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Chronic Heart Failure: Global Left Ventricular Perfusion and Coronary Flow Reserve with Velocity-encoded Cine MR Imaging: Initial Results¹

¹ From the Department of Radiology, University of California, San Francisco, 505 Parnassus Ave, Rm L-308, San Francisco, CA 94143-0628 (G.K.L., N.W., M.S., G.P.R., M.Y., P.A.A., C.B.H.); Altos Cardiovascular, Los Altos, Calif (D.C.); and Novartis Pharmaceuticals, East Hanover, NJ (M.B.). Received January 14, 2002; revision requested March 5; final revision received August 13; accepted August 26. Supported in part by Novartis Pharmaceuticals, East Hanover, NJ. G.K.L. supported in part by a scholarship from the University Hospital Eppendorf, Hamburg, Germany. N.W. supported by a scholarship from the Max-Kade Foundation, New York, NY. Address correspondence to C.B.H. (e-mail: charles.higgins@radiology.ucsf.edu).

View larger version (88K): [in a new window]   Figure 1. Top row: Long-axis MR images of the heart obtained in a volunteer. Bottom row: Long-axis MR images of the heart obtained in a patient with chronic heart failure. Images were obtained with a non-breath-hold VEC MR sequence. A, Heart is depicted at midsystole with closed mitral valve and open aortic valve. B, Heart is depicted at middiastole with open mitral valve and closed aortic valve. C, Heart is depicted at end diastole with the aortic (black arrow) and mitral (open arrow) valves closed. In all images, the coronary sinus (white arrows) is situated in the atrioventricular grove dorsal to the left atrium. Images were obtained with identical field of view and magnification. Note the marked dilatation of the heart and the coronary sinus in the patient.

View larger version (123K): [in a new window]   Figure 2a. Top row: Magnified coronary sinus (arrows) on magnitude MR images. Bottom row: Magnified coronary sinus (arrows) on corresponding phase MR images. Images were obtained in (a) a volunteer and (b) a patient with chronic heart failure. Positive flow velocities are observed during midsystole and middiastole and are represented by hyperintense pixels on phase images.

View larger version (122K): [in a new window]   Figure 2b. Top row: Magnified coronary sinus (arrows) on magnitude MR images. Bottom row: Magnified coronary sinus (arrows) on corresponding phase MR images. Images were obtained in (a) a volunteer and (b) a patient with chronic heart failure. Positive flow velocities are observed during midsystole and middiastole and are represented by hyperintense pixels on phase images.

View larger version (18K): [in a new window]   Figure 3a. Graphs depict representative phasic data obtained throughout the cardiac cycle for (a) area of coronary sinus, expressed as the number of pixels measured on magnitude images; (b) velocity of coronary sinus blood flow obtained from phase images; and (c) volume flow calculated as the product of area and velocity. Left graphs represent data from a volunteer, and right graphs depict data from a patient with chronic heart failure. All data are shown at rest () and after infusion of dipyridamole (). Coronary sinus is depicted with a large number of pixels, which enables close tracing of the vessel throughout the cardiac cycle. Note dilatation of the coronary sinus in the patient. At rest, blood flow velocities show a biphasic pattern, with a first peak during midsystole and a second peak during early diastole. Negative velocities occur at end diastole because of backward flow into the coronary sinus as a result of right atrial contraction. After administration of dipyridamole, the increase in flow velocity is more pronounced in the volunteer, with peak flow velocities at end systole and early diastole. In c, mean coronary sinus flow is represented by the area under the volume flow curve. Note that coronary sinus flow at rest is lower in the volunteer (126 mL/min) than in the patient (173 mL/min), which is related to the smaller LV mass in the volunteer. Normalized LV perfusion per myocardial mass is identical in the volunteer and the patient. After administration of dipyridamole, mean coronary sinus flow increases to 528 mL/min in the volunteer and 545 mL/min in the patient, which represents CFRs of 4.2 and 3.2, respectively.

