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What does Cardiac Nuclear Magnetic Resonance consist of?

Cardiac nuclear magnetic resonance imaging (MRI) is a diagnostic test based on the application of a high intensity magnetic field to the chest, with the aim of visualizing cardiac structures and tissues. Compared to other imaging methods, it has several advantages: low invasiveness, absence of ionizing radiation, and images in three dimensions.

Different conditions, ranging from ischemic heart disease to cardiomyopathies, congenital heart disease, or valve abnormalities, share the possibility of triggering complex ventricular arrhythmias. To date, the most effective tool for the prevention of sudden arrhythmic death is the cardiac defibrillator (ICD) implant. Although the decision to implant a defibrillator for primary or secondary prevention of sudden arrhythmic death is fundamentally based on the definition of severe dysfunction of the left ventricular ejection fraction (LVFE ≤35%), this criterion alone has not proven to be specific or sensitive enough.

In fact, only a fifth of all patients who experience sudden death have an LVEF of ≤35%, and appropriate therapy by the ICD occurs in less than a third of patients undergoing implantation defibrillators due to evidence of LVEF of ≤35%. (1,2). On the other hand, lethal arrhythmic events often occur in patients with cardiomyopathies even if they have a preserved left ventricular function (LVEF ≥50%).

In this context, cardiac nuclear magnetic resonance imaging (MRI) is an extremely useful diagnostic tool by quantifying in a detailed way the volume of the cardiac chambers, the mass and the global and segmental function of the left and right ventricle, and analyzing the histology and cardiac morphology. 

In which arrhythmogenic cardiopathies is Cardiac Nuclear Magnetic Resonance indicated?

 The execution of a cardiac nuclear magnetic resonance exam plays a role of fundamental importance, especially in the study of arrhythmogenic substrates of the following pathologies associated with the risk of sudden death: 

• Ischemic heart disease: It is the main cause of sudden death, above all due to the arrhythmogenicity of the post-infarct scar visible through the late gadolinium enhancement (LGE) technique. Several studies have correlated the presence and extent of LGE to the risk of malignant ventricular arrhythmia, sudden death and the occurrence of appropriate shock by the ICD (3).

• Primary Dilated Cardiomyopathy: Primary dilated heart disease is characterized by biventricular dilation not caused by ischemic conditions or by volume or pressure overload. Also in this case, the presence of fibrosis, detectable by LGE, was associated with the risk of malignant ventricular arrhythmia and sudden death. Furthermore, a reduced overall longitudinal strain has been independently associated in various studies with a composite endpoint comprising ventricular arrhythmias and sudden death (4).
• Hypertrophic cardiomyopathy: Hypertrophic cardiomyopathy is a genetic pathological condition characterized by extreme myocardial hypertrophy. The study with MRI enables the evaluation of the extension of the hypertrophic segments (global, septal, apical or middle ventricular hypertrophy), to evaluate the presence of elements associated with arrhythmogenic risk, such as left ventricular thickening> 30 mm, apical aneurysmal dilation, left ventricular ejection obstruction, the presence and extent of ischemia / fibrosis. All these elements have proven to be strong predictors of sudden death in patients with this condition (5, Figure 1).
• Arrhythmogenic Right Ventricular Dysplasia (ARVD): ARVD is a genetic pathology of the heart muscle characterized by a fibro-fat substitution of the right ventricular myocardium, but which can also affect the left ventricle in a variable percentage. According to the European Society of Cardiology, the diagnosis is based on the presence of major and minor diagnostic criteria, which include structural, histological, electrocardiographic and clinical elements, such as the family history of sudden death. In this context, cardiac magnetic resonance imaging plays a fundamental role in defining the size, global function, segmental kinetics of the right ventricle and histological characterization. In particular, the demonstration of fibro-fat substitution can guide the decision to implant an ICD (6, Figure 2).
• Sarcoidosis: Sarcoidosis is a granulomatous systemic disease involving the heart in 2-5% of cases. The presence of granulomas and possibly areas of focal fibrosis is associated in various studies with the risk of sudden death (7).
• Viral myocarditis: The most common cause of viral myocarditis in humans is Herpesvirus 6 (HHV6) and Parvovirus B19 infection. Sudden cardiac death occurs from 2 to 8.6% of cases and is associated with the presence of areas of LGE and the degree of acute global systolic dysfunction (8).
• Cardiomyopathy from iron accumulation: In hemochromatosis, the iron deposit of the myocardium is associated with the risk of ventricular arrhythmias. In this case, the T2 * relaxometry value correlates with the risk of malignant ventricular arrhythmia. In patients with T2 * <20 msec the relative risk of malignant ventricular arrhythmia is 4.60 times greater than in those with T2 *> 20 msec (9).
• Mitral valve prolapse: Mitral valve prolapse is a myxomatous degenerative valve heart disease affecting the valve system as a whole (ring, flaps, tendon cords) and which can be associated with mechanical stress of the papillary muscles and the lower wall of the left ventricle. The presence of LGE at the apex of the papillary muscle at the chordal insertion is associated with the presence of complex ventricular arrhythmias in 63% of patients suffering from mitral valve prolapse and a consequent increased risk of sudden death (10).
• Congenital heart disease: Congenital heart disease is an important cause of sudden death in the population under 30 years old, and especially in children. In this context, cardiac MRI enables the acquisition of important morphological and functional information, with the advantage of not administering ionizing radiation. For example, the presence of severe left, right ventricular dysfunction or the right outflow tract and the presence of LGE areas has proven to be able to predict in several studies the occurrence of adverse cardiovascular events in patients undergoing surgical correction of Tetralogy Fallot (11).

