Hypertrophic cardiomyopathy MRI
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Editors-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2]
Overview
Late myocardial enhancement has been associated with myocardial fibrosis and may allow for earlier detection of hypertrophic cardiomyopathy (HCM) than is currently available with echocardiography and ECG. MRI is helpful in visualizing the asymmetric thickening of the interventricular septum in patients with HCM. However, it may be more helpful than other forms of imaging to differentiate the variant types of hypertrophic cardiomyopathy. MRI can be helpful in evaluating the extent of systolic anterior motion of the mitral valve. MRI can help visualize turbulence in the left ventricular outflow tract created by an obstruction in patients with obstructive hypertrophic cardiomyopathy.
Cardiac MRI
Late myocardial enhancement
Late myocardial enhancement has been associated with myocardial fibrosis and may allow for earlier detection of hypertrophic cardiomyopathy than is currently available with echocardiography and ECG.
- It has been shown that in patients with previously diagnosed hypertrophic cardiomyopathy[1]:
- Late myocardial enhancement following gadolinium administration in a patchy intramyocardial distribution.
- Typically occurred in the hypertrophied regions, predominantly in the middle third of the ventricular wall in a patchy, multifocal distribution.
- If enhancement occurred, it occurred at the junctions of the intraventricular septum and right ventricular free wall.
- Moon et al looked at whether the extent of hyperenhancement on MRI in patients with HCM is associated with an elevated risk of heart failure and sudden death [2] The study involved 53 patient were selected for the presence or absence of an increased clinical risk of sudden death and/or progressive adverse left ventricular remodeling.
- Myocardial hyperenhancement was present in 79% of patients.
- They found no evidence of abnormal myocardium on non-contrast images.
- There was more hyperenhancement in patients with the progressive disease than without.
- There was greater hyperenhancement in patients with ≥ 2 risk factors for sudden death.
- Patients with diffuse hyperenhancement had ≥ 2 risk factors for sudden death vs patients with confluent hyperenhancement.
Of note, other investigators have discovered that in carriers without signs of hypertrophy on EKG or echocardiography, Cardiac MR can detect the presence of crypts in the LV wall which may progress to hypertrophy.
Left Ventricular Hypertrophy
MRI is helpful in visualizing the asymmetric thickening of the interventricular septum in patients with HCM. However, it may be more helpful than other forms of imaging to differentiate the variant types of hypertrophic cardiomyopathy.[3]
Systolic Anterior Motion
MRI can be helpful in evaluating the extent of systolic anterior motion of the mitral valve.
Obstruction
MRI can help visualize turbulence in the left ventricular outflow tract created by an obstruction in patients with obstructive hypertrophic cardiomyopathy.
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2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[4]
Recommendations for CMR Imaging Referenced studies that support the recommendations are summarized in the Online Data Supplement
| Class I |
| 1. For patients suspected to have HCM in whom echocardiography is inconclusive, CMR imaging is indicated for diagnostic clarification.(Level of Evidence: B-NR)
2. For patients with LVH in whom there is a suspicion of alternative diagnoses, including infiltrative or storage disease as well as athlete’s heart, CMR imaging is useful(Level of Evidence: B-NR) 3. For patients with HCM who are not otherwise identified as high risk for SCD, or in whom a decision to proceed with ICD remains uncertain after clinical assessment that includes personal/family history, echocardiography, and ambulatory electrocardiographic monitoring, CMR imaging is beneficial to assess for maxi-mum LV wall thickness, ejection fraction (EF), LV apical aneurysm, and extent of myocardial fibrosis with LGE(Level of Evidence: B-NR) 4. For patients with obstructive HCM in whom the anatomic mechanism of obstruction is inconclusive on echocardiography, CMR imaging is indicated to inform the selection and planning of SRT.(Level of Evidence: B-NR) |
