Number 08-16: Advanced late gadolinium enhancement optimisation
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Number 08-16: Advanced late gadolinium enhancement optimisation




Case from: Giovanne Quarta, Derek Hausenloy, Diana Holdright, James Moon.

History: 48 Y/O male from Kuwait presented with dyspnea and palpitations. Holter shows 2:1 heart block episodes. PMH: severe asthma.
Echo: LV impairment with regional wall motion abnormalities
Angiography: Normal. Patient referred for CMR
Cine CMR: Mild LV impairment, multiple subtle RWMAs
LGE CMR: Imaging optimization progressed through the following steps:
1. IR-FLASH - suspicion for endocardial LGE
– but blood pool bright:suggest waiting (blood pool darkens) and imaging in systole (to image when trabeculae are compressed together)




2. Switched to imaging in systole
- But image blurry with IR-FLASH (long readout – 23x6ms = 138ms so motion artefact)



3. Switched to IR-FISP imaging
-Better: The faster readout per line (3ms vs 6ms) can be used in a variety of ways



4. Switched to IR-FISP in systole
- Better: Squashing trabeculae together (systole) and shorter readout (IR-FISP)



5. ‘Pushing the envelope’ – more of the above, but inevitably a longer breath-hold
25 lines readout (75ms) – best image: valve leaflets static and clearly seen



6. Cross cuts (othagonal plane imaging) to prove EMF
Short axis and 2-chamber confirm findings

CMR diagnosis: Probable endomyocardial fibrosis: consider filiarial disease, Churgg-Strauss. What was the eosinophil count?
Follow-up: Eosinophils normal: Unfortunately patient returned to home country before full investigation.
CMR perspective: Advanced practionners of CMR can get the most out of LGE imaging by taking many images and adjusting the acquisitions for both for patient characteristics and the disease under investigation. An SSFP readout is twice as fast and frequently this permits increased optimisation. See table below for suggested imaging modifications.


Patient characteristic






Trigger 2

23 segments

20 degree flip angle

115-140 lines

(14 heart beats)


Trigger 2

65 segments

50-60 degree flip angle

130 lines

(12 heart beats)


HR <800ms


Trigger 3

Segments 19-21

Flip angle 22 degrees

Trigger 3 or 4 segments


Trigger 3 or 4

Segments 45


HR Variable


Trigger 3

(if possible)


Trigger 3 or 4

Consider systolic








Trigger 3 or 4

Consider systolic



Severe fluid





Increase FOV, switch PE direction, use presaturation bands, Consider shorter scan or single shot


Poor breath-hold




Segments 65 or single shot 1 average


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