Does heart rate influence CMR image quality of the coronary vessel wall?

  • E. E. van der Wall
  • E. J. S. Kröner
  • H. M. Siebelink
  • A. J. Scholte
  • M. J. Schalij
Open Access
Editorial Comment


Black Blood Double Inversion Recovery Fast Heart Rate Pulse Wave Velocity Measurement Coronary Wall 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Cardiovascular magnetic resonance (CMR) has made tremendous advances over the past years, providing accurate evaluation of left ventricular mass, volumes and function [1, 2, 3, 4]. CMR has shown unique abilities in characterizing myocardial tissue composition. In particular, high-resolution contrast-enhanced CMR has been used to visualize myocardial fibrosis with a high accuracy [5, 6, 7]. For instance, in patients with acute myocardial infarction, the injured myocardium shows increased CMR contrast compared to normal myocardium when imaged by delayed gadolinium enhancement. The transmural extent of delayed gadolinium enhancement predicts functional outcome after interventional procedures performed in patients with acute myocardial infarction and chronic ischemic heart disease [8, 9, 10]. Not only in the setting of an acute myocardial infarction, but also in patients with various manifestations of cardiomyopathy, evidence of delayed gadolinium enhancement may have important clinical and prognostic implications [11, 12, 13]. CMR has become the first choice imaging modality in complex congenital heart disease and imaging great vessels [14, 15, 16, 17, 18]. Magnetic resonance angiography (MRA) has been introduced as a method that can provide visualization of all three major coronary arteries, coronary bypasses and the aorta within a single three-dimensional acquisition [19, 20, 21, 22]. In particular, CMR has proven to be of indispensable value in identifying aortic stiffness in Marfan patients using pulse wave velocity measurements [23, 24].

A rather new aspect of CMR is coronary vessel wall imaging. In a study by Macedo et al. [25], 88 arterial segments in 38 asymptomatic participants of the Multi-Ethnic Study of Atherosclerosis (MESA) study were evaluated using black blood CMR. CMR-assessed coronary wall thickness was compared with computed tomography calcium score, carotid intima-media thickness, and risk factors for coronary artery disease. Coronary artery wall CMR detected increased coronary wall thickness in asymptomatic individuals with subclinical markers of atherosclerotic disease and in individuals with zero calcium score. Gerretsen et al. [26] showed that both in patients with angiographically proven coronary artery disease and age-matched asymptomatic subjects, coronary vessel wall thickening was detectable with CMR coronary vessel wall imaging. Maximum and mean wall thicknesses were significantly higher in the patient population. The vast majority of asymptomatic subjects had either positive remodeling without luminal narrowing, or non-significant stenoses. Kelle et al. [27] demonstrated coronary artery vessel wall enhancement using 3.0 Tesla CMR imaging after a single, low-dose gadolinium contrast injection in patients with coronary artery disease, but not in healthy subjects. In the majority of the evaluated coronary segments in the patient group, late contrast enhancement of the coronary vessel wall was already detectable 30–45 min after administration of the contrast agent. Recently, Scott et al. [28] showed that high-resolution thee-dimensional spiral imaging with beat-to-beat respiratory-motion-correction allowed coronary vessel wall assessment over multiple thin contiguous slices in a clinically feasible duration. Excellent reproducibility of the technique potentially enables studies of disease progression or regression.

In the current issue of the International Journal of Cardiovascular Imaging, Lin et al. [29] interestingly hypothesized that black blood steady-state free precession (SSFP) would provide coronary wall images comparable to images from turbo spin-echo imaging (TSE) and would better perform than TSE under conditions of increased heart rates. The aim of the study was to prospectively evaluate a two-dimensional double inversion recovery (DIR) prepared SSFP CMR imaging sequence for black blood coronary wall imaging and to estimate its value in the detection of coronary artery disease. The authors investigated 30 healthy volunteers (19 men, 11 women, from 26 to 83 years old) using a 1.5 Tesla CMR scanner. Cross-sectional black-blood images of the proximal portions of coronary arteries were acquired with a two-dimensional, double inversion recovery prepared TSE sequence and a two-dimensional double inversion recovery SSFP sequence on the same planes. Image quality, vessel wall area and thickness, signal-to-noise ratio of the wall and contrast-to-noise ratio (wall to lumen) were compared between SSFP and TSE with SPSS software. For SSFP and TSE no differences in image quality were observed. SSFP had a higher signal-to-noise ratio and wall to lumen contrast-to-noise. Good agreements between measured wall area and thickness were found. For 10 individuals with heart rates over 80 beats per minute, the image quality of SSFP was significantly better than TSE. With its higher performance under fast heart rate conditions, SSFP allows higher thresholds for heart rate and extends therefore the clinical applicability of coronary wall MR imaging to more patient populations.