Are particular precautions required to perform Cardiac Nuclear Magnetic Resonance?

In general, there are no special preparations for undergoing cardiac magnetic resonance imaging. In rare cases, preventive treatments may be carried out to avoid allergic reactions in some people who must undergo the examination with contrast medium (Gadolinium). In case of particular allergies, the patient must inform our center in advance.

Which patients cannot undergo Cardiac Nuclear Magnetic Resonance?

Patients with pacemakers or defibrillators or cardiac resynchronizers not declared compatible, and carriers of implantable devices with magnetic activation – such as electrodes and neurostimulators – and wearers of prostheses that cannot be ascertained to be compatible with magnetic fields cannot undergo cardiac MRI. Patients with MRI compatible cardiac devices (MRI Conditional) must report the presence of the device at the time of booking, in order to schedule the examination in specific conditions.  

 See information for performing MRI in carriers of implantable cardiac devices 

Information for cardiac device users by the manufacturing companies

In general, cardiac MRI is not recommended in the first trimester of pregnancy. If there are doubts about the presence of metal parts in the body, the patient will have to inform the medical staff who will arrange radiograms to determine if the metal implants exist.

In the case of patients suffering from claustrophobia or particular situations, the examination can be carried out under sedation, subject to agreement with the Radiology Service at the moment. These situations should be reported at the time of booking.

What are the risks of Cardiac Nuclear Magnetic Resonance?

Cardiac MRI is not painful or dangerous. The only annoyance can be caused by the noise of the machinery in operation. Headphones will be provided to reduce perceived noise. There is a risk of a rare allergic reaction due to the contrast medium, which must be reported upon booking of the exam, if it is known.

How is Cardiac Magnetic Resonance Imaging performed?

The patient lies down on a bed, where electrodes for monitoring the heart beat will be applied. For the success of the magnetic resonance imaging, it is essential that the patient remains still and is able to hold their breath for about 10 seconds when asked to do so. The acquisitions are performed while holding the breath and with heart rate monitoring, in order to eliminate the artifacts from cardiac and respiratory movement. About halfway through the examination, a contrast agent is administered intravenously, if necessary. The duration of the exam varies from case to case, with an average of 30 minutes.

Hypertrophic cardiomyopathy with evidence of areas of late gadolinium enhancement at the junctions with the right ventricular free wall indicative of fibrotic replacement. 

Biventricular arrhythmogenic dysplasia associated with an area of adipose infiltration in the distal lateral wall and apex of the left ventricle.

