Role of magnetic resonance imaging in coronary artery disease MRCA part 7 Dr Ahmed Esawy Magnetic Resonance Imaging in Coronary Artery Disease MULTISCLICE CTcoronary artery angiography Coronary artery segments Coronary artery anatomy Coronary artery stenosis Coronary artery calcification score Coronary artery stricture Coronary artery aneurysm Coronary artery pos operative changes Coronary artery by pass Coronary artery stent Coronary artery bridge Artifacts recognition and management 1/ Fundamental CT artifacts Scanner hardware failure Partial volume artifacts Beam hardening artifacts Metal related artifacts Coronary artery angiography pitfalls Artifact Cardiac motion Pulmonary motion Body motion Beam hardening Metallic object A Artifacts recognition and management 1/ Fundamental CT artifacts Scanner hardware failure Partial volume artifacts Beam hardening artifacts Metal related artifacts rtifacts recognition and management 1/ Fundamental CT artifacts Scanner hardware failure Partial volume artifacts Beam hardening artifacts Metal related artifacts 2/ Artifacts specific to cardiac CT Slab misalignment Tube modulation artifacts Cardiac motion Patient motion

1. Dr/AHMED ESAWY

2. Magnetic Resonance
Imaging in Coronary
Artery Disease
Dr/AHMED ESAWY

3. Dr. Ahmed Esawy
MBBS M.Sc. MD
Dr/AHMED ESAWY

4. Noncontrast-Enhanced 1.5-T Whole-Heart Coronary MRA in a 58-Year-Old Man Presenting With
Chest Pain on Effort Sliding thin-slab maximum intensity projection image
(A) and volume-rendered image (B)
detect coronary artery stenoses
in the LAD (arrowhead) and
diagonal branch (arrow).
Curved planar reconstruction
image shows severe coronary
artery stenosis in the LAD C,
arrowhead). Good agreement is
observed between coronary MRA
and X-ray coronary angiography
(D). Black arrowhead in D indicates
coronary artery stenosis in the LAD;
black arrow in D indicates coronary
artery stenosis in the diagonal
branch.
Dr/AHMED ESAWY

5. Noncontrast-Enhanced 1.5-T Whole-Heart Coronary MRA in a 66-Year-Old Woman
Significant coronary artery
stenosis in the LCX (white
arrowhead) is observed in the
sliding thin-slab maximum
intensity projection image (A),
the volume-rendered
image (B),
and the curved planar
reconstruction image (C), with
good correlation with X-ray
coronary angiography (black
arrowhead) (D).
Dr/AHMED ESAWY

6. Coronary Angiography in a 53-Year-Old Man with Exertional Chest Pain
Panel A shows a coronary magnetic
resonance angiogram (left) and a
corresponding x-ray coronary
angiogram (right) indicating a severe
lesion at the bifurcation of the left
anterior descending coronary artery
and the left circumflex coronary
artery, involving the left main
coronary artery (solid arrows) ,and a
more distal focal stenosis of the left
circumflex coronary artery (broken
arrows).
Panel B shows a coronary magnetic
resonance angiogram (left) and a
corresponding x-ray angiogram
(right) indicating two stenoses of the
proximal (solid arrows) and middle
(broken arrows) right coronary artery
Dr/AHMED ESAWY

7. A 74 year-old asymptomatic male. A lumen stenosis on the RCA could be
identified by noncontrast MRA (confirmed by coronary angiogram)
Dr/AHMED ESAWY

8. A 73 year-old healthy male. His peripheral blood pressure was 130/70 mmHg (PP= 60mmHg).
(a) Longitudinal view of the RCA in mid-diastole (b) Longitudinal view of the RCA in end-
systole. (c) Transverse view of lumen in mid-diastole (d) Transverse view of lumen in end-
systole (e) Zoomed diastolic lumen with contour shows the area is 7.61mm2. (f) Zoomed
systolic lumen with contour shows the area is 15.05 mm2Dr/AHMED ESAWY

9. A 71 year-old asymptomatic female with a history of T2DM for 10 years. An eccentrically
remodeled coronary segment on the LAD (without significant lumen stenosis) could be
identified by MRI.
Dr/AHMED ESAWY

10. a 61-year-old female, who had a HTx 7 years ago. Her heart rate is 108 beats/minute.
We can clearly see the RCA using black-blood SSFP MRI technique.
Dr/AHMED ESAWY

11. T2prep images of the right coronary artery (RCA) (A) and the left main stem (D) in a
patient with Takayasu arteritis (TA). B and E show the post IR scan of the same
patient, revealing late gadolinium enhancement (LGE) of the coronary artery wall.
C and F depict the corresponding x-ray angiography.
Dr/AHMED ESAWY

12. T2prep image of the RCA in a patient
with CAD, while B represents the x-
ray angiography and C the IR scan pre
and D the IR scan post gadolinium
administration in the same patient. At
the bottom right of Figure 1D is the
enlarged cross sectional view of the
appended IR scan.
the prevalence and amount of coronary enhancement after gadolinium (CNR) in TA seems
to be similar to that in patients with CAD
Dr/AHMED ESAWY

13. T2prep image of the RCA in a patient with TA, while B represents the IR scan pre- and
C the IR scan postgadolinium administration in the same patient. The white arrow
indicates the area of localized coronary artery vessel wall enhancement in C,
the dotted arrow the coronary segment without LGE of the coronary vessel wall post
contrast in the same coronary artery
the prevalence and amount of coronary enhancement after gadolinium (CNR) in TA seems
to be similar to that in patients with CAD
Dr/AHMED ESAWY

