J. Assessment of systemic right ventricular function
685
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
in patients with transposition of the great arteries using
the myocardial performance index: comparison with cardiac
magnetic resonance imaging. Circulation 2004;110:3229-3233
149. Warnes CA. Transposition of the great arteries. Circulation
2006;114:2699-2709
150. Rutledge JM, Nihill MR, Fraser CD, Smith OE, McMahon
CJ, Bezold LI. Outcome of 121 patients with congenitally
corrected transposition of the great arteries. Pediatr Cardiol
2002;23:137-145
151. Didier D, Higgins CB. Identification and localization of
ventricular septal defect by gated magnetic resonance
imaging. Am J Cardiol 1986;57:1363-1368
152. Hundley WG, Li HF, Lange RA, Pfeifer DP, Meshack BM,
Willard JE, et al. Assessment of left-to-right intracardiac
shunting by velocity-encoded, phase-difference magnetic
resonance imaging. A comparison with oximetric and
indicator dilution techniques. Circulation 1995;91:2955-2960
153. Körperich H, Gieseke J, Barth P, Hoogeveen R, Esdorn H,
Peterschröder A, et al. Flow volume and shunt quantification
in pediatric congenital heart disease by real-time magnetic
resonance velocity mapping: a validation study. Circulation
2004;109:1987-1993
154. Beerbaum P, Körperich H, Gieseke J, Barth P, Peuster
M, Meyer H. Rapid left-to-right shunt quantification in
children by phase-contrast magnetic resonance imaging
combined with sensitivity encoding (SENSE). Circulation
2003;108:1355-1361
155. American College of Cardiology; American Heart Association
Task Force on Practice Guidelines (Writing Committee to
revise the 1998 guidelines for the management of patients
with valvular heart disease); Society of Cardiovascular
Anesthesiologists, Bonow RO, Carabello BA, Chatterjee K, et
al. ACC/AHA 2006 guidelines for the management of patients
with valvular heart disease: a report of the American College
of Cardiology/American Heart Association Task Force on
Practice Guidelines (writing Committee to Revise the 1998
guidelines for the management of patients with valvular
heart disease) developed in collaboration with the Society of
Cardiovascular Anesthesiologists endorsed by the Society for
Cardiovascular Angiography and Interventions and the Society
of Thoracic Surgeons. J Am Coll Cardiol 2006;48:e1-e148
156. Rebergen SA, Chin JG, Ottenkamp J, van der Wall EE, de
Roos A. Pulmonary regurgitation in the late postoperative
follow-up of tetralogy of Fallot. Volumetric quantitation by
nuclear magnetic resonance velocity mapping. Circulation
1993;88:2257-2266
157. Apitz C, Webb GD, Redington AN. Tetralogy of Fallot. Lancet
2009;374:1462-1471
158. Therrien J, Provost Y, Merchant N, Williams W, Colman J,
Webb G. Optimal timing for pulmonary valve replacement
in adults after tetralogy of Fallot repair. Am J Cardiol
2005;95:779-782
159. Oosterhof T, van Straten A, Vliegen HW, Meijboom FJ, van
Dijk AP, Spijkerboer AM, et al. Preoperative thresholds for
pulmonary valve replacement in patients with corrected
tetralogy of Fallot using cardiovascular magnetic resonance.
Circulation 2007;116:545-551
160. Babu-Narayan SV, Kilner PJ, Li W, Moon JC, Goktekin O,
Davlouros PA, et al. Ventricular fibrosis suggested by
cardiovascular magnetic resonance in adults with repaired
tetralogy of fallot and its relationship to adverse markers of
clinical outcome. Circulation 2006;113:405-413
161. Attenhofer Jost CH, Edmister WD, Julsrud PR, Dearani JA,
Savas Tepe M, Warnes CA, et al. Prospective comparison of
echocardiography versus cardiac magnetic resonance imaging
in patients with Ebstein’s anomaly. Int J Cardiovasc Imaging
2012;28:1147-1159
162. Yalonetsky S, Tobler D, Greutmann M, Crean AM,
Wintersperger BJ, Nguyen ET, et al. Cardiac magnetic
resonance imaging and the assessment of ebstein anomaly in
adults. Am J Cardiol 2011;107:767-773
163. Lemmer J, Heise G, Rentzsch A, Boettler P, Kuehne T,
Dubowy KO, et al. Right ventricular function in grown-up
patients after correction of congenital right heart disease.
Clin Res Cardiol 2011;100:289-296
164. Grothoff M, Spors B, Abdul-Khaliq H, Gutberlet M. Evaluation
of postoperative pulmonary regurgitation after surgical
repair of tetralogy of Fallot: comparison between Doppler
echocardiography and MR velocity mapping. Pediatr Radiol
2008;38:186-191
165. Roest AA, Helbing WA, Kunz P, van den Aardweg JG,
Lamb HJ, Vliegen HW, et al. Exercise MR imaging in the
assessment of pulmonary regurgitation and biventricular
function in patients after tetralogy of fallot repair. Radiology
2002;223:204-211
166. Oosterhof T, Mulder BJ, Vliegen HW, de Roos A.
Cardiovascular magnetic resonance in the follow-up of
patients with corrected tetralogy of Fallot: a review. Am
Heart J 2006;151:265-272
167. Oosterhof T, Mulder BJ, Vliegen HW, de Roos A. Corrected
tetralogy of Fallot: delayed enhancement in right ventricular
outflow tract. Radiology 2005;237:868-871
168. Davlouros PA, Kilner PJ, Hornung TS, Li W, Francis JM, Moon
JC, et al. Right ventricular function in adults with repaired
tetralogy of Fallot assessed with cardiovascular magnetic
resonance imaging: detrimental role of right ventricular
outflow aneurysms or akinesia and adverse right-to-left
ventricular interaction. J Am Coll Cardiol 2002;40:2044-2052
169. Taylor AM, Dymarkowski S, Hamaekers P, Razavi R, Gewillig
M, Mertens L, et al. MR coronary angiography and late-
enhancement myocardial MR in children who underwent
arterial switch surgery for transposition of great arteries.
