Skip Navigation

European Journal of Echocardiography 2005 6(5):317-326; doi:10.1016/j.euje.2004.12.008
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Paetsch, I.
Right arrow Articles by Nagel, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Paetsch, I.
Right arrow Articles by Nagel, E.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Copyright © 2005, The European Society of Cardiology

Current clinical applications of stress wall motion analysis with cardiac magnetic resonance imaging

Ingo Paetscha,*, Cosima Jahnkea, Eckart Fleck and Eike Nagel

Department of Cardiology, German Heart Institute Berlin, Augustenburger Platz 1, 13353 Berlin, Germany

Received 16 August 2004; received in revised form 30 November 2004; accepted after revision 7 December 2004.

paetsch{at}dhzb.de

* Corresponding author. Tel.: +49 30 4593 2457; fax: +49 30 4593 2458.


   Abstract
Top
 Abstract
Introduction
 General pathophysiological...
 Safety of DSMR
 Outlook
 Conclusions
 Notes
 References
 
Over the last years the indications for cardiac magnetic resonance (CMR) imaging have rapidly broadened, in particular those dealing with the non-invasive detection of myocardial ischemia. This review describes the imaging technique, methodology and safety aspects of stress cine magnetic resonance imaging and summarizes the current knowledge with regard to its applicability in clinical routine.

Keywords: Magnetic resonance imaging; Pharmacological stress; Dobutamine stress magnetic resonance; Myocardial ischemia; Myocardial viability


   Introduction
Top
 Abstract
 Introduction
General pathophysiological...
 Safety of DSMR
 Outlook
 Conclusions
 Notes
 References
 
In recent years cardiac magnetic resonance (CMR) imaging has been increasingly used not only to detect the presence of coronary artery disease but also to assess its functional consequences to the myocardium. Several approaches have been applied to detect coronary artery disease with CMR including direct visualization of coronary arteries1 (magnetic resonance coronary angiography), the characterization of myocardial tissue2 (delayed enhancement) or the visualization of the effects of induced ischemia3,4 (wall motion analysis or perfusion measurements). The latter is particularly valuable in clinical decision making since the detection of epicardial coronary luminal narrowing alone does not necessarily predict its haemodynamic consequences to the underlying myocardium.

With the development of rapid gradient systems and the routine application of 1.5T CMR scanner systems, it became possible to perform cine imaging of the heart at rest and under stress conditions. Together with parallel imaging techniques and a two lead ECG triggering (so called Vector-ECG) reliably working even in the presence of strong magnetic fields, it is now possible to acquire cine images of the heart with a consistently high temporal and spatial resolution up to heart rates of 190–200 beats per minute. In addition, the sequence type (steady-state free precession, SSFP) used for visualization of cardiac wall motion provides an excellent endocardial border definition due to the inherently high blood-myocardium contrast5 without the need for application of contrast agents.

More recently, research efforts have been focused on the definition of the clinical role of magnetic resonance pharmacological stress for the detection of inducible wall motion abnormalities,6,7 preferably using dobutamine infusion (dobutamine stress magnetic resonance, DSMR). High-dose DSMR proved to be highly accurate for the detection of inducible wall motion abnormalities3,8,9 and its usefulness for determination of patient prognosis has been shown.10 Over and above this, DSMR at low-dose dobutamine levels was found to be highly predictive of functional improvement of resting wall motion abnormalities after coronary revascularization procedures (detection of viable myocardium).11

This review describes the imaging technique, methodology and safety aspects of stress cine magnetic resonance imaging and summarizes the current knowledge with regard to its applicability in clinical routine.


   General pathophysiological considerations
Top
 Abstract
 Introduction
 General pathophysiological...
Safety of DSMR
 Outlook
 Conclusions
 Notes
 References
 
Conceptually, stress wall motion analysis relies on the "ischemic cascade" with perfusion disturbances preceding wall motion abnormalities and electrocardiographic changes, finally followed by anginal symptoms. Several reports and invasive studies revealed the importance of assessing the haemodynamic significance of epicardial coronary artery stenoses rather than determining its angiographic luminal appearance (percent diameter or area reduction) in order to accurately detect flow-limiting stenoses.12–14

