DECLARATION OF CONFLICT OF INTEREST. Grant support: Philips Healthcare Bayer Schering

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1 DECLARATION OF CONFLICT OF INTEREST Grant support: Philips Healthcare Bayer Schering

2 Cardiac magnetic resonance imaging has replaced nuclear: pro Prof. Eike Nagel King s College London

3 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial Be highly accurate Be highly reproducible and validated Provide quantitative data (extent and severity of Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage

4 Degree and location of stenoses does not correlate with presence and severity of ischemia ΔP = (f 1 Q) + (f 2 Q 2 ) Uren et al. NEJM 1994 Kern et al. Circulation. 2006;114:

5 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial Be highly accurate Be highly reproducible and validated Provide quantitative data (extent and severity of Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage

6 Comparison to SPECT animal experiments Lee; Circulation 2004

7 Autoregulation SPECT PET MRI Guy s and St Thomas NHS Foundation Trust and King s College London s comprehensive Biomedical Research Centre

8 Spatial Resolution 3 x 3 mm (MR-standard) 1 x 1 mm (high resolution 3T)

9 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial Be highly accurate Be highly reproducible and validated Provide quantitative data (extent and severity of Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage

10 2456 patients Sensitivity: 90% Specificity: 81% Vs. invasive angiography

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12 Clinical Evaluation of Magnetic Resonance Imaging in Coronary Heart Disease (The CE-MARC Study) A Prospective Evaluation of 750 Patients John P. Greenwood, Neil Maredia, John F. Younger, Julia M Brown, Jane Nixon, Colin C Everett, John P Ridgway, Aleksandra Radjenovic, Catherine Dickinson, Mark Sculpher, Stephen G. Ball, Sven Plein CMR SPECT Sensitivity 86.5% 66.5% P<0.001 Specificity 83.4% 82.6% P=0.916 PPV 77.2% 71.4% P=0.061 NPV 90.5% 79.1% P<0.001

13 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial Be highly accurate Be highly reproducible and validated Provide quantitative data (extent and severity of Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage

14 Validation Klocke, et al Circulation 2001

15 Quantification Correlation with microspheres Christian TF, et al. Radiology, 2004(9);232(3):677-84

16 Left myocardial compartment Coronary arteries originating from the proximal aorta Distal aorta (flow to the control unit) 4-chamber heart Pulmonary artery and pulmonary vein Gadolinium injection site Vena cava (flow from the pump) Normal perfusion Increasing flow reproducibility Right Myoc mean Reference (100%)

17 Schuster et al. JCMR 2010 In collaboration with J. Spaan; M. Siebes

18 Validation vs PET Area under ROC curve for detection of CAD: MPR PET: 0.84 ( ) MPR CMR: 0.83 ( ). 3.5 MPR PET <1.44 sensitivity 87%, specificity 82% MPR CMR <1.45 sensitivity 82%, specificity 81% Morton et al. Unpublished data MPR MPRw2 CMR MPR PET r=0.82, p=< MPRw2 PET

19 Lockie et al. JACC 2011 Validation vs FFR Quantitative 3T CMR perfusion data

20 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial Be highly accurate Be highly reproducible and validated Provide quantitative data (extent and severity of Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage

21 Modeling myocardial perfusion 60 radial profiles per slice 600 segments / slice = 1800 segments / patient 10 transmural segments per radius Hautvast et al. MRM in press

22 6 3 0 ml/g/min

23 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial Be highly accurate Be highly reproducible and validated Provide quantitative data (extent and severity of Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage

24 Additive risk of cancer/exam From ICRP 1990 to BEIR 2005: fatal and non-fatal cancer 1 su in 500 Thallium Coronary stenting Cardiac ablation Risk category Minimal Very low Low 1 in 750 MSCT 1 su 1,000 1 in 1000 Abdomen CT Stress Sestamibi scintigraphy Chest CT Barium enema 1 su 10,000 Lung scintigraphy Bone scintigraphy The lifetime attributable risk for cancer due to a SPECT study can be estimated as app. 1:1250 for men and 1:750 for women (Einstein, JAMA 2008) Equivalent number of chest x-rays Picano E. BMJ, 9 ottobre 2004

25 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial Be highly accurate Be highly reproducible and validated Provide quantitative data (extent and severity of Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage

26 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial Be highly accurate Be highly reproducible and validated Provide quantitative data (extent and severity of Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage

27 SPECT vs MR for scar Wagner, et al; Lancet 2003

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29 Baseline RV contrast uptake LV contrast uptake Myocardial contrast uptake Stress- Perfusion Rest- Perfusion Viability and coronary angiography

30 JACC 2006; 47:

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32 Which is the optimal test for the detection of ischaemia? Measure early in the ischaemic cascade Provide high resolution imaging (subendocardial MR ++ + Be highly accurate ++ + Be highly reproducible and validated + ++ Provide quantitative data (extent and severity of ++ + Do not use radiation Provide information non-invasively Provide additional information on function and irreversible damage ++ + SPECT

33 Imaging Sciences (Cardiovascular Non-congenital) Eike Nagel Valentina Puntmann Amedeo Chiribiri Andreas Schuster Geraint Morton Shazia Hussain Matthias Paul Masaki Ishida (Mie, Japan) Sven Plein (Leeds) Roy Jojiga Radmila Maksimovic Reza Razavi Cardiology (King s Health Partners) Tim Lockie Divaka Pereira Gerry Carr-White Simon Redwood Animal Imaging and Support Andrea Protti Sarah Peel IT Davide Poccecai Radiographer Stephen Sinclair Annette Dahl Lorna Smith In cooperation with: Philips Healthcare Bayer Schering Pharma German Heart Institute Berlin Swiss Federal Institute of Engineering Gyrotools University of Nancy