Radiology 2005;234:542-547
170. Garg R, Powell AJ, Sena L, Marshall AC, Geva T. Effects of
metallic implants on magnetic resonance imaging evaluation
of Fontan palliation. Am J Cardiol 2005;95:688-691
171. Grosse-Wortmann L, Al-Otay A, Yoo SJ. Aortopulmonary
collaterals after bidirectional cavopulmonary connection or
Fontan completion: quantification with MRI. Circ Cardiovasc
Imaging 2009;2:219-225
172. Fogel MA, Weinberg PM, Chin AJ, Fellows KE, Hoffman
EA. Late ventricular geometry and performance changes
686
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
of functional single ventricle throughout staged Fontan
reconstruction assessed by magnetic resonance imaging. J
Am Coll Cardiol 1996;28:212-221
173. Cawley PJ, Maki JH, Otto CM. Cardiovascular magnetic
resonance imaging for valvular heart disease: technique and
validation. Circulation 2009;119:468-478
174. Søndergaard L, Hildebrandt P, Lindvig K, Thomsen C,
Ståhlberg F, Kassis E, et al. Valve area and cardiac output
in aortic stenosis: quantification by magnetic resonance
velocity mapping. Am Heart J 1993;126:1156-1164
175. Caruthers SD, Lin SJ, Brown P, Watkins MP, Williams
TA, Lehr KA, et al. Practical value of cardiac magnetic
resonance imaging for clinical quantification of aortic valve
stenosis: comparison with echocardiography. Circulation
2003;108:2236-2243
176. Djavidani B, Debl K, Lenhart M, Seitz J, Paetzel C, Schmid
FX, et al. Planimetry of mitral valve stenosis by magnetic
resonance imaging. J Am Coll Cardiol 2005;45:2048-2053
177. Honda N, Machida K, Hashimoto M, Mamiya T, Takahashi T,
Kamano T, et al. Aortic regurgitation: quantitation with MR
imaging velocity mapping. Radiology 1993;186:189-194
178. Ley S, Eichhorn J, Ley-Zaporozhan J, Ulmer H, Schenk JP,
Kauczor HU, et al. Evaluation of aortic regurgitation in
congenital heart disease: value of MR imaging in comparison
to echocardiography. Pediatr Radiol 2007;37:426-436
179. Kon MW, Myerson SG, Moat NE, Pennell DJ. Quantification of
regurgitant fraction in mitral regurgitation by cardiovascular
magnetic resonance: comparison of techniques. J Heart Valve
Dis 2004;13:600-607
180. Cawley PJ, Hamilton-Craig C, Owens DS, Krieger EV, Strugnell
WE, Mitsumori L, et al. Prospective comparison of valve
regurgitation quantitation by cardiac magnetic resonance
imaging and transthoracic echocardiography. Circ Cardiovasc
Imaging 2013;6:48-57
181. Lee C, Kim YM, Lee CH, Kwak JG, Park CS, Song JY, et al.
Outcomes of pulmonary valve replacement in 170 patients
with chronic pulmonary regurgitation after relief of right
ventricular outflow tract obstruction: implications for
optimal timing of pulmonary valve replacement. J Am Coll
Cardiol 2012;60:1005-1014
182. Sarikouch S, Koerperich H, Dubowy KO, Boethig D, Boettler
P, Mir TS, et al. Impact of gender and age on cardiovascular
function late after repair of tetralogy of Fallot: percentiles
based on cardiac magnetic resonance. Circ Cardiovasc
Imaging 2011;4:703-711
183. Mercer-Rosa L, Yang W, Kutty S, Rychik J, Fogel M,
Goldmuntz E. Quantifying pulmonary regurgitation and right
ventricular function in surgically repaired tetralogy of Fallot:
a comparative analysis of echocardiography and magnetic
resonance imaging. Circ Cardiovasc Imaging 2012;5:637-643
184. Koca B, Öztunç F, Erog˘lu AG, Gökalp S, Dursun M, Yilmaz
R. Evaluation of right ventricular function in patients with
tetralogy of Fallot using the myocardial performance index
and isovolumic acceleration: a comparison with cardiac
magnetic resonance imaging. Cardiol Young 2014;24:422-429
185. Botnar R, Nagel E, Scheidegger MB, Pedersen EM, Hess
O, Boesiger P. Assessment of prosthetic aortic valve
performance by magnetic resonance velocity imaging.
