Magnetic resonance imaging evaluation of myocardial perfusion

Noninvasive qualitative/quantitative assessment of myocardial perfusion is considered to be fundamental in the management of known and suspected coronary artery disease patients, as shown by the widespread utilization of thallium-201- and technetium-99m-labeled agents in myocardial single-photon emission computed tomography (SPECT) scintigraphy for diagnostic as well as prognostic purposes. Recently, the availability of subsecond ultrafast magnetic resonance imaging (MRI) sequences (FLASH, TurboFLASH, EPI) has provided new avenues for assessing myocardial perfusion by MRI in conjunction with contrast-agent bolus administration (contrast-enhanced first-pass MRI). MRI contrast agents can be classified into relaxation agents (T1 "positive") and susceptibility agents (T2 star [T2*] "negative"). All the commercially available MRI contrast agents used in clinical practice are relaxation agents employing the T1 shortening effect of metal ions like gadolinium (paramagnetism), thus producing a tissue signal-intensity increase on T1-weighted images (positive enhancement). On the other hand, T2* agents induce mainly susceptibility effects, i.e., rapid dephasing of spins with resultant signal loss on T2*-sensitive sequences (negative enhancement). Unfortunately, both relaxation and susceptibility agents are, by definition, "extracellular" contrast media, as they rapidly diffuse into the interstitial space, thus hampering the simple application of indicator-dilution kinetics for myocardial perfusion assessment. Blood pool agents are therefore needed to obtain predictable relations between the concentration of contrast medium in the myocardium and the change in signal intensity. In addition, newer MRI techniques for tissue perfusion quantitation have been recently reported, based on blood-sensitive sequences, thus without intravenous contrast administration.