https://doi.org/10.5272/jimab.2019254.

2718
Journal of IMAB
ISSN: 1312-773X
https://www.journal-imab-bg.org
Review article

APPLICATIONS OF ROUTINE CARDIAC MRI

PULSE SEQUENCES – A CONTEMPORARY
REVIEW
Georgi Valchev1,2, Ralitsa Popova 3, Samar El Shemeri 1,2, Yana Bocheva 4,5,
Nataliya Usheva6, Sonya Galcheva7,8, Violeta Iotova7,8, Yoto Yotov9,10
1) Clinic of Diagnostic Imaging, UMHAT Sveta Marina, Varna, Bulgaria
2) Department of Radiology, Medical University,Varna, Bulgaria
3) Department of Diagnostic Imaging, UMHAT Heart and Brain Center of
Excellence, Pleven, Bulgaria
4) Department of Clinical Laboratory, UMHAT Sveta Marina, Varna, Bulgaria
5) Department of General Medicine and Clinical Laboratory, Medical
University, Varna, Bulgaria
6) Department of Social Medicine and Organization of Healthcare, Medical
University, Varna, Bulgaria
7) First Paediatric Clinic with Intensive Care Department, UMHAT Sveta
Marina, Varna, Bulgaria
8) Department of Paediatrics, Medical University, Varna, Bulgaria
9) Second Clinic of Cardiology, UMHAT Sveta Marina, Varna, Bulgaria
10) First Department of Internal Medicine, Medical University, Varna, Bulgaria.

ABSTRACT: bringing new insights into pathology. Magnetic resonance

Cardiac magnetic resonance imaging is a relatively tomography (MRT) has now established itself as a stand-
novel method, which has recently vastly expanded its ap- ard of care in diagnosing cardiac tumors and infiltrative
plications and usefulness. It is a non-ionizing method, disease, exceeding the traditional gold standard of tran-
with very few contraindications, allowing for characteri- sthoracic ultrasonography (US) in terms of morphologi-
zation of the full spectrum of cardiac diseases. This is cal capacity and achieving levels of accuracy in func-
done by means of performing a multitude of specially-tai- tional imaging similar to those of real-time US. Cardiac
lored pulse sequences, each of which images different as- magnetic resonance (CMR) is also capable of evaluating
pects of morphology and pathology. When putting to- cardiac viability via perfusion techniques, making it a
gether all the data, acquired from the separate sequences, well-rounded diagnostic modality, albeit requiring expen-
a skilled radiologist can provide a comprehensive and in- sive equipment and highly experienced personnel. Unfor-
sightful interpretation to great clinical benefit. There are tunately, despite its great advances in imaging technol-
morphological, functional, quantitative, and contrast- ogy, cardiac MRI continues to be a time-consuming ex-
based imaging sequences, but not all of them are per- amination, demanding periods between 40 and 60 min-
formed on every patient – due to time constraints every utes for the acquisition of a comprehensive set of image
imaging protocol is individually calibrated to suit the sequences [2].
corresponding clinical query. Some advantages of CMR over Röntgen-ray-based
computed tomography (CT) include a strong native con-
Keywords: Magnetic Resonance Tomography, Car- trast between the varying soft tissues, the ability to de-
diac Imaging, Electromagnetic Pulse Sequences, Func- crease the field of view with retaining the same matrix
tional Imaging, Medical Imaging, Diagnostic Imaging, size (and thereby improve resolution), the ability to at-
tain data from any plane (unlike axial-only CT). Most im-
BACKGROUND: portantly, CMR is completely devoid of ionising radia-
Magnetic resonance imaging (MRI) is a relatively tion, making it superior to CT and nuclear medicine ex-
young imaging modality (the first MRI images of a hu- aminations in terms of patient dose. Cardiac MRI also pro-
man being were acquired in 1977 [1]). At the same time, vides superior spatial and temporal resolution when com-
MRI is one of the most rapidly and expansively develop- pared with nuclear medicine modalities, and, unlike ul-
ing imaging techniques. It has experienced further ad- trasonography, does not observe the limitations of acous-
vancements in recent years, with many new imaging se- tic windows [2].
quences having been introduced in a short time – each Cardiac MRT is not devoid of drawbacks, however.

