Visualising the invisible:dark-blood late gadolinium enhancement MRI for improved detection of subendocardial scar

In a blockage of the coronary arteries, also known as a heart attack, the heart muscle cells slowly die due to a lack of oxygen. The dead muscle cells no longer contribute to the heart's pumping function and are eventually replaced by fibrous scar tissue. Using an MRI technique called late gadolinium enhancement (LGE), these regions of fibrous scar tissue can be detected. However, since fibrous scar tissue appears almost equally bright as the neighbouring blood pool, detection and assessment of small infarcts directly adjacent to the blood pool are currently challenging. As the presence, size, and spread of the scar tissue largely determine the necessary follow-up treatment, accurate detection and assessment of scar tissue is crucial. So-called 'dark-blood' LGE methods have the potential to increase the limited contrast between the scar tissue and blood pool for improved visualization of this scar tissue. The development and evaluation of a novel, readily available, dark-blood LGE method form the core of this thesis. Studies in both animals and in a group of 300 patients showed that this new method improves the detection and quantification of subendocardial scar tissue compared to the current reference standard, and is able to detect regions that remain undetected when using the current method. Furthermore, the new method has been optimized so that scar tissue can also be imaged using 3D imaging. Lastly, several new clinical applications for this new method were successfully investigated, as well as directly put into clinical practice as described in two case reports. This thesis therefore describes the complete ‘bench to bedside’ trajectory of the development, evaluation, and validation of a new, improved MRI technique that is readily available and is already in daily use in various centres worldwide.