MAGMA 2000;10:18-26
186. Kozerke S, Hasenkam JM, Nygaard H, Paulsen PK, Pedersen
EM, Boesiger P. Heart motion-adapted MR velocity mapping
of blood velocity distribution downstream of aortic valve
prostheses: initial experience. Radiology 2001;218:548-555
187. von Knobelsdorff-Brenkenhoff F, Rudolph A, Wassmuth R,
Bohl S, Buschmann EE, Abdel-Aty H, et al. Feasibility of
cardiovascular magnetic resonance to assess the orifice area
of aortic bioprostheses. Circ Cardiovasc Imaging 2009;2:397-
404
188. Marcus FI, McKenna WJ, Sherrill D, Basso C, Bauce B,
Bluemke DA, et al. Diagnosis of arrhythmogenic right
ventricular cardiomyopathy/dysplasia: proposed modification
of the Task Force Criteria. Eur Heart J 2010;31:806-814
189. Sen-Chowdhry S, Prasad SK, Syrris P, Wage R, Ward D,
Merrifield R, et al. Cardiovascular magnetic resonance in
arrhythmogenic right ventricular cardiomyopathy revisited:
comparison with task force criteria and genotype. J Am Coll
Cardiol 2006;48:2132-2140
190. Keller DI, Osswald S, Bremerich J, Bongartz G, Cron TA, Hilti
P, et al. Arrhythmogenic right ventricular cardiomyopathy:
diagnostic and prognostic value of the cardiac MRI in
relation to arrhythmia-free survival. Int J Cardiovasc Imaging
2003;19:537-543; discussion 545-547
191. Tandri H, Saranathan M, Rodriguez ER, Martinez C, Bomma C,
Nasir K, et al. Noninvasive detection of myocardial fibrosis
in arrhythmogenic right ventricular cardiomyopathy using
delayed-enhancement magnetic resonance imaging. J Am
Coll Cardiol 2005;45:98-103
192. Hosch W, Kristen AV, Libicher M, Dengler TJ, Aulmann S, Heye
T, et al. Late enhancement in cardiac amyloidosis: correlation
of MRI enhancement pattern with histopathological findings.
Amyloid 2008;15:196-204
193. Vogelsberg H, Mahrholdt H, Deluigi CC, Yilmaz A, Kispert
EM, Greulich S, et al. Cardiovascular magnetic resonance
in clinically suspected cardiac amyloidosis: noninvasive
imaging compared to endomyocardial biopsy. J Am Coll
Cardiol 2008;51:1022-1030
194. Syed IS, Glockner JF, Feng D, Araoz PA, Martinez MW, Edwards
WD, et al. Role of cardiac magnetic resonance imaging in the
detection of cardiac amyloidosis. JACC Cardiovasc Imaging
2010;3:155-164
195. Shimada T, Shimada K, Sakane T, Ochiai K, Tsukihashi
H, Fukui M, et al. Diagnosis of cardiac sarcoidosis and
evaluation of the effects of steroid therapy by gadolinium-
DTPA-enhanced magnetic resonance imaging. Am J Med
2001;110:520-527
196. Fallah-Rad N, Walker JR, Wassef A, Lytwyn M, Bohonis
S, Fang T, et al. The utility of cardiac biomarkers, tissue
velocity and strain imaging, and cardiac magnetic resonance
imaging in predicting early left ventricular dysfunction in
patients with human epidermal growth factor receptor II-
positive breast cancer treated with adjuvant trastuzumab
therapy. J Am Coll Cardiol 2011;57:2263-2270
687
Appropriate Use Criteria for CMR
Korean J Radiol 15(6), Nov/Dec 2014
kjronline.org
197. Oechslin EN, Attenhofer Jost CH, Rojas JR, Kaufmann PA,
Jenni R. Long-term follow-up of 34 adults with isolated left
ventricular noncompaction: a distinct cardiomyopathy with
poor prognosis. J Am Coll Cardiol 2000;36:493-500
198. Petersen SE, Selvanayagam JB, Wiesmann F, Robson MD,
Francis JM, Anderson RH, et al. Left ventricular non-
compaction: insights from cardiovascular magnetic resonance
imaging. J Am Coll Cardiol 2005;46:101-105
199. Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg
J, Longe TF, et al. Acute and reversible cardiomyopathy
provoked by stress in women from the United States.
