Analysis of Segmental Strain for the Detection of Chronic Ischemic Scars in Non-Contrast Cardiac MRI Cine Images: A Feasibility Study
Authors: Polacin Malgorzata , Karolyi Mihaly , Eberhard Matthias , Gotschy Alexander , Baessler Bettina , Alkadhi Hatem , Sebastian Kozerke , Manka Robert 
Published: December 2020

Aims Cardiac magnetic resonance imaging (MRI) with late gadolinium enhancement (LGE) is considered the gold standard for scar detection after myocardial infarction. In times of increasing skepticism about gadolinium depositions in brain tissue and contraindications of gadolinium administration in some patient groups, tissue strain-based techniques for detecting ischemic scars should be further developed as part of clinical protocols. Therefore, the objective of the present work was to investigate the feasibility of scar detection in segmental strain calculations based on routinely acquired non-contrast cine images in patients with chronic infarcts.Methods Forty-six patients with chronic infarcts and scar tissue in LGE images (5 female, mean age 52 ± 19 years) and 24 gender- and age- matched healthy controls (2 female, mean age 47 ± 13 years) were included. Global (global peak circumferential [GPCS], global peak longitudinal [GPLS], global peak radial strain [GPRS]) and segmental (segmental peak circumferential [SPCS], segmental peak longitudinal [SPLS], segmental peak radial strain [SPRS]) strain parameters were calculated from standard balanced SSFP cine sequences using commercially available software (Segment CMR, Medviso, Sweden). Two independent blinded readers localized potentially infarcted segments in segmental circumferential strain calculations (endo-/epicardially contoured short axis cine and resulting polar plot strain map) and by visual wall motion assessment of cine images. Results Global strain values were reduced in patients compared to controls (GPCS p= 0.02; GPLS p= 0.04; GPRS p= 0.01). Patients with preserved ejection fraction showed also reduced GPCS compared to healthy individuals (p=0.04). In patients, mean SPCS was significantly impaired in subendocardially (- 5,4% +/- 2) and in transmurally infarcted segments (- 1,2% ± 3) compared to remote myocardium (-12,9% +/- 3, p= 0.02 and 0.03, respectively). ROC analysis revealed an optimal cut- off value for SPCS for discriminating infarcted from remote myocardium of - 7,2 % with a sensitivity of 89,4 % and specificity of 85,7%. Mean SPRS was impeded in transmurally infarcted segments (15,9 % +/- 6) compared to SPRS of remote myocardium (31,4% +/- 5; p= 0.02). The optimal cut-off value for SPRS for discriminating scar tissue from remote myocardium was 16,6% with a sensitivity of 83,3% and specificity of 76,5%. 80.3 % of all in LGE infarcted segments (118/147) were correctly localized in segmental circumferential strain calculations based on non-contrast cine images compared to 53.7% (79/147) of infarcted segments detected by visual wall motion assessment (p > 0.01). Conclusion Global strain parameters are impaired in patients with chronic infarcts compared to healthy individuals. Mean SPCS and SPRS in scar tissue is impeded compared to remote myocardium in infarcts patients. Blinded to LGE images, two readers correctly localized 80% of infarcted segments in segmental circumferential strain calculations based on non-contrast cine images, in contrast to only 54% of infarcted segments detected by visual wall motion assessment. Analysis of segmental circumferential strain shows a promising alternative for scar detection based on routinely acquired, non-contrast cine images for patients who cannot receive or decline gadolinium.