REVIEWS AND COMMENTARY•REVIEW

Cardiac MRI: State of the Art

Prabhakar Shantha Rajiah, MBBS, MD, FRCR  •  Christopher J. François, MD  •  Tim Leiner, MD, PhD
From the Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905. Received November 21, 2022; revision requested December 12; revision received
February 6, 2023; accepted February 10. Address correspondence to P.S.R. (email: radpr73@gmail.com).

Conflicts of interest are listed at the end of this article.

Radiology 2023; 000:e223008  •  https://doi.org/10.1148/radiol.223008  •   Content codes:

Cardiac MRI plays an important role in the evaluation of cardiovascular diseases (CVDs), including ischemic heart disease,
cardiomyopathy, valvular disease, congenital disease, pericardial disease, and masses. Large multicenter trials have shown the positive
impact of MRI-based management on outcomes in several CVDs. These results have made MRI an indispensable technique in the
evaluation of these diseases, and cardiac MRI has an important role in multisociety guidelines. MRI is the reference standard for
quantification of ventricular volumes and function. Flow imaging enables accurate quantification of flow and velocities through
valves, shunts, and surgical conduits or baffles. Late gadolinium enhancement and parametric mapping techniques enable tissue
characterization and yield prognostic information. In the past decade, cardiac MRI technology has seen rapid advances in both
hardware and sequences. Multiple novel sequences, such as parametric mapping and four-dimensional flow, are increasingly being
incorporated into routine clinical practice. Acceleration strategies have matured, allowing faster acquisition of cardiac MRI sequenc-
es in patients with arrhythmia and poor breath holding. Challenges of cardiac MRI at high-field-strength magnets and in patients
with indwelling cardiac devices or severe renal dysfunction have been mitigated. Artificial intelligence techniques are decreasing
the complexity of MRI acquisition and postprocessing. This article reviews the current state of the art and emerging techniques in
cardiac MRI.
© RSNA, 2023

Supplemental material is available for this article.