Circulation 2005;111:472-479
200. Haghi D, Fluechter S, Suselbeck T, Kaden JJ, Borggrefe M,
Papavassiliu T. Cardiovascular magnetic resonance findings in
typical versus atypical forms of the acute apical ballooning
syndrome (Takotsubo cardiomyopathy). Int J Cardiol
2007;120:205-211
201. Mitchell JH, Hadden TB, Wilson JM, Achari A, Muthupillai
R, Flamm SD. Clinical features and usefulness of cardiac
magnetic resonance imaging in assessing myocardial viability
and prognosis in Takotsubo cardiomyopathy (transient
left ventricular apical ballooning syndrome). Am J Cardiol
2007;100:296-301
202. Monney PA, Sekhri N, Burchell T, Knight C, Davies C, Deaner
A, et al. Acute myocarditis presenting as acute coronary
syndrome: role of early cardiac magnetic resonance in its
diagnosis. Heart 2011;97:1312-1318
203. Jeserich M, Brunner E, Kandolf R, Olschewski M, Kimmel S,
Friedrich MG, et al. Diagnosis of viral myocarditis by cardiac
magnetic resonance and viral genome detection in peripheral
blood. Int J Cardiovasc Imaging 2013;29:121-129
204. Marian AJ, Roberts R. The molecular genetic basis for
hypertrophic cardiomyopathy. J Mol Cell Cardiol 2001;33:655-
670
205. Rickers C, Wilke NM, Jerosch-Herold M, Casey SA, Panse P,
Panse N, et al. Utility of cardiac magnetic resonance imaging
in the diagnosis of hypertrophic cardiomyopathy. Circulation
2005;112:855-861
206. Maron MS, Lesser JR, Maron BJ. Management implications
of massive left ventricular hypertrophy in hypertrophic
cardiomyopathy significantly underestimated by
echocardiography but identified by cardiovascular magnetic
resonance. Am J Cardiol 2010;105:1842-1843
207. Moon JC, Fisher NG, McKenna WJ, Pennell DJ. Detection
of apical hypertrophic cardiomyopathy by cardiovascular
magnetic resonance in patients with non-diagnostic
echocardiography. Heart 2004;90:645-649
208. Maron MS, Maron BJ, Harrigan C, Buros J, Gibson CM,
Olivotto I, et al. Hypertrophic cardiomyopathy phenotype
revisited after 50 years with cardiovascular magnetic
resonance. J Am Coll Cardiol 2009;54:220-228
209. Adabag AS, Maron BJ, Appelbaum E, Harrigan CJ, Buros JL,
Gibson CM, et al. Occurrence and frequency of arrhythmias
in hypertrophic cardiomyopathy in relation to delayed
enhancement on cardiovascular magnetic resonance. J Am
Coll Cardiol 2008;51:1369-1374
210. Minami Y, Kajimoto K, Terajima Y, Yashiro B, Okayama D,
Haruki S, et al. Clinical implications of midventricular
obstruction in patients with hypertrophic cardiomyopathy. J
Am Coll Cardiol 2011;57:2346-2355
211. Maron MS, Hauser TH, Dubrow E, Horst TA, Kissinger
KV, Udelson JE, et al. Right ventricular involvement in
hypertrophic cardiomyopathy. Am J Cardiol 2007;100:1293-
1298
212. Rudolph A, Abdel-Aty H, Bohl S, Boyé P, Zagrosek A, Dietz
R, et al. Noninvasive detection of fibrosis applying contrast-
enhanced cardiac magnetic resonance in different forms of
left ventricular hypertrophy relation to remodeling. J Am Coll
Cardiol 2009;53:284-291
213. Moravsky G, Ofek E, Rakowski H, Butany J, Williams L,
Ralph-Edwards A, et al. Myocardial fibrosis in hypertrophic
cardiomyopathy: accurate reflection of histopathological
findings by CMR. JACC Cardiovasc Imaging 2013;6:587-596
214. Flett AS, Hasleton J, Cook C, Hausenloy D, Quarta G, Ariti
C, et al. Evaluation of techniques for the quantification of
myocardial scar of differing etiology using cardiac magnetic
resonance. JACC Cardiovasc Imaging 2011;4:150-156
215. Moon JC, Reed E, Sheppard MN, Elkington AG, Ho SY, Burke M,
et al. The histologic basis of late gadolinium enhancement
cardiovascular magnetic resonance in hypertrophic
cardiomyopathy. J Am Coll Cardiol 2004;43:2260-2264
216. O’Hanlon R, Grasso A, Roughton M, Moon JC, Clark S, Wage
R, et al. Prognostic significance of myocardial fibrosis in
hypertrophic cardiomyopathy. J Am Coll Cardiol 2010;56:867-
874
217. Bruder O, Wagner A, Jensen CJ, Schneider S, Ong P, Kispert
EM, et al. Myocardial scar visualized by cardiovascular
magnetic resonance imaging predicts major adverse events
in patients with hypertrophic cardiomyopathy. J Am Coll
Cardiol 2010;56:875-887
218. Ismail TF, Prasad SK, Pennell DJ. Prognostic importance
of late gadolinium enhancement cardiovascular magnetic
resonance in cardiomyopathy. Heart 2012;98:438-442
219. Maron MS, Appelbaum E, Harrigan CJ, Buros J, Gibson CM,
Hanna C, et al. Clinical profile and significance of delayed
enhancement in hypertrophic cardiomyopathy. Circ Heart Fail
2008;1:184-191
220. Rubinshtein R, Glockner JF, Ommen SR, Araoz PA, Ackerman
MJ, Sorajja P, et al. Characteristics and clinical significance
of late gadolinium enhancement by contrast-enhanced
magnetic resonance imaging in patients with hypertrophic
cardiomyopathy. Circ Heart Fail 2010;3:51-58
221. Green JJ, Berger JS, Kramer CM, Salerno M. Prognostic
value of late gadolinium enhancement in clinical outcomes
for hypertrophic cardiomyopathy. JACC Cardiovasc Imaging
2012;5:370-377
222. Moon JC, McKenna WJ, McCrohon JA, Elliott PM, Smith GC,
Pennell DJ. Toward clinical risk assessment in hypertrophic
cardiomyopathy with gadolinium cardiovascular magnetic
resonance. J Am Coll Cardiol 2003;41:1561-1567
223. Fluechter S, Kuschyk J, Wolpert C, Doesch C, Veltmann C,
Haghi D, et al. Extent of late gadolinium enhancement
688
Yoon et al.
