David A' Bluemke, M'D', Ph'D'

1
David A. Bluemke, M.D., Ph.D.
How to Perform MRI for Arrhythmogenic Right
Ventricular Dysplasia/ Cardiomyopathy (ARVD/C)
Associate Professor, Clinical Director,
MRI Departments of Radiology and Medicine Johns
Hopkins University School of Medicine Baltimore,
Maryland
2
Disclosures

• Off-label gadolinium MRI of the heart
• Sponsorship JHU ARVD Center, NHLBI
  N01-CM-27018, Donald W. Reynolds Foundation

Acknowledgements

• João Lima, MD, Hugh Calkins, MD, Henry Halperin,
  MD, Saman Nazarian, MD
• Frank Marcus, MD
• Harikrishna Tandri, MD, Chandra Bomma, MD,
  Ernesto Castillo, MD
• Crystal Tichnell, JHH ARVD center

3
ARVD/C Protocol Summary

• Axial short axis T1 images, with blood
  suppression (double IR FSE/ TSE)
• - 5 mm slice thickness, ETL 24-28
• - to avoid wrap-around, use anterior coils only
• - 10-12 slices axial, 5 slices short axis over
  the heart.
• Same as (1), but axial only, with fat suppression
• SSFP Cine axial and short axis, long axis cine
• - 10-12 short axis cine images, 8 axial images, 4
  chamber cine
• Delayed gadolinium images
• - 5 short axis images, 6-8 axial images

Note since the protocol is long, the minimum
of slices in each plane is given above.
4
Black blood double IR TSE/ FSE images

• Either 1 RR or 2 RR is fine, blood suppression
  pulse for dark blood
• TE 20-30 ms, ETL 24-32, 256x256, ZIP to 512
• 5x3 mm, 1 NEX, breath-holding
• Anterior coil only to avoid wrap, FOV 24-28

short axis shows LV and the inferior RV wall
Axial shows free wall of the RV
5
Repeat the axial images with fat sat

• Axial T1 images, blood/ fat suppression
• TE min, ETL 24-32, 256x256, ZIP
• 5x3 mm (same slice locations as non fatted
  images)
• Anterior coil, FOV 24-28

Fat suppression reduces artifacts especially for
the RV free wall The axial plane for fat sat is
sufficient.
6
Common protocol questions

• What about prone imaging?
• not necessary with breath-hold imaging.
• difficult for patients to sustain for the
  duration of this protocol (45 minutes).

• 2. Why is there some much axial imaging?
• Axial imaging provides an excellent view of the
  anterior RV wall and RVOT. It is easy for the
  technologist.
• HLA (long axis) images do not image the RVOT

7
Common protocol questions

• 3. We have a double IR single shot sequence
  (ssfse, HASTE) that is much faster should I use
  this?
• NO!
• As seen below, these images blur RV detail and
  are not used for ARVD/C

HASTE
8
Axial/ Short Axis Cine SSFP Images

• Axial 6 mm, skip 2 mm, FOV 36 cm, same slice
  locations as the black blood images for axials.
  8-10 images from the diaphragm to the aortic
  root.
• Obtain a 10-12 short axis cines to quantitate LV
  and RV function (short axis not shown).

37 of normal volunteers have a normal anterior
bulge. The remainder have a round shaped RV.
17 of normal volunteers, triangular shape RV
9
Last Step IR prepped delayed Gad

• Same pulse sequence as for infarct (viability)
  imaging
• 8-10 axial images, 5 short axis images (same
  locations as black blood images)
• We perform short axis first then reduce the TI
  (inversion time) by 25 msec for axial images.

30-80 of (advanced) cases have LV, as well as RV
enhancement
10
ARVD/C MRI Reports

• MRI criteria a) enlargement of the RV, b)
  regional RV wall motion abnormalities or
  aneurysms. Double reading of all cases is
  recommended.
• Presence of fat and fibrosis (delayed gad) can
  help, but are not official diagnostic criteria.
• Major criterion Severe abnormalities can be
  seen by the first year resident.
• Minor criterion Mild-moderate abnormalities
  you are not sure, probably present and you want
  to document these.
• MRI Impression, choose one of the following
• 1. Normal MRI
• 2. Nonspecific findings (minor criterion)
• 3. MRI consistent with ARVD/C (major criterion)
• 2nd Opinions can be obtained at www.ARVD.com