C ardiac MRI is an indispensable technique in the evalu-

ation of cardiovascular diseases (CVDs), providing
comprehensive information on morphology, function,
flow, and tissue characteristics. Over the past 2 decades,
unparalleled innovations in cardiac MRI have led to several
novel techniques getting incorporated into routine clinical
practice. These techniques have significantly reduced the
complexity of cardiac MRI and provided new insights into
CVD (Table). With appropriate guidelines and precau-
tions, cardiac MRI can be offered to patients with indwell-
ing cardiac devices and severe renal dysfunction. Here, we
review the state of the art in cardiac MRI and highlight key
emerging techniques.
Hardware
High-Field-Strength MRI
Most cardiac MRI examinations are performed with 1.5-T
magnets. With increasing availability, high-field-strength
MRI at 3.0 T is also used more and more. At 3.0 T, high
inherent signal-to-noise ratio (SNR), which can be traded
for increased spatiotemporal resolution or decreased acqui-
sition time, high T1 values, and improved spectral sepa-
ration are beneficial for several sequences. These include
perfusion, MR angiography, myocardial tagging, fat sup-
pression, opposed-phase imaging, four-dimensional (4D)
flow, and late gadolinium enhancement (LGE). However,
3.0-T field strength increases the complexity of cardiac
MRI, with increased field inhomogeneities (B0, B1) and
more artifacts, such as susceptibility, band, chemical shift,
and dielectric shading. Balanced steady-state free precession
(SSFP), the workhorse of cardiac MRI, is compromised
by the higher T1 and off-resonance band/flow artifacts,
which necessitate patient-specific shimming, frequency
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adjustment, or decreasing repetition time (1,2). Ferromag-
netic attraction, radiofrequency deposition, and specific
absorption rate are higher at 3.0 T than at 1.5 T, resulting
in a different safety profile for devices. Electrocardiography
(ECG) signals are less reliable at 3.0 T due to magneto-
hydrodynamic effects and may require peripheral pulse
gating (1). Normal reference ranges for T1, T2, and T2*
are different at 3.0 T compared with 1.5 T (1).
The challenges of 3.0-T MRI are amplified with 7.0-T
MRI, which is sparsely available. Acoustic triggering may
be required for cardiac gating. Patient discomfort has
been reported but without clinical implication (3). Small
studies have highlighted the benefits of 7.0-T MRI, in-
cluding higher spatial resolution that can evaluate subtle
myocardial crypts and vessel wall; higher temporal resolu-
tion that is useful in arrhythmias and real-time imaging;
decreased acquisition time including for 4D flow; and
longer persistence of myocardial tags and improved spec-
troscopic analysis. All these advantages are accomplished
with comparable volumetric and functional values as
1.5-T MRI (3,4). Flip angles must be adjusted for opti-
mal SNR and contrast.
Low-Field-Strength MRI
On the other end of the spectrum, there is increased in-
terest in low-field-strength cardiac MRI using magnets
weaker than 1.5 T equipped with advanced gradient and
coil technology. These are smaller permanent magnets
without cryogens that are easier to use and maintain,
some in an open configuration (5). The lower cost of these
scanners can potentially increase cardiac MRI access, es-
pecially in low-to-middle-income countries, where three-
quarters of worldwide deaths from CVD occur, and to
community centers in high-income countries (6). Earlier
Cardiac MRI
Abbreviations
CVD = cardiovascular disease, DL = deep learning, ECG = electro-
cardiography, ECV = extracellular volume, 4D = four-dimensional,
GBCA = gadolinium-based contrast agent, LGE = late gadolinium
enhancement, SNR = signal-to-noise ratio, SSFP = steady-state free
precession, 3D = three-dimensional, 2D = two-dimensional
Summary
Novel cardiac MRI sequences provide new insights on cardiovascular
disease, while acceleration strategies and artificial intelligence offer
faster scan times with easier image acquisition and postprocessing.
Essentials
■ Advances in cardiac MRI acceleration strategies can decrease the
number of breath holds or eliminate them entirely, eliminate
electrocardiography synchronization, and provide real-time
information and volumetric coverage.
■ Parametric mapping techniques allow direct quantification of
myocardial tissue properties, which helps in classification and
prognosis of cardiomyopathies.
■ The four-dimensional flow technique can now be performed and
postprocessed rapidly, simplifying workflow in complex diseases
and providing several novel biomarkers for disease prognosis.
■ Quantitative MR perfusion techniques provide myocardial
blood flow and volume on a pixelwise basis, which is beneficial in
balanced ischemia and microvascular dysfunction.
■ Artificial intelligence can simplify every step in the pipeline of
cardiac MRI, including optimization of imaging protocols, image
acquisition, image reconstruction, postprocessing, image analysis,
disease classification, report creation, and derivation of prognostic
information.
studies were performed with user-modified ramped-down
1.5-T magnets, but dedicated low-field-strength magnets are
now commercially available. Although the SNR is lower than
1.5 T, the homogeneous magnetic field and lower T1 and spe-
cific absorption rate enable higher flip angles, longer repetition
time, and lower bandwidth. Hence, image quality and acquisi-
tion time of 0.35- and 0.55-T scanners are comparable to those
of 1.5-T scanners (7,8). The SNR can be further boosted by us-
ing artificial intelligence (6). Compressed sensing can achieve
two to three times higher acceleration than at 3.0 T due to
decreased data corruption from decreased inhomogeneities (5).
Specific absorption rate, noise, and ECG signal distortion are
lower. Device scanning is safer.
Cine Imaging
Cine imaging provides comprehensive anatomic and func-
tional information about the heart, typically performed with a
balanced SSFP sequence that has high myocardial–blood pool
contrast. A traditional gradient-echo sequence is useful in pa-
tients with cardiac devices or artifacts and in 3.0-T scanning
due to lower vulnerability for magnetic inhomogeneities. Cine
imaging uses a segmented k-space acquisition that fills only a
few k-space lines for each cardiac phase in each cardiac cycle.
After all the data are acquired, it is temporally reordered based
on retrospective ECG synchronization and presented as a con-
tinuously acquired time series (9). The required 15–20 breath
holds can be a challenge with cardiac and other causes of dys-
pnea, resulting in motion artifacts. Consistent cardiac cycles
2 radiology.rsna.org  ■  Radiology: Volume 000: Number 0—Month 2023
are a prerequisite for temporal reordering, which is not pos-
sible in arrythmia. To mitigate arrhythmias, arrhythmic cycles
can be rejected or prospective ECG triggering to R wave can
be used, but this will increase scan time or compromise end-
diastolic information, respectively. Another disadvantage of
using only consistent cardiac cycles is the elimination of the
dynamic pattern that might be a sign of specific CVDs. Unlike
echocardiography, cine MRI is typically not real-time. Real-
time cine MRI is a challenge, often a compromise between
spatiotemporal resolution and reconstruction times (10). Real-
time cine MRI is beneficial in the setting of cardiac arrhyth-
mias and in young children who may otherwise need sedation
or anesthesia. Real-time cine MRI is also useful in the diagno-
sis of pericardial constriction based on respiratory variations in
septal motion (Movie 1) (11), evaluation of dynamic changes
with exercise, fetal cardiac MRI, and interventional cardiac
MRI (10,12–14).
Developments in cine imaging have focused on decreasing
the number of breath holds or eliminating them altogether,
eliminating ECG synchronization, and providing real-time
information and three-dimensional (3D) volumetric cover-
age (9,10). Acceleration strategies that undersample k-space,
including parallel imaging and non-Cartesian trajectories, are
widely used (Table S1) (15). The k-t techniques exploit coher-
ences in the time domain of dynamic acquisitions for more
acceleration but are prone to reconstruction errors (16). Com-
pressed sensing techniques have now matured to allow four to
16 times acceleration by recovering signals from sparse data in
some transform domains, using incoherencies from random
undersampling and performing nonlinear reconstruction (9).
Compressed sensing accomplishes cine imaging in half the
time of conventional sequences with comparable volumetric
values, even with free breathing, in arrhythmia and in children
(17). Long reconstruction time was a challenge, which was
mitigated by using higher computing power of graphic process-
ing units (18). Self-gated techniques use information from the
­images to eliminate respiratory and cardiac motion. These free-
running five-dimensional sequences that also use other accel-
eration strategies can be used to acquire motion-resolved free-
breathing whole-heart cine images (19). Deep learning (DL)
techniques can achieve up to 11 times acceleration (Movie 2),
either by reconstructing undersampled noisy k-space signal
based on training with noisy images or by figuring the transform
function itself (20,21). MR multitasking is a novel technique
that envisions cardiac MRI as a multidimensional modality,
with one dimension indexing the voxel location and the other
dimensions indexing different time dimensions, such as car-
diac motion, respiratory motion, T1 recovery, T2 decay, and
dynamic contrast (22).
Myocardial Perfusion
First-pass MR perfusion has high accuracy in assessing
myocardial ischemia, superior to SPECT, echocardiography,
and invasive angiography and comparable to PET and inva-
sive fractional flow reserve (23–26). Hence, MR perfusion is
now included in guidelines for chronic coronary syndromes
(27). Dynamic postcontrast images are obtained at rest and

