Purpose/ Objective
Myocardial perfusion with cardiovascular magnetic resonance (CMR) imaging is an established diagnostic test for evaluation of myocardial ischaemia. For quantification purposes, however, the 16 segment American Heart Association (AHA) model poses limitations in terms of extracting relevant information on the extent/severity of ischaemia as perfusion deficits will not always fall within an individual segment, which reduces its diagnostic value, and makes an accurate assessment of outcome data or a result comparison across various studies difficult. The article will therefore focus on how subsegmentation of the myocardium improves diagnostic accuracy and facilitates an objective cut-off-based description of hypoperfusion.
What is the ideal state/ if the The 16 segment American Heart Association (AHA) model poses limitations in terms of extracting relevant information on the extent/severity of ischaemia as perfusion deficits will not always fall within an individual segment, which reduces its diagnostic value, and makes an accurate assessment of outcome data or a result comparison across various studies difficult. By further dividing the myocardial segments into epi- and endocardial layers and a further circumferential subdivision, the accuracy of detecting myocardial hypoperfusion is improved.problem is gone?
Following this activity, learners will be aware of the advantages / disadvantages of the different subsegmentation approaches and they will understand how to use the 96 (sub-)subsegments approach.
This activity was designed to make the learner familiar with the advantages / disadvantages of subsegmentation approaches based on transmural segments (16 AHA and 48 segments) vs. subdivision into epi- and endocardial (32) subsegments vs. further circumferential subdivision into 96 (sub-)subsegments.
Accreditation Statement
The Society for Cardiovascular Magnetic Resonance (SCMR) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit Designation Statement
The Society for Cardiovascular Magnetic Resonance (SCMR) designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit (s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Instructions for Claiming CME
- Attend the sessions in full for which credit is sought
- Complete the post-activity evaluation
- A certificate of completion will be available once the evaluation is submitted
Financial Disclosures
The planners and faculty for this activity did not have any relationships to disclose.
Disclosure of Commercial Support
SCMR received funding to support this activity from the following organizations: None.
Bibliography1. Knuuti J, Wijns W, Saraste A, Capodanno D, Barbato E, Funck-Brentano C, et al. 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2019 Aug 31. https://doi.org/10.1093/eurheartj/ehz425. 2. Roffi M, Patrono C, Collet J-P, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2016;37:267–315. 3. Hendel RC, Friedrich MG, Schulz-Menger J, Zemmrich C, Bengel F, Berman DS, Camici PG, Flamm SD, Le Guludec D, Kim R, Lombardi M, Mahmarian J, Sechtem U, Nagel E. CMR first-pass perfusion for suspected inducible myocardial ischemia. JACC Cardiovasc Imaging. 2016;9(11):1338–48. 4. Puntmann VO, Valbuena S, Hinojar R, Petersen SE, Greenwood JP, Kramer CM, et al. Society for Cardiovascular Magnetic Resonance (SCMR) expert consensus for CMR imaging endpoints in clinical research: part I - analytical validation and clinical qualification. J Cardiovasc Magn Reson. BioMed Cent. 2018;20:67. 5. Nagel E, Greenwood JP, McCann GP, Bettencourt N, Shah AM, Hussain ST, et al. Magnetic resonance perfusion or fractional flow reserve in coronary disease. N. Engl. J. Med. Mass Med Soc. 2019;380:2418–28. 6. Schulz-Menger J, Bluemke DA, Bremerich J, Flamm SD, Fogel MA, Friedrich MG, et al. Standardized image interpretation and post processing in cardiovascular magnetic resonance: Society for Cardiovascular Magnetic Resonance (SCMR) board of trustees task force on standardized post processing. J Cardiovasc Magn Reson. 2013;15:35. 7. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, Laskey WK, Pennell DJ, Rumberger JA, Ryan T, Verani MS. American Heart Association writing group on myocardial segmentation and registration for cardiac imaging. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the cardiac imaging committee of the council on clinical cardiology of the American Heart Association. Circ. 2002;105(4):539–42. 8. Shaw LJ, Blankstein R, Brown DL, Dhruva SS, Douglas PS, Genders TSS, et al. controversies in diagnostic imaging of patients with suspected stable and acute chest pain ayndromes. JACC: Cardiovasc Imaging. 2019;12:1254–78. 9. Selvadurai BSN, Puntmann VO, Bluemke DA, Ferrari VA, Friedrich MG, Kramer CM, et al. Definition of left ventricular segments for cardiac magnetic resonance imaging. JACC Cardiovasc Imaging. 2017;11:926–8. 10. Shaw LJ, Berman DS, Picard MH, Friedrich MG, Kwong RY, Stone GW, et al. Comparative definitions for moderate-severe ischemia in stress nuclear, echocardiography, and magnetic resonance imaging. JACC Cardiovasc Imaging. 2014;7:593–604. 11. Hsu L-Y, Groves DW, Aletras AH, Kellman P, Arai AE. A quantitative pixel-wise measurement of myocardial blood flow by contrast-enhanced first-pass CMR perfusion imaging. JACC Cardiovasc Imaging. 2012;5:154–66. 12. Ta AD, Hsu L-Y, Conn HM, Winkler S, Greve AM, Shanbhag SM, et al. Fully quantitative pixel-wise analysis of cardiovascular magnetic resonance perfusion improves discrimination of dark rim artifact from perfusion defects associated with epicardial coronary stenosis. J Cardiovasc Magn Reson. 2018;20:16–1. 13. Chung S, Shah B, Storey P, Iqbal S, Slater J, Axel L. Quantitative perfusion analysis of first-pass contrast enhancement kinetics: application to MRI of myocardial perfusion in coronary artery disease. PLoS One. 2016;11:e0162067. 14. Ishida M, Schuster A, Morton G, Chiribiri A, Hussain S, Paul M, et al. Development of a universal dual-bolus injection scheme for the quantitative assessment of myocardial perfusion cardiovascular magnetic resonance. J Cardiovasc Magn Reson. 2011;13:28. 15. Puntmann VO, Carr-White G, Jabbour A, Yu C-Y, Gebker R, Kelle S, et al. Native T1 and ECV of noninfarcted myocardium and outcome in patients with coronary artery disease. J Am Coll Cardiol. 2018;71:766–78.