Dr/AHMED ESAWY

Magnetic Resonance Imaging in Coronary

Artery Disease

Dr/AHMED ESAWY

Dr. Ahmed Esawy

MBBS M.Sc. MD

Dr/AHMED ESAWY

Noncontrast-Enhanced 1.5-T Whole-Heart Coronary MRA in a 58-Year-Old Man Presenting With Chest Pain on Effort Sliding thin-slab maximum intensity projection image

(A) and volume-rendered image (B) detect coronary artery stenoses in the LAD (arrowhead) and diagonal branch (arrow).

Curved planar reconstruction image shows severe coronary artery stenosis in the LAD C, arrowhead). Good agreement is observed between coronary MRA and X-ray coronary angiography (D). Black arrowhead in D indicates coronary artery stenosis in the LAD; black arrow in D indicates coronary artery stenosis in the diagonal branch.

Dr/AHMED ESAWY

Noncontrast-Enhanced 1.5-T Whole-Heart Coronary MRA in a 66-Year-Old Woman

Significant coronary artery stenosis in the LCX (white arrowhead) is observed in the sliding thin-slab maximum intensity projection image (A), the volume-rendered image (B), and the curved planar reconstruction image (C), with good correlation with X-ray coronary angiography (black arrowhead) (D).

Dr/AHMED ESAWY

Coronary Angiography in a 53-Year-Old Man with Exertional Chest Pain

Panel A shows a coronary magnetic resonance angiogram (left) and a corresponding x-ray coronary angiogram (right) indicating a severe lesion at the bifurcation of the left anterior descending coronary artery and the left circumflex coronary artery, involving the left main coronary artery (solid arrows) ,and a more distal focal stenosis of the left circumflex coronary artery (broken arrows).

Panel B shows a coronary magnetic resonance angiogram (left) and a corresponding x-ray angiogram (right) indicating two stenoses of the proximal (solid arrows) and middle (broken arrows) right coronary artery

Dr/AHMED ESAWY

A 74 year-old asymptomatic male. A lumen stenosis on the RCA could be identified by noncontrast MRA (confirmed by coronary angiogram)

Dr/AHMED ESAWY

A 73 year-old healthy male. His peripheral blood pressure was 130/70 mmHg (PP= 60mmHg). (a) Longitudinal view of the RCA in mid-diastole (b) Longitudinal view of the RCA in end-systole. (c) Transverse view of lumen in mid-diastole (d) Transverse view of lumen in end-systole (e) Zoomed diastolic lumen with contour shows the area is 7.61mm2. (f) Zoomed systolic lumen with contour shows the area is 15.05 mm2 Dr/AHMED ESAWY

A 71 year-old asymptomatic female with a history of T2DM for 10 years. An eccentrically remodeled coronary segment on the LAD (without significant lumen stenosis) could be identified by MRI.

Dr/AHMED ESAWY

a 61-year-old female, who had a HTx 7 years ago. Her heart rate is 108 beats/minute. We can clearly see the RCA using black-blood SSFP MRI technique.

Dr/AHMED ESAWY

T2prep images of the right coronary artery (RCA) (A) and the left main stem (D) in a patient with Takayasu arteritis (TA). B and E show the post IR scan of the same patient, revealing late gadolinium enhancement (LGE) of the coronary artery wall. C and F depict the corresponding x-ray angiography.

Dr/AHMED ESAWY

T2prep image of the RCA in a patient with CAD, while B represents the x-ray angiography and C the IR scan pre and D the IR scan post gadolinium administration in the same patient. At the bottom right of Figure 1D is the enlarged cross sectional view of the appended IR scan.

the prevalence and amount of coronary enhancement after gadolinium (CNR) in TA seems to be similar to that in patients with CAD

Dr/AHMED ESAWY

T2prep image of the RCA in a patient with TA, while B represents the IR scan pre- and C the IR scan postgadolinium administration in the same patient. The white arrow indicates the area of localized coronary artery vessel wall enhancement in C, the dotted arrow the coronary segment without LGE of the coronary vessel wall post contrast in the same coronary artery

the prevalence and amount of coronary enhancement after gadolinium (CNR) in TA seems to be similar to that in patients with CAD

Dr/AHMED ESAWY

cardiac short-axis spin-echo magnetic resonance image of a patient without cardiac disease. Myocardial walls of the left and right ventricle are clearly depicted

