Imaging congestive heart failure: role of coronary computed tomography angiography (CCTA)

Transcription

1 Imaging congestive heart failure: role of coronary computed tomography angiography (CCTA) Gianluca Pontone, MD, PhD, FESC, FSCCT Director of MR Unit Deputy Director of Cardiovascul CT Unit Clinical Cardiology Unit Centro Cardiologico Monzino, IRCCS University of Milan, Italy 0

2 DISCLOSURE SPEAKER BUREAU FOR GENERAL ELECTRIC SPEAKER BUREAU FOR MEDTRONIC SPEAKER BUREAU FOR BRACCO RESEARCH GRANT FROM GENERAL ELECTRIC RESEARCH GRANT FROM HEARTFLOW 1

3 SUMMARY Volume, function and remodelling Rule out coronary artery disease To evaluate LV myocardial damage To evaluate cardiac veins anatomy 2

4 1. VOLUME, FUNCTION AND REMODELLING Global Left Ventricular Function: MDCT vs Echo/SPECT Cury R, J Nucl Cardiol 2007

5 1. VOLUME, FUNCTION AND REMODELLING Global Left Ventricular Function: MDCT vs MRI Raman S, AHJ 2006

6 1. VOLUME, FUNCTION AND REMODELLING Regional Left Ventricular Function: MDCT vs Echo Lessick J AJC 2005

7 1. VOLUME, FUNCTION AND REMODELLING Regional Left Ventricular Function: MDCT and SPECT vs MRI MDCT vs MRI K:0.86 SPECT vs MRI K: 0.51

8 1. VOLUME, FUNCTION AND REMODELLING Clinical implication on myocardial mass estimation Armstrong A JACC CI

9 1. VOLUME, FUNCTION AND REMODELLING Clinical implication on left ventricle volume estimation Armstrong A JACC CI

10 1. VOLUME, FUNCTION AND REMODELLING Systematic simulation of MR LV remodeling with respect to control. The MR heart has the same LVES dimension (LVESD) as and a long-axis length similar to that of the control. However, there is less curvature from the mid to distal LV segments represented by the dimmer red in the MR patient vs control (bright yellow). These changes in the MR patient contribute to a more spherical LV remodeling and a larger LVES volume. Schiros CG Circulation

11 1. VOLUME, FUNCTION AND REMODELLING The difference between the measured LVESV from summated short-axis images and LVESV calculated from the Bullet formula in MR are plotted vs LVES circumferential curvature at the distal LV. Correlation between left ventricular (LV) end-systolic volume (LVESV) and dimension (LVESD) in mitral regurgitation (MR) patients (A) and control subjects(b). The solid lines represent the fitted model for the LVESD vs LVESV relation with 95% confidence intervals (dash lines), which is cubic in MR patients (n94) and quadratic in control subjects (n51). Schiros CG Circulation

12 1. VOLUME, FUNCTION AND REMODELLING 11

13 1. VOLUME, FUNCTION AND REMODELLING Left Ventricular Function: limitations Temporal Resolution Single Source CT: msec Dual Source CT: 75 msec MRI, Echo < 50 msec -blockade Because -blocker is generally used in MDCT, it can alter the functional parametrs and thus limit the utility of functional analysis Other Mitral Plane and LVOT Radiation Exposure

14 SUMMARY Volume, function and remodelling Rule out coronary artery disease To evaluate LV myocardial damage To evaluate cardiac veins anatomy 13

15 2. RULE OUT CAD Andreini D, Pontone G, JACC

16 2. RULE OUT CAD *: P<0.05 Group 1 (DCM) Group 2 (Control) Number Feasibility 97,2% 96,1% Andreini D, Pontone G, JACC

17 2. RULE OUT CAD *: P<0.05 Group 1 (DCM) Group 2 (Control) Sensitivity 99% 86,1%* Specificity 96,2% 96,4% NPV 99,85 96,4%* PPV 81,2% 86,1% less motion artifacts in DCM population Andreini D, Pontone G, JACC

18 2. RULE OUT CAD LCX LM LAD D1 M1 not-evaluable segments were excluded from the analysis 17

19 2. RULE OUT CAD Andreini D, Pontone G, Circulation CI

20 2. RULE OUT CAD Andreini D, Pontone G, Circulation CI

21 2. RULE OUT CAD Dilated cardiomyopathy associated with severe CAD. Head-to-head comparison of invasive coronary angiography (left panel) compared with MDCT multiplanar reconstruction (right panel). White arrows show significant stenosis on the proximal segments of left anterior descending artery (LAD), first marginal branch (M1), and right coronary artery (RCA). Andreini D, Pontone G, Circulation CI 2009

