Advanced Cardiac Imaging in Heart Failure Echo and MRI Beyond the LVEF

Transcription

1 West Virginia Am Coll Cardiol Sci Sessions, April, 2016 Advanced Cardiac Imaging in Heart Failure Echo and MRI Beyond the LVEF Vincent L. Sorrell, MD DeMaria Professor of Medicine (Card/ Rad) University of Kentucky / Gill Heart Institute Assistant Chief, Division of Cardiovascular Medicine Chair, Cardiac Imaging Director, Adult Cardiology Fellowship Program

2 Disclosures Potential conflict of interests Research support (Philips, GE, Astellas, AtCor) Educational Consultant (BMS / Lantheus / Edwards) Off-label use Gadolinium MR contrast for the Heart Sponsorship AHA, NHLBI, DCVRI, Steven M. Gootter Foundation

3 Outline ACI for HF The LVEF - What s normal? - How does it impact care? Echo Myocardial Mechanics / current technology Cardiac MRI LGE outperforms LVEF (? ICD) Case Examples

4 ACI in Heart Failure Echo, CMR, Nuclear LV (and RV) size, shape, function Cardiac physiology: SV, CO (CI), PA, LA, RA Valve function Pericardium (effusion, constraint) Myocardium (edema, fibrosis, too thick/thin)

5 How Far We ve Come

6 Echo in 2016

7 Value Equation for ACI Comprehensive Dx Mature technology Proven Dx / Px utility Widely available Immediate (RT) results ECHO = Benefits Costs PUE / HHE Safe Relatively inexpensive

8 Value Equation for ACI Comprehensive Dx Mature technology Outperforms Echo, SPECT, PET CMR = Benefits Costs Reference standard for Dx / Px utility Travel to expert center Safe (rare NSF) Expensive / test Cost savings / healthcare Immediate (RT) results Claustrophobia

9 EF 45% EF 35% Hypertrophic EF 50% Dilated Restrictive

10 Get with the (EF) Guidelines HF guidelines: must check LVEF ( r vs p ) CRT / ICD: consider if LVEF <30-35% Most surgical interventions rely on EF VHD guidelines: no MVR if LVEF <30% Post-infarct Rx recommendations Many percutaneous decisions

11 State of the art = 3DE LV volumes & LVEF

12 3D ECHOCARDIOGRAPHY LVEF using biplane Simpson similar accuracy to 2D if normal LV shape In pts with LVEF <50% by CMR: 3DE: sensitivity = 53%; False (-) rate 47% 2DE: sensitivity = 25%; False (-) rate 75% 2D vs 3D serial evaluation of Chemo pts Variability 3DE 4.9% (vs 2DE 10%) Also highest inter-, intra-variability and test-retest Armstrong GT, et al. J Clin Oncol 2012;30: Thavendiranathan P, et al. J Am Coll Cardiol 2013;61:77-84.

13 Errors in Quantitation Image Position (IP) 2DE errors in Normal controls Geometric Assumption (GA) 2DE errors in CAD Boundary Tracing (BT) A barely visible 1mm error in BT results in ~10% error in volumes* * Mor Avi V, et al. JACCI 2008; 1:

14 Modified from Rudski LG, et al. J Am Soc Echocardiogr 2010; 23:

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16 Is this a normal LV?

17 LV mechanics in Hypertension Onset of T-tubule disruption HTN Strain LVEF Abnormal calcium transients LVH Fibrosis Systolic dysfunction OVERT HEART FAILURE Diastolic dysfunction Time (months) Shah et al. Am J Physiol Heart Circ Physiol. 2103

18 Twist and Shout Myocardial Mechanics

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21 Expanding conventional techniques LVEF 55% LVEF 50% GLS -5.6% GLS -5.0%

22 Used as a measure to: - define HFpEF - implant ICD - perform CRT

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28 PATIENT CASE 40F with multiple cycles of chemorx and BMT

29 PATIENT CASE 40F with multiple cycles of chemorx and BMT

30 PATIENT CASE 40F with multiple cycles of chemorx and BMT

31 PATIENT CASE 40F with multiple cycles of chemorx and BMT

32 SPECKLE TRACKING To date, there are 17 peer-reviewed reports on deformation indices (St, SR, twist) in detection of subclinical cardiotoxicity in pts Rx for cancer Decrease in myocardial systolic function is rapid (within 2 hours of first dose) 10-20% This precedes reduced LVEF; or may occur without low LVEF No preference to subendo, midmyo, or subepi (consistent with biopsy data of diffuse apoptosis) Sawaya H, et al. Early detection and prediction of cardiotoxicity in chemotherapy-treated patients. Am J Cardiol 2011;107:

33 LV Compensation (LVEF preservation) Subendocardial dysfunction (ischemia): effect on LV rotation Counteraction of torsion by contraction of the subendocardial myofibers is less effective, causing torsion to increase

34 Canary in the KY Coalmine Use strain in the echo lab LVEF is prognostic in large population studies LVEF is not a reliable marker of LV function in individual patients Extensive LV systolic dysfunction will often occur despite normal LVEF