2718 https://www.journal-imab-bg.org J of IMAB. 2019 Oct-Dec;25(4)

There is a necessity for sedation in children and claustro- to perform, and additionally – rather expensive [2].
phobic patients. Additionally, metallic implants with Each individual sequence consists of a mandatory
ferromagnetic effects as well as pacemakers are consid- imaging engine and non-mandatory image modifiers. Ex-
ered contraindications. amples of current imaging engines are Fast (or Turbo) Spin
Cardiac MRT is a noninvasive tomographic ima- Echo (FSE/TSE), Gradient-Recalled Echo (GRE) and its
ging method that can yield important morphological and successor balanced Steady-State Free Precession (SSFP),
functional data with a high image resolution. It has the Echo-Planar Imaging (EPI), while examples of modifiers
added advantage of imaging surrounding structures when are Inversion Recovery (IR), Fat Saturation (Fat Sat, sup-
anatomical sequences are employed, as well as the possi- pressing signal from fat by means of chemical shift), and
bility of adding intravenous contrast (Gadolinium chela- Phase-Contrast Imaging [3].
tes) and characterizing its passage. Measurements per- Morphologic sequences
formed on still images or cine series allow for accurate Morphologic sequences yield anatomic still images
calculation of chamber volume, mass, and size. The of the heart and great vessels as a mandatory part of any
imaging process is electrocardiographically (ECG) syn- clinical CMR investigation. They provide the most value
chronized – either ECG-gated (creates cine series of the when analyzing complex congenital anomalies and esti-
whole cardiac cycle) or ECG-triggered (static image ac- mating the span of cardiac masses. Most commonly at least
quisition in a specific part of the cardiac cycle – usually one of the anatomical series will be done in the standard
diastole). Cine series are small movies of a single slice, thoracic axial plane, however, quite often additional ob-
acquired from several consecutive and averaged out full lique planes, specific to the heart, are imaged as well –
cardiac cycles that enable for characterization of horizontal and vertical long axis views, two- and four-
contractility and calculation of left ventricular ejection chamber views, short axis view, views of the valves, out-
fraction [2]. Finally, respiratory synchronization needs to flow tracts, and great vessels [4-6].
be applied to adequately account for non-cardiogenic CMR sequences can be separated into two catego-
motion artefacts. This is usually done with short (18-25 ries, based on their myocardium-blood pool native con-
second) breath-hold commands in T1-weighted images or trast – dark (black) blood and bright (white) blood se-
with respiratory gating in T2-weighted images. The rea- quences. It is often desirable to use both of them for easier
son for this is that in T1, there are short time gaps in be- comparison. Dark blood sequences are aimed at optimal
tween imaging cycles, allowing for short breath-holds. representation of morphology as they provide a very clear
Conversely, with respiratory gating, no breath-hold com- distinction between the vessel wall and blood. They are
mands are given, instead, the patient’s diaphragmatic usually performed at multiple slice locations during di-
movements are automatically monitored, because, in T2- astole to produce a stack of 4-5mm thick slices. This par-
weighted images, the long gaps between cycles make tial coverage only of relevant anatomy is optimal in the
breath-hold techniques inapplicable [2]. view of time constraints. Dark blood images utilize a se-
Potential indications for CMR include cardiac ries of Inversion Recovery prepulses to null unwanted sig-
masses, quantifying myocardial ischemia or infarction (vi- nal – respectively a double IR prepulse to null blood sig-
ability), cardiomyopathies, valvular disease, coronary ar- nal, or a triple IR prepulse to null blood and fat. Exam-
tery disease (perfusion), pericardial disease, and complex ples of the imaging engines used are TSE, and its faster
congenital anomalies. [2, 3] variant Half-Fourier Acquired Single-shot Turbo spin Echo
(HASTE). Additionally, the Short-Tau Inversion Recovery
REVIEW RESULTS: (STIR) modifier can be of great use for identifying high-
There is a myriad of different pulse sequences. signal myocardium at risk in the setting of acute myocar-
These are unique combinations of field gradients and RF dial infarction. T2 STIR can also be used to search for
pulses, performed at different intervals that create differ- edema associated with acute infarction [3-7].
ently weighted images (T1-weighted, T2-weighted, diffu- Cine functional sequences
sion-weighted, etc.). Each such image provides different Bright blood sequences are built upon the SSFP and
information about the same anatomical area. For exam- EPI gradient engines and are an integral part of CMR ex-
ple, water appears very bright (high signal or hyper- aminations. They display high-intensity signal from fast-
intense) on T2-weighted sequences, and dark on T1- flowing blood (with an excellent distinction between
weighted sequences; fat appears bright on both T1 and blood and myocardium – figure 1) and are excellent at
T2. Both T1 and T2 series can additionally be performed evaluating cardiac function. These sequences continu-
with suppression of the signal from fat. Only when tak- ously image a single slice across several whole cardiac
ing all pertinent imaging sequences into consideration, cycles, creating a short averaged-out movie (cine) of the
one can acquire a comprehensive understanding of a heart in motion. The cine contains 20-30 frames, acquired
pathological finding. Additionally, as computing power with 30-50 msec temporal resolution – a set of 4 example
increases and the intrinsic engineering complexities of frames is shown in figure 2. Typically, a stack of multiple
magnets stack up, newer sequences emerge at an almost closely spaced short-axis slices (6-8 mm thick, with 1-2
alarming rate. It is this vast array of different types of im- mm gaps in between) is each turned into individual cine
ages that a radiologist must be familiar with that makes series to achieve adequate coverage. Thus they facilitate
MRT exceptionally difficult to interpret, time-consuming accurate assessment of the systolic and diastolic motion