22 2. RULE OUT CAD Idiopathic form of dilated cardiomyopathy. Head-to-head comparison of MDCT multiplanar reconstruction (left panel) compared with invasive coronary angiography (right panel). LAD indicates left anterior descending artery; LCX, left circumflex artery; RCA, right coronary artery. Andreini D, Pontone G, Circulation CI 2009

23 SUMMARY Volume, function and remodelling Rule out coronary artery disease To evaluate LV myocardial damage To evaluate cardiac veins anatomy 22

24 3. TO EVALUATE LEFT VENTRICLE DAMAGE Thickness Attenuation

25 3. TO EVALUATE LEFT VENTRICLE DAMAGE Late Enhancement with MDCT It is known that MRI can characterize MI with both early and late contrast patterns. First-pass imaging performed immediately after contrast administration may demonstrate areas of hypoenhancement in the endocardial core of the infarct corresponding to microvascular obstruction. Delayed images acquired more than 10 minutes after contrast administration may demonstrate regional hyperenhancement, corresponding to myocardial necrosis or scar. Because iodinated contrast agents used in CT have kinetics similar to gadolinium used in MRI, as discussed later, there is a rationale to believe that DHE-MDCT would be able to identify areas of MI

26 3. TO EVALUATE LEFT VENTRICLE DAMAGE Delayed Time: 5 10 min Tube Voltage: 80 Kv Tube Current: 420 ma Collimation: 64x0.625 mm Gantry Rotaion time: 350 msec ECG-gating: prospective ECG Se Sp NPV PPV 78% 100% 100% 97% Effective Radiation Dose: msv

27 3. TO EVALUATE LEFT VENTRICLE DAMAGE 52 PTS with Acute MI PTCA+Stent CT LE and Tl-SPECT 0 and 6 Month

28 3. TO EVALUATE LEFT VENTRICLE DAMAGE Transmural LE Subend. LE No LE SATO A EHJ 2008

29 3. TO EVALUATE LEFT VENTRICLE DAMAGE Significant increase of LVEDV only in transmural LE Higher incidence of hospitalization only in transmural LE

30 3. TO EVALUATE LEFT VENTRICLE DAMAGE Late Enhancement 0 = no LE Late Enhancement 1: 1% - 25% Late Enhancement 2: 26% - 50% Late Enhancement 3: 51% - 75% Late Enhancement 4: : >75%

31 DELINEATION OF THE ETIOLOGY OF LV DYSFUNCTION

32 DELINEATION OF THE ETIOLOGY OF LV DYSFUNCTION * * * * * * * * Le Polain De Waroix et al EHJ 2008

33 DELINEATION OF THE ETIOLOGY OF LV DYSFUNCTION Se Sp Accuracy 92% 97% 94% Le Polain De Waroix et al EHJ

34 SUMMARY Volume, function and remodelling Rule out coronary artery disease To evaluate LV myocardial damage To evaluate cardiac veins anatomy 33

35 4. CARDIAC VEINS ANATOMY 34

36 4. CARDIAC VEINS ANATOMY Pontone G IJC

37 4. CARDIAC VEINS ANATOMY Pontone G IJC

38 4. CARDIAC VEINS ANATOMY DCM: lower percentage of cardiac veins DCM without specific protocol: more artifacts No differences between DCM and control regard to anatomical details of veins PVLV and LMV are less in all groups Ischemic DCM group shows the less suitable anatomy for CRT 37

39 4. CARDIAC VEINS ANATOMY Normal Cardiac Veins anatomy GCV CS GCV PV MCV LMV GCV PV LEGENDS CS:coronarysinus;MCV:middlecardiacvein;PV:posteriorvein; GCV: great cardiac vein; LMV: left marginal vein; AIV: anterior interventricular vein. AIV LMV

40 4. CARDIAC VEINS ANATOMY Great Cardiac Veins from SVC

41 4. CARDIAC VEINS ANATOMY Fistula between greta cardiac vein and left atrial appendage

42 4. CARDIAC VEINS ANATOMY Giraldi F, Pontone G et al JACC

43 4. CARDIAC VEINS ANATOMY Giraldi F, Pontone G et al JACC

44 4. CARDIAC VEINS ANATOMY Giraldi F, Pontone G et al JACC

45 TAKE HOME MESSAGE Giraldi F, Pontone G et al JACC

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