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Combined Assessment of Myocardial Perfusion and Late Gadolinium Enhancement in Patients After Percutaneous Coronary Intervention or Bypass Grafts

A Multicenter Study of an Integrated Cardiovascular Magnetic Resonance Protocol

Peter Bernhardt, MD^_*,,_*, Jochen Spiess, MD^_*, Benny Levenson, MD, Günter Pilz, MD, Berthold Höfling, MD, Vinzenz Hombach, MD^_*, Oliver Strohm, MD

^_* Department of Internal Medicine II, Cardiovascular MRI Unit, University of Ulm, Ulm, Germany
CMR-Center at the Hospital Agatharied, Academic Teaching Hospital of the University of Munich, Hausham, Germany
Cardiac Praxis, Catheterization Laboratory at the St.-Gertrauden-Hospital, Berlin, Germany
Stephenson Cardiovascular MR Centre, University of Calgary, Calgary, Canada

^_* Reprint requests and correspondence: Dr. Peter Bernhardt, Department of Internal Medicine II, University of Ulm, 89077 Ulm, Germany (Email: peter.bernhardt{at}uniklinik-ulm.de).

Objectives: We sought to assess the accuracy of an integrated cardiac magnetic resonance (CMR) protocol for the diagnosis of relevant coronary artery or bypass graft stenosis in patients with suspected coronary artery disease (CAD) or with previously performed percutaneous coronary intervention (PCI) or coronary bypass graft surgery (CABG).

Background: CMR is suitable for diagnosing inducible myocardial ischemia in patients with suspected CAD and has been proven to be a helpful diagnostic tool for decision of further treatment. However, little is known about its diagnostic accuracy in patients with known CAD who previously were treated by PCI or CABG.

Methods: A total of 477 patients with suspected CAD, 236 with previous PCI, and 110 after CABG referred for coronary X-ray angiography (CXA) underwent an integrated CMR examination before CXA. Myocardial ischemia was assessed using first-pass perfusion after vasodilator stress with adenosine (140 µg/kg/min for 3 min) using gadolinium-based contrast agents (0.1 mmol/kg). Late gadolinium enhancement (LGE) was assessed 10 min after a second contrast bolus.

Results: CXA demonstrated a relevant coronary vessel stenosis (70% luminal reduction) in 313 (38%) patients using quantitative coronary analysis. The combination of CMR perfusion and LGE assessment for detecting a relevant coronary stenosis in patients with suspected CAD yielded sensitivity and specificity of 0.94 and 0.87, in PCI patients 0.91 and 0.90, and in CABG patients 0.79 and 0.77, respectively.

Conclusions: A combined CMR protocol for the assessment of myocardial perfusion and LGE is feasible for the detection of relevant coronary vessel stenosis even in patients who previously were treated by PCI or CAG in a routine clinical setting. However, diagnostic accuracy is reduced in patients with CABG. This could be due to different flow and perfusion kinetic. Further studies are needed to optimize the clinical protocols especially in post-surgical patients.

Key Words: adenosine stress • cardiac magnetic resonance • perfusion • CABG • PCI

Abbreviations and Acronyms   CABG = coronary artery bypass graft   CAD = coronary artery disease   CMR = cardiac magnetic resonance   CXA = coronary X-ray angiography   LGE = late gadolinium enhancement   PCI = percutaneous coronary artery intervention