Korean J Radiol 15(6), Nov/Dec 2014 kjronline.org
detected by cardiovascular magnetic resonance correlates
with the inducibility of ventricular tachyarrhythmia in
hypertrophic cardiomyopathy. J Cardiovasc Magn Reson
2010;12:30
224. To AC, Dhillon A, Desai MY. Cardiac magnetic resonance
in hypertrophic cardiomyopathy. JACC Cardiovasc Imaging
2011;4:1123-1137
225. Germans T, Wilde AA, Dijkmans PA, Chai W, Kamp O, Pinto
YM, et al. Structural abnormalities of the inferoseptal left
ventricular wall detected by cardiac magnetic resonance
imaging in carriers of hypertrophic cardiomyopathy
mutations. J Am Coll Cardiol 2006;48:2518-2523
226. Maron MS, Rowin EJ, Lin D, Appelbaum E, Chan RH, Gibson
CM, et al. Prevalence and clinical profile of myocardial crypts
in hypertrophic cardiomyopathy. Circ Cardiovasc Imaging
2012;5:441-447
227. Maron MS, Olivotto I, Harrigan C, Appelbaum E, Gibson
CM, Lesser JR, et al. Mitral valve abnormalities identified
by cardiovascular magnetic resonance represent a primary
phenotypic expression of hypertrophic cardiomyopathy.
Circulation 2011;124:40-47
228. Rowin EJ, Maron MS, Lesser JR, Maron BJ. CMR with late
gadolinium enhancement in genotype positive-phenotype
negative hypertrophic cardiomyopathy. JACC Cardiovasc
Imaging 2012;5:119-122
229. Weinsaft JW, Kim HW, Crowley AL, Klem I, Shenoy C,
Van Assche L, et al. LV thrombus detection by routine
echocardiography: insights into performance characteristics
using delayed enhancement CMR. JACC Cardiovasc Imaging
2011;4:702-712
230. Mollet NR, Dymarkowski S, Volders W, Wathiong J, Herbots L,
Rademakers FE, et al. Visualization of ventricular thrombi with
contrast-enhanced magnetic resonance imaging in patients
with ischemic heart disease. Circulation 2002;106:2873-2876
231. Hong YJ, Hur J, Kim YJ, Lee HJ, Nam JE, Kim HY, et al. The
usefulness of delayed contrast-enhanced cardiovascular
magnetic resonance imaging in differentiating cardiac
tumors from thrombi in stroke patients. Int J Cardiovasc
Imaging 2011;27 Suppl 1:89-95
232. Weinsaft JW, Kim RJ, Ross M, Krauser D, Manoushagian S,
LaBounty TM, et al. Contrast-enhanced anatomic imaging
as compared to contrast-enhanced tissue characterization
for detection of left ventricular thrombus. JACC Cardiovasc
Imaging 2009;2:969-979
233. Motwani M, Kidambi A, Herzog BA, Uddin A, Greenwood JP,
Plein S. MR imaging of cardiac tumors and masses: a review of
methods and clinical applications. Radiology 2013;268:26-43
234. Fieno DS, Saouaf R, Thomson LE, Abidov A, Friedman JD,
Berman DS. Cardiovascular magnetic resonance of primary
tumors of the heart: a review. J Cardiovasc Magn Reson
2006;8:839-853
235. Gulati G, Sharma S, Kothari SS, Juneja R, Saxena A,
Talwar KK. Comparison of echo and MRI in the imaging
evaluation of intracardiac masses. Cardiovasc Intervent Radiol
2004;27:459-469
236. Francone M, Dymarkowski S, Kalantzi M, Rademakers FE,
Bogaert J. Assessment of ventricular coupling with real-
time cine MRI and its value to differentiate constrictive
pericarditis from restrictive cardiomyopathy. Eur Radiol
2006;16:944-951
237. Mastouri R, Sawada SG, Mahenthiran J. Noninvasive imaging
techniques of constrictive pericarditis. Expert Rev Cardiovasc
Ther 2010;8:1335-1347
238. Zurick AO, Bolen MA, Kwon DH, Tan CD, Popovic ZB,
Rajeswaran J, et al. Pericardial delayed hyperenhancement
with CMR imaging in patients with constrictive pericarditis
undergoing surgical pericardiectomy: a case series with
histopathological correlation. JACC Cardiovasc Imaging
2011;4:1180-1191
239. Axel L. Assessment of pericardial disease by magnetic
resonance and computed tomography. J Magn Reson Imaging
2004;19:816-826
240. Shiga T, Wajima Z, Apfel CC, Inoue T, Ohe Y. Diagnostic
accuracy of transesophageal echocardiography, helical
computed tomography, and magnetic resonance imaging for
suspected thoracic aortic dissection: systematic review and
meta-analysis. Arch Intern Med 2006;166:1350-1356
241. Lacomis JM, Pealer K, Fuhrman CR, Barley D, Wigginton W,
Schwartzman D. Direct comparison of computed tomography
and magnetic resonance imaging for characterization of
posterior left atrial morphology. J Interv Card Electrophysiol
2006;16:7-13
242. Kato R, Lickfett L, Meininger G, Dickfeld T, Wu R, Juang G, et
al. Pulmonary vein anatomy in patients undergoing catheter
ablation of atrial fibrillation: lessons learned by use of
magnetic resonance imaging. Circulation 2003;107:2004-2010
243. Mansour M, Refaat M, Heist EK, Mela T, Cury R, Holmvang
G, et al. Three-dimensional anatomy of the left atrium by
magnetic resonance angiography: implications for catheter
ablation for atrial fibrillation. J Cardiovasc Electrophysiol
2006;17:719-723
244. Durongpisitkul K, Tang NL, Soongswang J, Laohaprasitiporn
D, Nana A, Kangkagate C. Cardiac magnetic resonance
imaging of atrial septal defect for transcatheter closure. J
Med Assoc Thai 2002;85 Suppl 2:S658-S666
245. Weber C, Weber M, Ekinci O, Neumann T, Deetjen A, Rolf A,
et al. Atrial septal defects type II: noninvasive evaluation
of patients before implantation of an Amplatzer Septal
Occluder and on follow-up by magnetic resonance imaging
compared with TEE and invasive measurement. Eur Radiol
2008;18:2406-2413
246. Thomson LE, Crowley AL, Heitner JF, Cawley PJ, Weinsaft JW,
Kim HW, et al. Direct en face imaging of secundum atrial
septal defects by velocity-encoded cardiovascular magnetic
resonance in patients evaluated for possible transcatheter
closure. Circ Cardiovasc Imaging 2008;1:31-40
247. La Manna A, Sanfilippo A, Capodanno D, Salemi A, Polizzi
G, Deste W, et al. Cardiovascular magnetic resonance for
the assessment of patients undergoing transcatheter aortic
valve implantation: a pilot study. J Cardiovasc Magn Reson
2011;13:82
... Given recent technical advances, cardiac magnetic resonance (CMR) imaging is widely used in many areas of cardiovascular disease assessment (1). Currently, health insurance in Korea covers CMR for cardiomyopathy and complex congenital heart disease, though insurance coverage is expected to expand further in 2019, which will probably increase the number of tests compared with the past. ...