Cardiac MRI Sequences or Techniques and Their Applications
Sequence or
Technique Clinical Applications
Cine imaging Morphologic assessment of heart and valves
Quantification of ventricular and atrial
volumes, mass, and function
GRE sequence in patients with artifacts or
devices and high-field-strength MRI
Real-time imaging in pericardial constriction,
arrhythmias, poor breath holders, children
Myocardial Detection of myocardial ischemia in
perfusion epicardial coronary artery disease and
microvascular dysfunction
Late gadolinium Detection of infarction, fibrosis, infiltration,
enhancement inflammation
Characterization of cardiomyopathies
Myocardial viability assessment for myocardial
revascularization
Risk stratification in cardiomyopathies
Phase-sensitive inversion recovery technique:
decreases reliance on accurate inversion time
Wide-band sequence: decreases high-signal
artifact in patients with cardiac devices
Parametric T1, T2, extracellular volume: for assessment
mapping of diffuse fibrosis in cardiomyopathies,
particularly amyloidosis, Fabry disease,
hypertrophic cardiomyopathy, myocarditis;
T2* for iron deposition
Risk stratification
Flow-sensitive 2D flow: quantification of valvular
imaging regurgitation, stenosis, shunts
Contrast agents Gadolinium: in angiography, perfusion,
late enhancement
after pharmacologic stress with a vasodilator (regadenoson, ad-
enosine, or dipyridamole). With pharmacologic stress, normal
coronary arteries dilate, but diseased coronary arteries cannot
dilate any further, resulting in a relative perfusion defect. Semi-
quantitative evaluation of the upslope of time-intensity curves
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Rajiah et al
Emerging Techniques or Applications
Accelerated imaging to decrease or eliminate breath holding, eliminate
ECG synchronization, real-time imaging
4D cine sequence with volumetric coverage
Real-time imaging for fetal and interventional MRI
Quantitative perfusion technique for three-vessel and microvascular
disease
Higher spatial resolution, increased volumetric coverage sequences are
emerging
Exercise perfusion: more physiologic evaluation of perfusion
Noncontrast techniques: T1 mapping, arterial spin labeling, blood
oxygenation level–dependent technique
Dark- and gray-blood techniques for subendocardial infarct
Multiecho fat or water technique: distinguishes fat from scar, useful in
lipomatous metaplasia in myocardial infarction or arrhythmogenic
cardiomyopathy
Noncontrast scar assessment: T1/T1ρ mapping, strain, texture analysis,
deep learning
3D volumetric coverage, parametric mapping over the entire cardiac cycle
T1ρ: elevation in edema, scarring, fibrosis
MR fingerprinting: multiple tissue properties from single acquisition
MR multitasking: multiple tissue parameters from single acquisition
Free-breathing 2D flow: in poor breath holders, hemodynamic information
4D flow-simplified acquisition for complex congenital heart diseases, subtle
shunts, accurate quantification of stenosis by identifying vena contracta,
avoiding measurement in vortices, ensuring internal consistency, improved
retrospective valve tracking for atrioventricular valves
4D flow: flow patterns with risk stratification
4D flow: advanced metrics helical flow, flow displacement, flow angle, wall
shear stress
4D flow: intraventricular flow patterns for diastolic function,
cardiomyopathies
5D flow: free-running sequence without ECG synchronization or breath
holding
2D/4D flow: quantification of diastolic dysfunction
High-relaxivity agents: enhanced vascular signal or decreased contrast
doses
Ferumoxytol: for simplified workflow in congenital heart disease
without specific planning, alternative to CT angiography for annular
measurements in TAVR
(Table continues )
at stress versus rest can generate a myocardial perfusion reserve
index. MR perfusion is performed with several T1-weighted
pulse sequences, preparations, resolutions, contrast techniques,
and coverage. Typically, three two-dimensional (2D) short-axis
sections are acquired, but accelerated sequences can provide
Cardiac MRI

Table (continues): Cardiac MRI Sequences or Techniques and Their Applications

Sequence or
Technique Clinical Applications Emerging Techniques or Applications
Coronary artery Evaluation of proximal coronary artery Assessment for coronary artery stenosis
imaging anomalies Improved spatial resolution
Improved respiratory efficiency using acceleration strategies, navigator/
self/image gating
5D sequence: free running
Coronary wall imaging for plaque burden, high-risk features, thrombus
Strain imaging … Early diagnosis of cardiomyopathies, particularly anticancer therapy related
Predicting response to cardiac resynchronization therapy
Risk stratification
Artificial Automated postprocessing of volumes, Clinical decision-making
intelligence function, perfusion, strain, flow, Image reconstruction: super resolution, decreased noise
parametric mapping Image analysis
Disease classification
Report created
Prognostic information
Automated pipeline that covers multiple steps
Note.—ECG = electrocardiography, 5D = five-dimensional, 4D = four-dimensional, GRE = gradient-recalled echo, 3D = three-dimensional,
TAVR = transcatheter aortic valve replacement, 2D = two-dimensional.

Figure 1:  Quantitative myocardial perfusion. Quantitative stress myocardial perfusion MRI scans in a 71-year-old man with chest pain. Rest (top) and stress (bottom)
cardiac MRI scans show normal global myocardial perfusion without any visible perfusion defect. Global myocardial blood flow (MBF) was 0.92 at rest and 1.78 at stress.

extended 2D or even 3D volumetric coverage (28). Higher
spatial resolution techniques reduce artifacts and improve the
accuracy of subendocardial ischemia detection (28,29).
Quantitative perfusion techniques are entering routine
clinical practice, facilitated by automated in-line postprocess-
ing. This requires using either two sequences or two contrast
material injections to obtain arterial input function. The dy-
namic signal intensity profiles of the left ventricle blood pool
and myocardium are converted to gadolinium concentration
profiles. After modeling, myocardial blood flow in milliliters
per minute per gram of tissue is displayed at stress and at rest
for the entire heart at the segmental level (17-segment Ameri-
can Heart Association model) and at endo- and epicardial lev-
els (Fig 1). Myocardial perfusion reserve is the difference in
myocardial blood flow between rest and stress (30,31). A low
global myocardial blood flow despite adequate hemodynamic
response indicates three-vessel or microvascular disease, which
cannot be detected visually. Quantitative perfusion also pro-
vides better assessment of disease extent, particularly for multi-
vessel disease and peri-infarct ischemia. Quantitative perfusion
is suitable for follow-up after therapy and is an independent
prognostic determinant (32).
Dobutamine, an inotropic agent that increases myocardial
oxygen demand, is less commonly used in cardiac MRI. After
several incremental doses of dobutamine to achieve peak heart
rate, new or worsening (from rest) wall motion abnormalities or
perfusion defect indicates inducible ischemia (33). Dobutamine
MRI has higher performance than stress echocardiography, fur-
ther improved by using strain (34,35). Improved wall motion
at low doses and worsened wall motion at high doses implies
contractile reserve and salvageable hibernating myocardium
(33,36). Exercise can be safely performed during MRI with