Resting blood flow does not decrease until more than 90% of the arterial lumen is obstructed and the physiologic relevance of high grade lesions correlates well with the angiographic assessment. However, for moderately severe stenoses (50–75% luminal diameter reduction) a wide range of variability between physiologic and angiographic assessments of stenosis severity has been described.15 Interestingly, a good agreement was reported between the invasively determined fractional flow reserve as a physiologic measure of stenosis severity and the results of non-invasive stress tests (exercise testing, thallium scan and dobutamine stress echocardiography).13 For intermediate stenoses, the comparison of a pharmacological stress test with coronary angiography as the standard of reference may end up controversial. This is especially true in the presence of other confounding conditions that are known to affect the functional capacity of the microvasculature (e.g. diabetes mellitus, hypertrophy, hyperlipoproteinaemia). Since with dobutamine stress the effect on myocardial function is tested, an ischemic myocardial response may be observed in the presence of an angiographically less severe epicardial luminal narrowing (Fig. 1). In addition, the morphology of a coronary lesion (excentricity), its location (bifurcational stenoses) or the serial arrangement of stenotic lesions are determinants of coronary arterial blood supply.12,14


Figure 1
View larger version (113K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 DSMR cine images (short axis and 2-chamber view) of a patient with suspected CAD complaining about atypical chest pain. Normal regional wall motion at rest and under increasing dobutamine levels. However, at maximum stress, an inducible wall motion abnormality was detected in the inferior and inferolateral segment (white arrows). X-ray coronary angiography. Single vessel disease of the LCX with excentric luminal narrowing in its distal portion (black arrows). Note the large posterolateral branch responsible for the blood supply to the inferolateral myocardium. Repeat DSMR two weeks after percutaneous revascularization of the LCX was normal (images not shown).

 
In most centers, measurements of fractional flow reserve are not routinely performed and the decision whether or not to proceed with revascularization procedures mainly relies on the morphological assessment of coronary stenoses. Due to the lack of an unequivocal reference standard, the diagnostic performance of DSMR with regard to epicardial coronary stenosis detection (>50% luminal diameter reduction) as reported in previous studies might rather be considered the capability of the test to act as a "gatekeeper" for further invasive testing and therapy rather than its capability to detect ischemia.

Stress agents
Dobutamine or adenosine?
Physical exercise represents the most physiologic stress method provoking a concomitant increase in systolic blood pressure and heart rate and, thus, a sufficiently high "heart rate pressure product". In the last decade, pharmacological stress has been extensively evaluated as an alternative stress method and is particularly advised to those patients, who are not able to perform adequately either due to limited exercise capability or a disabling disease. Since space is limited within the MR scanner bore and patient movement impairs image quality, pharmacological stress is preferred for MR imaging.

For induction of ischemic wall motion abnormalities, adenosine/dipyridamole or dobutamine are routinely used and the test results are often considered alike and interchangeable. Yet, early studies comparing adenosine and dobutamine stress echocardiography found a significantly lower diagnostic accuracy for the detection of epicardial coronary stenoses with vasodilator stress.16,17

In a recent study, we reported the results of a direct comparison of dobutamine stress MR, adenosine stress MR and adenosine stress MR perfusion as assessed during a single, combined examination with all stress tests evaluated against coronary angiography as the standard of reference.9 This study proved that dobutamine is superior to adenosine stress for the detection of inducible wall motion abnormalities related to the presence of epicardial coronary stenoses>50%, with DSMR and adenosine stress MR yielding an overall diagnostic accuracy of 86% and 58%, respectively. Only for the detection of coronary stenosis>75%, a reasonably good diagnostic accuracy of adenosine stress MR was found. However, it is important to accurately determine the haemodynamic impact of coronary lesions with intermediate stenosis (50–75%). Thus, adenosine cannot be recommended for the detection of inducible wall motion abnormalities resulting from epicardial coronary stenoses.

Interestingly, the transmurality of the concomitantly determined adenosine inducible perfusion deficit could be identified as a strong predictor of adenosine inducible wall motion abnormalities which exclusively occurred in myocardial segments with high grade inducible perfusion deficits (>75% transmurality); this finding supports previously published data suggesting a potential role of vasodilator inducible wall motion abnormalities as a prognostic tool to identify patients being at high risk for future cardiac events.18,19

Imaging technique
Scanner environment
For state-of-the-art MR cine imaging the following technical requirements are advised: DSMR is performed with the patient in the supine position using a superconducting MR scanner (Fig. 2) which produces a homogeneous static magnetic field of 1.5T. The characteristics of additionally applied gradient fields determine the speed of the MR acquisition: the gradient strength should be >30mT/m with a slew rate of >100mT/m/ms. However, qualitatively sufficient MR cine imaging is possible by using a static magnetic field of 1.0T and less rapidly switching gradient systems though at the expense of a reduced signal-to-noise ratio and a decreased temporal resolution.


