Ve V rmont rmon Card Car iac d Netw Ne ork tw Scott E. Friedman April 28, 2016

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1 Vermont Cardiac Network Scott E. Friedman April 28, 2016

2 Conflict Disclosures Th S k h d i ifi fi i l l i hi ih The Speaker has reported no significant financial relationship with any companies whose product may be germane to the content of their presentations or who are supporting this program.

3 Series Learning Objectives Understandthe the range of information that cardiac MRI can supply Identify clinical scenarios where cardiac MRI provides additive diagnostic value to traditional testing Contrast the benefits and shortfalls of cardiac MRI with other forms of cardiac imaging.

4 Cased Based cmri : Outline What can it do for you? Function Tissue Characterization Physiology Anatomy Wrap up with diagnosis specific indications

5 cmri WRJ VA Program initiated Feb studies to date Stress cmri beganapril Stress cmri to date 100 Cardiac MRI volume by Calendar 90 Year Radiology over read for noncardiac findings

6 40% Indications for Cardiac MRI at WRJ (N=235) 35% 30% 25% 20% 35% 15% 10% 20% 5% 0% 9% 4% 5% 3% 10% 8%

7 Cardiac MRI: National Use Patterns Kwang ACC 2011

8 Function Tissue Characterization/Viability Physiology Anatomy

9 Function

10 Case 1 57 yomale y.o s/p MI in 2003, presented with unstable angina, found to have 3 vessel disease on cath and underwent CABG. EF was 35% prior to CABG. Echo ordered to determine LVEF post CABG.

11 Echo clip 2

12 Echo clip 2

13 Next Step A. Go with the old EF, start spironolactone and place an AICD. B. Do a nuclear stress test C. MUGA D. Cardiac MRI 0% 0% 0% 0% 0% E. Nothing Go with the old EF, start... Do a nuclear stress test MUGA Cardiac MRI Nothing

14 Does he need an AICD now? A. Yes B. No 0% 0% Yes No

15 Case 1: Conclusion EF was 44%, no need for primary prevention ACID, spironolactone. Continue beta blocker and ACEI.

16 Case 2 61 yo male veteran with atypical chest pains 61 y.o male veteran with atypical chest pains. EKG and echo ordered to evaluate this symptom.

17 Echo Result EF 50%, dyskinesis (movement in the wrong direction) of the inferior and inferolateral walls.

18 EKG

19 Next Step A. Cardiac cath B. Nuclear Stress Test C. Medical management for presumed ASCVD 0% 0% 0% 0% D. Cardiac MRI Cardiac cath Nuclear Stress Test Medical ma anagement for... Cardiac MRI

20 Scar Maps Inferior MI Our Patient

21 Conclusion No evidence of coronary disease, infarct or abnormal inferior wall motion. Mesenteric fat pushing on diaphragm exertion pressure (diastolic) on the inferior i wall of lf left ventricle.

22 Tissue Characterization

23 Case 3 70 yomale y.o with a history of stroke, CABG, anteroapical MI and apical thrombus (seen OSH echo) who presented with chest pain. Eh d l d db i Echo and nuclear scan were ordered by inpt team

24 Findings 1. Echo demonstrated LVEF 35%, anteroapical wall motion abnormalites, apical thrombus 2. Nuclear scan showed : anteroapical fixed defect, no ischemia Cardiac MRI was ordered to assess myocardial viability prior to deciding upon cath and revascularization in this patient with prior CABG and LV apical thrombus

25 Example of an apical thrombus

26 Gadolinium enhanced MRI pictures 2 chamber 4 chamber

27 Case 3 Conclusion NO LV apical thrombus Stop warfarin Prominent muscle band in apex Apical scar from prior infarct, no viability

