The cardiac MRI iron overload protocol encompasses a set of different MRI sequences for the cardiac assessment in case of suspected iron overload cardiomyopathy.
Note: This article aims to frame a general concept of a cardiac MRI protocol in the above setting.
Protocol specifics will vary depending on additional clinical questions, differential diagnosis, MRI scanner type, specific hardware and software, radiologist and perhaps referrer preference, patient factors e.g. arrhythmia or breathing problems or implants, specific indications and time constraints.
On this page:
Indications
1.5 vs 3 tesla
The mainstay for the assessment of iron overload is T2* mapping; this should be performed at 1.5 tesla 3.
Patient preparation
Checking indications, contraindications, explanation of the examination and obtaining informed consent is obvious as in other examinations.
Beyond that patient preparation for cardiac MRI includes the following:
instruction how to breathe
an electrocardiogram signal need to be acquired
Patient positioning
A cardiac MRI is conducted in the supine position.
Technical parameters
Coil
Multiphased array coils are recommended.
anterior surface coil, posterior coil
cardiac coil
Scan geometry
in-plane spatial resolution: will vary with the sequence
field of view (FOV): will vary, for most planes a FOV ≤320 mm is recommended
slice thickness: varies with the sequence and is usually 6-10 mm
Planning
The cardiac imaging planes differ from the normal axial, coronal and sagittal body planes 1-4:
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overview
angulation: strictly axial
volume: from the thoracic inlet to the diaphragm
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horizontal long axis view or 4-chamber view (4ch)
angulation: along the left ventricular long axis through the apex and the centers of the mitral and tricuspid valves
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left ventricular vertical long axis view or 2-chamber view (2ch)
angulation: along the left ventricular long axis through the left ventricular apex and the center of the mitral valve
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sagittal left ventricular outflow tract (LVOT) or 3-chamber view (3ch)
angulation: through the left ventricular apex, the center of the mitral valve and the left ventricular outflow tract and aortic valve
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short-axis view (sax)
angulation: perpendicular to the left ventricular long axis
Sequences
Standard sequences
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T2 black-blood or SSFP
purpose: overview, depiction of the cardiac surroundings and greats vessels, assessment of mediastinal lymphadenopathy in suspected sarcoidosis
technique: T1 black-blood, T2 black-blood, SSFP ideally over 1-2 breath-holds
planes: axial
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purpose: left ventricular wall motion, left ventricular volumetry
technique: cine SSFP or spoiled GRE
planes: 2ch, 4ch, 3ch and short-axis views
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purpose: cardiac tissue characterization (iron overload)
technique: single breath-hold GRE, multi-echo with 8 equally distributed echo times 3
planes: short-axis views
Optional sequences
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late gadolinium enhancement (C+)
purpose: for the evaluation of myocardial viability (myocardial necrosis, myocardial fibrosis and myocardial scar tissue)
planes: 2ch, 4ch, 3ch and short-axis views
inversion time (TI) as determined by TI scout (Look-Locker) or fixed TI (PSIR)
Practical points
The following considerations can be made in certain conditions:
single shot modules or free breathing with real-time image acquisition in patients with difficulties holding their breath
abdominal bands in profound respiratory motion
peripheral pulse gating in patients with a weak ECG signal
postponing the exam in patients with severe pleural effusion and related ghosting artifacts and breathing problems until after pleural drainage
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cine imaging
cardiac volumes should be obtained as in every cardiac MRI
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should be performed in case of decreased ejection fraction
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