Figure 2
View larger version (106K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 Scanner environment for cardiac MR examinations. (A) Trolley under the table; (B) two flexible coil elements (=signal receiver) for placement on the anterior chest, three additional coil elements are integrated in the table; (C) blood pressure cuff; (D) display unit of continuous vector-ECG and respiratory control at the scanner. Setup for a dobutamine stress magnetic resonance (DSMR) examination with the patient in the supine position. (E) Table-trolley unit for rapid patient evacuation; (F) rack with blood pressure monitor and infusion pumps for administration of the stress agent. Display of the scanner console. (G) Continuous vector-ECG and respiratory control; (H1–H3) three viewports for image planning; (I) automatic view window for instantaneous visual control of myocardial wall motion during scanning.

 
It is advisable to use a multiple element phased array coil for signal detection which also allows to apply parallel imaging techniques (e.g. sensitivity encoding=SENSE). Cardiac synchronization should be performed with a robust, preferably multi channel ECG (vector-ECG).20 This is important since reliable ECG triggering ensures high image quality of MR cine loops which also depends on the coordinated and accurately timed data sampling during several heart beats. Notably, under the conditions of dobutamine stress the increase in cardiac output and, thus, the induction of high blood flow states might impair a single lead ECG triggering due to the magneto-hydrodynamic effect. In general, a retrospective ECG gating mode is preferable.

Magnetic resonance imaging technique
For cine imaging, a steady-state free precession (SSFP) sequence should be used which in combination with parallel image acquisition (SENSE) and retrospective gating allows the acquisition of 25 phases/cardiac cycle during an end-expiratory breathhold of 4–6s up to heart rates of 190–200 beats per minute. The in-plane spatial resolution of such a cine scan usually lies in the range of 1.6mmx1.6mm with a slice thickness of 8mm.

The procedure for acquisition of the standard cardiac geometries at rest i.e. three short axis planes (apical, mid and basal), a four-, two- and three-chamber view, has been described in detail elsewhere.10 Notably, for all views acquired at rest the technician should check for adequate visualization of the left ventricular cavity throughout the cardiac cycle and adjust the imaging plane if needed. Afterward, the rest scans can simply be repeated under stress while still avoiding visualization of the left ventricular outflow tract in the most basal slice, or imaging of an apical slice without visible left ventricular cavity.

Dobutamine stress MR protocol
The pharmacological stress protocol for MR imaging follows the standard high-dose dobutamine/atropine regimen as used in stress echocardiography. Briefly, after acquisition of rest cine scans in the diagnostic standard views (apical, mid and basal short axis view, four-chamber, two-chamber and three-chamber view), dobutamine is infused intravenously at 3min stages at doses of 10, 20, 30 and 40µg/kg/min and all standard views are acquired at each level. If target heart rate – defined as age predicted submaximal heart rate ([220–age]x0.85) – is not reached at the highest dobutamine level, atropine is applied in 0.25mg fractions (maximal dose 2mg). Termination criteria are identical to those of dobutamine stress echocardiography.3,21


   Safety of DSMR
Top
 Abstract
 Introduction
 General pathophysiological...
 Safety of DSMR
Outlook
 Conclusions
 Notes
 References
 
Contraindications for cardiac MR imaging and feasibility of DSMR
In general, MR imaging cannot be performed in patients with claustrophobia (4–6% of patients)22,23 and is contraindicated in those with non-compatible biometallic implants and pacemakers or implanted defibrillators (ICDs). Despite recent literature being suggestive of considering certain types of modern pacemakers/ICDs as MR safe or even MR compatible at 1.5T,24 for the time being examination of this patient group with MR cannot be recommended without further investigation of the safety profile of the specific devices. Coronary stents, sternal wires after thoracic surgery and the majority of prosthetic valve types (except for the old ball-in-cage Starr Edwards valve) do not represent a general contraindication for cardiac MR imaging and usually their influence on cine scan image quality is negligible.

Historically, when performing high-dose dobutamine stress MR, patient safety seemed to be of special concern, and, as a result, the test was performed only in a limited number of centers despite its high diagnostic value.

In a routine clinical setting, DSMR was proved to be feasible and safe, and resulted in a high number of diagnostic examinations (89.5%) in patients without contraindications to magnetic resonance imaging.22 This recently provided data of a five-year experience in performing high-dose dobutamine stress MR in 1000 consecutive patients showed an impressive safety profile with only one patient suffering sustained ventricular tachycardia and successful emergent defibrillation while no cases of death or myocardial infarction occurred over the years.