J of IMAB. 2019 Oct-Dec;25(4) https://www.journal-imab-bg.org 2719

of the ventricular walls, both quantitative and qualitative. essarily easily reproducible with US. Phase Contrast meas-
Also, measurements can be made of left ventricular end ures the phase shift from blood protons moving through
diastolic and end systolic volumes, ejection fraction and the magnetic field (without the need for intravenous con-
myocardial mass can be estimated. Some sources recom- trast material), which is proportional to their speed, al-
mend cine SSFP as an alternative to echocardiography lowing for estimation of said speed and its direction. A
(cardiac US) [3]. cine series encompassing several phases of the cardiac cy-
cle is created. Velocity is encoded in a way reminiscent
Fig. 1. A single axial slice from a bright blood se- of colour Doppler in ultrasound. The imaging plane is
quence, clearly demonstrating left ventricular hypertro- usually perpendicular to a vessel, chamber, or valve of in-
phy. terest, with antegrade flow coded in light grey to white,
and retrograde flow coded in dark grey to black, while
stationary tissues appear intermediate grey. Time-veloc-
ity and time-flow curves can be generated. VENC is valu-
able for evaluating shunts and shunt fractions, determin-
ing pressure gradients across stenotic valves, and deter-
mining regurgitated flow [5, 6].
Quantitative MRI
In the last five years CMR mapping techniques
have been introduced, enabling the objective numerical
measurement of signal strength in every pixel of either
T1-, T2-, or T2*-weighted mapped images (which is im-
possible to do in images acquired via a different sequence).
This technique is mostly used for analyzing diffuse myo-
cardial changes. T1 mapping, for example, is very precise
in detecting infiltrative disease – myocarditis, amyloido-
sis, sarcoidosis, and cardiomyopathies. It is usually per-
formed in two phases – pre- and post-contrast. T2-map-
ping is excellent for distinguishing edema, while T2*-
mapping is less frequently used, as it demonstrates only
iron overload (e. g. in haemochromatosis). It should be
stipulated that T2-mapping sequences assess myocardial
Fig. 2. Four frames from a coronal bright blood cine edema quantitatively (objective T2 relaxation time) and
sequence, showing the heart in motion. A dilation of the not qualitatively (arbitrary signal intensity) like the T2-
aortic root is evident. STIR sequences. Popular sequences include Modified
Look-Locker (MOLLI) and Saturation Recovery (SASHA)
[3, 8, 9].
Myocardial perfusion
CMR perfusion accurately diagnoses coronary ar-
tery disease with high sensitivity and specificity. Perfusion
can be performed at rest and at (adenosine-induced) stress.
Perfusion sequences usually based on the balanced SSFP,
GRE or EPI engine, aim to create a short movie of the
blood (either by using an exogenous intravenous Gado-
linium-based tracer or endogenous arterial spins). As the
blood washes in and passes through the myocardium, ar-
eas with lower signal (hypointense areas) are easily rec-
ognized as hypoperfused. Because of the need to acquire
multiple images within a single cardiac cycle, image qual-
ity invariably diminishes, especially in tachycardic pa-
tients, where RR intervals are much shorter. Additionally,
better signal-to-noise ratios for this method can be
achieved at field strengths of 3 Tesla than at 1.5 Tesla. It
also needs to be stipulated that Greenwood et al. claim
that CMR perfusion can demonstrate higher accuracy than
single-photon emission computed tomography (SPECT)
in detecting ischemic myocardium [10].
Additionally, blood velocity and flow direction can Perfusion can be performed without intravenous
be measured using the modifier Phase Contrast (velocity- contrast material by using arterial spin-labelling [11]. It
encoded, VENC) – a task impossible for CT, and not nec- is a sensitive technique which allows the spin population

2720 https://www.journal-imab-bg.org J of IMAB. 2019 Oct-Dec;25(4)