| Class IIb |
| 5. For patients with HCM, repeat contrast-enhanced CMR imaging on a periodic basis (every 3 to 5 years) for the purpose of SCD risk stratification may be considered to evaluate changes in LGE and other morphologic changes, including EF, development of apical aneurysm, or LV wall thickness(Level of Evidence: C-EO) |
ACC/AHA Guidelines- ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance (DO NOT EDIT)[5]
| “ |
CMR may be used for assessment of patients with LV dysfunction or hypertrophy or suspected forms of cardiac injury not related to ischemic heart disease. When the diagnosis is unclear, CMR may be considered to identify the etiology of cardiac dysfunction in patients presenting with heart failure, including
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” |
2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy (DO NOT EDIT)[6]
Cardiac Magnetic Resonance (DO NOT EDIT)[6]
| Class I |
| "1. CMR imaging is indicated in patients with suspected HCM when echocardiography is inconclusive for diagnosis.[7][8] (Level of Evidence: B) " |
| "2. CMR imaging is indicated in patients with known HCM when additional information that may have an impact on management or decision making regarding invasive management, such as magnitude and distribution of hypertrophy or anatomy of the mitral valve apparatus or papillary muscles, is not adequately defined with echocardiography.[7][8][9][10][11] (Level of Evidence: B) " |
| Class IIa |
| "1. CMR imaging is reasonable in patients with HCM to define apical hypertrophy and/or aneurysm if echocardiography is inconclusive.[7][9] (Level of Evidence: B) " |
| Class IIb |
| "1. In selected patients with known HCM, when SCD risk stratification is inconclusive after documentation of the conventional risk factors, CMR imaging with assessment of late gadolinium enhancement (LGE) may be considered in resolving clinical decision making.[12][13][14][15][16] (Level of Evidence: C) " |
| "2. CMR imaging may be considered in patients with LV hypertrophy and the suspicion of alternative diagnoses to HCM, including cardiac amyloidosis, Fabry disease, and genetic phenocopies such as LAMP2 cardiomyopathy.[17][18][19] (Level of Evidence: C) " |
References
- ↑ Choudhury et al. Myocardial scarring in asymptomatic or mildly symptomatic patients with hypertrophic cardiomyopathy. J. Am Coll Card. 2002; 40: 2156.
- ↑ Moon et al., Toward Clinical Risk Assessment in Hypertrophic Cardiomyopathy with Gadolinium Cardiovascular Magnetic Resonance. J Am Coll Card. 2003; 41; 1561.
- ↑ Germans, T et al. Structural Abnormalities of the inferoseptal left ventricular wall detected by Cardiac Magnetic Resonance Imaging in carriers of Hypertrophic Cardiomyopathy mutations. J Am Coll Cardiol. 2006: 48; 2518.
- ↑ Ommen SR, Mital S, Burke MA, Day SM, Deswal A, Elliott P; et al. (2020). "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 142 (25): e558–e631. doi:10.1161/CIR.0000000000000937. PMID 33215931 Check
|pmid=value (help). - ↑ American College of Cardiology Foundation Task Force on Expert Consensus Documents. Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA; et al. (2010). "ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents". Circulation. 121 (22): 2462–508. doi:10.1161/CIR.0b013e3181d44a8f. PMC 3034132. PMID 20479157.
- ↑ 6.0 6.1 Gersh BJ, Maron BJ, Bonow RO, Dearani JA, Fifer MA, Link MS, Naidu SS, Nishimura RA, Ommen SR, Rakowski H, Seidman CE, Towbin JA, Udelson JE, Yancy CW (2011). "2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the American Association for Thoracic Surgery, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Journal of the American College of Cardiology. 58 (25): e212–60. doi:10.1016/j.jacc.2011.06.011. PMID 22075469. Retrieved 2011-12-19. Unknown parameter