... Herein, we offer a practical standard CMR protocol for beginners designed to be easy to follow and implement. This protocol guideline is based on previously reported CMR guidelines (1)(2)(3)(4)(5)(6)(7)(8)(9) and includes sequence terminology used by vendors, essential MR physics (10)(11)(12)(13)(14)(15)(16)(17), imaging planes (2,18), field strength considerations (19)(20)(21)(22)(23)(24)(25), MRI-conditional devices (10,20,(26)(27)(28)(29)(30)(31)(32)(33), drugs for stress tests (34), various CMR modules (16,(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46), and disease/symptom-based protocols (47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58) based on a survey of cardiologists, and various appropriate use criteria. It will be of considerable help in planning and implementing tests. ...
... CMR imaging is useful in the diagnosis, stratification, treatment planning, prognosis prediction, and therapeutic effect evaluation of various cardiac diseases (53,59,60). However, appropriate criteria for disease, ethnicity, socioeconomic status, and the medical insurance system are essential to maximizing its clinical utility (1,61). In 2014, guidelines for the appropriate use of CMR were published jointly by the Korean Society of Cardiology and the Korean Society of Radiology to guide physicians, imaging specialists, medical associates and patients, and improve the overall performance of the health system (1). ...
... Moreover, there is a raising concern about sensitivity and specificity of TTE criteria, and whether, in fact, LVNC may be overdiagnosed [22,23]. In this scenario, cardiac MRI (CMRI) offers a high spatial resolution, and is becoming more and more used in LVNC evaluation, displacing TTE [24]. However, CMRI also raises concerns about overdiagnosis [25][26][27]. ...
Article
Full-text available
Left ventricle non-compaction cardiomyopathy (LVNC) has gained great interest in recent years, being one of the most controversial cardiomyopathies. There are several open debates, not only about its genetic heterogeneity, or about the possibility to be an acquired cardiomyopathy, but also about its possible overdiagnosis based on imaging techniques. In order to better understand this entity, we identified 38 LVNC patients diagnosed by cardiac MRI (CMRI) or anatomopathological study that could underwent NGS-sequencing and clinical study. Anatomopathological exam was performed in eight available LVNC hearts. The genetic yield was 34.2%. Patients with negative genetic testing had better left ventricular ejection fraction (LVEF) or it showed a tendency to improve in follow-up, and a possible trigger factor for LVNC was identified in 1/3 of them. Nonetheless, cerebrovascular accidents occurred in similar proportions in both groups. We conclude that in LVNC there seem to be different ways to achieve the same final phenotype. Genetic testing has a good genetic yield and provides valuable information. LVNC without an underlying genetic cause may have a better prognosis in terms of LVEF evolution. However, anticoagulation to prevent cerebrovascular accident (CVA) should be carefully evaluated in all patients. Larger series with pathologic examination are needed to help better understand this entity.
Article
Full-text available
Background: Ebstein's anomaly (EA) is a congenital heart disorder characterized by abnormal function of the tricuspid valve. There are several ways to study tissue composition using magnetic resonance imaging (MRI). One of the most accurate methods is strain calculation using the feature tracking (FT) technique. Due to the novelty of the FT technique in cardiac magnetic resonance (CMR) imaging, there is a lack of comprehensive guidelines to conduct FT-MRI and to present a quantitative report. The current study is aimed to evaluate the FT technique in EA patients and to compare the obtained numerical values with those of healthy individuals. Methods: A total of 33 individuals were enrolled in a study conducted in 2018-2019 at Shahid Rajaei Hospital, Tehran, Iran. Radial, longitudinal, and circumferential strain patterns of the left and right ventricles were determined in both the patients and the controls using the FT technique. Data were analyzed using SPSS software, version 22.0. Results: The results showed a significantly lower left ventricular (LV) radial strain in EA patients compared to the control group (P=0.002). In addition, the right ventricular (RV) global longitudinal strain (GLS) in EA patients was significantly lower than in the controls (P=0.001). Other parameters (LV global longitudinal strain, RV radial strain, LV circumferential strain, and RV circumferential strain) did not differ significantly between the two groups. Conclusion: Determination of strain patterns using cardiac MRI is a promising method for the diagnosis of EA. Markers such as LV longitudinal strain and RV-GLS are the most suitable parameters for the early diagnosis of heart dysfunction.