The study suffers from several limitations (also recognized by the authors). First, the thickness of the coronary wall may have been overestimated due to the limited spatial resolution of coronary wall MR imaging. In this respect, a gold standard such as IVUS should have used to verify the true thickness of the wall. Second, there were only 10 (33%) individuals with a heart rate over 80 beats per minute. Therefore, image quality rather than accuracy could be established. Third it should be realized that many physical and physiological parameters could have affected image quality in coronary wall CMR imaging. These parameters should be taken into account for upcoming studies. Fourth, only healthy volunteers were studied, precluding a valid extrapolation of the findings to patients with atherosclerotic vessel walls.

In summary, Lin et al. [29] successfully evaluated two coronary MR techniques (SSFP vs. TSE) in an asymptomatic healthy population with increased heart rates. It turned out that SSFP performed better than TSE under conditions of fast heart rate, opening avenues for studying more and different patient populations. In the near future, these important findings have to be confirmed in patients with coronary artery disease.


Conflict of interest


Open Access

This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.


  1. 1.
    Olimulder MA, van Es J, Galjee MA (2009) The importance of cardiac MRI as a diagnostic tool in viral myocarditis-induced cardiomyopathy. Neth Heart J 17:481–486PubMedCrossRefGoogle Scholar
  2. 2.
    Matheijssen NA, Louwerenburg HW, van Rugge FP et al (1996) Comparison of ultrafast dipyridamole magnetic resonance imaging with dipyridamole SestaMIBI SPECT for detection of perfusion abnormalities in patients with one-vessel coronary artery disease: assessment by quantitative model fitting. Magn Reson Med 35:221–228PubMedCrossRefGoogle Scholar
  3. 3.
    van der Wall EE, Heidendal GA, den Hollander W, Westera G, Roos JP (1981) Metabolic myocardial imaging with 123I-labeled heptadecanoic acid in patients with angina pectoris. Eur J Nucl Med 6:391–396PubMedGoogle Scholar
  4. 4.
    Matheijssen NA, Baur LH, Reiber JH et al (1996) Assessment of left ventricular volume and mass by cine magnetic resonance imaging in patients with anterior myocardial infarction intra-observer and inter-observer variability on contour detection. Int J Card Imaging 12:11–19PubMedCrossRefGoogle Scholar
  5. 5.
    Nemes A, Geleijnse ML, van Geuns RJ et al (2008) Dobutamine stress MRI versus threedimensional contrast echocardiography: it’s all black and white. Neth Heart J 16:217–218PubMedCrossRefGoogle Scholar
  6. 6.
    van der Wall EE, van Dijkman PR, de Roos A et al (1990) Diagnostic significance of gadolinium-DTPA (diethylenetriamine penta-acetic acid) enhanced magnetic resonance imaging in thrombolytic treatment for acute myocardial infarction: its potential in assessing reperfusion. Br Heart J 63:12–17PubMedCrossRefGoogle Scholar
  7. 7.
    Nijveldt R, Beek AM, Hirsch A et al (2008) ‘No-reflow’ after acute myocardial infarction: direct visualisation of microvascular obstruction by gadolinium enhanced CMR. Neth Heart J 16:179–181PubMedCrossRefGoogle Scholar
  8. 8.
    Oemrawsingh PV, Mintz GS, Schalij MJ, Zwinderman AH, Jukema JW, van der Wall EE (2003) Intravascular ultrasound guidance improves angiographic and clinical outcome of stent implantation for long coronary artery stenoses: final results of a randomized comparison with angiographic guidance (TULIP study). Circulation 107:62–67PubMedCrossRefGoogle Scholar
  9. 9.
    van der Wall EE, den Hollander W, Heidendal GA, Westera G, Majid PA, Roos JP (1981) Dynamic myocardial scintigraphy with 123I-labeled free fatty acids in patients with myocardial infarction. Eur J Nucl Med 6:383–389PubMedGoogle Scholar
  10. 10.
    van der Laarse A, Kerkhof PL, Vermeer F et al (1988) Relation between infarct size and left ventricular performance assessed in patients with first acute myocardial infarction randomized to intracoronary thrombolytic therapy or to conventional treatment. Am J Cardiol 61:1–7PubMedCrossRefGoogle Scholar
  11. 11.
    Torn M, Bollen WL, van der Meer FJ, van der Wall EE, Rosendaal FR (2005) Risks of oral anticoagulant therapy with increasing age. Arch Intern Med 165:1527–1532PubMedCrossRefGoogle Scholar
  12. 12.