14. cardiac short-axis spin-echo magnetic resonance image of a patient without cardiac
disease. Myocardial walls of the left and right ventricle are clearly depicted
Dr/AHMED ESAWY

15. Transverse cardiac spin-echo magnetic resonance image of a patient with an anterior wall
infarction with apical and septal involvement. For this T2-weighted image, a multi-echo study
(TE 30-60-90-120 ms) was performed. Note the aneurysmal dilatation of the apicoseptal wall
with increased signal intensity on the images with echo times 60 ms (upper right), 90 ms
(lower left), and 120 ms (lower right).Dr/AHMED ESAWY

16. Series of six sequential ultrafast magnetic resonance images showing signal enhancement after
administration of Gd-DTPA: Baseline image (upper left), right ventricular cavity (upper middle
and upper right), pulmonary vasculature, left ventricular cavity and aorta (lower left and lower
middle), and myocardium (lower right)Dr/AHMED ESAWY

17. Short-axis cardiac spin-echo magnetic resonance image of a patient with a 2-day-old
myocardial infarction of the inferoposterior wall. There is marked wall thinning of the
inferoposterior wall and a clear dilatation of the left ventricle.
Dr/AHMED ESAWY

18. Transverse cardiac spin-echo magnetic
resonance (MR) image of patient with
anteroseptal wall infarction before
administration of Gd-DTPA. Apart from
some apical thinning, no clear MR signs of
myocardial infarction are recognized. B,
Same MR image 20 to 25 minutes after
administration of Gd-DTPA. Contrast
enhancement is visible in the anteroseptal
area with extension to the apex.
Dr/AHMED ESAWY

19. A, Computer-constructed contours of subepicardial (1) and subendocardial (2)
borders on cardiac spin-echo magnetic resonance (MR) image after administration
of Gd-DTPA in patient with anterior wall infarction. B, After subtraction of mean
cardiac signal intensity (+2 SD), the MR image shows marked contrast enhancement
of Gd-DTPA in anteroapical area (3)
Dr/AHMED ESAWY

20. . Series of six sequential ultrafast magnetic resonance images after bolus administration of
Gd-DTPA in a patient with healed myocardial infarction of the inferolateral wall. Ultimately
(lower middle and lower right), decreased myocardial signal intensity is observed in the
infarcted inferolateral wall compared with the normal anterior region (arrowheads)
Dr/AHMED ESAWY

21. Top, Transverse cardiac spin-echo magnetic
resonance image plane showing a left
ventricular thrombus occupying the whole
left ventricle of a patient with a previously
sustained large anterior wall infarction.
Aneurysmal formation of the anteroapical
area can be observed. After surgical
removal, the largest diameter of the
thrombus measured 7 cm. Bottom,
Schematic drawing of top image. LV
indicates left ventricle; RV, right ventricle;
and T, thrombus
Dr/AHMED ESAWY

22. Top, Transverse magnetic resonance image of
the origin of the right coronary artery (RCA)
using a body coil. Bottom, Image quality is
markedly improved with the surface coil. RAA
indicates right atrial appendag
Dr/AHMED ESAWY

23. Oblique magnetic resonance image along the major axis at the level of the proximal
right coronary artery identified in transverse section. The image was acquired in
breathhold using turbo fast low-angle shot imagingDr/AHMED ESAWY

24. MSCT or MRI
Sensitivity 97% 73%
Specificity 75% 48%
Pretest likelihood determines utility
CT better than MRI
CT good for 20-60% likelihood
Dr/AHMED ESAWY

25. Systematic approach to reading
coronary CT angiography studies
• 1. Obtain a quick overview of the gross anatomy,
e.g.,by looking at three-dimensional renderings
• 2. Assess the individual coronary arteries and
major side-branches by using reconstruction tools
and viewing original slices, preferably
simultaneous
• 3. Evaluate the cardiac extracoronary structuresc
• 4. Evaluate extracardiac organsd
Dr/AHMED ESAWY

26. Reconstructions available for reading
coronary CT angiography studies
• 1.Axial, coronal, and sagittal images are the
primary source of information
• 2. Curved multiplanar reformations are
convenient for identifying stenoses
• 3. Maximum-intensity projections give a good
overview of vessels and lesions but may obscure
stenoses and overestimate calcified lesions
• 4. Angiographic emulations and three-
dimensional renderings may be used for elegant
display and presentation of findings
Dr/AHMED ESAWY

27. (A) Axial image showing left main coronary ostium and its divisions into left anterior
descending, ramus intermedius,and left circumflex arteries. (B) Multiplanar
reconstructed image. (C) Anatomic 3-dimensional volume-rendered image showing
relationships among left main artery, branches, and adjacent cardiac structures. (D)
Curved multiplanar reconstruction of entire length of left circumflex artery.Dr/AHMED ESAWY

28. (A) Axial view showing normal anatomy of 4 pulmonary veins and left atrial
appendage clear of thrombus (asterisk). (B) Axial view from another patient
undergoing evaluation before radiofrequency ablation of atrial fibrillation.
Thrombus (asterisk) is visible in left atrial appendage
Dr/AHMED ESAWY