The Cleveland Clinic Director of Cardiac MRI, Dr. Deborah Kwon, discusses the principles and clinical applications of cardiac MRI, taking us from the protons to the bedside with a series of illustrative cases. CardioNerds hosts Amit Goyal, Daniel Ambinder, and Carine Hamo are joined by Dr. Nicole Pristera (Cleveland Clinic cardiology fellow). Flutter moment by student doctor Arooma Shahid.
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Dr. Debbie Kwon attended medical school at the University of Michigan and internal medicine residency at the University of Pennsylvania. She completed her general cardiology and cardiovascular imaging fellowships at the Cleveland Clinic. She is the Director of Cardiac MRI At the Cleveland Clinic and serves as the Core Lab MRI director for the Pulmonary Vascular Disease Phenomics (PVDOMICS) multicenter National institution of Health (NIH) Study.
Dr. Nicole Pristera is a cardiology fellow at the Cleveland Clinic. She earned her medical degree at Case Western Reserve University and completed her internal medicine residency training at Duke University. Her clinical interests include interventional cardiology and cardiac critical care. Outside of the hospital, she enjoys traveling, hiking, and learning foreign languages.
Dr. Arooma Tahir completed her medical degree from Lahore Medical and Dental college in Lahore Pakistan. She went to medical school to pursue her passion and currently she is studying for USMLEs in Fresno, CA. She enjoys hiking, trying out different cuisines, and podcast by cardionerds.
- What should we know about the common sequences for cardiac MRI?
- We all learn about the risks of NSF. How much of these risks are a reality and when should we truly avoid gadolinium exposure?
- What are some challenges to MRI:
- Time of scanning
- Patient tolerability: breath holding, claustrophobia, lying flat
- No patient monitor
- Ferromagnetic devices (especially CIEDs)
- Artifacts (lead)
- What types of information about the heart can we obtain with a CMR?
- Anatomic: 0.5 x 0.5 x 0.5mm spatial resolution
- Chamber dimensions, volumes, mass, anomalies (LV aneurysm, hypertrophy)
- Aortic Dissection
- Cardiac Tumors and Thrombi
- Congenital defects
- Cine images: EF, systolic wall thickening, wall motion
- Myocardial tagging → strain (infarct/scar)
- Measurement of blood flow velocity across the cardiac valves and the great vessels: regurg, stenosis, shunts, angio
- Tissue characterization: gadolinium enhancement
- Perfusion (stress, rest)
- Scar (LGE)
- Anatomic: 0.5 x 0.5 x 0.5mm spatial resolution
The role for Cardiac MRI in particular cases discussed with Dr. Kwon
- CAD: A 45 year old G1P1 woman with prior preeclampsia and anterior STEMI s/p LAD PCI 3 years ago is being seen for chest pain. TTE shows LVEF 45% with mid-apical anterior hypokinesis and apical aneurysm. How does CMR help delineate ischemic heart disease (perfusion, viability, chambers)
- Pericarditis: her stress MRI shows an anteroapical perfusion defect and apical aneurysm with mural thrombus, with corresponding LGE. On further review, her chest pain is sharp, pleuritic, and worsens with recumbency. EKG on follow-up shows diffuse ST elevations and PR depressions except for in aVR which shows ST depression and PR elevation. ESR and CRP are moderately elevated.
- ARVC: A 35 year old female athlete who is admitted after VF arrest that occurred during a tennis match. Thankfully she received immediate bystander CPR with early defibrillation and prompt ROSC. She has had prior syncope during training and an uncle died suddenly at age 40. Resting EKG shows an incomplete right bundle, right precordial TWIs, and epsilon waves in V1-V3. On tele she’s had multiple runs of NSVT of LBBB morphology. Echocardiogram shows RV dilation. A heart failure consult is considering EMBx but requests a CMR beforehand.
- Role in select other cardiomyopathies: HCM, Amyloid, hemochromatosis etc (if time)
- Valvular Heart Disease: A 28 year old man with no PMH who presents with progressive dyspnea during his routine morning runs. On exam he has a early diastolic decrescendo murmur best heard at end expiration while leaning forward. While concentrating on the murmur you notice a subtle rhythmic head bobbing. TTE shows eccentric AI and a dilated LV, but further characterization is limited. (CMR shows bicuspid aortic valve, TAA, LV dilation)
- Cardiac mass: a 55 year old woman with subacute fevers, chills, and night sweats now presents with acute ischemic left leg pain. Auscultation reveals a mid-diastolic plop. TTE is limited by poor sonographic windows, but there is a nondescript echodensity in the LA. What is the role of CMR in cardiac masses?
- Myocarditis: Chas Miller is our patient from episodes 31 & 32 who had presented with cardiogenic shock and heart block found to have fulminant myocarditis. Now unfortunately he was too sick to undergo a cardiac mri, but how would it have helped?