View larger version (17K): [in a new window]   Figure 3b. Graphs depict representative phasic data obtained throughout the cardiac cycle for (a) area of coronary sinus, expressed as the number of pixels measured on magnitude images; (b) velocity of coronary sinus blood flow obtained from phase images; and (c) volume flow calculated as the product of area and velocity. Left graphs represent data from a volunteer, and right graphs depict data from a patient with chronic heart failure. All data are shown at rest () and after infusion of dipyridamole (). Coronary sinus is depicted with a large number of pixels, which enables close tracing of the vessel throughout the cardiac cycle. Note dilatation of the coronary sinus in the patient. At rest, blood flow velocities show a biphasic pattern, with a first peak during midsystole and a second peak during early diastole. Negative velocities occur at end diastole because of backward flow into the coronary sinus as a result of right atrial contraction. After administration of dipyridamole, the increase in flow velocity is more pronounced in the volunteer, with peak flow velocities at end systole and early diastole. In c, mean coronary sinus flow is represented by the area under the volume flow curve. Note that coronary sinus flow at rest is lower in the volunteer (126 mL/min) than in the patient (173 mL/min), which is related to the smaller LV mass in the volunteer. Normalized LV perfusion per myocardial mass is identical in the volunteer and the patient. After administration of dipyridamole, mean coronary sinus flow increases to 528 mL/min in the volunteer and 545 mL/min in the patient, which represents CFRs of 4.2 and 3.2, respectively.

View larger version (22K): [in a new window]   Figure 3c. Graphs depict representative phasic data obtained throughout the cardiac cycle for (a) area of coronary sinus, expressed as the number of pixels measured on magnitude images; (b) velocity of coronary sinus blood flow obtained from phase images; and (c) volume flow calculated as the product of area and velocity. Left graphs represent data from a volunteer, and right graphs depict data from a patient with chronic heart failure. All data are shown at rest () and after infusion of dipyridamole (). Coronary sinus is depicted with a large number of pixels, which enables close tracing of the vessel throughout the cardiac cycle. Note dilatation of the coronary sinus in the patient. At rest, blood flow velocities show a biphasic pattern, with a first peak during midsystole and a second peak during early diastole. Negative velocities occur at end diastole because of backward flow into the coronary sinus as a result of right atrial contraction. After administration of dipyridamole, the increase in flow velocity is more pronounced in the volunteer, with peak flow velocities at end systole and early diastole. In c, mean coronary sinus flow is represented by the area under the volume flow curve. Note that coronary sinus flow at rest is lower in the volunteer (126 mL/min) than in the patient (173 mL/min), which is related to the smaller LV mass in the volunteer. Normalized LV perfusion per myocardial mass is identical in the volunteer and the patient. After administration of dipyridamole, mean coronary sinus flow increases to 528 mL/min in the volunteer and 545 mL/min in the patient, which represents CFRs of 4.2 and 3.2, respectively.

View larger version (21K): [in a new window]   Figure 4. Bar graph depicts LV perfusion per gram of myocardial mass in volunteers and patients with chronic heart failure. At rest (white bars), no differences in LV perfusion were observed between the two groups. After infusion of dipyridamole (black bars), perfusion increased in both groups (P = .01 [*] vs values at rest). However, the increment in LV perfusion was smaller in patients than that in volunteers (P = .03).

View larger version (21K): [in a new window]   Figure 5. Bar graph depicts CFR in volunteers and in patients with chronic heart failure. Mean CFR was severely reduced in patients compared with that in volunteers (P = .01).

View larger version (27K): [in a new window]   Figure 6. Graph depicts results of regression analysis, which revealed a significant linear relationship between CFR and ejection fraction (Y = 0.84 + 0.05X, r = 0.54, P = .02, standard error of the estimate = 1.34) with data from volunteers () and patients with chronic heart failure (). Note that three of the 10 patients had an ejection fraction greater than 40% at cine MR imaging despite an inclusion criterion of reduced ejection fraction of less than 40%, which was based on echocardiographic measurements at the time of enrollment.