Article
Objectives Although cardiovascular magnetic resonance (CMR) is widely used in the assessment of left ventricular non-compaction (LVNC), there are no universally accepted diagnostic criteria and limited data regarding their prognostic value. We assessed the long-term prognostic role of the planimetric global Grothoff’s criteria and of the CMR findings in predicting adverse cardiovascular events (CE).Methods We prospectively enrolled 78 patients (46.7 ± 18.7 years, 33.3% females) with documented positive Jenni’s echocardiographic criteria for LVNC. Cine images were used to quantify function parameters and to assess for the presence of all four quantitative Grothoff’s criteria (global Grothoff’s criteria). Late gadolinium enhancement (LGE) images were acquired to detect the presence of replacement myocardial fibrosis.ResultsPetersen’s CMR criterion for LVNC (NC/C ratio > 2.3 in at least one myocardial segment) was fulfilled in the whole population. Twenty-six patients fulfilled the global Grothoff’s criteria (four out of four). The mean duration of the follow-up was 44.2 ± 27.4 months and 28 CE were registered: 10 ventricular tachycardias, 12 episodes of heart failure (HF), four strokes, and two cardiac deaths. In the multivariate analysis, the independent predictive factors for CE were positive global Grothoff’s criteria (hazard ratio, HR = 3.33, 95% CI = 1.52–7.29; p = 0.003) and myocardial fibrosis (HR = 2.41, 95% CI = 1.08–5.36; p = 0.032).Conclusions Positive global Grothoff’s criteria and myocardial fibrosis were powerful predictors of CE in patients with a diagnosis of LVNC by CMR Petersen’s criterion. Thus, we strongly suggest a step approach confirming the diagnosis of LVNC by using the global planimetric Grothoff’s criteria, which showed a prognostic impact.Key Points • Positive global Grothoff’s criteria and replacement myocardial fibrosis were powerful predictors of cardiovascular events in patients with a diagnosis of LVNC by CMR Petersen’s criterion. • Positive global Grothoff’s criteria were associated with a higher frequency of ventricular arrhythmias in patients with a diagnosis of LVNC by CMR Petersen’s criterion.
Chapter
In athletes of all age groups, the appropriate application of advanced imaging techniques is crucial to detect, graduate and potentially treat cardiovascular conditions that may pose an increased risk for continued sports participation. This primarily refers to the prevention of acute cardiac events such as sudden cardiac death, but also involves the identification of both negative and positive effects on the development and the clinical course of chronic cardiac disorders. This is of particular relevance in recreational/master athletes, since these individuals very often perform strenuous activities such as marathon or triathlon in a non-organized and non-supervised fashion. In addition, recreational/master athletes are usually at least middle-aged and have very often been exposed to elevated cardiovascular risk factor profiles over a longer period of time as compared to young competitive athletes. By means of echocardiography, for example, a common clinical scenario is to differentiate between increased left ventricular wall thickness induced by either long-term intensive exercise training or by hypertension. Coronary computed tomography contributes to advanced risk stratification and to the detection of coronary artery disease as the main cause of SCD in this cohort; this also holds true for exercise echocardiography, nuclear imaging and cardiac magnetic resonance imaging. The latter also identifies regions of myocardial fibrosis that may indicate an increased risk for arrhythmias, either by late gadolinium enhancement or by T1 mapping. Invasive coronary angiography, if indicated according to symptoms or suggestive findings during non-invasive procedures, either confirms or excludes relevant coronary stenosis and allows immediate interventional treatment. Advanced intracoronary artery imaging including intravascular ultrasound or assessment of fractional flow reserve can help to graduate the severity of stenoses and to understand epicardial and intramyocardial microvascular causes of symptoms. However, the need of radiation exposure and contrast agents as well as cost issues require careful risk-benefit assessment, especially in asymptomatic athletes with risk factors.
Article
Full-text available
We differentiated the left ventricle non-compaction (LVNC) from hypertrabeculated myocardium due to a negative remodeling in thalassemia intermedia (TI) patients applying linear and planimetric criteria and comparing the cardiovascular magnetic resonance (CMR) findings. CMR images were analyzed in 181 TI patients enrolled in the Myocardial Iron Overload in Thalassemia Network and 27 patients with proved LVNC diagnosis. The CMR diagnostic criteria applied in TI patients were: a modified linear CMR Petersen’s criterion based on a more restrictive ratio of diastolic NC/C > 2.5 at segmental level and the combination of planimetric Grothoff's criteria (percentage of trabeculated LV myocardial mass LV–MM ≥ 25% of global LV mass and total LV–MMI NC ≥ 15 g/m2). Seventeen TI patients showed at least one positive NC/C segment. Compared to LVNC patients, these patients showed a lower frequency of segments with non-compaction areas (2.41 ± 1.33 vs 5.48 ± 2.26; P < 0.0001), significantly lower LV–MM NC percentage (10.99 ± 4.09 vs 28.20 ± 4.27%; P < 0.0001), LV–MMI (7.58 ± 4.86 vs 19.88 ± 5.02 g/m2; P < 0.0001) and extension of macroscopic fibrosis (0.44 ± 0.18 vs 4.65 ± 2.89; P = 0.004), and significantly higher LV ejection fraction (61.29 ± 5.17 vs 48.50 ± 17.55%; P = 0.016) and cardiac index (4.80 ± 1.49 vs 3.46 ± 1.11 l/min/m2; P = 0.002). No TI patient fulfilled the Grothoff's criteria. All TI patients with an NC/C ratio > 2.5 showed morphological and functional CMR parameters significantly different from the patients with a proved diagnosis of LVNC. Differentiation of LVNC from hypertrabeculated LV in β-TI patients due to a negative heart remodeling depends on the selected CMR criterion. We suggest using planimetric Grothoff's criteria to improve the specificity of LVNC diagnosis.
