J Cardiovasc Imaging.  2019 Apr;27(2):73-92. 10.4250/jcvi.2019.27.e17.

Role of Cardiac Computed Tomography in the Diagnosis of Left Ventricular Myocardial Diseases

• Ko SM
• Hwang SH
• Lee HJ

• KMID: 2442741
• DOI: http://doi.org/10.4250/jcvi.2019.27.e17

Abstract

Multimodality imaging is indicated for the evaluation of left ventricular (LV) myocardial diseases. Cardiac magnetic resonance (CMR) allows morphological and functional assessment of the LV along with soft tissue characterization. Technological advances in cardiac computed tomography (CT) have led to the development of techniques for diagnostic acquisition in LV myocardial disease. Cardiac CT facilitates the characterization of LV myocardial disease based on anatomy, function, and enhancement pattern. LV regional and global functional parameters are evaluated using multi-phasic cine CT images. CT myocardial perfusion facilitates the identification of hemodynamically significant coronary artery stenosis. Cardiac CT with delayed enhancement is used to detect myocardial scarring or fibrosis in myocardial infarction and non-ischemic cardiomyopathy, and for the measurement of extracellular volume fraction in non-ischemic cardiomyopathy. In this review, we review imaging techniques and key imaging features of cardiac CT used for the evaluation of myocardial diseases, along with CMR findings.

Keyword

Computed tomography; Hypertrophy; Myocardium; Echocardiography; Magnetic resonance imaging

MeSH Terms

Cardiomyopathies*
Cicatrix
Coronary Stenosis
Diagnosis*
Echocardiography
Fibrosis
Hypertrophy
Magnetic Resonance Imaging
Myocardial Infarction
Myocardium
Perfusion
Tomography, X-Ray Computed

Figure

• 

  Figure 1 Changes of left ventricular (LV) wall thickness during mid- and end-diastole. Evaluations of LV wall thickness require precise measurements, usually at end-diastole. Cardiac computed tomography is normally performed mid-diastole to assess the coronary artery. Interpretation of LV wall thickness with short-axis multiplanar reformatted images may be misleading at mid-diastole (A) compared to end-diastole (B).

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  Figure 2 Static stress perfusion cardiac computed tomography (CT) imaging in a 40-year-old male with chest discomfort. Short-axis multiplanar reformatted images of cardiac CT acquired at stress (A) and rest (B) show reversible subendocardial perfusion defects in the mid lateral, inferior, and inferoseptal left ventricular (LV) walls (arrowheads). Cardiovascular magnetic resonance perfusion imaging acquired at stress (C) and delayed contrast enhancement (D) show subendocardial myocardial infarction at the mid inferolateral and inferior LV wall (D, arrowheads), and peri-infarction ischemia in the mid lateral, inferior and inferoseptal LV wall (C, arrowheads). Stress perfusion CMR is superior to stress perfusion cardiac CT for the depiction of stress induced myocardial perfusion defects.

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  Figure 3 Infarct imaging using arterial and delayed-enhancement cardiac computed tomography (CT) in a patient with an old myocardial infarction in the left circumflex territory. Short-axis multiplanar reformatted (MPR) images of arterial (A) and delayed-phase (B) cardiac CT show thinned myocardium with fixed subendocardial perfusion defect (arrowheads) and delayed transmural hyperenhancement (arrow) in the mid inferior left ventricular wall. (C) Curved MPR coronary CT angiography image shows significant stenosis with noncalcified plaque of the left main coronary artery (arrow) and occlusion at the distal left circumflex artery (arrowhead). Subendocardial perfusion defect indicates microvascular occlusion.

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  Figure 4 Global and regional left ventricular (LV) function assessment with cardiac computed tomography (CT) in an 80-year-old woman with ischemic cardiomyopathy. Four-chamber multiplanar reformatted (MPR) images of cardiac CT obtained during end-diastole (A) and end-systole (B) show dilated LV cavity and apical ballooning with thinned apical lateral wall and akinesia/dyskinesia (arrows, apical aneurysm). The mid inferior and mid inferolateral LV walls (arrowheads) are noted to be thin and akinetic on short-axis MPR image of cardiac CT obtained at the end-systolic phase (C). LV ejection fraction, end-diastolic, and end-systolic volumes were 31%, 198 mL, and 137 mL, respectively. Conventional coronary angiography confirmed total occlusion at the proximal right coronary artery and subtotal occlusion at the mid anterior descending coronary artery and distal left circumflex coronary artery (not shown).

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  Figure 5 Left ventricular (LV) myocardial fat with cardiac computed tomography (CT) in a 51-year-old male with old myocardial infarction. (A) A curved multiplanar reformatted coronary CT angiography image shows significant stenosis (arrowhead) of the proximal left anterior descending coronary artery. Precontrast (B) and arterial phase (C) cardiac CT images show curvilinear fat deposition (arrowheads) in the subendocardium of the thinned LV myocardium (6 mm in thickness) in apical septal and lateral LV wall.

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  Figure 6 Left ventricular (LV) aneurysm with calcification and intracavitary thrombus in a 65-year-old male with old myocardial infarction (MI). Axial delayed-phase cardiac computed tomography image obtained at the end-systolic phase shows an LV apical aneurysm with calcification (arrow), intracavitary thrombus (arrowheads), and delayed transmural hyperenhancement of the apical to mid septal LV myocardium (thin arrows). Four-chamber delayed-phase cardiac magnetic resonance image obtained at the mid-diastolic phase shows an apical aneurysm with intracavitary thrombus (arrowheads) and diffuse subendocardial delayed hyperenhancement of the LV septum and lateral wall (arrows), consistent with old MI.