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 Rajiah et al

MRI-­compatible ergometers
or treadmills in the scanner,
providing more physiologic
stress than vasodilators for the
evaluation of perfusion or wall
motion. Although exercise car-
diac MRI has good diagnostic
performance, it is only sparsely
available and is limited by tech-
nical challenges (37,38).
Noncontrast techniques
are emerging in the evalua-
tion of myocardial ischemia.
Normal myocardial native T1 Figure 2:  Phase-sensitive late gadolinium-enhanced
increases with vasodilator ad- MRI scans. (A) Two-chamber phase-sensitive inversion
recovery image in a 52-year-old man with myocardial
ministration due to increased
infarction shows transmural infarction in the distribution
myocardial blood volume. of the left anterior descending coronary artery (straight
This response is absent in cor- arrow). A large intracavitary thrombus (curved arrow)
onary stenosis and blunted in is also seen in the left ventricular apex. (B) Short-axis
type 2 diabetes mellitus due to phase-sensitive inversion recovery image in a 55-year-
old man with hypertrophic cardiomyopathy shows patchy
microvascular dysfunction and
midmyocardial enhancement in the ventricular septum
concentric remodeling (39). at the right ventricular insertion points (straight arrows),
However, accurate measure- consistent with interstitial fibrosis due to hypertrophic car-
ment of T1 can be challenging diomyopathy. There is also patchy enhancement in the
at high heart rates after phar- lateral wall that is not hypertrophied (curved arrow).
(C) Short-axis phase-sensitive inversion recovery image
macologic stress (40). Other in a 43-year-old man with cardiac sarcoidosis shows extensive subepicardial to midmyocardial late gadolinium enhance-
alternatives include arterial spin ment in the interventricular septum (arrow) with relative sparing of the subendocardium.
labeling, which traces water
protons labeled by altering their
longitudinal magnetization with and without the inflow of la- The magnitude LGE technique is reliant on choosing an
beled blood or blood oxygenation level–dependent techniques optimal inversion time to null normal myocardium. This can
that depict deoxygenated hemoglobin (41,42). be challenging for inexperienced technologists, particularly in
the presence of amyloidosis or artifacts. The alternative phase-­
LGE Images sensitive inversion recovery technique is not reliant on optimal
LGE images acquired 10–15 minutes after administration of inversion time and uses the fact that scar maintains contrast with
gadolinium-based contrast agents (GBCAs) demonstrate scar, normal myocardium at a broad range of inversion times (50).
fibrosis, and infiltration as high-signal-intensity areas due to The 3D volumetric techniques performed with either breath
increased uptake and delayed washout of GBCA. High signal holding or navigator gating provide a higher SNR but are associ-
intensity is also seen in acute myocardial infarction and myo- ated with partial volume. Single-shot acquisition in one heart-
carditis due to GBCA entering intracellular space secondary to beat with respiratory motion correction and signal averaging
ruptured cell membranes. Inversion recovery images obtained is useful in patients with arrhythmias or poor  breath holding.
at the null point of normal myocardium provide excellent con- Wide-band sequences mitigate the high-signal-­intensity artifact
trast between dark normal myocardium and bright scar, de- in patients with devices caused by off resonance. D ­ ark-blood
tecting even tiny amounts of scar (43,44). Cardiomyopathies LGE using flow-independent techniques helps in the assessment
can be characterized based on the pattern of myocardial LGE of small subendocardial scars that have similar contrast to the
(Fig 2) (45). LGE provides risk stratification, with its presence adjacent blood pool (51); a simpler approach is to obtain phase-
and extent correlating with adverse events, irrespective of the sensitive inversion recovery images at the inversion time of the
cause or ejection fraction (46,47). In myocardial infarction, blood pool, where the blood pool appears gray and the scar ap-
the likelihood of improvement in contractility after coronary pears bright (52). A multiecho water- and fat-separated sequence
revascularization progressively declines in a stepwise fash- can help in distinguishing scar from fat, which can be seen in
ion as the transmural extent of hyperenhancement increases. lipomatous metaplasia in chronic myocardial infarction and in
This principle is used to assess viability, with survival benefit arrhythmogenic cardiomyopathy. Since LGE relies on relative
demonstrated for revascularization of these patients (48,49). variations in signal intensities and a normal reference tissue, it is
In acute myocardial infarction, microvascular obstruction and not sensitive in diffuse myocardial diseases.
intramyocardial hemorrhage are seen as nonenhancing areas New techniques are being developed to assess scar. Scar can
within LGE, indicating reperfusion injury, risk of adverse re- be mapped with native or postcontrast T1 techniques, but scar
modeling, and poorer prognosis (48). is underestimated in the former and overestimated in the latter

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Cardiac MRI

(53). T1ρ is also significantly

­elevated in infarct, which can
help in mapping scars (54).
Strain is decreased in myocar-
dial infarction using feature
tracking or tagging techniques
(55). Texture analysis or ra-
diomics of noncontrast cine
MRI can accurately distinguish
infarcted from normal myo-
cardium (56). DL frameworks
can classify scar and normal
tissue in noncontrast cine im-
ages (57), which can then be
presented as binary images of
scar or normal tissue, and are
Figure 3:  Parametric mapping. (A) Native myocardial T1 map in short-axis plane at the midventricular level in a 49-year-
old man with hypertrophic cardiomyopathy shows elevated native T1 value of 1110 msec due to fibrosis (normal range, more accurate in transmural
950–1000 msec). (B) The extracellular volume in this patient was increased to 31% (normal range, 25%–29%). than subendocardial scar (58).
Texture analysis and DL tech-
niques can be combined (56).

