Current Guidelines for Diagnosis of AMI Chest pain ST change on EKG Cardiac Enzymes

Transcription

1 Noninvasive Cardiac Imaging in Myocardial Infarction Sangchol Lee Sungkyunkwan University Samsung Medical Center

2 Current Guidelines for Diagnosis of AMI Chest pain ST change on EKG Cardiac Enzymes

3 Do We Need Imaging for AMI Management? Confusing results on EKG Time needed d for enzymes to rise Chest pain - typical? atypical? Measurement of infarct size Post-PCI PCI complications Assessment of residual viable myocardium

4 Current Noninvasive Imaging Modalities for AMI Diagnosis Echocardiography Radionuclide perfusion scan Cardiac CT Cardiac MRI

5 Conventional Echocardiography Global LV function Regional wall motion for diagnosis i Complications of MI Myocardial area at risk Myocardial viability - stress echo

6 Survival of Patients with Acute MI Prognosis EF 40% EF >40% E/e E/e 15 1 Surviva al E/e > E/e > Follow-up (months) Follow-up (months) No. at risk Hillis et al: JACC 43(3):360, 2004 CP

7 Prognostic Value of E/E' After Acute MI In DTBT < E/e' 15 In DTBT 90 E/e' 15 h) al (death Surviva P=0.06 E/e' >15 h) al (death Surviva E/e' >15 P< Follow-up (days) Follow-up (days) Park SJ, Ting H, Oh JK Unpublished CP

8 Unconventional Echocardiography Myocardial strain imaging Contrast t echocardiography h

9 Strain Imaging Strain: Deformation of an object, relative to its original length = L - L 0 L = L0 L 0 L 0 L 0 If 10 cm original length is shortened to 7.5 cm, strain is (-) 25 %. Normal strain is > 20 %. CP

10 2D Speckle Tracking Image Normal Radial strain (SAX) K.Ogawa, T.Hozumi et al. AJC 2006 Transversal strain (A4) Aplio (SSA-770A, Toshiba Japan)

11 Longitudinal strain: normal case Display 4C 2C Lengthening APLAX Shortening Bull s Eye

12 Bull s Eye Mapping of Strain +20% Lengthening g -20% Shortening Anteroseptal MI (LAD) Inferolateral MI (LCX) Inferior MI (RCA)

13 Contrast Echocardiography h Perfusion Defect in the apical segments

14 Contrast Perfusion Echo for Viability 2 patients with Anterior STEMI and PCI Baseline Follow up

15 Is there apical thrombus?

16 CT for Myocardial Imaging Coronary CT angiography Arterial phase myocardial imaging i Myocardial motion interpretation Viability imaging with delayed enhancement

17 Role of CCT in AMI Evaluation of acute chest pain Myocardial viability

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19 Quantification of Infarct Size

20 Myocardial Viability

21 Dual-Phase CT

22 Dual-Phase CT

23 CMR: Delayed Enhancement

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25 Two Patients with Inferior STEMI Soon after PCI

26 Two Patients with Inferior STEMI After PCI and Follow-up

27 Two Patients with Inferior STEMI Follow-up Echo and Baseline MRI Small DE by Gd Large DE by Gd

28 Myocardial Function and DHE Transmural extent of infarction and contractility Marholdt, JACC 2003

29 All Dysfunctional Segments Segments with Severe Hypokinesia, Akinesia, i or Dyskinesia i Segments with Akinesia i or Dyskinesia i ility (% %) ontract oved co Impro (12 of 12) (128 of 148) (23 (256 of 28) of 329) (56 of (109 86) of 183) (45 of (29 of (9 of 20) 110) 68) (13 of (10 of 124) 103) (4 (1 of (0 of of 54) (0 of 58) 57) 46) Transmural extent of hyperenhancement (%) R. Kim et al NEJM 2000 CP

30 Prognosis Associated with DHE Chest pain without known OMI Post-STEMI Kwong, Circ 2006 Wu, Heart 2008

31 Additional Information: Microvascular Obstruction Sakuma, JMRI 2007

32 Functional Recovery after AMI and MO Nijveldt, JACC 2008

33 MO and Prognosis Wu, Circulation 1998

34 AMI with Edema Sakuma, JMRI 2007

35 T2WI for Edema in MI T2WI-triple IR Myoview Scan

36 Acute MI with Swelling T2WI

37 With a Newer Sequence Acute MI Chronic MI Kellman, Magn Reson Med 2007

38 Peri-Infarct Zone Enhancement (The Grey Zone) 2-3 SD >3 SD Yan AT et al. Circulation 2006;114;32-39.

39 STEMI? Chest and left arm pain for 1 hr. Increased Troponin

40 65 year old woman with chest pain

41 Cine Delayed Enhancement Courtesy of Siemens Med. Systems

42 Cardiac MRI New Technology Diffusion Tensor Imaging g Myocardial Strain Imaging

43 Evaluation of Chest Pain Prognosis Viability Imaging CAD Function Infarct size Unstable Hemodynamics and dc Complications CP