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  Figure 7 Left ventricular (LV) pseudoaneurysm with calcification and intracavitary thrombus in a 65-year-old male with stable angina. Short-axis multiplanar reformatted (A) and thick slap maximum intensity projection (B) images of cardiac computed tomography obtained at the end-diastolic phase show LV inferior wall outpouching with a relatively narrow neck (black arrow), intracavitary thrombus, and multiple calcifications along its wall (arrowheads).

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  Figure 8 Asymmetrical septal hypertrophic cardiomyopathy in a 57-year-old man with chest pain. (A) Short-axis multiplanar reformatted (MPR) image of arterial phase cardiac computed tomography (CT) shows asymmetrical hypertrophy of the mid anterior, septal, and inferior left ventricular (LV) wall at end-diastole. Short-axis MPR images of delayed phase cardiac CT (B) and cardiac magnetic resonance (C) show diffuse transmural enhancement in the septum, anterior, and inferior LV wall (arrowheads).

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  Figure 9 End-stage midventricular hypertrophic cardiomyopathy in a 76-year-old female. Four-chamber multiplanar reformatted arterial (A) and delayed-phase (B) cardiac computed tomography images show hypertrophy involving the middle third of the left ventricle (LV) (A, arrows) along with apical thinning, resulting in the characteristic hourglass or dumbbell-shaped appearance of the LV cavity, transmural apical enhancement (B, arrows), and hypoenhancing foci along the subendocardial surface in this region (A and B, arrowhead), compatible with thrombus.

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  Figure 10 Cardiac sarcoidosis in a 61-year-old female with irregular cardiac rhythm and dyspnea. (A) Short-axis multiplanar reformatted image of cardiac computed tomography (CT) was used to obtain the arterial phase, which shows asymmetrically hypertrophied mid septum and inferior left ventricular (LV) wall (arrowheads) at end-diastole. Delayed-phase cardiac CT (B) and cardiovascular magnetic resonance (C) images diffuse midwall and transmural delayed enhancement (arrowheads) in the entire LV wall.

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  Figure 11 Cardiac amyloidosis in a 74-year-old male who presented with chest pain. Two-chamber multiplanar reformatted image of arterial (A) and delayed-phase cardiac computed tomography (B) obtained during mid-diastole shows hypertrophy of the left ventricular (LV) myocardial wall and diffuse, concentric subendocardial and transmural enhancement (arrowheads) in the LV myocardial wall.

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  Figure 12 Dilated cardiomyopathy in a 63-year-old male. Short-axis multiplanar reformatted images of arterial-phase cardiac computed tomography obtained during end-diastole (A) and end-systole (B) show a dilated left ventricle (LV), preserved myocardial thickness, and severe global hypokinesia. (C) Delayed-phase four-chamber cardiovascular magnetic resonance imaging shows dilated left cardiac chambers and subtle midwall delayed enhancement (arrowhead). LV ejection fraction, end-diastolic, and end-systolic volumes were 14.7%, 341 mL, and 291 mL, respectively.

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  Figure 13 Non-compaction cardiomyopathy in a 33-year-old female with acute pain. Short-axis multiplanar reformatted images of arterial phase cardiac computed tomography obtained during end-diastole show increased thickness of the noncompacted layer in the anterior, lateral, and inferior segments of the mid left ventricular wall, with a ratio of noncompacted (black arrow) to compacted myocardium (white line) > 2.3:1.

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  Figure 14 Myocarditis in a 25-year-old male who had complained of dyspnea for 10 days. Short-axis multiplanar reformatted image of delayed-phase cardiac computed tomography shows midwall delayed enhancement in the mid anteroseptum (arrow) and subepicardial enhancement in the lateral and anterior left ventricular wall (arrowheads).

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  Figure 15 Hypertensive heart disease in a 72-year-old male. Short-axis and four-chamber multiplanar reformatted early-phase cardiac computed tomography images obtained during end-diastole show a concentrically hypertrophied entire left ventricular wall.

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  Figure 16 Severe aortic valve stenosis in a 79-year-old man with chest discomfort and shortness of breath. (A) Double oblique multiplanar reformatted (MPR) image of aortic valve shows thickened and calcified cusps of the bicuspid aortic valve (arrowheads) with a severely reduced opening (aortic valve area of 82 mm2) during early systole. (B) Short-axis MPR image shows the hypertrophied mid left ventricular (LV) wall, and particularly asymmetric septal hypertrophy (arrowheads). Delayed-phase cardiac computed tomography (CT) (C) and cardiovascular magnetic resonance (CMR) (D) images show delayed subendocardial hyperenhancement in the lateral and inferior LV wall (arrowheads). Diffuse midwall delayed enhancement in the LV septum (arrows) is only identified on delayed-enhancement CMR. Delayed enhancement CMR is superior to delayed-enhancement cardiac CT for the depiction of patterns of delayed myocardial enhancement.

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  Figure 17 Sigmoid septum of a 77-year-old male without hypertension. A three-chamber multiplanar reformatted image of early-phase cardiac computed tomography shows focal hypertrophy of the basal inter-ventricular septum (arrowheads) without hypertrophy elsewhere within the myocardium mid-diastole in the left ventricular outflow tract.

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