Case based learning: CMR in Heart Failure

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Marylou Atkins
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1 Case based learning: CMR in Heart Failure Milind Y Desai, MD FACC FAHA FESC Associate Professor of Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland, OH Disclosures: none Use of Gadolinium is off-label for cardiac use in USA

$CMR and Cardiomyopathies Dynamic CMR For LV/RV mass, volumes and EF Perfusion CMR Rest/stress Phase contrast for regurgitant fraction Tissue characterization LGE for$

2 CMR and Cardiomyopathies Dynamic CMR For LV/RV mass, volumes and EF Perfusion CMR Rest/stress Phase contrast for regurgitant fraction Tissue characterization LGE for fibrosis T2 weighted imaging for edema T1 mapping for diffuse fibrosis Cine T2-weighted for edema Pre and post contrast T1W LGE Friedrich M et al. JACC 2009, 53:

3 Late Gadolinium Hyperenhancement and differential diagnosis Ischemic Subendocardial Infarct Mid-wall HE Nonischemic Transmural Infarct Idopathic Dilated Cardiomyopathy Myocarditis Epicardial HE Global Endocardial HE Hypertrophic Cardiomyopathy Right ventricular pressure overload (pulmonary HTN) Sarcoidosis Myocarditis Anderson-Fabry Chagas Disease Amyloidosis Systemic Sclerosis Post Cardiac Transplantation Sarcoidosis Myocarditis Anderson-Fabry Chagas Disease

4 Suggested CMR protocol for nonischemic CMP Sequence Scan planes Utility Bright-blood single shot SSFP and black blood HASTE Axial General morphologic assessment T1-weighted DIR and TIR FSE T2-weighted DIR and TIR FSE Axial Tissue characterization Inflammation B-SSFP Axial stack SA stack 4 and 2-chamber stack Atrio/ventricular size and function Restriction vs. constriction Tagged cine Typically SA Epicardial/pericardial tethering Regional mechanics Real-time GRE cine Typically SA Monitor respiratory variation for ventricular interdependence Rest perfusion T1-weighted multislice gradient echo LGE (T1-weighted inversion recovery spoiled gradient echo min following injection Typically SA Short axis, 2 and 4-chamber Assess for resting perfusion Fibrosis

5 Case Sometimes it s not what meets the eye

6 History 56 year old female presents with intermittent rightsided chest heaviness relieved with rest for last 4 days Dog of 9 years put to death a week ago and in tears since Now getting dyspneic so seeks attention No CV risk factors, non smoker, negative family Hx ROS suggested occasional joint pain attributed to arthritis; a facial rash for which she has not sought attention PMHx: Depression, hypothyroidism No meds

7 Examination VS: Afebrile, 121/78 mm Hg, 81 BPM and regular Exam negative except for anxiousness Labs: WBC 14K, H and H 13 and 38 mg/dl, Cr 0.9 TnT 0.3, CK 35, BNP 225 LDL 110, HDL 52, Tg 154 mg/dl

8 Echocardiography Large WMA in LAD territory. EF reduced ~ 40 %? Takotsubo vs. ACS

9 Coronary angiography Normal coronaries Diagnosis Takotsubo s CMP

10 Cardiac Magnetic Resonance: Cine

11 T2 FSE

12 T2 STIR

13 LGE

14 CMR findings: EF 43 %, large LAD scar So final diagnosis was NOT Takotsubo CMP, but rather an ACS Further workup revealed positive lupus anticoagulant and hence, this was likely an embolic ACS So now patient has following diagnoses: MI, LV systolic sysfunction and Lupus

15 Case Look beyond the obvious

16 History 64 year old male referred for evaluation DOE occurs with exertion and relieved with rest Recently had epigastric pain Occasional dizziness, especially with positional changes Told of a benign murmur for many years. 1 echo in the past, never really followed up PMHx of controlled HTN, dyslipidemia, negative family history for SCD Meds: Metoprolol, Lasix, Lisinopril, Omeprazole, Aspirin, Atorvastatin (recent). Not on ASA due to GI upset Most recent cholesterol: Total Chol 254: HDL 39: LDL 106: TG 541

17 Examination VS: BP 132/92, HR 72, Afebrile RS: Clear CV: 3/6SEM at LUSB, dynamic changes with position CXR: Clear at presentation

18 Surface echocardiography Asymmetric septal hypertrophy Stage 2 diastolic dysfunction. LAD territory WMA suspected. Rest: Mild leaflet tip SAM. 1+ MR. LVOT gradient 25 mmhg Amyl: Increase in SAM with septal contact. 3+ MR. Dynamic LVOT gradient 73 mmhg.

19 Stress echocardiography Exercised for only 5 METS, stopped due to DOE LVOT gradient 60 mm Hg Had 3 + MR also

20 B-SSFP CMR

21 Late gadolinium enhancement HOCM with severe asymmetric septal hypertrophy, LVEF = 42%. Hypokinesis and a thin layer of subendocardial scar in the LAD territory

22 Cardiac Cath LAD with 90% proximal stenosis, 60% in a medium-size mid-lad, 30-40% in the rest of the mid-lad, and 60% in a small-sized distal LAD.

23 Diagnosis: HOCM with concomitant severe obstructive CAD Stopped ACE-I, Lasix intake minimized Aggressive secondary prevention Underwent septal myectomy, anterior MV repair and CABG (LIMA to LAD and SVG to RCA)

24 Case: The great masquerader 57 y/o male, who works as a nurse presented to PCP with palpitations and dizziness No PMHx. Family history unremarkable Examination unremarkable As part of work up, a stress echo was ordered. Patient developed NSVT at peak stress Referred to EPS. CMR ordered.

25 CMR

26 Cine

Patchy LGE: usually basal-mid anteroseptal and

27 LGE Cath revealed normal coronaries Underwent EMB which confirmed sarcoidosis Normal or impaired LVEF Patchy LGE: usually basal-mid anteroseptal and basal lateral segments Sens 100%, spec 78% in 58 patients

28 Case: Young girl with DCM

Noncompaction Rare CMP Jenni criteria: Severely thickened LV 2-layered ventricular myocardium with a ratio of noncompacted/compacted wall >2 in systole, Excessive trabeculations, and

29 Noncompaction Rare CMP Jenni criteria: Severely thickened LV 2-layered ventricular myocardium with a ratio of noncompacted/compacted wall >2 in systole, Excessive trabeculations, and deep intertrabecular recesses CMR criteria: Ratio > 2.3 in diastole has a high diagnostic accuracy (sensitivity, specificity, PPV and NPV of 86%, 99%, 75%, and 99%, Prognosis generally poor

30 Conclusions CMR has invaluable role of imaging techniques in evaluation of patients with CHF and suspected cardiomyopathies More than likely, multimodality imaging useful in arriving at a specific diagnosis Echo still remains the initial test of choice Emerging role of Cardiac MRI and CT for a comprehensive diagnostic approach

Case based learning: CMR in Heart Failure

Case based learning: CMR in Heart Failure Milind Y Desai, MD FACC FAHA FESC Associate Professor of Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland, OH Disclosures: none Use of Gadolinium