Stress MRI is here to stay. Professor James Moon Barts Heart Centre UCL Director of Imaging

Transcription

1 Stress MRI is here to stay Professor James Moon Barts Heart Centre UCL Director of Imaging

2 My Hospital Barts Heart Centre US visitor: shocked by 3 things: 1. No parking 2. Drs doing the CMR 3. No nuclear Multimodality Balanced Portfolio Grow DSE Grow nuclear Hold back CMR perfusion

3 Starting point - function

4 Kinetics of gadolinium: 3 time periods [Gd] Blood pool 1:First pass 2: Early 3: Late <10s 1-3min min t

5 Kinetics of gadolinium: 3 time periods [Gd] Normal Blood pool 1:First pass 2: Early 3: Late <10s 1-3min min t

6 Kinetics of gadolinium: 3 time periods [Gd] Normal Blood pool 1:First pass 2: Early 3: Late Isc h <10s 1-3min min t

7 Kinetics of gadolinium: 3 time periods [Gd] Normal Blood pool 1:First pass 2: Early 3: Late Isc h Infarcted <10s 1-3min min t

8 Kinetics of gadolinium: 3 time periods [Gd] Normal Blood pool 1:First pass 2: Early 3: Late Isc h Infarcted Microvascular obs. <10s 1-3min min t

9 Scar imagnig (LGE)

10 Perfusion CMR Stress Transmural resolution No TID no/less balanced 3VD Rest 15 year old girl, chest pain. Strong Fhx, Chol = 7 Chol=7 ON treatment; 17 prior to Rx

11 Not just epicardial flow limiting stenoses MVO Synd X HCM Rest Perf Rest Perf Rest Perf Early Gd Stress Perf Late Gd Rules: Artefact: MI/MVO: Synd X Non-ischemic present on rest and stress, no late enhancement present on rest and stress, early hypo or late enhancement global subendocardial enhancement - RARE LVH present, global subendo/mid-wall +/-late

12 Whats the evidence?

13 Perfusion evidence 2001: Single centre 2004: Multicentre, single vendor 2008: Multicentre, multivendor MR-IMPACT n= : n= : n= : pending studies New technologies MR-Inform MR-IMPACT2 CE-MARC n=918, against FFR, outcome MACE Ischemia trial n=8000, testing multimodality and OMT vs revasc, outcome MACE

14 Sensitivity CMR perfusion Zurich Single Center Europe Multicenter Single-vendor MR: subendocardial 0.2 (87%/85%/0.91) MR: transmural (83%/67%/0.84) Specificity Schwitter et al. Circulation, Adequate Quality Score <4 Central 3 Slices Specificity Giang et al. Eur Heart J., 2004 Acknowledgement: J Schwitter

15 MR-IMPACT Magnetic Resonance Imaging for Myocardial Perfusion Assessment in Coronary Artery Disease Trial 18 Study Centers Multi-Vendor: Amsterdam Bad Nauheim Berlin (3) Dresden Houston Minneapolis GE Healthcare A. Müller-York, MD G. Thorheim, PhD L. Johansson, PhD K. Meurer, VD Blinded Readers SPECT, MR Core Laboratories QCA, Blood work München New Haven New York Paris Pisa St. Louis Trondheim Uppsala Würzburg Zurich J. Schwitter et al. Eur Heart J, 2008, 29,

16 MR-IMPACT Eligible patients and reasons for drop-outs

17 MR-IMPACT (A) Shows the diagnostic performance Diagnostic (receiver operating performance characteristics) (ROCs) for for the the different CM contrast medium doses ranging doses from from 0.01 to to mmol/kg 0.10 mmol/kg Gd-DTPA-BMA Gd-DTPA-BMA 1-3 Vessel Disease CMR vs SPECT: 0.86 vs 0.67 p=0.013 CMR vs gated SPECT 0.86 vs 0.75 P=0.18 Schwitter, J. et al. Eur Heart J :ehm617v1-10; doi: /eurheartj/ehm617 Copyright restrictions may apply.

18 MR-IMPACT (A) Shows the diagnostic performance Diagnostic (receiver operating performance characteristics) (ROCs) for for the the different CM contrast medium doses ranging doses from from 0.01 to to mmol/kg 0.10 mmol/kg Gd-DTPA-BMA Gd-DTPA-BMA 2-3 Vessel Disease CMR vs SPECT: 0.89 vs 0.70 p=0.006 Schwitter, J. et al. Eur Heart J :ehm617v1-10; doi: /eurheartj/ehm617 J. Schwitter et al. Eur Heart J 2008; 29, Copyright restrictions may apply.

