196 Chapter 9 visual first-pass stress perfusion imaging using gadolinium-based contrast agent is an established non-invasive method to test for ischemia. However, this approach requires healthy myocardium to discriminate between ischemia and healthy myocardium since is depends on signal variations between the depicted myocardium. In case of a generalized disease, such as ANOCA, the myocardium might appear normally perfused during firstpass imaging, despite being hypo-perfused. Quantitative perfusion CMR provides absolute measurements of myocardial blood flow (MBF, ml/g/min) and myocardial perfusion reserve (MPR) which offers a more precise assessment and could therefore enhance the diagnostic accuracy of ANOCA using CMR. Yet, integration into clinical practice of quantitative perfusion CMR remains difficult due to the need of a dual-sequence or dual-bolus method, requiring a specific, dedicated pulse sequence or a time-consuming preparation of the diluted pre-bolus, respectively. In Chapter 7 we propose a new readyto-use quantitative perfusion CMR workflow implementing a simplified dual-bolus gadolinium-based contrast agent administration scheme and fully automated QP postprocessing. This approach was tested in 25 patients with suspected myocardial ischemia, who underwent both quantitative perfusion CMR and invasive coronary angiography (CAG) or coronary computed tomography angiography (CCTA) to evaluate obstructive CAD. Our proposed approach provided good image quality and high diagnostic accuracy for detection of obstructive CAD leading to ischemia. In Chapter 8 this ready-to-use quantitative perfusion CMR workflow was used in ANOCA patients and compared to healthy controls, as a sub-study of the MICORDIS to evaluate if this technique could be used as a new technique to diagnose ANOCA instead of invasive coronary testing. Interestingly, visual assessment of myocardial perfusion was similar between the groups, while the ANOCA group showed a reduced global myocardial perfusion reserve (MPR) as determined using QP. MPR showed variation across coronary territories, suggesting the compromised perfusion might be heterogeneous in the myocardium.
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