28 Case 4 66 yo male with atypical chest pain. PE 30 yrs ago Rheumatoid Arthritis Afib

29 Nuclear stress test (8METS) obtained and ( ) demonstrated anterolateral ischemia.

30 Case 4 : Cath

32 Next Step A. Nothing to worry about 25% 25% 25% 25% B. Echo C. Cardiac MRI D. Something else Nothing to worry about Echo Cardiac MRI Something else

33 Conclusion: Case 4 Diagnosis : Anterolateral non compaction of the left ventricle. Not the cause of his atypical chest pain

34 Case 5: This is a 79 y.o male who was recently admitted to WRJ VA with a receptive aphasia. MRI imaging demonstrated small vessel disease and a large subacute infarct in the left MCA distribution. He was monitored on telemetry for 4 days in the hospital and all telemetry notes suggest he was in sinus rhythm.

35 Head MRI

36 Neurology E Consult Neurology asks if cardiology agrees, have him go to Boston to get long term out pt monitoring set up (at least 3 months) to see if we capture occult afib

37 Ready to place an ILR? A. Yes B. No 0% 0% Yes No

40 Case 5: Conclusion Small LV apical thrombus Begin warfarin? ILR now

41 Physiologic Data

42 Case 6 36 yomale y.o veteran from Colebrook, NH. Colleague tried out new echo machine on him and told him to come get checked out.

43 PA = 105 ml Aorta =70 ml

44 Case 6: Conclusion Qp:Qs = RV enlarged Patient went for surgical repair of the atrial secondum septal defect prior to onset of symptoms

45 Anatomy

46 Case 7 69 yomale with >50 pk year history of smoking 69 y.o male with >50 pk year history of smoking sent for lung cancer screening CT scan.

47 CT Scan

48 What is this Finding? A. Sarcoma B. Clot C. Lipoma D. Not sure 0% 0% 0% 0% Sarcoma Clot Lipoma Not sure

49 Tissue Characterization T2 weighted (Bright fat) T2with fat saturation (Dark Fat)

50 Conclusion: Case 7 No further diagnostics warranted Benign tumor? Yearly follow to ensure SVC does not become compressed

51 Function Tissue Characterization/Viability Physiology Anatomy

52 Cost Procedure $ Source Echocardiogram $3879 DHMC published rate Nuclear Stress $7618 DHMC published rate Stress Echocardiogram $5581 DHMC published rate Cardiac MRI $3800 National average hitchcock.org/billing charges/diagnostic_tests_dhmc.html#17

53 Time Procedure Echocardiogram Nuclear Stress Stress Echocardiogram Cardiac MRI Patient Time 45 minutes 3 4hours 1 hour hours

54 Wrap up: Common Indications 1) Coronary artery disease A. Assessment of global ventricular function and mass B. Detection of CAD C. Acute and chronic myocardial infarction 2) Cardiomyopathies A. Hypertrophic cardiomyopathy B. Dilated cardiomyopathy C. Arrhythmogenic Right Ventricular Cardiomyopathy D. Restrictive cardiomyopathies i. Sarcoid ii. Amyloid iii. Eosinophilic E. Myocarditis 3) Cardiac and pericardiac masses, thrombus

55 Common Indications 4) Pericardial disease A. Pericardial effusion B. Constrictive pericarditis 5) Valvular heart disease A. Quantification of regurgitation g 6) Congenital heart disease (CHD) A. Assessment of shunt size B. Anomalous pulmonary venous return C. Ebstein's s anomaly D. Pulmonary regurgitation E. Atrial septal defect 7) Diseases of the aorta and great vessels A. Aortic aneurysm B. Aortic dissection C. Intramural hematoma

Conflict Disclosures. Vermont Cardiac Network. Outline. Series Learning Objectives 4/27/2016. Scott E. Friedman April 28, 2016

Conflict Disclosures. Vermont Cardiac Network. Outline. Series Learning Objectives 4/27/2016. Scott E. Friedman April 28, 2016 Conflict Disclosures Vermont Cardiac Network The Speaker has reported no significant financial relationship with any companies whose product may be germane to the content of their presentations or who