19 Sensitivity Sensitivity Evidence for excellent diagnostic performance and reliability of perfusion-cmr in patients with suspected CAD, after PCI, with/without MI Zurich Single Center Europe Multicenter Single-vendor MR-IMPACT Multicenter Multi-vendor MR: subendocardial 0.2 (87%/85%/0.91) MR: transmural (83%/67%/0.84) Specificity Adequate Quality Score <4 Central 3 Slices Specificity 1-Specificity Schwitter et al. Circulation, 2001 Giang et al. Eur Heart J., 2004 Schwitter et al. Eur Heart J. 2008

20 MR-IMPACT II: Performance in Women 33 Centers in USA and Europe - Multivendor Aachen, D Houston, USA Regensburg, D Amerfoort, NL Gainesville, USA Roslyn, NY, USA Amsterdam, NL Landshut, D Royal Oak, USA Berlin, D (2) Los Angeles, USA Stavanger, NO Bad Nauheim, D Ludwigshafen, D St. Louis, USA Budapest, HU Munich, D Tulln, A Charlottesville, USA Niewegen, NL Tulsa, USA Dallas, USA Paris, F Wuerzburg, D (2) Essen, D Pecs, HU Zurich, CH Hannover, D Pisa, I 33 Centers Women (n=112) Perfusion-CMR SPECT p=0.023 J. Schwitter et al. Featured Research, ESC Meeting Munich, 2008

21 Sensitivity Sensitivity sensitivity better Specificity worse Evidence for excellent diagnostic performance and reliability of perfusion-cmr in patients with suspected CAD, after PCI, with/without MI Zurich Single Center Europe Multicenter Single-vendor MR-IMPACT Multicenter Multi-vendor MR-IMPACT II Multicenter Multivendor: Women MR: subendocardial 0.2 (87%/85%/0.91) MR: transmural (83%/67%/0.84) Specificity Adequate Quality Score <4 Central 3 Slices Specificity 1-Specificity 33 Centres Femmes n-cmr SPECT (n=112) Perfusio p=0.023 Schwitter et al. Circulation, 2001 Giang et al. Eur Heart J., 2004 Schwitter et al. Eur Heart J Schwitter et al. Featured Research ESC Meeting, 2008

22 Trial Design Eligibility: At least one cardiac risk factor Suitable for revascularisation No contraindications for CMR or adenosine Obtain written informed consent BHF funded 39% CAD rate REGISTER AND RANDOMISE ORDER OF TESTS (ETT for all eligible patients before or after randomisation) Comparator gated SPECT CMR-SPECT SPECT-CMR X-ray coronary angiogram Yearly FU for clinical endpoints (CV death, MI, revascularisation, readmission) (MR angiography included legacy technique) Greenwood J Plein S. Lancet 2012 feb 379;453-60

23 Results

24 Perfusion-CMR: exclude CAD in a lowlikelihood population p<0.001 by log-rank test N=513 Normal Perfusion-CMR Abnormal Perfusion-CMR Normal DSCMR or normal MPR 3 year survival: 99.2% Incremental over clinical risk stratification Jahnke et al, Circulation. 2007;115:

25 CMR perfusion Advantages: Combine with function and LGE No ionising radiation Target Women <40 LBBB (esp with LV impairment) Multivessel disease/prior intervention Recent negative Inx or recent intervention

26 CMR perfusion - problems Technically demanding Latest equipment Still developing - not completely standardized Sequences, parameters, Gd doses Artefact Other causes of perfusion defects Availability growing Failure to learn from nuclear medicine Inconsistent stress protocols Drugs to stop, time of caffeine abstinence Swamps my service

27 New advances - splenic switch-off Rest Stress Adenosine Regadenason Manisty C 2015 Radiology

28 New advances - splenic switch-off Manisty C 2015 Radiology

29 New advances - splenic switch-off Clinical service: 1 in 9 failed splenic switch-off False negatives: 1 in 3 failed splenic switch-off Manisty C 2015 Radiology

30 New advances Perfusion mapping This is real I expect all our cases by this within 2 years Li-Yueh Hsu..Arai Jacc imaging 2012

31 Conclusion Stress CMR CMR stress Dobutamine Vasodilator Incremental rather than disruptive Likely better than gated SPECT Likely development faster than other modalities Different camera Function, scar imaging Better transmural resolution No ionising radiation Less artifact (or at least different) But Not all perfusion defects epicardial Need state-of-the-art equipment Just another tool Doesn t address questions about revasc vs medical