Myocardial Viability on Cardiac Magnetic Resonance

Souto, Ana Luiza Mansur; Souto, Rafael Mansur; Teixeira, Isabella Cristina Resende; Nacif, Marcelo Souto

doi:10.5935/abc.20170056

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Review Article • Arq. Bras. Cardiol. 108 (5) • May 2017 • https://doi.org/10.5935/abc.20170056 copy

Myocardial Viability on Cardiac Magnetic Resonance

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The study of myocardial viability is of great importance in the orientation and management of patients requiring myocardial revascularization or angioplasty. The technique of delayed enhancement (DE) is accurate and has transformed the study of viability into an easy test, not only for the detection of fibrosis but also as a binary test detecting what is viable or not. On DE, fibrosis equal to or greater than 50% of the segmental area is considered as non-viable, whereas that below 50% is considered viable. During the same evaluation, cardiac magnetic resonance (CMR) may also use other techniques for functional and perfusion studies to obtain a global evaluation of ischemic heart disease. This study aims to highlight the current concepts and broadly emphasize the use of CMR as a method that over the last 20 years has become a reference in the detection of infarction and assessment of myocardial viability.

Keywords
Myocardial Infarction / metabolism; Myocardial Revascularization; Tissue Survival; Magnetic Resonance Spectroscopy; Angioplasty

	Nontransmural Myocardial Infarction	Transmural Myocardial Infarction	Stunned myocardium	Hibernated myocardium	Post-infarction remodeling	Nonischemic cardiomyopathies
Perfusion	Normal or reduced depending on the existence or not of adequate reperfusion or microvascular obstruction	Normal or reduced depending on the existence or not of adequate reperfusion or microvascular obstruction	Normal by definition	Reduced by definition	Normal	Normal
Function	Normal	Reduced	Reduced but reversible with perfusion restoration (hours or weeks)	Reduced but reversible with perfusion restoration (may take months to recover)	Reduced	Normal or reduced(depending on the percentage of the affected area)
Metabolism	Normal or reduced (low FDG uptake)	Reduced (low FDG uptake)	Not reduced (high FDG uptake)	Not reduced (high FDG uptake, perfusion-metabolism mismatch)	Probably normal	Normal or reduced (low FDG uptake)
Histology	Replacement fibrosis	Replacement fibrosis	Normal myocytes	May be normal or present a certain degree of differentiation of the myocytes, with loss and disorganization of cellular elements	Hypertrophy, dilation, and architectural distortion of myocardial fibers	Replacement fibrosis
Delayed Enhancement	Delayed enhancement in the subendocardium (< 50% of the area of the segment). Usually in a coronary territory, unless it has multiple infarctions or the patient has undergone surgery with graft placement	Transmural delayed enhancement that may compromise from the subendocardium to the epicardium (> 50% of the area of the segment). Usually in a coronary territory, unless it has multiple infarctions or the patient has undergone surgery with graft placement	Normal, unless there is a combination of stunned myocardium and myocardial infarction	Normal, unless there is a combination of hibernated myocardium and myocardial infarction	Negative (myocardial dysfunction remote to a large infarction) and, therefore, viable.	Variable, best identified as mesocardial, epicardial, diffuse, or even negative

Agent	Name	Manufacturer	Recommended dose
Gadopentetate Dimeglumine (Gd-DTPA2)	Magnevist®	Bayer Healthcare	0.1 mmol/kg (0.2 mL/Kg)
Gadodiamide (Gd-DTPA-BMA)	Omniscan®	GE Healthcare	0.1 mmol/kg (0.2 mL/Kg)0.05 mmol/kg (0.1 mL/Kg)§
Gadoversetamide (Gd-DTPA-BMEA)	OptiMark®	Mallinckrodt	0.1 mmol/kg (0.2 mL/Kg)
Gadoteridol	ProHance®	Bracco Diagnostics	0.1 mmol/kg (0.2 mL/Kg)Additional dose of 0.2 mmol/kg (0.4 mL/Kg)
Gadobenate Dimeglumine (Gd-BOPTA)	MultiHance®	Bracco Diagnostics	0.1 mmol/kg (0.2 mL/Kg)
Gadobutrol (Gd-DO3A-butrol)	Gadavist®Gadovist®	Bayer Healthcare	0.1 mmol/kg (0.1 mL/Kg)
Gadofosveset trisodium	Ablavar®	Lantheus Medcl	0.03 mmol/kg (0.12 mL/Kg)
Gadoxetate disodium	Eovist®Primovist®	Bayer Healthcare	0.025 mmol/kg (0.1 mL/Kg)
Gadobenate Dimeglumine (Gd-DTPA- Dimeglumine)	Viewgam®	M.R. Pharma S.A. / Alko do Brasil	0.1 mmol/kg (0.2 mL/Kg)
Gadoterate Meglumine (Gd-HP-DOTA)	Dotarem®Artirem®	Guerbet	0.1 mmol/kg (0.2 mL/Kg)

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[1] Mailing address: Marcelo Souto Nacif, Av. Sâo João 2400 apto 232B. Postal Code 12242-000, Jd das Colinas, São José dos Campos, SP - Brazil. E-mail: msnacif@yahoo.com.br, msnacif@gmail.com