Dr/AHMED ESAWY

Transverse cardiac spin-echo magnetic resonance image of a patient with an anterior wall infarction with apical and septal involvement. For this T2-weighted image, a multi-echo study (TE 30-60-90-120 ms) was performed. Note the aneurysmal dilatation of the apicoseptal wall with increased signal intensity on the images with echo times 60 ms (upper right), 90 ms (lower left), and 120 ms (lower right). Dr/AHMED ESAWY

Series of six sequential ultrafast magnetic resonance images showing signal enhancement after administration of Gd-DTPA: Baseline image (upper left), right ventricular cavity (upper middle and upper right), pulmonary vasculature, left ventricular cavity and aorta (lower left and lower middle), and myocardium (lower right) Dr/AHMED ESAWY

Short-axis cardiac spin-echo magnetic resonance image of a patient with a 2-day-old myocardial infarction of the inferoposterior wall. There is marked wall thinning of the inferoposterior wall and a clear dilatation of the left ventricle. Dr/AHMED ESAWY

Transverse cardiac spin-echo magnetic resonance (MR) image of patient with anteroseptal wall infarction before administration of Gd-DTPA. Apart from some apical thinning, no clear MR signs of myocardial infarction are recognized. B, Same MR image 20 to 25 minutes after administration of Gd-DTPA. Contrast enhancement is visible in the anteroseptal area with extension to the apex.

Dr/AHMED ESAWY

A, Computer-constructed contours of subepicardial (1) and subendocardial (2) borders on cardiac spin-echo magnetic resonance (MR) image after administration of Gd-DTPA in patient with anterior wall infarction. B, After subtraction of mean cardiac signal intensity (+2 SD), the MR image shows marked contrast enhancement of Gd-DTPA in anteroapical area (3)

Dr/AHMED ESAWY

. Series of six sequential ultrafast magnetic resonance images after bolus administration of Gd-DTPA in a patient with healed myocardial infarction of the inferolateral wall. Ultimately (lower middle and lower right), decreased myocardial signal intensity is observed in the infarcted inferolateral wall compared with the normal anterior region (arrowheads)

Dr/AHMED ESAWY

Top, Transverse cardiac spin-echo magnetic resonance image plane showing a left ventricular thrombus occupying the whole left ventricle of a patient with a previously sustained large anterior wall infarction. Aneurysmal formation of the anteroapical area can be observed. After surgical removal, the largest diameter of the thrombus measured 7 cm. Bottom, Schematic drawing of top image. LV indicates left ventricle; RV, right ventricle; and T, thrombus

Dr/AHMED ESAWY

Top, Transverse magnetic resonance image of the origin of the right coronary artery (RCA) using a body coil. Bottom, Image quality is markedly improved with the surface coil. RAA indicates right atrial appendag

Dr/AHMED ESAWY

Oblique magnetic resonance image along the major axis at the level of the proximal right coronary artery identified in transverse section. The image was acquired in breathhold using turbo fast low-angle shot imaging Dr/AHMED ESAWY

MSCT or MRI

Sensitivity 97% 73% Specificity 75% 48%

Pretest likelihood determines utility CT better than MRI CT good for 20-60% likelihood

Dr/AHMED ESAWY

Systematic approach to reading coronary CT angiography studies

• 1. Obtain a quick overview of the gross anatomy,

e.g.,by looking at three-dimensional renderings

• 2. Assess the individual coronary arteries and major side-branches by using reconstruction tools and viewing original slices, preferably simultaneous

• 3. Evaluate the cardiac extracoronary structuresc

• 4. Evaluate extracardiac organsd

Dr/AHMED ESAWY

Reconstructions available for reading coronary CT angiography studies

• 1.Axial, coronal, and sagittal images are the primary source of information

• 2. Curved multiplanar reformations are convenient for identifying stenoses

• 3. Maximum-intensity projections give a good overview of vessels and lesions but may obscure stenoses and overestimate calcified lesions

• 4. Angiographic emulations and three-dimensional renderings may be used for elegant display and presentation of findings

Dr/AHMED ESAWY

(A) Axial image showing left main coronary ostium and its divisions into left anterior descending, ramus intermedius,and left circumflex arteries. (B) Multiplanar reconstructed image. (C) \Anatomic 3-dimensional volume-rendered image showing relationships among left main artery, branches, and adjacent cardiac structures. (D) Curved multiplanar reconstruction of entire length of left circumflex artery. Dr/AHMED ESAWY

(A) Axial view showing normal anatomy of 4 pulmonary veins and left atrial appendage clear of thrombus (asterisk). (B) Axial view from another patient undergoing evaluation before radiofrequency ablation of atrial fibrillation. Thrombus (asterisk) is visible in left atrial appendage

Dr/AHMED ESAWY