Parametric Mapping
Parametric mapping is a pixel-
wise map of magnetic relaxation
parameters, which allows direct
visualization and quantification
of tissue properties. T1, T2,
T2*, and extracellular volume
(ECV) are the most frequently
used parameters. T1 mapping
measures longitudinal relaxation
from T1-weighted images at
different inversion times. Inver-
sion recovery–based techniques,
such as MOLLI (MOdified
Look-Locker Inversion recov-
ery) and shMOLLI (shortened
MOdified Look-Locker Inver-
sion recovery), are precise but
also highly dependent on heart
rate. Saturation-based tech-
niques, such as SASHA (SAtu-
ration recovery single-SHot
Acquisition) and SAPPHIRE
(SAturation Pulse Prepared
Heart rate independent Inver-
sion REcovery), are more ac-
curate but less precise (59). Na-
tive T1 measures the relaxation
property of myocardium, blood
pool, and interstitium, allowing
Figure 4:  Cardiomyopathy. Comprehensive role of cardiac MRI in a 55-year-old man with cardiac amyloidosis. tissue characterization without a
(A) Four-chamber cine balanced steady-state free precession image shows mild concentric thickening of the left ventricular GBCA. Native T1 is increased
myocardium. (B) Four-chamber phase-sensitive inversion recovery image shows extensive subendocardial enhancement of in fibrosis, amyloid, and edema
the left ventricular myocardium and the right ventricular myocardium, atria, and interatrial septum, consistent with cardiac
amyloidosis. (C) Short-axis T1 mapping image at midventricular level shows elevated native T1 value of 1150 msec. (Normal
(Fig 3) and is decreased in iron
range in this scanner is 950–000 msec.) (D) Short-axis extracellular volume (ECV) map in midventricular level shows elevated and fat. T1 mapping is valuable
ECV values of 45% (normal is <25%), consistent with extensive expansion of extracellular space due to amyloid deposition. in the setting of Fabry disease,

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 Rajiah et al

particularly in distinguishing it
from similar-appearing hyper-
trophic cardiomyopathy, with
Fabry disease having low T1
from sphingolipid and hyper-
trophic cardiomyopathy hav-
ing high T1 from fibrosis. T1
mapping can also distinguish
lipid and fibrosis, which appear
similar in LGE. T1 is poten-
tially more sensitive than T2*
for myocardial iron deposi-
tion (60). However, T1 values
are dependent on multiple
variables, including sequence,
magnet strength, heart rate,
cardiac phase, myocardial re-
gion, age, and sex. Local refer-
ence ranges at the institutional
level should be used.
Postcontrast T1 is decreased
in fibrosis, but this is not typi-
cally used for diagnosis due
to high variability. ECV mea-
sures extracellular vascular and
plasma volume, calculated as
(1/T1 myocardium-post-1/T1
myocardium-pre/1/T1 blood-
pool post-1/T1 blood-pool pre)
× (100-hematocrit). Normal Figure 5:  Acute myocarditis. Comprehensive role of cardiac MRI in a 32-year-old woman with acute myocarditis.
ECV ranges from 23% to 29% (A) Short-axis T2-weighted image shows high signal intensity in the lateral (arrow) and inferior walls due to myocardial
and is less variable than T1, edema. (B) Short-axis phase-sensitive inversion recovery image shows subepicardial to midmyocardial late gadolinium en-
which allows standardization. hancement (arrow) in a distribution similar to that of edema. (C) T2 mapping shows elevated myocardial T2 values (>55
msec) in multiple segments, consistent with acute myocarditis.
The need for hematocrit close
to MRI adds time, cost, and in-
convenience and discomfort for
patients. Synthetic hematocrit level can be estimated from blood ­mapping has been shown to increase the reader confidence
pool T1, but its accuracy is uncertain (61). ECV is elevated in and decrease downstream costs, especially in those with acute
fibrosis (Fig 3B), edema, myocardial injury, and amyloid, with myocarditis, amyloidosis, or Fabry disease (67). A combina-
highest values seen in amyloid, more in amyloid transthyretin tion of T1 and T2 distinguishes edema from fibrosis or infil-
than in amyloid light chain type (62–64). tration. ECV provides incremental value in some populations,
T2 mapping is used to measure transverse relaxation us- especially in those with amyloidosis and acute myocarditis
ing T2-prepared balanced SSFP and gradient-echo, spin- (64,68). T1, T2, and ECV are included in diagnostic criteria
echo, or fast spin-echo sequences. At 1.5 T, normal myo- for myocarditis and are markers of adverse outcomes in sev-
cardial T2 is 48–54 msec (59). Increased T2 is specific for eral diseases (Fig 5) (65,68). ECV may potentially quantify
myocardial edema, commonly seen in acute myocardial in- myocardial infarction more accurately than LGE, including
farction and myocarditis, but also in stress cardiomyopathy, remote myocardium (63).
postpartum cardiomyopathy, transplant rejection, and can- Newest developments in parametric mapping include
cer therapy cardiotoxicity (60). T2 is higher with amyloid novel parameters and capability to evaluate multiple parame-
light chain than with amyloid transthyretin amyloidosis, ters with a single acquisition. T1ρ is T1 relaxation time in the
although this is not useful at a patient level. T2 and T2* are rotating frame that represents longitudinal relaxation in the
decreased in iron and hemorrhage. Abnormal T2 precedes presence of an on-resonance spin-lock radiofrequency field.
symptoms or functional changes and can be used to predict T1ρ is sensitive to interactions between water and macromol-
adverse outcomes (65,66). ecules, such as collagen and proteoglycans, and is elevated in
Parametric mapping is useful in the diagnosis of cardio- edema, scarring, and fibrosis. MR fingerprinting is an emerg-
myopathies, particularly those without LGE (Fig 4) (62). In ing technique that enables simultaneous mapping of multiple
­patients suspected of having cardiomyopathies, parametric tissue parameters including T1, T2, T2*, T1ρ, proton density

