Perfusion CMR: State of the Art

Transcription

1 Perfusion CMR: State of the Art Dudley Pennell MD FRCP FACC FESC Director CMR Unit, Royal Brompton Hospital Professor of Cardiology National Heart & Lung Institute, Imperial College

2 Outline Current status Clinical trials Future Quantification Contrast agent No contrast agent Speed & resolution

3 Detection of Ischemia, MR-IMPACT SPECT results of the MR-IMPACT are in close agreement with Multicenter SPECT studies using invasive coronary X-ray angiograpy as standard of reference Eur Heart J 2004; 25: Courtesy J. Schwitter University Hospital Lausanne, Switzerland

4 Meta-Analysis of Single Centre Studies 55 studies CMR vs angiography Sensitivity: 89% [88-91%] Specificity: 80% [78-83%]

5 MR-IMPACT II 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 in USA and Europe - Multivendor J. Schwitter et al. Featured Research, ESC Meeting Munich, 2008

6 Sensitivity MR-IMPACT II * Specificity Perfusion-CMR n=465 AUC: 0.75 ±0.02 SPECT all n=465 AUC: 0.65 ±0.03 P= gated-spect n=277 AUC: 0.69 ±0.03 P=0.018 ungated-spect n=188 AUC: 0.63 ±0.04 P=0.023 P=ns vs Gated J. Schwitter et al. Featured Research, ESC Meeting Munich, 2008

7 Sensitivity MR-IMPACT II * Perfusion-CMR FEMALE, n=112 AUC: 0.76 ±0.04 ΔAUC: 0.13 p=0.033 SPECT FEMALE AUC: 0.63 ± Specificity Perfusion-CMR Male, n=313 AUC: 0.75 ±0.02 ΔAUC: 0.09 p=0.004 SPECT Male, n=313 AUC: 0.66 ±0.03 J. Schwitter et al. Featured Research, ESC Meeting Munich, 2008

8 Outline Current status Clinical trials Future Quantification Contrast agent No contrast agent Speed & resolution

9 High Resolution Quantitative Perfusion CMR ~0.036 mg/voxel First-Pass MR Perfusion Images Exp 1 Exp 2 Exp 3 Exp 4 Exp 5 Exp 6 Exp 7 Myocardial Blood Flow Pixel Maps Microsphere Reference Standard * MR and microsphere perfusion are displayed on the same absolute color scale Li-Yueh Hsu, DSc, Andrew Arai, MD et al AHA Scientific Sessions 2009

10 Myocardial Blood Flow: CMR vs Microspheres Li-Yueh Hsu, DSc, Andrew Arai, MD et al AHA Scientific Sessions 2009

11 Outline Current status Clinical trials Future Quantification Contrast agent No contrast agent Speed & resolution

12 Molecular MR Imaging of Myocardium using EP-3600, a Collagen Specific Contrast Agent: Assessment of Myocardial Perfusion Defects in a Swine Model E Spuentrup 1,2, KM Ruhl 1, RM Botnar 3, AJ Wiethoff 4, A Buhl 1, V Jacques 5, MT Greenfield 5, GA Krombach 1, RW Günther 1, P Caravan 6 1 Department of Diagnostic Radiology, RWTH Aachen, Aachen, Germany 2 Department of Radiology, University of Cologne, Cologne, Germany 3 Department of Nuclear Medicine, Technical University Munich, Munich, Germany 4 Philips Medical Systems, Best, The NL 5 EPIX Pharmaceuticals, Lexington, MA, USA 6 A. A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA

13 Cyclic Peptide Binds to Collagen Spuentrup Circulation 2009; 119:

14 Enhancement of Normal Myocardium T1-FFE pre 5min 20min 40min 60min

15 Perfusion Defect T1-FFE pre 5min 20min 40min 60min

16 Conclusion: EP-3600 Collagen specific, binds to myocardium Visualization of perfusion defects for 20 min High spatial resolution imaging Stress can be performed outside the MR room

17 Outline Current status Clinical trials Future Quantification Contrast agent No contrast agent Speed & resolution

18 Perfusion T2 Oxygen 90% area LCx stenosis Perfusion (Rest) Perfusion (Dipyridamole) X-ray MRI LCx T2 T2 (Rest) T2 (Dipyridamole) McCommis, Zheng. Circulation Imaging 2010; 3: 41-6

19 Quantification of Cardiac BOLD Imaging Two-compartment T2 Model to Estimate Hyperemic Oxygen Extraction Fraction (OEF) 1 S/S 0 = Exp(-R2*TE) =MBV * exp(-r2 blood *TE) + (1-MBV)*exp(-R2 tissue *TE) Where: R2 blood = ( )*OEF + ( )*OEF 2 + ( ) 2 R2 tissue = R2 0 + R2 1 * 2 *MBV 2 * OEF 2 MBV = Myocardial Blood Volume Myocardial T2 = Function (MBV, OEF, Imaging Parameters) McCommis, Zheng. Circulation Imaging 2010; 3: 41-6

20 Intracoronary Dipyridamole: Regional OEF DIP or Gd LAD X-ray Perfusion(Rest) Gadolinium Dipyridamole OEF Maps Rest 3 min 5 min 9 min 12 min McCommis, Zheng. Circulation Imaging 2010; 3: 41-6

21 Fast Mapping of Myocardial Perfusion (90% Area LCx Stenosis) Rest Stress MBF LV ml/100 g/min MBV ml/100 g Goldstein T, Zheng J, et al, Magn Reson Med 2008

22 CMR vs PET (Dipyridamole) MRI MBF MRI MBV MRI OEF PET 11 C-acetate Control LV Severe Stenosis Jie Zheng, Washington University

23 MR MVO 2 (μmol/g/min) MVO 2 Results Fick s Law : MVO2 (ml/100g/min) = [O2] a x OEF x Y a x MBF 25 MR vs PET MVO 2 (Stress only) y = 0,87x + 1,13 R² = 0,78 P < PET MVO 2 (μmol/g/min) McCommis K, Zheng J, et al, Circulation: Cardiovascular Imaging, 2009

24 Outline Current status Clinical trials Future Quantification Contrast agent No contrast agent Speed & resolution

25 k-t SENSE Accelerated Perfusion at 1.5 T 3 x 3 x 10 mm 1.5 x 1.5 x 10 mm Plein et al. Magn Reson Med 2007

26 k-t SENSE Accelerated Perfusion: 3T vs FFR Stress perfusion Comparison of FFR and diameter stenosis (%) with reference lines indicating an FFR of 0.75 and diameter stenosis of 50%. Pearson correlation co-efficient was r=-0.76 [95%CI to-0.66], P<0.0001) indicating a good degree of correlation. Lockie, Plein. In review

27 k-t SENSE Accelerated Perfusion: 3T vs FFR Receiver Operator Curve (ROC) showing the sensitivity and specificity of MPR to detect a haemodynamically significant coronary stenosis using a dichotomous value of 0.75 for fractional flow reserve (FFR). The area under the curve (AUC) was 0.89 Lockie, Plein. In review

28 k-t SENSE: Spatial vs Temporal Resolution 120ms, 2.5 x 2.5mm 60ms, 2.5 x 2.5mm 120ms, 1.3 x 1.3mm 100ms, 2 x 2mm Maredia Plein. Magn Reson Med In press

29 Standard vs High Resolution Perfusion in 3VD Standard resolution High resolution

30 Perfusion CMR: Conclusions Clinically valuable today Multicentre trials show superiority to SPECT Absolute quantification ready New developments High resolution accelerated imaging New contrast agents No contrast agent: BOLD