in arterial water to be magnetically labelled by an IR perfusion images with an initial Gd bolus, followed by a
pulse, and thus used as an endogenous diffusible tracer. second Gd bolus and then, finally, the most important se-
Unfortunately, this sequence has limited use, due to in- ries – delayed imaging at about 10-20 minutes [3].
terference caused by cardiac motion and relatively low sig- The underlying mechanism responsible for late Gd
nal. For these reasons, Gadonilium-based perfusion is pre- enhancement is postulated as follows: after being admin-
ferred. It allows for strong contrast in T1-weighted images, istered intravenously, the extracellular contrast agent Gd
large coverage of myocardium, and adequate spatial reso- DTPA (diethylenetriamine penta-acetic acid) shortens the
lution [12]. T1 relaxation times of irreversibly damaged myocardium,
When doing the stress perfusion examination, ad- making it hyperintense (of higher MRI signal) in T1-
enosine dosed at 140 micrograms per kilogram of patient weighted images. This is thought to be due to the fact that
weight per minute is injected over a period of 2-3 min- in acutely infarctioned myocytes, the ruptured membranes
utes, alongside a dose of Gadolinium (Gd). Adenosine is allow for Gd to pass intracellularly via diffusion. Con-
an endogenous purine nucleoside, which has a very short versely, chronic infarctions consist of scar tissue with
half-life (less than 10 seconds) and acts as a vasodilator greater interstitial space than normal myocardium – there-
by influencing the A2A receptors. Its effect is a maximum fore, Gd would accumulate in greater volume within the
dilation of the distal arteriolar bed. Coronary flow can be scar [2].
thus increased by about 4 times in the absence of steno- Delayed Gd enhancement CMR is a highly sensitive
sis. In significantly stenotic arteries, however, there is no method for detection of acute myocardial infarction (99%),
change, since they are already fully dilated prior to the as well as chronic infarction (94% sensitivity for a scar).
adenosine administration. This results in a “steal phenom- The technique can demonstrate infarctions as small as 1
enon” from the stenotic to the normal arteries. The zones cubic cm, greatly outdoing other relevant imaging
supplied by normal arteries demonstrate a multifold flow modalities. Unfortunately, the edematous border of acute
increase, while the ones corresponding to stenotic arter- infarctions is included in the total area of hypersignal, ef-
ies show little or no flow increase, appearing hypointense. fectively slightly exaggerating the nonviable area. Despite
Usually, the stress test precedes the rest test with roughly that, delayed enhancement CMR is recognized as the ref-
15 minutes in between them, necessary for complete wash- erence standard for myocardial viability testing [14, 15, 16].
out of the first Gadolinium bolus. Finally, another 10-15 CMR angiography
minutes after the rest test, a late Gd enhancement series Even though MRT is capable of performing angi-