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Cardiac MRI

Flow-sensitive Imaging
The 2D flow-sensitive phase contrast
sequence has been widely used for
imaging blood flow since the early
days of cardiac MRI. Flow sensitivity
in through-plane orientation enables
quantification of flow volumes and
velocities, and flow sensitivity in in-
plane orientation enables detection of
flow direction and velocity. The 2D
flow-sensitive phase contrast sequence
is typically performed with breath
holding, but free-breathing sequences
are available. Free breathing also yields
hemodynamic information, which is
useful in diagnosis of pericardial con-
striction based on respiratory variations
of mitral and tricuspid inflow, respira-
tory and cardiac components of flow in
Fontan circuit, quantification of left-to-
right shunts, and evaluation of exercise-
induced changes in Fontan shunt (10).
The 4D flow MRI sequence is a 3D
sequence that is sensitive to blood flow
in three orthogonal dimensions and
that is synchronized to the cardiac cy-
cle to provide time-resolved data. The
4D flow MRI sequence has been in de-
velopment for the past 15 years and is
now increasingly implemented due to
ease of acquisition from routine imag-
Figure 6:  MR fingerprinting is a technique for simultaneous mapping of multiple tissue properties. A special-
ized pulse sequence that is sensitive to multiple tissue properties is used to collect data; a highly undersampled non- ing planes (72). Acceleration strategies,
Cartesian k-space trajectory (spiral in this example) is often used for rapid data collection. The collected signals on efficient flow encoding, partial-echo
a pixelwise basis are matched to dictionary signals. The dictionary is created by performing a physics stimulation for imaging, and echo-planar imaging
many different tissue property combinations where the tissue properties and MR fingerprinting pulse sequences are have decreased scanning times to 5–10
supplied as inputs, and the output is the signal evolution that would result. The result is a set of maps of the tissue prop-
minutes with acceptable image qual-
erties that the MR fingerprinting was designed to measure. With cardiac MRI, tissue properties including T1, T2, T1ρ,
T2*, proton density (M0), and proton density fat fraction (PDFF) have been measured in the heart. (Image courtesy of ity and spatial resolution and values
Nicole Seiberlich, PhD, and Gastao Cruz, PhD, University of Michigan.) comparable to those of 2D flow MRI.
When compared with 2D flow MRI,
4D flow MRI improves the workflow
fat fraction, diffusion coefficient, perfusion, B0, B1, magne- in complex congenital heart diseases by obviating the need for
tization transfer, chemical exchange saturation transfer, and dedicated acquisitions at multiple locations (Fig 7A, Movie 3).
flow from a single scan (69). Assumptions on tissue proper- The 4D flow MRI sequence also improves visualization of subtle
ties are fewer, and scanner-to-scanner variability is lower. MR cardiac shunts. The 4D flow MRI sequence improves quantifica-
fingerprinting uses random acquisition with varying values tion of atrioventricular valves due to more options for retrospec-
of imaging parameters (repetition time, echo time, inversion tive valve tracking (73). The 4D flow MRI sequence improves
time, and flip angle) to generate signal evolutions or finger- quantification of flow by avoiding measurement in helices which
prints unique to different tissues. These fingerprints are then lead to inaccuracies and quantification of velocity by identifying
matched to a precalculated dictionary of fingerprints, and the narrowest portion of jet (vena contracta) with the highest
the best match reveals the underlying parameters that can be velocities. The 4D flow MRI sequence can also yield 3D v­ olume
evaluated (Fig 6) (69,70). Technical developments have made renderings of vascular structures without administration of
MR fingerprinting vendor independent, more efficient, and ­intravenous contrast material.
more accurate with capabilities for cine, free-running, simul- The 4D flow MRI sequence can p ­ rovide advanced metrics,
taneous multislice, and 3D whole-ventricle coverage (70). including pressure gradients, wall shear stress, kinetic energy,
MR multitasking and Bloch equation stimulation with sec- energy losses, and pulse wave velocity in a wide variety of
tion profile correction can also be used to measure T1 and T2 CVDs. In bicuspid aortic valve, abnormal flow patterns, such
simultaneously (71). as helical systolic flow, systolic flow displacement, abnormal

8 radiology.rsna.org  ■  Radiology: Volume 000: Number 0—Month 2023

 Rajiah et al

Figure 7:  Four-dimensional (4D) flow cardiac MRI. (A) Coronal 4D flow cardiac MRI scan with path lines in a 42-year-old woman with left atrioventricular (A-V) valve
atresia, pulmonary valve atresia, large inlet ventricular septal defect, overriding aorta, Blalock-Taussig shunt with subsequent takedown, and lateral Tunnel Fontan. With one
coronal plane 4D flow acquisition, flow can be interrogated and quantified in any structure within the imaging plane without the need for dedicated and time-consuming
planning. In this patient with a Fontan shunt, flow was measured in the inferior vena cava (IVC), superior vena cava (SVC), left pulmonary artery (LPA), right pulmonary artery
(RPA), left pulmonary vein (LPV), right superior pulmonary vein (RSPV), right inferior pulmonary vein (RIPV), tricuspid valve (TV), ascending aorta (AO), and descending thoracic
aorta (DAO) to calculate various flow parameters. Asc = ascending, Desc = descending. (B) A 4D flow cardiac MRI scan in a 32-year-old woman with bicuspid aortic
valve shows helical flow in the ascending aorta. (C) A 4D flow cardiac MRI scan in a 40-year-old man with hypertrophic cardiomyopathy shows abnormal intracardiac
flow pattern. Direct flow (green) is 49%, delayed ejection (blue) is 13%, retained inflow (yellow) is 32%, and residual volume (red) is 7%. Compared with healthy individuals,
retained inflow is increased due to diastolic dysfunction.

flow angle, and wall shear stress, have been demonstrated,
variable with different phenotypes (Fig 7B, Movie 4) (74).
Elevated aortic wall shear stress has been shown to correlate
with extracellular matrix dysregulation and elastic fiber de-
generation, indicating the ability to stratify risk and predict
aortic growth (75). Flow sequences through mitral inflow,
mitral annulus, and pulmonary vein can be used to accurately
categorize diastolic dysfunction in 95% of patients (76,77).
Intracardiac flow metrics, such as flow components, kinetic
energy, intraventricular vortices, and pressure gradients, are
promising in evaluation of diastolic dysfunction and cardio-
myopathies (Fig 7C, Movie 5) (76). As a next development,
five-dimensional flow frameworks combine radial undersam-
pled data with cardiac and respiratory self-gating to provide