Monitoring
Heart rate and rhythm need to be monitored throughout the examination. In previous guidelines, pulse oximetry has been recommended as an additional means for rhythm control mainly used in the case of ECG failure. This is not required if a vector-ECG is applied.

Basically, changes of the ST segment are non-diagnostic as a result from the ECG-wave distortion in the static magnetic field. However, since wall motion abnormalities precede ST-segment changes and the former can readily be detected with MR imaging, monitoring is effective without a diagnostic ECG. In addition, cine MR real-time scans can be run repetitively within the 3min dobutamine infusion intervals in order to detect new or worsening wall motion abnormalities at their very first occurrence. Real-time cine scans have a high temporal resolution (appr. 35ms) at the expense of spatial resolution (appr. 2.7x2.7mm in-plane), but proved useful for the detection of inducible wall motion abnormalities.25

Blood pressure monitoring can be easily done with a conventional monitoring system outside the scanner room with an extension line placed through a waveguide in the radiofrequency cage. Alternatively, special CMR compatible equipment may be used which already exists at many MR sites.

Image display and analysis
During the pharmacological stress procedure the cine scans can be judged visually in an "automatic view" window as shown in the scanner console (Fig. 2). The reconstruction speed of the phase images has become very fast and allows online visual assessment of wall motion with the cine loops being displayed less than 1s after data acquisition. The scanner can be set to automatically transfer the scans to a nearby workstation and the cine loops are then displayed in a synchronized quadscreen. For visual assessment of left ventricular wall motion the standard four-point scoring system (1=normokinesis, 2=hypokinesis, 3=akinesis, 4=dyskinesis) is applied per myocardial segment (17-segment model)26 with ischemia defined as≥1 segment(s) showing an inducible wall motion abnormality (i.e. an increase in the segmental wall motion score of at least one) or a biphasic response. Though quantification of left ventricular wall motion and thickening using the centerline method may improve the accuracy for detection of significant CAD,27 the procedure is time consuming and rarely used in clinical routine.

Patient evacuation and emergency equipment
In general, monitoring during an MR examination requires the same precautions and emergency equipment as any other stress test. A physician appropriately trained in basic and advanced cardiac life support must be present throughout the stress examination and during the recovery phase.22 Specifically, we recommend the following set up for a dobutamine stress MR (Fig. 2): a trolley should be permanently placed under the table and a button for manual table release must be available. Alternatively, a specific emergency patient bedding can be used. At our department, every 3 months the maneuver for rapid patient evacuation is practiced including the immediate stop of the dobutamine infusion, disconnection of the cardiac coil and the ECG cable and evacuation of the patient using the table-trolley unit (this can usually be done in less than 30s by two staff members). Outside the scan room, resuscitation can be performed according to emergency guidelines without setting patient or personnel at risk.

Diagnostic performance
In single center trials, DSMR has been shown to be superior to dobutamine stress echocardiography for the detection of inducible wall motion abnormalities in patients with suspected coronary artery disease,3 patients with wall motion abnormalities at rest28 and patients not well suited for second harmonic echocardiography.8 Nagel et al. were the first to report the diagnostic accuracy of high-dose dobutamine/atropine stress MR in a larger patient cohort and evaluated its relative accuracy in a head-to-head comparison with dobutamine stress echocardiography, with X-ray coronary angiography as the standard of reference for both stress tests. In this study, DSMR was proved to be highly accurate for the detection of inducible wall motion abnormalities related to the presence of epicardial coronary stenosis in patients with suspected CAD with an overall diagnostic accuracy of 86% (sensitivity 86%; specificity 86%) and was found to be superior to dobutamine stress echocardiography. In patients with limited echocardiographic image quality, Hundley et al. reported a similar diagnostic performance of DSMR (accuracy 83%; sensitivity 83%; specificity 83%). The superiority of DSMR has been attributed primarily to the consistently high endocardial border definition inherent to the MR cine sequences5 which are independent of limited acquisition windows, thereby increasing the detectability of even subtle wall motion abnormalities without the need for application of contrast agents (see also Table 1). Thus, the gain in diagnostic accuracy is particularly high in those patients with inadequate acoustic windows (e.g. in the near field, see Fig. 3) or limited echocardiographic image quality despite the use of second harmonic imaging.


Figure 3
View larger version (195K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 3 DSMR cine images of a patient with suspected CAD. Normal regional wall motion at rest and under stress up to the 20µg/kg/min dobutamine infusion level. Under maximum stress, the apical and apico-septal segment became akinetic (white arrows). X-ray coronary angiography. Single vessel disease of the LAD with serial stenoses: a far distal LAD stenosis with 52% (closed arrows) and an excentric plaque (open arrow) in the mid portion with 46% luminal narrowing. Inlay shows the non-diseased RCA.