If you need to book a Cardiac Magnetic Resonance -> Information request and / or exam

Bibliography:

1. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. Bardy GH, Lee KL, Mark DB, Poole JE, Packer DL, Boineau R, Domanski M, Troutman C, Anderson J, Johnson G, McNulty SE, Clapp-Channing N, Davidson-Ray LD, Fraulo ES, Fishbein DP, Luceri RM, Ip JH; Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) Investigators. N Engl J Med. 2005 Jan 20;352(3):225-37.
2. Long-term clinical course of patients after termination of ventricular tachyarrhythmia by an implanted defibrillator. Moss AJ, Greenberg H, Case RB, Zareba W, Hall WJ, Brown MW, Daubert JP, McNitt S, Andrews ML, Elkin AD; Multicenter Automatic Defibrillator Implantation Trial-II (MADIT-II) Research Group. Circulation. 2004 Dec 21;110(25):3760-5. Epub 2004 Dec 6.
3. Scar extent evaluated by late gadolinium enhancement CMR: a powerful predictor of long term appropriate ICD therapy in patients with coronary artery disease. Alexandre J, Saloux E, Dugué AE, Lebon A, Lemaitre A, Roule V, Labombarda F, Provost N, Gomes S, Scanu P, Milliez P. J Cardiovasc Magn Reson. 2013 Jan 19;15:12. doi: 10.1186/1532-429X-15-12
4.  Assessment of myocardial deformation with cardiac magnetic resonance strain imaging improves risk stratification in patients with dilated cardiomyopathy. Buss SJ, Breuninger K, Lehrke S, Voss A, Galuschky C, Lossnitzer D, Andre F, Ehlermann P, Franke J, Taeger T, Frankenstein L, Steen H, Meder B, Giannitsis E, Katus HA, Korosoglou G. Eur Heart J Cardiovasc Imaging. 2015 Mar;16(3):307-15. doi: 10.1093/ehjci/jeu181. Epub 2014 Sep 21
5.  Prognostic Value of LGE-CMR in HCM: A Meta-Analysis. Weng Z, Yao J, Chan RH, He J, Yang X, Zhou Y, He Y. JACC Cardiovasc Imaging. 2016 Dec;9(12):1392-1402. doi: 10.1016/j.jcmg.2016.02.031. Epub 2016 Jul 20. Review.
6. Role of cardiovascular magnetic resonance imaging in arrhythmogenic right ventricular dysplasia. Jain A, Tandri H, Calkins H, Bluemke DA.m J Cardiovasc Magn Reson. 2008 Jun 20;10:32. doi: 10.1186/1532-429X-10-32. Review
7. Prognosis of Myocardial Damage in Sarcoidosis Patients With Preserved Left Ventricular Ejection Fraction: Risk Stratification Using Cardiovascular Magnetic Resonance. Murtagh G, Laffin LJ, Beshai JF, Maffessanti F, Bonham CA, Patel AV, Yu Z, Addetia K, Mor-Avi V, Moss JD, Hogarth DK, Sweiss NJ, Lang RM, Patel AR. Circ Cardiovasc Imaging. 2016 Jan;9(1):e003738. doi: 10.1161/CIRCIMAGING.115.003738.
8. Cardiovascular magnetic resonance predictors of clinicaloutcome in patients with suspected acute myocarditis. Sanguineti F, Garot P, Mana M, O’h-Ici D, Hovasse T, Unterseeh T, Louvard Y, Troussier X, Morice MC, Garot J. J Cardiovasc Magn Reson. 2015 Aug 29;17:78. doi: 10.1186/s12968-015-0185-2.
9. Prediction of cardiac complications for thalassemia major in the widespread cardiac magnetic resonance era: a prospective multicentre study by a multi-parametric approach. Pepe A, Meloni A, Rossi G, Midiri M, Missere M, Valeri G, Sorrentino F, D’Ascola DG, Spasiano A, Filosa A, Cuccia L, Dello Iacono N, Forni G, Caruso V, Maggio A, Pitrolo L, Peluso A, De Marchi D, Positano V, Wood JC. Eur Heart J Cardiovasc Imaging. 2018 Mar 1;19(3):299-309. doi: 10.1093/ehjci/jex012
10. Cardiovascular magnetic resonance characterization of mitral valve prolapse. Han Y, Peters DC, Salton CJ, Bzymek D, Nezafat R, Goddu B, Kissinger KV, Zimetbaum PJ, Manning WJ, Yeon SB. JACC Cardiovasc Imaging. 2008 May;1(3):294-303. doi: 10.1016/j.jcmg.2008.01.013
11.  Ventricular size and function assessed by cardiac MRI predict major adverse clinical outcomes late after tetralogy of Fallot repair. Knauth AL, Gauvreau K, Powell AJ, Landzberg MJ, Walsh EP, Lock JE, del Nido PJ, Geva T. Heart. 2008 Feb;94(2):211-6. Epub 2006 Nov 29.