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Cardiac MRI

motion-resolved multipoint velocity-encoded 3D hemody- and gadoquatrane, may allow improved vascular visualization
namics in 8 minutes (78,79). or decreased doses (80,81). Ferumoxytol is an ultrasmall su-
perparamagnetic iron oxide nanoparticle that is not e­ xcreted
Contrast Agents through the kidney but is metabolized in the reticuloendothe-
GBCAs are the default contrast media in cardiac MRI for per- lial system and incorporated in body iron stores after 15 days.
fusion, angiography, and LGE. Macrocyclic GBCAs can be Ferumoxytol can be used as an off-label alternative to GBCAs
safely administered, even in the setting of severe renal dys- in the setting of severe renal dysfunction or GBCA a­ llergies.
function. Novel high-relaxivity GBCAs, such as gadoplicenol Because of its unique properties, ferumoxytol provides high-
quality anatomic and func-
tional information with simpli-
fied acquisition and workflow
(82). Ferumoxytol has a higher
relaxivity (16 mmol−1sec−1 vs
3.6–6.3 mmol−1sec−1 at 1.5 T)
and stays longer in the blood
pool (14–21 hours vs 1 hour)
than ­GBCAs (83). This elimi-
nates the need for accurate
synchronization of scans with
a contrast material bolus, and
the study can be repeated any
number of times for up to 14
hours. High-spatial-resolution
Figure 8:  Ferumoxytol cardiac MRI in congeni- ECG-gated MR angiographic
tal heart disease. A 5-year-old girl with hypoplastic images can be obtained in the
left-sided heart syndrome, post Norwood procedure, steady state with sharply de-
revised Sano shunt, Glenn shunt, and central shunt. fined vessels and a suppressed
(A) Axial four-dimensional (4D) flow image at the level of
background, which facilitates
the central shunt shows a high velocity jet (red). (B) A three-
dimensional (3D) volume-rendered reconstruction of the excellent segmentation of
thoracic vasculature in the same patient using 4D flow data. arteries and veins (82). The
(C) Isotropic high-resolution (1 × 1 × 1 mm) 3D spoiled higher blood pool signal im-
gradient-recalled cine image has high signal intensity due proves the v­ elocity-to-noise ra-
to the presence of ferumoxytol, which could then be recon-
tio with the 4D flow sequence
structed in any plane.
and improves SNR with the
GRE sequence, which is useful
with cardiac devices.
Ferumoxytol is most useful
in complex congenital
heart disease, especially in
younger children, where
the need for radiologist
supervision, breath hold-
ing or anesthesia, and
syncing of the contrast
material bolus with breath
holding present chal-
lenges and may neces-
sitate repeat studies. The
4D flow and MR angi-
ography sequences in a
standard axial plane with
ferumoxytol on board en-
able unsupervised acqui-
sitions in such patients
Figure 9:  Strain imaging with MRI. (A) Feature-tracking longitudinal strain overlaid on a four-chamber cine image in a 47-year-
old woman with a history of breast cancer treated with carboplatin shows decreased longitudinal strain in multiple segments.
and subsequent recon-
(B) Polar map in the same patient shows abnormal longitudinal strain (greater than –18) in multiple segments, suggestive of cancer struction in any desired
therapy–induced cardiotoxicity. plane (Fig 8; Movies 6, 7).

10 radiology.rsna.org  ■  Radiology: Volume 000: Number 0—Month 2023

 Rajiah et al

Children can be scanned when

they are well fed, calm, or even
sleeping, even several hours after
injection. Dedicated sequences
are available, including those
that use breathing patterns of
ventilated children to combine
respiratory and cardiac gating
(84,85). Cine images obtained
with 4D flow are used for mor-
phologic and functional evalu-
ation. Volume renderings can
be obtained with 4D flow and
MR angiography. Ferumoxytol
can be used to obtain aortic an-
nular measurements in patients
Figure 10:  Artificial intelligence–based image reconstruction with denoising in a 59-year-old man with acute on-
evaluated for transcatheter aortic set of chest pain. (A) Phase-sensitive inversion recovery late gadolinium enhancement image in the short-axis plane
valve replacement with severe re- shows a moderate amount of noise. There is subepicardial late gadolinium enhancement (arrow) in the midinferior wall,
nal dysfunction (82). consistent with myocarditis. (B) Deep learning–based denoising in the same patient at the same level as in A shows a sub-
Ferumoxytol has potential stantial decrease in noise and improved depiction of the scar (arrow).
for imaging inflamed plaques
due to macrophage uptake and
imaging thrombus due to leukocyte phagocytosis at luminal image-based navigator acquired before each high-resolution ac-
interface (86,87). However, ferumoxytol is not widely available quisition (92). Motion-resolved or compensated techniques have
outside the United States and is expensive. Due to increased been developed. By combining these strategies, submillimeter res-
risk of serious hypersensitivity reactions with rapid and high- olution images can be acquired in as little as 270 seconds (91–94).
dose injections, the U.S. Food and Drug Administration issued Fully self-gated automated free-running sequences with resolved
a black box warning in 2015 (82). Self-limiting iron infusion respiratory and cardiac motion enable five-dimensional whole-
reactions such as flushing, myalgia, and arthralgia, also called heart reconstruction in any cardiac phase (95,96).
Fisbane reaction, have also been reported (82). The safety of MRI of coronary arterial wall and plaque is an emerging
ferumoxytol with adequate protocols is now established in a field. Plaque burden and high-risk plaque features, such as
multicenter study and minimized by hydration and slow infu- intraplaque hemorrhage, have been demonstrated in high-
sion (88). Ferumoxytol is contraindicated in patients with iron spatial-resolution T1-weighted images with motion correction
allergies and iron storage diseases. Furthermore, ferumoxytol and real-time section positioning (97). In addition to the draw-
cannot be used to evaluate LGE and interferes with subsequent backs of coronary MR angiography, misalignment between
MRI for 24 hours. coronary MR angiography and plaque imaging is a challenge.
Sequences are being developed to mitigate this misregistration
Coronary Artery Imaging by simultaneously acquiring bright- and dark-blood images
Coronary MR angiography with the whole-heart ECG-gated 3D (98,99). Maturation of coronary MR angiography and wall
SSFP technique can be used to evaluate coronary artery anomalies imaging will expand the capabilities of MRI, which is already
and coronary stenosis in patients with low to intermediate risk, established for function, ischemia, and viability.
without the radiation, nephrotoxic contrast material, and calcium
blooming associated with CT angiography (89,90). However, MR Strain Imaging
angiography is not commonly used for coronary stenosis due to Myocardial strain, an indicator of myocardial deformation
its limitations, which include low-spatial-resolution, the need for through the cardiac cycle, is abnormal in early stages of sev-
complex planning, motion artifacts, and a long scan time due to eral CVDs. Echocardiography remains the reference standard
respiratory inefficiency. Furthermore, CT angiography has strong in assessment of strain in longitudinal, circumferential, and
advantages, including availability, standardization, and guideline- radial d ­ irections, as well as torsion. MRI strain techniques,
based indications. Acceleration strategies and high-field-strength such as myocardial tagging, strain-encoded imaging (SENC),
magnets have decreased the acquisition time of coronary MR displacement-­encoding with stimulated echoes (DENSE), and
angiography (91). Blood pool contrast agents and premedica- tissue phase mapping, are limited in availability (100). How-
tions (nitrates, β blockers) can improve image quality. Respiratory ever, MRI is now emerging as a viable alternative to echocar-
motion is typically managed by tracking diaphragmatic motion diography, largely driven by the feature-tracking technique,
using a navigator sequence, but this requires complex planning which measures strain from postprocessing of routine cine
and a correction factor with often unpredictable scan times (90). images. Strain is useful in the early diagnosis or screening of
Respiratory efficiency can be improved by self-gating, which uses cardiomyopathies, ischemic heart disease, pulmonary hy-
motion data inherent in cardiac MRI or with a low-resolution pertension, transplant rejection, and congenital heart disease