|month=ignored (help) - ↑ 7.0 7.1 7.2 Moon JC, Fisher NG, McKenna WJ, Pennell DJ (2004). "Detection of apical hypertrophic cardiomyopathy by cardiovascular magnetic resonance in patients with non-diagnostic echocardiography". Heart (British Cardiac Society). 90 (6): 645–9. PMC 1768283. PMID 15145868. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ 8.0 8.1 Rickers C, Wilke NM, Jerosch-Herold M, Casey SA, Panse P, Panse N, Weil J, Zenovich AG, Maron BJ (2005). "Utility of cardiac magnetic resonance imaging in the diagnosis of hypertrophic cardiomyopathy". Circulation. 112 (6): 855–61. doi:10.1161/CIRCULATIONAHA.104.507723. PMID 16087809. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ 9.0 9.1 Maron MS, Finley JJ, Bos JM, Hauser TH, Manning WJ, Haas TS, Lesser JR, Udelson JE, Ackerman MJ, Maron BJ (2008). "Prevalence, clinical significance, and natural history of left ventricular apical aneurysms in hypertrophic cardiomyopathy". Circulation. 118 (15): 1541–9. doi:10.1161/CIRCULATIONAHA.108.781401. PMID 18809796. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Maron MS, Lesser JR, Maron BJ (2010). "Management implications of massive left ventricular hypertrophy in hypertrophic cardiomyopathy significantly underestimated by echocardiography but identified by cardiovascular magnetic resonance". The American Journal of Cardiology. 105 (12): 1842–3. doi:10.1016/j.amjcard.2010.01.367. PMID 20538141. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Maron MS, Maron BJ, Harrigan C, Buros J, Gibson CM, Olivotto I, Biller L, Lesser JR, Udelson JE, Manning WJ, Appelbaum E (2009). "Hypertrophic cardiomyopathy phenotype revisited after 50 years with cardiovascular magnetic resonance". Journal of the American College of Cardiology. 54 (3): 220–8. doi:10.1016/j.jacc.2009.05.006. PMID 19589434. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Adabag AS, Maron BJ, Appelbaum E, Harrigan CJ, Buros JL, Gibson CM, Lesser JR, Hanna CA, Udelson JE, Manning WJ, Maron MS (2008). "Occurrence and frequency of arrhythmias in hypertrophic cardiomyopathy in relation to delayed enhancement on cardiovascular magnetic resonance". Journal of the American College of Cardiology. 51 (14): 1369–74. doi:10.1016/j.jacc.2007.11.071. PMID 18387438. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Maron MS, Appelbaum E, Harrigan CJ, Buros J, Gibson CM, Hanna C, Lesser JR, Udelson JE, Manning WJ, Maron BJ (2008). "Clinical profile and significance of delayed enhancement in hypertrophic cardiomyopathy". Circulation. Heart Failure. 1 (3): 184–91. doi:10.1161/CIRCHEARTFAILURE.108.768119. PMID 19808288. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Rubinshtein R, Glockner JF, Ommen SR, Araoz PA, Ackerman MJ, Sorajja P, Bos JM, Tajik AJ, Valeti US, Nishimura RA, Gersh BJ (2010). "Characteristics and clinical significance of late gadolinium enhancement by contrast-enhanced magnetic resonance imaging in patients with hypertrophic cardiomyopathy". Circulation. Heart Failure. 3 (1): 51–8. doi:10.1161/CIRCHEARTFAILURE.109.854026. PMID 19850699. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ O'Hanlon R, Grasso A, Roughton M, Moon JC, Clark S, Wage R, Webb J, Kulkarni M, Dawson D, Sulaibeekh L, Chandrasekaran B, Bucciarelli-Ducci C, Pasquale F, Cowie MR, McKenna WJ, Sheppard MN, Elliott PM, Pennell DJ, Prasad SK (2010). "Prognostic significance of myocardial fibrosis in hypertrophic cardiomyopathy". Journal of the American College of Cardiology. 56 (11): 867–74. doi:10.1016/j.jacc.2010.05.010. PMID 20688032. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Moon JC, McKenna WJ, McCrohon JA, Elliott PM, Smith GC, Pennell DJ (2003). "Toward clinical risk assessment in hypertrophic cardiomyopathy with gadolinium cardiovascular magnetic resonance". Journal of the American College of Cardiology. 41 (9): 1561–7. PMID 12742298. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Gange CA, Link MS, Maron MS (2009). "Utility of cardiovascular magnetic resonance in the diagnosis of Anderson-Fabry disease". Circulation. 120 (13): e96–7. doi:10.1161/CIRCULATIONAHA.109.849828. PMID 19786638. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Maceira AM, Joshi J, Prasad SK, Moon JC, Perugini E, Harding I, Sheppard MN, Poole-Wilson PA, Hawkins PN, Pennell DJ (2005). "Cardiovascular magnetic resonance in cardiac amyloidosis". Circulation. 111 (2): 186–93. doi:10.1161/01.CIR.0000152819.97857.9D. PMID 15630027. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help) - ↑ Moon JC, Sachdev B, Elkington AG, McKenna WJ, Mehta A, Pennell DJ, Leed PJ, Elliott PM (2003). "Gadolinium enhanced cardiovascular magnetic resonance in Anderson-Fabry disease. Evidence for a disease specific abnormality of the myocardial interstitium". European Heart Journal. 24 (23): 2151–5. PMID 14643276. Retrieved 2011-12-23. Unknown parameter
|month=ignored (help)