Article
Full-text available
Cardiovascular magnetic resonance imaging (CMR) is expected to be increasingly used in Korea due to technological advances and the expanded national insurance coverage of CMR assessments. For improved patient care, proper acquisition of CMR images as well as their accurate interpretation by well-trained personnel are equally important. In response to the increased demand for CMR, the Korean Society of Cardiovascular Imaging (KOSCI) has issued interpretation guidelines in conjunction with the Korean Society of Radiology. KOSCI has also created a formal Committee on CMR guidelines to create updated practices. The members of this committee review previously published interpretation guidelines and discuss the patterns of CMR use in Korea.
Article
Background— In patients with Kawasaki disease, serial evaluation of the distribution and size of coronary artery aneurysms (CAA) is necessary for risk stratification and therapeutic management. Although transthoracic echocardiography is often sufficient for this purpose initially, visualization of the coronary arteries becomes progressively more difficult as children grow. We sought to prospectively compare coronary magnetic resonance angiography (MRA) and x-ray coronary angiography findings in patients with CAA caused by Kawasaki disease. Methods and Results— Six subjects (age 10 to 25 years) with known CAA from Kawasaki disease underwent coronary MRA using a free-breathing T2-prepared 3D bright blood segmented k-space gradient echo sequence with navigator gating and tracking. All patients underwent x-ray coronary angiography within a median of 75 days (range, 1 to 359 days) of coronary MRA. There was complete agreement between MRA and x-ray angiography in the detection of CAA (n=11), coronary artery stenoses (n=2), and coronary occlusions (n=2). Excellent agreement was found between the 2 techniques for detection of CAA maximal diameter (mean difference=0.4±0.6 mm) and length (mean difference=1.4±1.6 mm). The 2 methods showed very similar results for proximal coronary artery diameter (mean difference=0.2±0.5 mm) and CAA distance from the ostia (mean difference=0.1±1.5 mm). Conclusion— Free-breathing 3D coronary MRA accurately defines CAA in patients with Kawasaki disease. This technique may provide a non-invasive alternative when transthoracic echocardiography image quality is insufficient, thereby reducing the need for serial x-ray coronary angiography in this patient group.
Article
Background— Managing chest pain in the emergency department remains a challenge with current diagnostic strategies. We hypothesized that cardiac MRI could accurately identify patients with possible or probable acute coronary syndrome. Methods and Results— The diagnostic performance of MRI was evaluated in a prospective study of 161 consecutive patients. Enrollment required 30 minutes of chest pain compatible with myocardial ischemia but an ECG not diagnostic of acute myocardial infarction. MRI was performed at rest within 12 hours of presentation and included perfusion, left ventricular function, and gadolinium-enhanced myocardial infarction detection. MRI was interpreted qualitatively but also analyzed quantitatively. The sensitivity and specificity, respectively, for detecting acute coronary syndrome were 84% and 85% by MRI, 80% and 61% by an abnormal ECG, 16% and 95% for strict ECG criteria for ischemia (ST depression or T-wave inversion), 40% and 97% for peak troponin-I, and 48% and 85% for a TIMI risk score ≥3. The MRI was more sensitive than strict ECG criteria for ischemia (P<0.001), peak troponin-I (P<0.001), and the TIMI risk score (P=0.004), and MRI was more specific than an abnormal ECG (P<0.001). Multivariate logistic regression analysis showed MRI was the strongest predictor of acute coronary syndrome and added diagnostic value over clinical parameters (P<0.001). Conclusions— Resting cardiac MRI exhibited diagnostic operating characteristics suitable for triage of patients with chest pain in the emergency department. Performed urgently to evaluate chest pain, MRI accurately detected a high fraction of patients with acute coronary syndrome, including patients with enzyme-negative unstable angina.
Article
OBJECTIVE To assess the use of dobutamine magnetic resonance imaging (MRI) as a preoperative predictor of myocardial functional recovery after revascularisation, comparing wall motion and radial wall thickening analyses by observer and semi-automated edge detection. PATIENTS 25 men with multivessel coronary disease and resting wall motion abnormalities were studied with preoperative rest and stress MRI. MAIN OUTCOME MEASURES Observer analysis for radial wall thickening was compared with a normal range, while wall motion analysis used a standard four point scale. Semi-automated analysis was performed using an edge detection algorithm. Segments displaying either improved or worsened thickening or motion with dobutamine were considered viable. Postoperative rest images were performed 3–6 months after coronary artery bypass grafting (CABG) for comparison. RESULTS For observer analysis the values for sensitivity and specificity were 50% and 72% for wall motion, with respective values of 50% and 68% for thickening. With semi-automated edge detection the figures for motion were 60% and 73%, with corresponding values of 79% and 58% for thickening. Combining thickening and motion for the semi-automated method to describe any change in segmental function yielded a sensitivity of 71% and specificity of 70%. CONCLUSIONS Dobutamine MRI is a reasonably good predictor of myocardial functional recovery after CABG. The use of semi-automated edge detection analysis improved results.