Radiology: Volume 000: Number 0—Month 2023  ■  radiology.rsna.org 11

Cardiac MRI
(101–103). For example, anticancer therapy cardiotoxicity can
be diagnosed with a decrease in global longitudinal strain of
more than 15% from baseline (Fig 9, Movie 8) (100,101). A
single-beat fast strain-encoded imaging technique has shown
feasibility to detect ischemia based on decreased strain (102).
Strain may provide independent risk stratification, with de-
creased strain correlating with adverse prognosis. In ischemia,
strain also predicts segments that will recover function after
­revascularization (102). MRI strain is useful in left ventricle
dyssynchrony to identify patients who may respond to cardiac
resynchronization therapy (ie, those with substantial delay in
peak strain between anteroseptal and lateral left ventricle seg-
ments) (100). Fast SENC sequence can also optimize MRI
workflow and operational efficiency, particularly in screening
patients with heart failure: A fast SENC sequence can be per-
formed first and postprocessed with subsequent cine or LGE
sequences performed only if strain is abnormal (104).
Artificial Intelligence
Artificial intelligence, particularly DL that learns from training
data without explicit programming, is well suited to simplify
every step in the pipeline of cardiac MRI, including optimiza-
tion of imaging protocols, image acquisition, image reconstruc-
tion, postprocessing, image analysis, disease classification, report
creation, and derivation of prognostic information (105). Com-
mercially available DL models are already being integrated in rou-
tine cardiac MRI workflow by hardware and software vendors.
Tasks assisted by DL models include accurate identification of
anatomic landmarks to automatically prescribe canonical cardiac
MRI planes (106), denoise highly accelerated MRI sequences
(107), accurately predict optimal inversion time for LGE (108),
and automatic segmentation of ventricular and atrial contours
for volume, mass, and function at accuracies comparable with
manual expert measurements (109). Automated postprocessing
is available for strain, 4D flow, perfusion, LGE, and paramet-
ric mapping (32). Despite the great progress that has been
made, oversight of algorithm output by human experts remains
essential. For example, most of the inaccuracies of DL-based
postprocessing solutions occur at the cardiac base, which should
then be corrected by the reader (109).
Super resolution is the recovery of high-spatial-resolution
images from low-spatial-resolution observations containing
noise. Super resolution is achievable using DL models and can
be used to reconstruct undersampled k-space data to decrease
acquisition time or improve image quality (Fig 10) (110–112).
Another practical example is the use of a model-based con-
volutional network to estimate a balanced SSFP image from
sparse sampled k-space data and coil sensitivity, with similar
image quality and volumetry accuracy as breath-hold SSFP
(113). DL can optimize other techniques, including accelera-
tion of perfusion and MR fingerprinting, and provides detailed
cardiac motion information for MRI multitasking (114,115).
The newest developments of artificial intelligence are starting
to build automated cardiac MRI pipelines that cover multiple
steps, including preprocessing segmentation, postprocessing,
extraction of data from multiple sequences, and reporting by
single end-to-end solutions (116). In the future, these pipelines
12 radiology.rsna.org  ■  Radiology: Volume 000: Number 0—Month 2023
could be ideally suited for batch processing of cardiac MR data,
for instance in the context of scientific studies. Limitations of
artificial intelligence techniques include the relatively small
and sometimes biased training data sets, inadequate details on
the learning process (black box), and lack of agreement regard-
ing quality criteria for algorithm design, although initial steps
are being taken to address these issues (117).
Conclusion
Modern cardiac MRI enables comprehensive assessment of car-
diac function, flow, tissue characteristics, and energetics. State-
of-the-art sequences and techniques continue to expand the
utility of cardiac MRI in CVDs and shorten acquisition times.
Exciting techniques are emerging and being validated for inte-
gration into clinical practice.
Disclosures of conflicts of interest: P.S.R. Royalties from Elsevier. C.J.F. No
relevant relationships. T.L. Prior institution received grants from Applied and En-
gineering Sciences, The Netherlands; Netherlands Heart Foundation; and Stichting
Hartekind; agreement with Pie Medical via prior institute, with no royalties paid;
payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing
or educational events from Philips Healthcare and Guerbet; U.S. patents 10 176 575,
10 395 366, and 11 004 198 for a method and system used to assess vessel obstruction
based on machine learning; on the advisory board of CartTech and AI4Med; past
president of the International Society for Magnetic Resonance in Medicine; incoming
Editor-in-Chief of the Journal of Cardiovascular Magnetic Resonance.
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