 


View this table:
[in this window]
[in a new window]

  		Table 1 Clinical value and imaging characteristics of dobutamine stress magnetic resonance (DSMR) and dobutamine stress echocardiography (DSE)

 
Functional assessment of viable myocardium
Cardiac MR imaging allows the assessment of viable myocardial regions from a morphological and a functional perspective. The morphological approach aims at detecting regions of scarred myocardium after intravenous application of an extracellular, gadolinium containing contrast agent ("delayed enhancement technique"): a heavily T1 weighted imaging sequence is used to differentiate scarred myocardium (appearing "white") from viable myocardium (appearing "black"). The transmural extent of myocardial scar is then determined (25%, 26–50%, 51–75% and >75%) and can be used to predict the likelihood of functional recovery after a revascularization procedure: segments with abnormal contraction at rest but without hyperenhancement are most likely to improve contractile function, while the likelihood of improvement decreases as the transmurality of the hyperenhancement increases i.e. segments with >75% transmurality of scar are highly unlikely to show any improvement of contractile function.2 Yet, with this approach an unequivocal prediction of a contractile improvement is problematic in case of scar transmurality ranging from 25 to 75% since such myocardial segments may or may not recover after restoration of blood supply.

Alternatively, the functional, contractile response to low-dose dobutamine stimulation can be determined (Fig. 4) which of course represents a concomitant diagnostic information readily at hand in all patients with wall motion abnormalities at rest who are referred for ischemia testing with DSMR. Recent reports directly comparing scar imaging and low-dose dobutamine stimulation found that the low-dose dobutamine challenge is superior to scar imaging in predicting recovery of function, particularly in those segments with a scar transmurality of 1–75%.11,29 A possible explanation for this finding is that even though scar imaging clearly depicts the area of myocardial fibrosis, it does not assess the functional state of the surrounding (viable) myocardium, and, thus, has limited capability for the prediction of functional recovery of non-transmurally scarred myocardium.


Figure 4
View larger version (170K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 4 Functional assessment of viable myocardium with DSMR. At rest, a severely hypokinetic inferolateral segment was found (white arrows). Under low-dose dobutamine infusion up to 20µg/kg/min a substantial and gradual improvement in the contractile response of the inferolateral segment could be demonstrated, though at maximum stress, both, the inferolateral and the inferior segment became akinetic. The "biphasic profile of contraction" of the inferolateral segment was compatible with viable myocardium. X-ray coronary angiography. Double vessel disease (LCX, RCA): subtotal occlusion of the distal portion of a marginal branch (arrowheads) and high grade stenosis of the distal LCX as well as a high grade stenosis of the distal RCA (closed arrows). Note the development of small, though angiographically visible coronary collaterals of the RCA (open arrows) in an effort to compensate for the chronically reduced blood supply to the inferolateral wall.

 
Prognostic value of DSMR
For the time being, there is only data from single center studies available on the prognostic information provided by high-dose DSMR. Hundley et al. reported the usefulness of DSMR for determination of patient prognosis in a retrospective study and found that the presence of inducible wall motion abnormalities during DSMR identifies those patients at risk of myocardial infarction and cardiac death independent of the presence of traditional risk factors for coronary artery disease.10 More importantly, a low cardiac event rate was demonstrated in case of a negative DSMR testing (2% over 2 years for patients with LVEF>40% and 0% over 2 years for patients with LVEF≥60%).

Similarly, the value of DSMR for the assessment of preoperative cardiac risk in patients undergoing non-cardiac surgery has been examined.30 In the subgroup of patients with intermediate clinical predictors of future cardiac events a positive DSMR test proved to be an independent factor for predicting myocardial infarction, cardiac death or congestive heart failure during or after the surgery.


   Outlook
Top
 Abstract
 Introduction
 General pathophysiological...
 Safety of DSMR
 Outlook
Conclusions
 Notes
 References
 
Tagged MR imaging (i.e. image acquisition with a grid that deforms with cardiac contraction) can be used to quantify wall motion in systole and diastole and to detect early occurring ischemic responses. The main limitation of this technique is the tediousness of quantitative evaluation. Consequently, visual analysis of tagged images has been proposed and evaluated in a patient study.31 These investigators found a higher diagnostic accuracy for the tagged versus the conventional cine approach, although no definite reading criteria for visual interpretation of tagged images were reported.

