Heart Failure and Cardiomyopathies: CT and MR from Basics to Advanced Imaging

Figures

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  Figure 1. In panel (A), systolic dysfunction; in panel (B), diastolic dysfunction, with an ideally preserved intrinsic inotropy. Each pressure–volume loop (P–V loop) represents a heartbeat. Panel (A): P–V loop diagrams show changes in inotropy with a relative change in the slope of the end-systolic pressure–volume relationship (ESPVR); the decreased inotropy decreases the slope-ESPVR, shifting to the right and downwards, with impaired myocardial contractility, which generates less pressure at a given LV volume. As a consequence, the P–V loop shifts to the right and downwards, with an overall smaller loop area, and with a decrease in stroke volume, which is the width of the P–V loop (and, consequently, a lower ejection fraction), and an increase in end-systolic volume (corresponding to the left lower corner of any P–V loop). Panel (B): Reduced myocardial compliance increases the slope of the ventricular end-diastolic pressure–volume relationship (EDPVR), which shifts to the left. The increase in EDPVR will result in a higher filling pressure or end-diastolic pressure in the left ventricle, and a normal or reduced ventricular filling volume (decreased end-diastolic volume). A greater…

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  Figure 2. CMR heart model using different imaging biomarkers. Images (a–j) show different examples of CMR biomarkers useful in a proper definition of a HF patient. Images (a,b) show cine images; in image (a): endocardial (red) and epicardial (green) contours are drawn in all SA stacks, both in diastole and systole through a dedicated software; endocardial and epicardial contouring are used to estimate ventricular volumes and myocardial mass, respectively. In image (b): an example of radial strain depicted by a colorimetric map superimposed on an SA cine image; colorimetric map shows the degree of myocardial deformation evaluated by the strain analysis. Bright colors suggest a lower deformation. Image (c) shows an example of first-pass perfusion imaging: the wide hypointense rhyme within the inferior wall represent a region of myocardial ischemia. Image (d), atrial evaluation: atrial volumes allow dimension and function to be estimated: left and right atria are showed in the figure through red and green reconstruction in systole (LA and RA maximum volume). Images (e) (phase image) and (f) (magnitude image) show an example of phase-contrast sequence for the evaluation of valvular flow.…

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  Figure 3. CCTA biomarkers useful for a proper definition of HF patient. Typically, CCTA is a well-known tool for description of cardiac anatomy; in image (d), volume-rendered reconstruction of aortic root and coronary anatomy superimposed onto an MIP reconstruction of cardiac chambers in a similar projection. CCTA allows (i) an accurate detection of coronary stenosis; (ii) a good definition of the degree of stenosis; (iii) an optimal definition of plaque phenotype. In image (e), a severe non-calcified stenosis in proximal RCA; the plaque shows a prevalent lipidic composition. High-temporal resolution exhibited by the latest CT scanners also allows the complete cardiac cycle with a relatively low-dose exposure to be acquired; the retrospective analysis could be useful for the estimation of cardiac volumes and function. Images (a,b) show the SA view of the same plane in diastolic and systolic phase: dedicated software can automatically derive volume and function from the contouring of the entire chamber, similar to CMR. Using vasodilator agents, CCTA also allows the evaluation of myocardial perfusion, both with static or dynamic acquisition, mainly depending on the technology of the scanner.…

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  Figure 4. Panels (A,B) show the comparison of two patients with left ventricular dilatation and HFrEF. In images (a,b), anatomic evaluation of the coronary tree shows NOCAD (black asterisks). In images (c,d), cine images of the diastolic and systolic phase are shown, respectively. In both cases, the inferolateral wall appears to be thin. In panel (B) is evident a segmental akinesia compared to panel (A) which shows different areas of akinesia with a non-territorial distribution. Moreover, areas of fatty replacement could be highlighted in case (A) (image (e), white arrows), compared to case (B). Image (f) shows the LGE. Panel (A) shows a subepicardial and mesocardial LGE (non-ischemic pattern) with a ring-like distribution (>3 contiguous segment; white arrowheads). Panel (B) shows a subendocardial-to-transmural LGE (ischemic pattern). Panel (A) shows a case of DSP cardiomyopathy, while panel (B) shows a MINOCA-like syndrome. HFrEF: heart failure with reduced ejection fraction; NOCAD: non-obstructive coronary artery disease; LGE: late gadolinium enhancement; DSP: desmoplakin; MINOCA: myocardial infarction with non-obstructive coronary arteries.

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  Figure 5. Panels (A–C) show the evolution of a cardiotoxic CHT with anthracycline. In panel (A), CMR examination obtained before the CHT. In panel (B,C), SA cine images of CMR examinations acquired at 3 and 12 months after the treatment. On the right, a volume rendered reconstruction obtained after contouring of entire SA stack, with a colorimetric map of peak strain. Colors correspond to the degree of deformation: brighter colors represent lower level of deformation. Similar kinesis and overall ventricular function are clearly preserved during the three examinations. In panel (A), overall longitudinal deformation is preserved (blue colors; white asterisks). In panel (B), the dotted white arrow highlights a lower deformation of basal segments compared to the first examination. Finally, after 12 months (panel (C)), peak strain analysis highlighted different areas of lower deformation (white arrowheads) and overall brighter colors meaning a reduced strain. CHT: chemotherapy; CMR: cardiac magnetic resonance; SA: short axis.

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  Figure 6. Panels (A,B) show two cases of HFrEF and myocardial hypertrophy. In panel (A), asymmetric hypertrophy is highlighted with prevalent involvement of the septum (images (a,b) showing frame of cine SA and HLA views). Patchy areas of edema (white asterisks) and LGE (white arrows) (images (c,d)) are clearly evident in the context of hypertrophic segments, with LGE also extended to non-hypertrophic segments (thick white arrow). Panel (A) findings are indicative of a primitive HCM. In panel (B), biventricular hypertrophy (white arrowheads in image (a) showing a cine-frame of SA view). Image (b) showing a cine-frame of the HLA view with evidence of pericardial and pleural effusion (white arrows). Image (c) shows a T2-w sequence with evidence of faded myocardial edema (white asterisks). Image (d) shows an LGE sequence, with the absence of clear myocardial nulling and prevalent subendocardial enhancement (white arrowheads) with an apparent transmural distribution in the inferolateral basal segment. Compared to panel (A), panel (B) findings clearly diverged from a typical primitive HCM pattern. Panel (B) findings indeed refer to a hypertrophic mimic (non-treated AL type amyloidosis). HFrEF:…