What does Coronary Computed Axial Tomography (Coronary Angio CT) consist of?

In the last decade, coronary CT has had an important role in the non-invasive diagnostics of various pathologies associated with the risk of sudden death, especially thanks to the substantial reduction in exposure to ionizing radiation obtained through the use of low voltage tubes and innovative image reconstruction techniques. For example, the PROTECTION VI multicenter registry showed that from 2007 to 2017, the average exposure to ionizing radiation for an examination of coronary angiography by CT decreased by 78%, from 885 mGy * cm to 195 mGy * cm.

Similar to Nuclear Magnetic Resonance, Cardiac Computed Tomography allows an accurate quantification of volumes, ejection fraction and biventricular mass. In addition, it enables the evaluation of the origin of the coronary arteries, and above all, the coronary circulation by quantifying the extent of any luminal atherosclerotic obstructions, using the Coronary Angiography CT (CCTA) technique, and the degree of calcification, by means of the technique of Calcium Scoring TC (CCS).

The technique of calcium scoring through validated scores, such as the Agatston score, allows a quantification of coronary calcifications which were found to be a valid element in predicting the risk of myocardial infarction and sudden death independently of traditional risk factors.

What are the main applications of Coronary Computed Tomography (Coronary CT)?

The main applications of cardiac CT are:

1 – Coronary artery atherosclerotic disease associated with stable angina: In the patient with stable angina and low-intermediate risk of obstructive coronary artery disease, the CCTA 64 slices has a sensitivity of 98%, a specificity of 90% in detecting a significant obstructive coronary artery disease and a negative predictive value greater than 95% (1). This means that, in these patients, a clinically relevant coronary obstruction can reasonably be excluded in the presence of negative findings.

Adding to this the possibility of studying coronary perfusion through the administration of vasodilating agents and iodinated contrast medium, it is possible to obtain functional, as well as anatomical, information related to the coronary obstructive plaque and the myocardium dependent on it for perfusion (2). However, this technique is rarely used to date, especially in consideration of the fact that it is possible to evaluate myocardial perfusion in an equally non-invasive way and without the administration of ionizing radiation using specific protocols of cardiac MRI.

2 – Patient with acute chest pain: Several randomized trials worldwide have assessed the role of CCTA in assessing patients with acute chest pain. One of the most important is the CATCH trial, which assessed the use of CCTA in the patient with acute chest pain with presentation in the emergency / urgency department with normal cardiac enzymes and normal or non-specific ECG findings. In these patients, the CCTA has proven to be able to safely rule out an acute coronary syndrome as demonstrated by an 18.7-month follow-up free from cardiovascular events (3). Furthermore, it should not be forgotten that in the setting of the patient with acute chest pain, computed tomography can be used for the differential diagnosis with other syndromes, such as acute aortic dissection and pulmonary embolism. In fact, it is possible to use a triple rule-out protocol which, through specific sequences, allows to study at the same time the presence of coronary atherosclerotic disease, aortic dissection and pulmonary embolism. Currently this protocol is applied only to 0.5% of the cases in question, most likely due to the higher doses of contraction medium required, the long apnea times and the increase in ionizing radiation administered.

3- Stratification of asymptomatic patients with intermediate-high cardiovascular risk profile: Calcium Scoring TC is a technique that by quantifying the presence of coronary calcifications allows to stratify patients with an intermediate-high cardiovascular risk profile, but still asymptomatic, and thus guide the intensity of preventive medical treatments (4). In fact, from a clinical point of view, the stratification of cardiovascular risk is primarily based on the analysis of traditional risk factors, such as diabetes, smoking, hypertension, dyslipidemia and the family history of atherosclerotic coronary artery disease using score systems, such as the EUROPEAN score, which, taking into account age and gender, are able to define the risk at 10 years.