Highly promising are real-time analysis tools for tagged MR images to facilitate direct visualization of regional myocardial strain (e.g. FastHARP)32,33: these techniques are currently intensely researched but further refinement and optimization of the imaging procedures is needed before they might be used in routine applications.


   Conclusions
Top
 Abstract
 Introduction
 General pathophysiological...
 Safety of DSMR
 Outlook
 Conclusions
Notes
 References
 
Dobutamine stress MR has the potential to become the preferred technique for stress wall motion analysis in those patients amenable to MR imaging and can be regarded the imaging method of choice in patients with only moderate echocardiographic image quality.

Functional assessment of viable myocardium with low-dose DSMR is superior to myocardial scar detection with MR delayed enhancement if scar transmurality is <75% and is an additional diagnostic information readily at hand in all patients with resting wall motion abnormalities referred for ischemia testing with DSMR. Over and above its diagnostic value, DSMR provides prognostically relevant information and can be used for preoperative assessment of patients scheduled for non-cardiac surgery.

All these very promising applications of DSMR warrant further verification in future large-scale multicenter trials.


   Notes
Top
 Abstract
 Introduction
 General pathophysiological...
 Safety of DSMR
 Outlook
 Conclusions
 Notes
References
 
a Both the authors contributed equally to the work. Back


   References
Top
 Abstract
 Introduction
 General pathophysiological...
 Safety of DSMR
 Outlook
 Conclusions
 Notes
 References
 