can be performed. To clarify further, intravenous Gado- ography without exogenous Gd contrast, this flow-related
linium is given once during the stress test, and once more enhancement method of imaging peripheral vessels is
during the rest test [2]. considered suboptimal for imaging the heart, which is in
Delayed contrast enhanced CMR and myocardial constant motion. Because of this CMR angiography is
viability usually performed with intravenous Gadolinium, and
Analyzing myocardial viability is of paramount im- based on a fast three-dimensional (3D) spoiled GRE se-
portance when considering coronary revascularization. quence. Being a 3D sequence, it has no gaps inbetween
With cardiac MRT, this can be accomplished on T1 map- slices and allows for multiplanar reformats of the obtained
ping, delayed enhancement series, as well as stress/rest images. Additionally, this also allows for the construction
perfusion series. Additionally, supported by correspond- of cast-like volume renderings of the contrasted vascular
ing clinical suspicion, delayed enhancement can be in- lumina and cardiac chambers – true 3D models. These can
dicative of a series of other conditions – myocarditis, in- prove invaluable when evaluating congenital vascular
filtrative processes, and tumors. It is also important to note diseases. [17, 18]
that the differentiation between intracardiac neoplasm and
thrombus can only be made by means of contrast enhance- CONCLUSION:
ment [3-7]. CMR is a novel method, with a vast arsenal of
Most frequently, viability studies are performed imaging sequences, offering a great amount of diagnos-
with late Gd enhancement, using T1-weighted GRE se- tic value, but also demanding a very thorough knowledge
quences [13]. The images are made with a single IR of the method’s intricacies for optimal effect.
prepulse, aimed at nulling the signal from normal myo-
cardium so that only the pathologically enhancing struc- Project acknowledgement:
tures can be of high signal. Healthy structures are to ap- The study is supported by Grant 13/3, 14. 12. 2017,
pear black, while blood within the left ventricle should of the National Research Fund of the Bulgarian Ministry
be of intermediate signal strength – neutral gray. A stand- of Education and Science.
ard protocol can procure precontrast images, first-pass

J of IMAB. 2019 Oct-Dec;25(4) https://www.journal-imab-bg.org 2721

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Please cite this article as: Valchev G, Popova R, El Shemeri S, Bocheva Y, Usheva N, Galcheva S, Iotova V, Yotov Y.
Applications of Routine Cardiac MRI Pulse Sequences - A Contemporary Review. J of IMAB. 2019 Oct-Dec;25(4):2718-
2722. DOI: https://doi.org/10.5272/jimab.2019254.2718

Received: 30/01/2019; Published online: 03/10/2019

Address for correspondence:

Georgi Valchev, MD, PhD,
UMHAT “Sveta Marina” Varna, Clinic of Diagnostic Imaging.
1, Hristo Smirnenski Blvd., Varna, Bulgaria.
E-mail: georgi.valchev@mu-varna.bg
2722 https://www.journal-imab-bg.org J of IMAB. 2019 Oct-Dec;25(4)