The purpose of the definition of CCS in asymptomatic intermediate-high risk patients is therefore to add an incremental risk to the analysis of traditional cardiovascular risk factors: patients who would benefit from aggressive treatment of these risk factors, in particular cholesterol and blood pressure, as well as promoting a change in lifestyle (Figure 2).

CCS is therefore a strong prognostic factor and it was recently included in the 2018 American guidelines for the management of cholesterol levels (5). Low-risk patients do not benefit from this type of analysis, and high-risk or symptomatic patients obtain greater benefits from performing coronary angiography.

4 –  Abnormalities of coronary artery origin: CCTA is the method of choice for the study of suspected anomalies of coronary origin. In particular, it allows the evaluation of the coronary anatomy and the exact course of the vessel, a particularly important element in cases of inter-arterial passage, i.e. between the trunk of the pulmonary artery and the ascending aorta. This course is associated with the risk of myocardial ischemia and sudden death (6).

5- Preoperative assessment in cases of percutaneous aortic valve replacement (TAVI): The aortic angio CT is the method of choice in the case of preventive assessment of percutaneous aortic valve implantation (TAVI), as it allows a three-dimensional evaluation of the aortic root, aortic annulus and ileofemoral vascular accesses (7, Figure 3 ).

6- Congenital heart malformations of children and adults: Cardiac CT obtains precise three-dimensional reconstructions of congenital heart disease. The need to administer a low dose of ionizing radiation, however, means that, currently, echocardiography and magnetic resonance imaging are still the preferred imaging methods in this regard. To date, it plays a fundamental role, especially in those patients in whom the presence of contraindications exist for echocardiography and cardiac magnetic resonance imaging (8).

What are the main advantages of coronary CT?

The main advantage of cardiac CT is that it is a non-invasive examination, which allows to accurately evaluate cardiovascular risk, calcium accumulation (CCS) and coronary anatomy, examining the state of the vessel wall, in addition to the characteristics of their lume (the internal space), giving a semi-quantitative assessment of the degree of stenosis (narrowing).

What are the risks of coronary CT?

Coronary CT is not painful or invasive. A potential problem is an allergy related to the contrast medium, for which a specific preparation must be carried out. Any known allergies must be reported at the time of booking.

What is the preparation for coronary CT?

The patient must completely fast for at least 6 hours before the exam. It is not necessary to stop taking medications in use (e.g. anti-hypertensives), which must be taken only with a little water.

On the day of the examination, the patient must bring the previous radiological examinations (X-rays, CT, Resonances, Ultrasounds, Visits, etc.) with them, even if performed elsewhere and have the result of the blood chemistry tests: Urea and Creatinine.

The patient must have the prescription of the attending physician (in the case of an examination with the NHS) or a simple specialist prescription (in the case of a private examination)

The duration of the exam is approximately 30 minutes.

The patient must be accompanied by a trusted person, since during the examination drugs are administered that can influence psychophysical abilities. Thus, it is advisable not to be alone and not to drive immediately after the examination.

In the case of patients with very frequent arrhythmias or with rapid atrial fibrillation, an optimization of the therapy may be necessary to control the heart rate, to be carried out according to the advice of the treating cardiologist. 

If you need to book a Coronary AngioTAC -> Information request and / or exam

Bibliography: 

