Segmental strain analysis for the detection of chronic ischemic scars in non-contrast cardiac MRI cine images

Abstract

Cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE) is considered the gold standard for scar detection after myocardial infarction. In times of increasing skepticism about gadolinium depositions in brain tissue and contraindications of gadolinium administration in some patient groups, tissue strain-based techniques for detecting ischemic scars should be further developed as part of clinical protocols. Therefore, the objective of the present work was to investigate whether segmental strain is noticeably affected in chronic infarcts and thus can be potentially used for infarct detection based on routinely acquired non-contrast cine images in patients with known coronary artery disease (CAD). Forty-six patients with known CAD and chronic scars in LGE images (5 female, mean age 52 ± 19 years) and 24 gender- and age-matched controls with normal cardiac MRI (2 female, mean age 47 ± 13 years) were retrospectively enrolled. Global (global peak circumferential [GPCS], global peak longitudinal [GPLS], global peak radial strain [GPRS]) and segmental (segmental peak circumferential [SPCS], segmental peak longitudinal [SPLS], segmental peak radial strain [SPRS]) strain parameters were calculated from standard non-contrast balanced SSFP cine sequences using commercially available software (Segment CMR, Medviso, Sweden). Visual wall motion assessment of short axis cine images as well as segmental circumferential strain calculations (endo-/epicardially contoured short axis cine and resulting polar plot strain map) of every patient and control were presented in random order to two independent blinded readers, which should localize potentially infarcted segments in those datasets blinded to LGE images and patient information. Global strain values were impaired in patients compared to controls (GPCS p = 0.02; GPLS p = 0.04; GPRS p = 0.01). Patients with preserved ejection fraction showed also impeded GPCS compared to healthy individuals (p = 0.04). In patients, mean SPCS was significantly impaired in subendocardially (− 5.4% ± 2) and in transmurally infarcted segments (− 1.2% ± 3) compared to remote myocardium (− 12.9% ± 3, p = 0.02 and 0.03, respectively). ROC analysis revealed an optimal cut-off value for SPCS for discriminating infarcted from remote myocardium of − 7.2% with a sensitivity of 89.4% and specificity of 85.7%. Mean SPRS was impeded in transmurally infarcted segments (15.9% ± 6) compared to SPRS of remote myocardium (31.4% ± 5; p = 0.02). The optimal cut-off value for SPRS for discriminating scar tissue from remote myocardium was 16.6% with a sensitivity of 83.3% and specificity of 76.5%. 80.3% of all in LGE infarcted segments (118/147) were correctly localized in segmental circumferential strain calculations based on non-contrast cine images compared to 53.7% (79/147) of infarcted segments detected by visual wall motion assessment (p > 0.01). Global strain parameters are impaired in patients with chronic infarcts compared to controls. Mean SPCS and SPRS in scar tissue is impeded compared to remote myocardium in infarcts patients. Blinded to LGE images, two readers correctly localized 80% of infarcted segments in segmental circumferential strain calculations based on non-contrast cine images, in contrast to only 54% of infarcted segments detected due to wall motion abnormalities in visual wall motion assessment. Analysis of segmental circumferential strain shows a promising method for detection of chronic scars in routinely acquired, non-contrast cine images for patients who cannot receive or decline gadolinium.

Segmental Strain for Scar Detection in Acute Myocardial Infarcts and in Follow-up Exams using Non-Contrast CMR Cine Sequences

“…Infarct detection in circumferential strain calculations and in cine images -Reader A and B were advised to identify possibly infarcted segments in segmental circumferential strain calculations (right column of Fig. 1a und 1b) as well as in the corresponding short axis cine images, visually recognizing wall motion abnormalities (VWMA) as previously described [3]. Datasets of all patients (AMI and FU exams) and controls were mixed and presented in random order to both readers.…”

“…Strain analysis -Dedicated software (Segment v3.0 R7946, Medviso, Lund, Sweden) was used to calculate global and segmental strain derived from native cine sequences as previously described [3]. Duration of data loading, image registration, contouring of myocardial borders and strain calculation was 10 min 17 s ± 43 s (range 9 min 15 s − 11 min 31 s) per patient or control, respectively.…”

“…Necrosis of myocytes after myocardial infarction with subsequent scar replacement disturbs mechanical properties of the myocardium with consecutively altered global and segmental strain [6]. Especially chronic myocardial scars with wall thinning and noticeable wall motion abnormality result in signi cant segmental strain impairment, which can be used to distinguish scar tissue from remote myocardium [2,3,7]. In contrast, acute infarcts might lack signi cant myocardial wall thinning and display less wall motion abnormalities in cine images.…”

“…Gadolinium-free options for the detection of ischemic myocardial scars are limited. One promising alternative is scar detection using regional myocardial deformation parameters [2,3]. Myocardial deformation during cardiac contraction can be quanti ed by myocardial feature tracking (FT) based on routinely acquired, non-contrast cine sequences [4,5].…”

Segmental strain for scar detection in acute myocardial infarcts and in follow-up exams using non-contrast CMR cine sequences

“…Gadolinium-free options for the detection of ischemic myocardial scars are limited. One promising alternative is scar detection using regional myocardial deformation parameters [ 2 , 3 ]. Myocardial deformation during cardiac contraction can be quantified by myocardial feature tracking (FT) based on routinely acquired, non-contrast cine sequences [ 4 , 5 ].…”