Accurate images from inside the heart

Prof. Dr. Jeanette Schulz-Menger is a cardiologist who specializes in cardiovascular MRI imaging. Her 'Cardiac MRI' working group is based at the Experimental and Clinical Research Center (ECRC), which is jointly run by Charité and MDC.

Prof. Schulz-Menger, what is the exact focus of your research?

We are studying how magnetic resonance imaging can be used to better visualize myocardial injury, i.e. damage to the heart muscle, and to use this information to better understand what causes it. Cardiovascular magnetic resonance imaging (cardiac MRI) is gradually turning into a key technological development. It is the only imaging technology that allows the heart muscle to be examined without the need for invasive procedures and without the use of x-rays or radioactive substances, which allows abnormalities to be diagnosed at an early stage. However, assessing changes in the heart muscle in vivo remains a serious challenge, both within cardiovascular research and clinical cardiology. Our aim is to gain an understanding of the disease mechanisms and to refine the diagnostic methods available to us to allow us to more accurately predict a patient's risk level. It is our hope that cardiac MRI will be able to provide a firm foundation for subsequent treatment decisions, and that it will make treatment more adaptable to clinical circumstances.
You are both a researcher and a physician. How did this link between research and clinical practice develop?

I have spent many years working as a Senior Physician and Head of Department, and have been part of the cardiac MRI working group, which was initially developed at 'Franz-Volhard-Klinik' in Berlin-Buch, since 1996. I have been leading this working group, which includes researchers, physicians, doctoral students, technical staff, and study nurses, since 2004. In 2008, I was appointed to the HELIOS Foundation Professorship for Cardiovascular Magnetic Resonance Imaging at Charité. This professorship allowed me to work in close cooperation with the Max Delbrück Center for Molecular Medicine and to develop a specific research focus that would be centered on the clinical applications of MRI.

How did this link between research and clinical practice develop?

I have spent many years working as a Senior Physician and Head of Department, and have been part of the cardiac MRI working group, which was initially developed at 'Franz-Volhard-Klinik' in Berlin-Buch, since 1996. I have been leading this working group, which includes researchers, physicians, doctoral students, technical staff, and study nurses, since 2004. In 2008, I was appointed to the HELIOS Foundation Professorship for Cardiovascular Magnetic Resonance Imaging at Charité. This professorship allowed me to work in close cooperation with the Max Delbrück Center for Molecular Medicine and to develop a specific research focus that would be centered on the clinical applications of MRI.

How important are these two roles to you?

It is important to me to be both researcher and physician. Direct contact to clinical practice is key for the medically-oriented researcher. Clinical practice tells us which problems can interfere with a patient's medical prognosis and treatment, for instance, during the early diagnosis of damage to the heart muscle. Conversely, it is important to use clinical research to find solutions that can be quickly adopted into clinical practice. In many of our research projects, we start by developing fundamental technological solutions, which includes experimental testing using phantom models. This then paves the way for more disease-specific research.

What successes have you had so far?

The use of MRI in the diagnosis of hypertrophic cardiomyopathy (a congenital abnormal thickening of the heart muscle) where changes in the heart muscle are assessed using pixel intensity analysis, Fig.: AG Kardiale MR (cardiac MRI working group)

Since its foundation in 1996, our cardiac MRI working group has led international efforts in the study of MRI scanning and its use in the differentiation of myocardial injury, particularly in non-coronary heart disease. We have developed a number of new techniques for the qualitative and quantitative evaluation of both inflammatory and non-inflammatory myocardial injury, which have since been incorporated into international guidelines. Our involvement in the ECRC's Berlin Ultrahigh Field Facility (B.U.F.F.) has allowed us to significantly expand and develop our experimental research endeavors. Thanks to our close cooperation with the B.U.F.F. research group, led by Prof. Thoralf Niendorf, we have been able to develop the technological prerequisites that allow us to perform cardiac MRIs on a 7T MRI scanner. Today, we are one of only five centers in the world capable of visualizing the beating heart using the 7T MRI technology. Over the past three years, we have been developing structures within the ECRC, which allow us to conduct systematic and innovative analyses of cardiac MRIs. We are collaborating with centers all over the world to further advance post-processing and to develop new techniques. Through parametric mapping, a method that allows us to accurately quantify changes, we are already in a position to assess structural changes to the heart muscle and to quantify its extracellular volume. We are, of course, also involved in a number of international, multi-center studies investigating a range of disorders. We are particularly excited to be involved in an NIH-funded multi-center study that will be aimed at investigating risk-level assessment in hypertrophic cardiomyopathy. This effectively completes the circle for us, as we were one of the first in the world to investigate the tissue characteristics associated with this disease.

What type of MRI scanner are you currently using?

Most of our work is done on either a 1.5T MRI or a 3T MRI scanner, both of which are capable of meeting the highest standards. We are currently running studies into diseases affecting the heart valves and heart muscle, and we are pleased that some of our findings have already been applied in clinical practice. B.U.F.F.'s 7T MRI scanner offers unique opportunities in this regard. MRI scanners operating at this type of field strength are capable of producing images of tissue structure at the microscopic scale. However, the device manufacturers have not as yet certified them for routine clinical use. So far, their use is limited to experimental research, and we are in the process of assessing their potential in cardiovascular research.

Does a higher tesla rating mean better image quality?

A higher tesla rating does not automatically translate into better image quality, but it does involve a number of theoretical and practical challenges. For instance, one needs to compare the different technologies to determine what is better about the 1.5T MRI and what is better about the 3 MRI scanners. Overall, what is important to remember is that higher resolution does not always mean 'better'. What makes a device better is when its use can be translated into an actual treatment concept, or if it allows an accurate assessment of a patient's level of risk. These are the questions that we are currently debating at international cardiac MRI meetings. What is certain, however, is that we have some way to go before the potential of the 1.5T MRI scanner is fully exploited.

Where is the funding for your research coming from?

This research is supported by government funding, as well as funding from different foundations, and from industry. As a Charité research group, we form part of Charité's performance-related funding program. We have also been successful in securing funding from the Federal Ministry of Education and Research, the German Heart Research Foundation, the German Center for Cardiovascular Disease, the German Cardiac Society, the Else-Kröner-Fresenius-Stiftung (Foundation), and the HELIOS Research Center's HELIOS research funding program.

How can patients benefit from the ECRC's Cardiology Outpatient Unit?

Patients who are referred to our Outpatient Unit are sent to us because they need highly specialized advice and diagnostics. In contrast to our colleagues in private practice, we do not offer services for patients insured through statutory insurance providers. We see ourselves as a contact point specifically for those interested in the type of heart muscle and heart valve disorders that form the focus of our own research. Therefore, it is only natural that we are able to provide highly specialized expertise in this area. Our advice and diagnostic services are provided in close cooperation with other Outpatient Units on campus. As part of our research endeavors, we also offer excellent examination facilities, and we can spend significantly more time with patients than might be possible in routine clinical practice.

Interview by:
Christine Minkewitz/ BBB Management GmbH Campus Berlin-Buch