1. 1. Head-to-head comparison of prospectively triggered vs retrospectively gated coronary computed tomography angiography: Meta- analysis of diagnostic accuracy, image quality, and radiation dose. Menke J, Unterberg-Buchwald C, Staab W et al (2013). Am Heart J 165:154–163 (e153) Varga-Szemes A, Meinel FG, De Cecco CN et al (2015) CT myocardial perfusion imaging. Ajr Am J Roentgenol 204:487–497.
   2. CT myocardial perfusion imaging. Varga-Szemes A, Meinel FG, De Cecco CN et al (2015)  Ajr Am J Roentgenol 204:487–497 
   3. Long- term clinical impact of coronary CT angiography in patients with recent acute-onset chest pain: the randomized controlled CATCH trial. Linde JJ, Hove JD, Sørgaard M et al (2015). JACC Cardiovasc Imaging 8:1404–1413 
   4. Coronary calcium score and cardiovascular risk. Greenland P, Blaha MJ, Budoff MJ et al (2018). J Am Coll Cardiol 72:434–447.
   5. Guideline on the management of blood cholesterol: a report of the American college of cardiology/American heart association task force on clinical practice guidelines. Grundy SM, Stone NJ, Bailey AL et al (2018) AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/ APhA/ASPC/NLA/PCNA. J Am Coll Cardiol pii:S0735-1097(18)39034-X. 
   6. Anomalous coronary arteries that need interven- tion: review of pre- and postoperative imaging appearances. Agarwal PP, Dennie C, Pena E et al (2017) Radiographics 37:740–757. 
   7. Computed tomography imaging in the context of transcatheter aortic valve implantation (TAVI)/ Transcatheter aortic valve replacement (TAVR): an expert consensus document of the society of cardiovascular computed Tomography. Blanke P, Weir-Mccall JR, Achenbach S et al (2019). Jacc Cardiovasc Imaging 12:1–24. 
   8. ECG- synchronized CT angiography in 324 consecutive pediatric patients: Spectrum of indications and trends in radiation dose. Meinel FG, Henzler T, Schoepf UJ et al (2015). Pediatr Cardiol 36:569–578. 

Team:

Dr. Simonetta Betti – Psychologist Consultant – Manager

Dr. Gabriele Bonalumi – Psychologist Consultant

Sometimes the best way to help yourself is to ask for help

In 1977, George Engel, an American psychiatrist, formulated and introduced the “Patient Centered” or “Biopsychosocial” model into medicine, according to which any health or disease condition is the consequence of an interaction between biological, psychological and social factors. It is on this model that, from the beginning of the 1980s, psychology extends its skills from mental illness to organic illness. The collaboration with the wards and clinics of oncology, gynecology, neurology, nephrology and dialysis and pediatric cardiac surgery was born. Work is being done on patients’ non-collaboration in “adherence to treatment”, on psychological support for family members in the organization of the practical and emotional management of the patient’s illness, on burn-out and on work-related stress of paramedical staff.

What is Health Psychology in Arrhythmology?

Those who have experienced cardiac arrest, and also those who are at risk of arrest because of the presence of a certain heart condition, are faced with unexpected changes in their lifestyle, due to both diagnosis and implantation of the cardiac defibrillator. For some people, the heart and its rhythm become an object of constant attention and obsession, it feels different from before, and also foreign and sometimes little understood by those around you. Sensations of stress, fatigue, and emotional distress may appear. The goal, shared with the medical team, is to improve the quality of life of the patient and family members.

How can we help patients and their families?

Mind and body are interconnected: What happens in the mind (emotions, thoughts) affects the body, and what happens in the body affects the mind. The psychological assistance we offer is focused on the whole person and follows the “biopsychosocial” model:

BIO (the body)

• Lifestyle (nutrition, smoking, leisure, etc.)
• Relaxation strategies

PSYCHO (the mind)

• Stress management
• Changes in mood (anxiety and depressive symptoms)
• Sleep disorders
• Adaptation to the defibrillator

SOCIAL (Interaction with others)

• Incentive of social support and communication
• Association of patients

Psychological counseling is carried out both in the ward and through Skype and provides a cycle of meetings tailored to the needs of the individual patient.

The techniques used are the Mindfulness MBSR protocol applied to cardiac disorders and Imaginative Therapy derived from Clinical Hypnosis.

What is Health Psychology in Cardiogenetics

The blood of your parents is alive within you (Odyssey, chap. IV)

The path of genetic counseling is divided into three phases: pre-test genetic counseling, genetic testing, post-genetic testing. According to the Guidelines for Medical Genetics Activities, this is a complex communication process that requires the collaboration of several professional figures such as the geneticist, laboratory technician, and psychologist to help the person and family in understanding the information related to the genetic component of the disease. and the risk of passing it on. The goal is to propose genetic diagnosis as a cognitive tool useful for safeguarding one’s own health and that of family members and not a source of anxiety and concern.

Practical information relating to the Psychology Service 

Psychological counseling can be carried out both privately and in agreement with the NHS.

For more information on how to access the Psychology Service and to make an appointment, you can write to cardio.psicologia@grupposandonato.it or call 02-5277-4260.

If you need to ask for information for the Psychology Service -> Information request and / or exam