David A. Bluemke, M.D., Ph.D.

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David A. Bluemke, M.D., Ph.D.
How I do CMR in 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 July 2006.
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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

Disclaimer
This presentation is posted for members of scmr
as an educational guide it represents the views
and practices of the author, and not necessarily
those of SCMR.
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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.
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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

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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.
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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

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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

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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
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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.

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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