  1. Kim W.Y., Danias P.G., Stuber M., Flamm S.D., Plein S., Nagel E., et al. Coronary magnetic resonance angiography for the detection of coronary stenoses. N Engl J Med (2001) 345(26):1863–1869.[Abstract/Free Full Text]
  2. Kim R.J., Wu E., Rafael A., Chen E.L., Parker M.A., Simonetti O., et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med (2000) 343(20):1445–1453.[Abstract/Free Full Text]
  3. Nagel E., Lehmkuhl H.B., Bocksch W., Klein C., Vogel U., Frantz E., et al. Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: comparison with dobutamine stress echocardiography. Circulation (1999) 99(6):763–770.[Abstract/Free Full Text]
  4. Nagel E., Klein C., Paetsch I., Hettwer S., Schnackenburg B., Wegscheider K., et al. Magnetic resonance perfusion measurements for the noninvasive detection of coronary artery disease. Circulation (2003) 108(4):432–437.[Abstract/Free Full Text]
  5. Thiele H., Nagel E., Paetsch I., Schnackenburg B., Bornstedt A., Kouwenhoven M., et al. Functional cardiac MR imaging with steady-state free precession (SSFP) significantly improves endocardial border delineation without contrast agents. J Magn Reson Imaging (2001) 14(4):362–367.[CrossRef][Web of Science][Medline]
  6. Pennell D.J., Underwood S.R., Manzara C.C., Swanton R.H., Walker J.M., Ell P.J., et al. Magnetic resonance imaging during dobutamine stress in coronary artery disease. Am J Cardiol (1992) 70(1):34–40.[CrossRef][Web of Science][Medline]
  7. van Rugge F.P., van der Wall E.E., de Roos A., Bruschke A.V. Dobutamine stress magnetic resonance imaging for detection of coronary artery disease. J Am Coll Cardiol (1993) 22(2):431–439.[Abstract]
  8. Hundley W.G., Hamilton C.A., Thomas M.S., Herrington D.M., Salido T.B., Kitzman D.W., et al. Utility of fast cine magnetic resonance imaging and display for the detection of myocardial ischemia in patients not well suited for second harmonic stress echocardiography. Circulation (1999) 100(16):1697–1702.[Abstract/Free Full Text]
  9. Paetsch I., Jahnke C., Wahl A., Gebker R., Neuss M., Fleck E., et al. Comparison of dobutamine stress magnetic resonance, adenosine stress magnetic resonance, and adenosine stress magnetic resonance perfusion. Circulation (2004) 110(7):835–842.[Abstract/Free Full Text]
  10. Hundley W.G. Magnetic resonance imaging determination of cardiac prognosis. Circulation (2002) 106:2328–2333.[Abstract/Free Full Text]
  11. Wellnhofer E., Olariu A., Klein C., Grafe M., Wahl A., Fleck E., et al. Magnetic resonance low-dose dobutamine test is superior to scar quantification for the prediction of functional recovery. Circulation (2004) 109(18):2172–2174.[Abstract/Free Full Text]
  12. Wilson R.F., Marcus M.L., White C.W. Prediction of the physiologic significance of coronary arterial lesions by quantitative lesion geometry in patients with limited coronary artery disease. Circulation (1987) 75(4):723–732.[Abstract/Free Full Text]
  13. Pijls N.H., De Bruyne B., Peels K., Van Der Voort P.H., Bonnier H.J., Bartunek J.K.J.J., et al. Measurement of fractional flow reserve to assess the functional severity of coronary-artery stenoses. N Engl J Med (1996) 334(26):1703–1708.[Abstract/Free Full Text]
  14. Pijls N.H., De Bruyne B., Bech G.J., Liistro F., Heyndrickx G.R., Bonnier H.J., et al. Coronary pressure measurement to assess the hemodynamic significance of serial stenoses within one coronary artery: validation in humans. Circulation (2000) 102(19):2371–2377.[Abstract/Free Full Text]
  15. Wilson R.F. Assessing the severity of coronary-artery stenoses. N Engl J Med (1996) 334(26):1735–1737.[Free Full Text]
  16. Marwick T., Willemart B., D'Hondt A.M., Baudhuin T., Wijns W., Detry J.M., et al. Selection of the optimal nonexercise stress for the evaluation of ischemic regional myocardial dysfunction and malperfusion. Comparison of dobutamine and adenosine using echocardiography and 99mTc-MIBI single photon emission computed tomography. Circulation (1993) 87(2):345–354.[Abstract/Free Full Text]
  17. Nguyen T., Heo J., Ogilby J.D., Iskandrian A.S. Single photon emission computed tomography with thallium-201 during adenosine-induced coronary hyperemia: correlation with coronary arteriography, exercise thallium imaging and two-dimensional echocardiography. J Am Coll Cardiol (1990) 16(6):1375–1383.[Abstract]
  18. Chiarella F., Domenicucci S., Bellotti P., Bellone P., Scarsi G., Vecchio C. Dipyridamole echocardiographic test performed 3 days after an acute myocardial infarction: feasibility, tolerability, safety and in-hospital prognostic value. Eur Heart J (1994) 15(6):842–850.[Abstract/Free Full Text]
  19. Picano E., Landi P., Bolognese L., Chiaranda G., Chiarella F., Seveso G., et al. Prognostic value of dipyridamole echocardiography early after uncomplicated myocardial infarction: a large-scale, multicenter trial The EPIC Study Group. Am J Med (1993) 95(6):608–618.[CrossRef][Web of Science][Medline]
  20. Fischer S.E., Wickline S.A., Lorenz C.H. Novel real-time R-wave detection algorithm based on the vectorcardiogram for accurate gated magnetic resonance acquisitions. Magn Reson Med (1999) 42(2):361–370.[CrossRef][Web of Science][Medline]
  21. Nagel E., Lorenz C., Baer F., Hundley W.G., Wilke N., Neubauer S., et al. Stress cardiovascular magnetic resonance: consensus panel report. Detecting left ventricular myocardial ischemia during intravenous dobutamine with cardiovascular magnetic resonance imaging (MRI). J Cardiovasc Magn Reson (2001) 3(3):267–281.[CrossRef][Web of Science][Medline]
