IMAGING VIGNETTE Imaging Ischemic and Reperfusion Injury in Acute Myocardial Infarction Putting the Pieces Together With CMR Jan Bogaert, MD, PHD, a Davide Curione, MD, a Pedro Morais, MSC, b,c,d Manuel Barreiro-Perez, MD, a Sofie Tilborghs, MSC, e Frederik Maes, PHD, e Tom Dresselaers, PHD a ACUTE MYOCARDIAL INFARCTION IS A COMPLEX CLINICAL CONDITION THAT AFFECTS THE MYOCARDIUM in multiple ways. Cardiac magnetic resonance provides a range of noninvasive sequences that can optimally characterize jeopardized myocardium in acute coronary syndrome patients through both visual and quanti- tative (parametric) techniques, including nonenhanced (T 2 -weighted imaging, native T 1 -mapping, T 2 and T 2 * mapping) and contrast-enhanced imaging (early and late gadolinium-enhanced imaging, post-gadolinium T1-mapping and calculation of extracellular volume) (Figures 1 to 4). These techniques identify myocardial edema and infarction, presence of microvascular obstruction and intramyocardial hemorrhage as well quantify myocardial and ventricular performance (Figures 1 to 4, Table 1). Correct use and interpretation of cardiac magnetic resonance images can provide a wealth of information for diagnosis and prognostication on in acute myocardial infarction (1,2). It should be noted relaxation times are dependent on the field strength and to some extent as well on the acquisition protocol used. All cases discussed were performed on a 1.5-T magnet. TABLE 1 Characterization of the Different Components of the Jeopardized Myocardium Using Comprehensive CMR T1 ECV T2 T2* T2-Weighted EGE LGE Remarks Myocardial edema [ [ [[ — Bright [† [† Edema typically in CA perfusion territory Myocardial necrosis [ [[ — — — [ [[ Enhancement typically in CA perfusion territory, subendocardial pattern with variable transmural spread of enhancement MVO — ‡ — — — Dark Dark§ MVO in center of enhancement area IMHk Y ¶ — YY Dark — — IMH in center of myocardial edema The key findings for differentiation of the different components in the jeopardized myocardium are shown in bold. †Faint enhancement. ‡Presence of MVO may affect accuracy of ECV calculation. §Fill-in of MVO between EGE and LGE. kIMH is nearly always associated with MVO (not vice versa). ¶Presence of IMH may affect accuracy of ECV calculation. CA ¼ coronary artery; CMR ¼ cardiac magnetic resonance; ECV ¼ extracellular volume; EGE ¼ early gadolinium-enhanced imaging; IMH ¼ intramyocardial hemorrhage; LGE ¼ late gadolinium-enhanced imaging; MVO ¼ microvascular obstruction. From the a Department of Imaging and Pathology, KU Leuven–University of Leuven, Leuven, Belgium; b Lab on Cardiovascular Imaging and Dynamics, Department of Cardiovascular Sciences, KU Leuven–University of Leuven, Leuven, Belgium; c Life and Health Sciences Research Institute/Biomaterials, Biodegradables and Biomimetics Research group—Portugal Government Associate Laboratory, Braga/Guimarães, Portugal; d Instituto de Engenharia Mecânica e Gestão Industrial, Faculdade de Engenharia, Universidade do Porto, Porto, Portugal; and the e Medical Imaging Research Center, ESAT-PSI, Processing Speech and Images (PSI), Department of Electrical Engineering (ESAT), KU Leuven, Leuven, Belgium. Dr. Morais has received funding for his PhD scholarship (FCT—Fundacão para a Ciência e a Tecnologia, Portugal, for funding support through the Programa Operacional Capital Humano in the scope of the PhD grant SFRH/BD/95438/2013). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received February 13, 2017; revised manuscript received March 28, 2017, accepted April 14, 2017. JACC: CARDIOVASCULAR IMAGING VOL. -, NO. -, 2017 ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER ISSN 1936-878X/$36.00 http://dx.doi.org/10.1016/j.jcmg.2017.04.008