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Late gadolinium enhancement (LGE)

a) SCMR official document standardized acquisition guidelines – relevant extract

1. Need at least 10 minute wait after gadolinium injection (0.1–0.2 mmol/kg). Note – The delay may be shorter than 10 minutes if lower doses are used as blood pool signal falls below that of late enhanced myocardium.
2. 2D segmented inversion recovery GRE imaging during diastolic stand-still
3. Same views as for cine imaging (short- and long-axis views)
4. Slice thickness, same as for cine imaging
5. In-plane resolution, ~1.4–1.8 mm
6. Acquisition duration per R-R interval below 200 ms but should be less in the setting of tachycardia.
7. Inversion time set to null normal myocardium. Alternative is to use fixed TI with a phase-sensitive sequence.
8. Read-out is usually every other heart beat but should be modified to every heart beat in the setting of bradycardia, and every third heart beat in the setting of tachycardia or arrhythmia.
9. Optional
   a. Single-shot imaging (SSFP readout) performed as backup for patients with irregular heart beat, difficulty breath holding.
   b. 3D sequences with parallel imaging in appropriate patients if signal-to-noise is sufficient.
10. Analysis
    a. Interpret visually using AHA 17-segment model.
    b. Estimate area (mean transmural extent) of enhancement within each segment (0%, 1–25%, 26–50%, 51–75%, 76–100%).

b) SCMR official document reporting recommendations – relevant extract

Late gadolinium enhancement (LGE):

The amount of intense signal >2 SD above the average of normal myocardium should be reported for the area within each segment.  Overall, LGE should be described as subepicardial, intramural, subendocardial, or transmural.  Patchy or linear streaks of LGE should be identified.  The transmural extent of the LGE should be defined as 0, <25%, 26% to <50%, 51% to <75%, and 76% to 100%.  In addition, the total amount of infarcted tissue (volume or grams) relative to the total myocardial volume or mass (g) may be reported.  It is not recommended, but measures of LV end-diastolic wall thickness for the 17 myocardial segments may also be reported.  When clinically appropriate, those providing an interpretation should indicate whether the pattern of LGE is consistent with ischemic heart disease, myocarditis, etc.

d) Case of the Week example(s)

Number 08-16: Advanced late gadolinium enhancement optimisation
History: 48 Y/O male from Kuwait presented with dyspnea and palpitations. Holter shows 2:1 heart block episodes. PMH: severe asthma.

e) Expert opinion – ‘How we do’

How We Perform Delayed Enhancement Imaging (Ray Kim and Bob Judd, Duke University)
Late enhancement imaging quiz, provided by James Moon — Questions here, Answers here

f) Relevant Online Talks

Free talks

Late enhancement CMR
By Matthias Friedrich
Recorded at EuroCMR 2008

Members only talks - general

How to perform high quality Late Gadolinium Enhancement Imaging
By Afshin Farzaneh-Far - Duke University Medical Centre
Recorded at SCMR 2010

Contrast-enhanced Sequences
By Tom Foo - GE, Schenectady
Recorded at SCMR2008 Physician Pre-Conference Section 1: MR Physics

Myocardial infarction
By Hassan Abdel-Aty - Berlin
Recorded at SCMR2008 Physician Pre-Conference Section 4: Clinical Applications of CMR

Small areas of LE: Pathology or artifact?
By Tareq Ibrahim - Munich
Recorded at SCMR2008 Physician Pre-Conference Section 3: Tips and Tricks

g) Relevant papers (starting point):

KimRJ et al, The Use of Contrast Enhanced MRI to Identify Reversible Myocardial Dysfunction. N Engl J Med 2000;343: 1445-53
Kim RJ et al. Relationship of MRI delayed contrast enhancement to irreversible injury, infarct age and contractile function. Circulation 1999;100:1992-02.
A. Wagner et al H. Contrast-enhanced MRI and routine SPECT perfusion imaging for detection of subendocardial MIs: an imaging study.  2003:361:374-379
Kim HW et al. Unrecognized non-Q-wave myocardial infarction: prevalence and prognostic significance in patients with suspected coronary disease. PLoS Med. 2009 Apr 21;6(4):e1000057. Epub 2009 Apr 21.