  22. Wahl A., Paetsch I., Gollesch A., Roethemeyer S., Foell D., Gebker R., et al. Safety and feasibility of high-dose dobutamine-atropine stress cardiovascular magnetic resonance for diagnosis of myocardial ischaemia: experience in 1000 consecutive cases. Eur Heart J (2004) 25(14):1230–1236.[Abstract/Free Full Text]
  23. Francis J.M., Pennell D.J. Treatment of claustrophobia for cardiovascular magnetic resonance: use and effectiveness of mild sedation. J Cardiovasc Magn Reson (2000) 2(2):139–141.[Web of Science][Medline]
  24. Roguin A., Zviman M.M., Meininger G.R., Rodrigues E.R., Dickfeld T.M., Bluemke D.A., et al. Modern pacemaker and implantable cardioverter/defibrillator systems can be magnetic resonance imaging safe. In vitro and in vivo assessment of safety and function at 1.5T. Circulation (2004) 110(5):475–482.[Abstract/Free Full Text]
  25. Schalla S., Klein C., Paetsch I., Lehmkuhl H., Bornstedt A., Schnackenburg B., et al. Real-time MR image acquisition during high-dose dobutamine hydrochloride stress for detecting left ventricular wall-motion abnormalities in patients with coronary arterial disease. Radiology (2002) 224(3):845–851.[Abstract/Free Full Text]
  26. Cerqueira M.D., Weissman N.J., Dilsizian V., Jacobs A.K., Kaul S., Laskey W.K., et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association. Int J Cardiovasc Imaging (2002) 18(1):539–542.[Web of Science][Medline]
  27. van Rugge F.P., van der Wall E.E., Spanjersberg S.J., de Roos A., Matheijssen N.A., Zwinderman A.H., et al. Magnetic resonance imaging during dobutamine stress for detection and localization of coronary artery disease. Quantitative wall motion analysis using a modification of the centerline method. Circulation (1994) 90(1):127–138.[Abstract/Free Full Text]
  28. Wahl A., Paetsch I., Roethemeyer S., Klein C., Fleck E., Nagel E. High-dose dobutamine-atropine stress cardiovascular magnetic resonance for follow-up after coronary revascularization procedures in patients with wall motion abnormalities at rest. Radiology (2004) 233:210–216.[Abstract/Free Full Text]
  29. Motoyasu M., Sakuma H., Ichikawa Y., Ishida N., Uemura S., Okinaka T., et al. Prediction of regional functional recovery after acute myocardial infarction with low dose dobutamine stress cine MR imaging and contrast enhanced MR imaging. J Cardiovasc Magn Reson (2003) 5(4):563–574.[CrossRef][Web of Science][Medline]
  30. Rerkpattanapipat P., Morgan T.M., Neagle C.M., Link K.M., Hamilton C.A., Hundley W.G. Assessment of preoperative cardiac risk with magnetic resonance imaging. Am J Cardiol (2002) 90(4):416–419.[CrossRef][Web of Science][Medline]
  31. Kuijpers D., Ho K.Y., van Dijkman P.R., Vliegenthart R., Oudkerk M. Dobutamine cardiovascular magnetic resonance for the detection of myocardial ischemia with the use of myocardial tagging. Circulation (2003) 107(12):1592–1597. [Epub 2003 Mar 17].[Abstract/Free Full Text]
  32. Garot J., Bluemke D.A., Osman N.F., Rochitte C.E., McVeigh E.R., Zerhouni E.A., et al. Fast determination of regional myocardial strain fields from tagged cardiac images using harmonic phase MRI. Circulation (2000) 101(9):981–988.[Abstract/Free Full Text]
  33. Kraitchman D.L., Sampath S., Castillo E., Derbyshire J.A., Boston R.C., Bluemke D.A., et al. Quantitative ischemia detection during cardiac magnetic resonance stress testing by use of FastHARP. Circulation (2003) 107(15):2025–2030. [Epub 2003 Mar 31].[Abstract/Free Full Text]
  34. Elhendy A., Schinkel A.F., Bax J.J., Van Domburg R.T., Poldermans D. Prognostic value of dobutamine stress echocardiography in patients with normal left ventricular systolic function. J Am Soc Echocardiogr (2004) 17(7):739–743.[CrossRef][Web of Science][Medline]
  35. Ciaroni S., Bloch A., Hoffmann J.L., Bettoni M., Fournet D. Prognostic value of dobutamine echocardiography in patients with intermediate coronary lesions at angiography. Echocardiography (2002) 19(7 Pt 1):549–553.[CrossRef][Web of Science][Medline]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 Eur Heart JHome page
R. Sicari, P. Nihoyannopoulos, A. Evangelista, J. Kasprzak, P. Lancellotti, D. Poldermans, J.-U. Voigt, J. L. Zamorano, and on behalf of the European Association of Echocardi
Stress Echocardiography Expert Consensus Statement--Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC)
Eur. Heart J., February 1, 2009; 30(3): 278 - 289.
[Full Text] [PDF]

Home page
 Circ Cardiovasc ImagingHome page
R. Gebker, C. Jahnke, R. Manka, A. Hamdan, B. Schnackenburg, E. Fleck, and I. Paetsch
Additional Value of Myocardial Perfusion Imaging During Dobutamine Stress Magnetic Resonance for the Assessment of Coronary Artery Disease
Circ Cardiovasc Imaging, September 1, 2008; 1(2): 122 - 130.
[Abstract] [Full Text] [PDF]

Home page
 Eur J EchocardiogrHome page
R. Sicari, P. Nihoyannopoulos, A. Evangelista, J. Kasprzak, P. Lancellotti, D. Poldermans, J.-U. Voigt, J. L. Zamorano, and on behalf of the European Association of Echocardi
Stress echocardiography expert consensus statement: European Association of Echocardiography (EAE) (a registered branch of the ESC)
Eur J Echocardiogr, July 1, 2008; 9(4): 415 - 437.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Paetsch, I.
Right arrow Articles by Nagel, E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Paetsch, I.
Right arrow Articles by Nagel, E.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?