    Roeters van Lennep JE, Westerveld HT, Erkelens DW, van der Wall EE (2002) Risk factors for coronary heart disease: implications of gender. Cardiovasc Res 53:538–549PubMedCrossRefGoogle Scholar
  13. 13.
    van der Wall EE, Heidendal GA, den Hollander W, Westera G, Roos JP (1980) I-123 labeled hexadecenoic acid in comparison with thallium-201 for myocardial imaging in coronary heart disease. A preliminary study. Eur J Nucl Med 5:401–405PubMedCrossRefGoogle Scholar
  14. 14.
    Groothuis JG, Beek AM, Meijerink MR, Brinckman SL, Hofman MB, van Rossum AC (2010) Towards a noninvasive anatomical and functional diagnostic work-up of patients with suspected coronary artery disease. Neth Heart J 18:270–273PubMedCrossRefGoogle Scholar
  15. 15.
    Germans T, Nijveldt R, Brouwer WP et al (2010) The role of cardiac magnetic resonance imaging in differentiating the underlying causes of left ventricular hypertrophy. Neth Heart J 18:135–143PubMedCrossRefGoogle Scholar
  16. 16.
    Lexis CP, Rahel BM, van Langen H et al (2010) Cardiac magnetic resonance imaging in daily practice in a peripheral medical centre: description of the first 383 patients. Neth Heart J 18:524–530PubMedCrossRefGoogle Scholar
  17. 17.
    Bakx AL, van der Wall EE, Braun S, Emanuelsson H, Bruschke AV, Kobrin I (1995) Effects of the new calcium antagonist mibefradil (Ro 40–5967) on exercise duration in patients with chronic stable angina pectoris: a multicenter, placebo-controlled study. Ro 40–5967 International Study Group. Am Heart J 130:748–757PubMedCrossRefGoogle Scholar
  18. 18.
    Schuijf JD, Bax JJ, van der Wall EE (2007) Anatomical and functional imaging techniques: basically similar or fundamentally different? Neth Heart J 15:43–44PubMedCrossRefGoogle Scholar
  19. 19.
    Ten Cate FJ (2009) Cardiomyopathies: a revolution in molecular medicine and cardiac imaging. Neth Heart J 17:456–457PubMedCrossRefGoogle Scholar
  20. 20.
    Schuijf JD, Bax JJ, van der Wall EE (2007) Anatomical and functional imaging techniques: basically similar or fundamentally different? Neth Heart J 15:43–44PubMedCrossRefGoogle Scholar
  21. 21.
    Götte MJ, Rüssel IK, de Roest GJ et al (2010) Magnetic resonance imaging, pacemakers and implantable cardioverter-defibrillators: current situation and clinical perspective. Neth Heart J 18:31–37PubMedGoogle Scholar
  22. 22.
    Germans T, Nijveldt R, Brouwer WP et al (2010) The role of cardiac magnetic resonance imaging in differentiating the underlying causes of left ventricular hypertrophy. Neth Heart J 18:135–143PubMedCrossRefGoogle Scholar
  23. 23.
    Groenink M, Lohuis TA, Tijssen JG et al (1999) Survival and complication free survival in Marfan’s syndrome: implications of current guidelines. Heart 82:499–504PubMedGoogle Scholar
  24. 24.
    Nollen GJ, Groenink M, Tijssen JG, van der Wall EE, Mulder BJ (2004) Aortic stiffness and diameter predict progressive aortic dilatation in patients with Marfan syndrome. Eur Heart J 25:1146–1152PubMedCrossRefGoogle Scholar
  25. 25.
    Macedo R, Chen S, Lai S et al (2008) MRI detects increased coronary wall thickness in asymptomatic individuals: the multi-ethnic study of atherosclerosis (MESA). J Magn Reson Imaging 28:1108–1115PubMedCrossRefGoogle Scholar
  26. 26.
    Gerretsen SC, Kooi ME, Kessels AG et al (2010) Visualization of coronary wall atherosclerosis in asymptomatic subjects and patients with coronary artery disease using magnetic resonance imaging. PLoS One 5(9)Google Scholar
  27. 27.
    Kelle S, Schlendorf K, Hirsch GA et al (2010) Gadolinium enhanced MR coronary vessel wall imaging at 3.0 tesla. Cardiol Res Pract 856418Google Scholar
  28. 28.
    Scott AD, Keegan J, Firmin DN (2011) High-resolution 3D coronary vessel wall imaging with near 100% respiratory efficiency using epicardial fat tracking: reproducibility and comparison with standard methods. J Magn Reson Imaging 33:77–86PubMedCrossRefGoogle Scholar
  29. 29.
    Lin K, Bi X, Taimen K, Zuehlsdorff S, Lu B, Carr J, Li D (2011 Apr 2) Coronary wall MR Imaging in patients with rapid heart rates: a feasibility study of black-blood steady-state free precession (SSFP). Int J Cardiovasc Imaging (Epub ahead of print)Google Scholar

Copyright information

© The Author(s) 2011

Authors and Affiliations

  • E. E. van der Wall
    • 1
  • E. J. S. Kröner
    • 1
  • H. M. Siebelink
    • 1
  • A. J. Scholte
    • 1
  • M. J. Schalij
    • 1
  1. 1.Department of CardiologyLeiden University Medical CentreLeidenThe Netherlands

Personalised recommendations