Table 2 Summary of CMR protocol for patients with suspected TS

Scout

Balanced Steady State Free Precession (bSSFP)

Non-ECG-gated

Transaxial, coronal and sagittal covering the entire thorax

Standard for all CMR studies

Easily identify pleural and pericardial effusions

Edema

Black blood T2-weighted (fast spin echo) triple-inversion recovery (IR)

Short-axis plane covering the LV

Slice thickness = 8 mm

Recommended for differential distinction from myocarditis or acute MI. Usual finding is increase SI in mid-apical segments

T1-Mapping

Modified Look-Locker (MOLLI), Shortened Modified Look-Locker Inversion Recovery (ShMOLLI), saturation recovery single shot acquisition (SASHA), others

Short-axis plane covering the LV with specific TI = 100–5000 ms, collected using bSSFP readouts

Slice thickness = 8 mm

Research tool that may serve as a complementary technique to T2-weighted imaging. Quantitative means to detect myocardial edema without the need for reference ROIs

T2-Mapping

T2-prepared single-shot SSFP sequence, Multiecho FSE (MEFSE), others

Matching short-axis T1

Application under research evaluation.

T2 values more closely correlate with free water tissue content over T1-based techniques in suspected myocardial inflammation. It may offer a more stable and truly quantitative alternative for edema detection in cases when conventional T2-weighted imaging fails, specially in thin and rapidly moving walls

Morphology and Function

bSSFP

Short-axis plane covering entire LV

Long-axis - 3 slices each plane (2CH, 4CH and LVOT)

Slice thickness = 6–8 mm

Interslice gap = 2–4 mm

Mandatory for all CMR studies investigating TS. It will give information on the hallmark of the disease, regional abnormal contractility not related to coronary territory

Quantitative Tracking Techniques for Myocardial Motion and Strain

Myocardial Tissue Tagging (SPAMM or others) or a post-processing of regular bSSFP cine images

Short-axis plane covering entire LV

Long-axis - 3 slices each plane (2CH, 4CH and LVOT)

Slice thickness = 6–8 mm Interslice gap = 2–4 mm

Tagged or not tagged images require specific softwares for analysis. On bSSFP images is a novel technique with high potential for translating into routine clinical practice allowing tracking of tissue voxel motion of cine-CMR images to assess myocardial strain, velocities and displacement. Potentially useful for detection of subclinical cardiac involvement in TS, or previous TS in the recovery phase.

First-pass perfusion

Saturation-recovery imaging with bSSFP readout

Gd contrast-first-pass bolus: 0.1 mmol/kg at 4–5 mL/s

Immediately after – 2nd Gd bolus for LGE: + 0.1 mmol/kg

3–6 slices acquired in short axis plane of LV

Slice thickness = 8 mm

Images at rest can help on identifying thrombus or previous chronic myocardial infarctions with replacement fibrosis.

EGE

<2 min after 2nd Gd bolus

2D segmented IR gradient echo-inversion time set at 500–550 ms at 1,5 T (identify thrombus). Single-shot or PSIR versions can be an alternative here. Less adopted, the traditional non-gated free-breathing T1w FSE images pre and post Gd bolus, with myocardial SI per se or in relation to skeletal muscle can be used.

Short-axis plane covering LV (especially mid-apical segments)

Long-axis – 1 or more slice each plane (2CH, 4CH and LVOT)

Slice thickness = 8 mm

Interslice gap = 2

A surrogate for capillary leakage and hyperemia in the myocardium. Few data on the literature on the findings of these techniques in TS.

LGE

5–10 min after 2nd Gd bolus

2D segmented IR gradient echo with or without Phase-Sensitive IR (PSIR)

Single-shot or 3D versions of LGE can also be used.

Short-axis plane covering LV (especially mid-apical segments)

Long-axis – 1 or more slice each plane (2CH, 4CH and LVOT)

Slice thickness = 8 mm

Interslice gap = 2

The usual finding in TS is absence of significant myocardial LGE by visual analysis. Quantitative analysis using softwares with a variety of thresholds techniques can detect small amounts of patchy LGE.