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David A. Bluemke, M.D., Ph.D.Associate Professor, Clinical Director, MRI
Departments of Radiology and MedicineJohns Hopkins University School of
MedicineBaltimore, Maryland July 2006.
‘How I do’ CMR in Arrhythmogenic Right Ventricular Dysplasia/
Cardiomyopathy (ARVD/C)
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Disclosures
• Off-label: gadolinium MRI of the heart
• Sponsorship: JHU ARVD Center, NHLBI N01-CM-27018, Donald W. Reynolds Foundation
• João Lima, MD, Hugh Calkins, MD, Henry Halperin, MD, Saman Nazarian, MD
• Frank Marcus, MD
• Harikrishna Tandri, MD, Chandra Bomma, MD, Ernesto Castillo, MD
• Crystal Tichnell, JHH ARVD center
Acknowledgements
This presentation is posted for members of scmr as an educational guide – This presentation is posted for members of scmr as an educational guide – it represents the views and practices of the author, and not necessarily it represents the views and practices of the author, and not necessarily those of SCMR. those of SCMR.
Disclaimer
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ARVD/C – Protocol Summary
1. Axial & short axis “T1” images, with blood suppression (double IR FSE/ TSE)
- 5 mm slice thickness, ETL 24-28
- to avoid wrap-around, use anterior coils only
- 10-12 slices axial, 5 slices short axis over the heart.
2. Same as (1), but axial only, with fat suppression
3. SSFP Cine: axial and short axis, long axis cine- 10-12 short axis cine images, 8 axial images, 4 chamber cine
4. Delayed gadolinium images- 5 short axis images, 6-8 axial imagesNote: since the protocol is long, the minimum # of slices
in each plane is given above.
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Black blood double IR TSE/ FSE images• Either 1 RR or 2 RR is fine, blood
suppression pulse for dark blood– TE 20-30 ms, ETL 24-32, 256x256, ZIP to 512– 5x3 mm, 1 NEX, breath-holding– Anterior coil only to avoid wrap, FOV 24-28
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Repeat the axial images with fat sat
• Axial “T1” images, blood/ fat suppression– TE min, ETL 24-32, 256x256, ZIP– 5x3 mm (same slice locations as non fatted images)– Anterior coil, FOV 24-28
Fat suppression reduces artifacts especially for the RV free wallThe axial plane for fat sat is sufficient.
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Common protocol questions:
1. What about prone imaging?• not necessary with breath-hold imaging.• difficult for patients to sustain for the duration
of this protocol (45 + minutes).
2. Why is there some much “axial” imaging?
• Axial imaging provides an excellent view of the anterior RV wall and RVOT. It is easy for the technologist.
• HLA (long axis) images do not image the RVOT
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Common protocol questions:3. We have a double IR single shot sequence (ssfse,
HASTE) that is much faster – should I use this?
NO!As seen below, these images blur RV detail and are
not used for ARVD/C
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Axial/ Short Axis Cine SSFP Images
17% of normal volunteers, triangular shape RV
37% of normal volunteers have a normal “anterior” bulge. The remainder have a “round” shaped RV.
• Axial: 6 mm, skip 2 mm, FOV 36 cm, same slice locations as the black blood images for axials. 8-10 images from the diaphragm to the aortic root.
• Obtain a 10-12 short axis cines to quantitate LV and RV function (short axis not shown).
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Last Step: IR prepped delayed Gad
• Same pulse sequence as for infarct (viability) imaging
• 8-10 axial images, 5 short axis images (same locations as black blood images)
• We perform short axis first; then reduce the TI (inversion time) by 25 msec for axial images.
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ARVD/C MRI Reports• MRI criteria: a) enlargement of the RV, b) regional RV
wall motion abnormalities or aneurysms. Double reading of all cases is recommended.
• Presence of fat and fibrosis (delayed gad) can help, but are not official diagnostic criteria.
• Major criterion: Severe abnormalities: can be seen by the first year resident.
• Minor criterion: Mild-moderate abnormalities: you are not sure, probably present and you want to document these.
• MRI Impression, choose one of the following:– 1. Normal MRI– 2. Nonspecific findings (minor criterion)– 3. MRI consistent with ARVD/C (major criterion)
2nd Opinions can be obtained at www.ARVD.com