35 LV Function LVEF = Cub Strain = 787

36 HFpEF LVEF partitioning cutoff E/e as surrogate of LVEDP Type of LV remodeling Rest vs exercise symptoms

37 LVEF cutoff 40% 45% 50% 55% 60% ASE 52% (M) and 54% (F)

38 LA stiffness PCWP / LA strain / E/e are better correlates to HF than LVEF

39 LVEF % HFpEF Preserved Cardiac Functional Reserve HF with intermediate EF Reduced CFR and contractility HFrEF

40 LVEF distribution CVH study N ~ 5000 Independent, community-dwelling >1 previous episode of HF

41 Too high an LVEF? N = 5,127 elderly women (>65y) GRACE Gr 1 = <55%; Gr 2 = 55-65%; Gr 3 >65% Gr 1; in-hospital mortality = 12% Gr 3 worse outcome Gr 2 (OR 2.5; p < 0.003); higher 6/12 death (2.0); higher VF / VT (2.5) J-shaped curve for LVEF? Is this real? Am Heart J 2010; 160: 849

42 Is LVEF additive in Elderly? N = 5,888; >65yrs CHS (CV Health Study) 4,137 had BNP and Echo 107 (<45%); 210 (45-55%) defilippi et al JACC 2011; 58: 1497

43 Time to new onset HF diagnosis Cardiovascular Mortality BNP >/< 190pg/ml LVEF >/< 55% BNP >/< 190pg/ml LVEF >/< 55% BNP is a better correlate to outcomes than LVEF

44 >10% of subjects with a change in BNP from <190 to >190 also show a change from an LVEF >55% to an LVEF <55% - OR - ~90% of subjects with elevated BNP or change from low to high have LVEF >55%

45 Cardiovascular MRI

46 Heart Failure Non-contrast cine images LVEF and RVEF LV and RV volumes (valve severity) Pericardium Contrast-enhanced images Scarred myocardium CAD vs DCM Prognosis (ICD benefit) Myocarditis / amyloidosis / chemorx

47 Reference Standard for LV volume and LV function SAX stack

48 Contrast Enhanced CMR bright Signal intensity Normal Myocardium Contrast Infarcted Myocardium injection Ischemic Myocardium dark First-Pass Late Gadolinium Enhancement time

49 MR imaging completely matches the pathology Wagner Lancet 2003; 361: 374

50 Prognosis of DCM based on LGE Multiple scientific reports

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52 ICDs save lives one way or another

53 SCD Paradox 20 milion Americans have CAD 800,000 new MI annually in the U.S. ICD s effective for primary prevention strategy when LVEF <35% Most SCD occurs in patients with LVEF >35% NEED: Identify patients with EF>35% at highest risk for SCD

54 SCD by CMR (%LGE) P = Chan Circulation 2014; 130: 484

55 SCD by LVEF P = Heart doi: /heartjnl

56 SCD by CMR (%LGE) P = Chan Circulation 2014; 130: 484

57 LVEF Robust predictor of cardiac outcome in general population Low sensitivity for early detection of cardiotoxicity Fails to detect small changes in LV contractility Inadequate visualization of LV true apex Inherent variability of measurements Geometric assumptions The Great and Wonderful Ejection Fraction Reliance on mostly radial function (radial strain) Reduced Ejection Fraction = extensive LV damage

58 DIAMOND HFpEF Developing Imaging And plasma biomarkers in Describing HFpEF (N = 138) Poorly phenotyped with marked heterogeneity Excluded: MI (<6mo), severe VHD Silent MI (13); HCM (4 definite, 3 prob, 1 poss); p-constr (5); amyloid (2); ischemia (27) with microvascular dz (11) LGE mid-wall (33); Inter-V grooves (24)

59 HFpEF why Rx trials fail!

60 LGE T1 ECV Soslow et al. Journal of Cardiovascular Magnetic Resonance :5

61 Rethinking Aortic Stenosis Severity Mild Moderate Severe Focus Novel Treatments Imaging AV Calcification Anti- Calcific CT; Echo Myocardial fibrosis AVR Antifibrosis CMR (LGE / T1map)

62 Rethinking Heart Failure Severity CFR Focus Novel Treatments Imaging Mild Moderate Severe Myo Mechanics ID etiology??? CMR; Echo Myocardial fibrosis Antifibrosis LGE, ECV, T1, GLS

63 Jean-Martin Charcot Disease is very old, and nothing about it has changed. It is we who change as we learn to recognize what was formerly imperceptible.

64 South Rim, Grand Canyon

65 ECHO in the Bluegrass Keynote Speakers: Mike Picard Steve Kentucky ACC16

66 Clinical Trials Heart failure medications Follow cavity dimensions Hypertensive agents Monitor LV thickness / LV mass 10g change in LV mass, power 90%, error D Echo study would need 505 patients CMR would need 14 patients Bottini PB (Gottdiener JS) et al. Am J Hypertens. 1995; 8:

67 One of the Best Diagnostic tools for Heart Failure

68 Contrast PLUS kinetic imaging

69 2D 3D Reduces foreshortening Does not rely on 2D geometry

70 A new (better) RV assessment VentriPoint Diagnostics Ltd

71 Remember, the danger of an appropriate noninvasive test lies not in its performance, but in the quality and accuracy of its interpretation