CMR stress Perfusion: what's new?

Transcription

1 CMR stress Perfusion: what's new? John P. Greenwood Professor of Cardiology, Leeds University, UK Consultant Cardiologist Leeds Teaching Hospitals NHS Trust, UK

2 CMR: multi-parametric CMR: multi-parametric Echo Multi-parametric SPECT DSE /PET Function Viability Perfusion /ischaemia SPECT ETT Coronaries Angiography CCT MCRC LICAMM LEEDS

3 Evolution of myocardial perfusion CMR 1990s Research tool Method development Feasibility studies

4 Evolution of myocardial perfusion CMR 1990s 2000s Research tool Method development Feasibility studies Standardisation Clinical uptake Single centre diagnostic accuracy studies

5 Evolution of myocardial perfusion CMR 1990s 2000s 2010s Research tool Method development Feasibility studies Standardisation Clinical uptake Single centre diagnostic accuracy studies Comparative effectiveness Outcome studies Guideline inclusion Technical refinement

6 CMR vs. SPECT

7 CMR vs. SPECT Stress perfusion CMR Mean 91% Mean 81% n = 1,516

8 The CE-MARC programme Results Diagnostic Performance CMR SPECT P value Sensitivity (%) P<0.001 Specificity (%) P=0.916 NPV (%) P<0.001 PPV (%) P=0.061 MCRC LICAMM LIGHT LEEDS

9 The CE-MARC programme Results

10 Comparative effectiveness vs FFR CMR (0.94) PET (0.93) CT (0.93) SPECT (0.83) ECHO (0.82) Takx RAP Circ Cardiovasc Imaging. 2015;8:e002666

11 Cardiac magnetic resonance

12

13 Clinical routine at 1.5T 90 o Slice 1 90 o Slice 290 o Slice 3 o 2 o o o o Saturation Prep Pulse Balanced SSFP 3 slices per heart beat 2.3 x SENSE 2.4 x 2.4 x 8 mm resolution

14 Perfusion: refinements High resolution High field 3D Post-processing

15 k-t BLAST/SENSE/PCA Improve spatial resolution in 2D perfusion

16 High vs standard resolution 5 fold acceleration 1.3 x 1.3 mm High resolution perfusion MRI Standard resolution 2.5 x 2.5mm

17 Spatial resolution and dark rims 3 x 3 x 10 mm 1.5 x 1.5 x 10 mm Increasing spatial resolution leads to a reduction in ring artefact and improved definition of perfusion defects

18 High ROC vs. curves standard of different resolution pulse - MVD sequences In 3VD, increasing spatial resolution leads to much clearer discrimination ischaemia burden and extent, through better detection of sub-endocardial ischaemia Motwani. EHJ - Cardiovascular Imaging 2014; 15:

19 High vs. standard resolution perfusion 100 patients, suspected CAD, high and standard resolution perfusion: AUC 0.93 (95% CI: ) vs (95% CI ); p<0.001 to detect CAD on angiography Motwani M. Circ Imaging 2012

20 High vs standard resolution perfusion Motwani M. Circ Imaging 2012

21 High-field and high resolution Improved myocardial perfusion imaging: Speed, resolution and signal: k-t SENSE & 3 Tesla

22 1.5T versus 3T

23 Using k-t BLAST/SENSE/PCA Three-dimensional whole heart perfusion

24 3D perfusion 3T Philips, fast GRE, 10x k-t acceleration (2.3x2.3x5mm) Motwani et al. JCMR 2014, 16:19

25 3D perfusion vs FFR multicentre study Typically limited coverage (2D, 3 slices) limits MIB assessment Prospective study of 3D perfusion vs. FFR 5 European centres (3T) Zurich, Aachen, Berlin, KCL, Leeds All clinically listed for angio and FFR already FFR only done in lesions 50-80% severity CAD prevalence 57% by FFR (63% by QCA) Core lab analysis blind to all clinical data N=155 Manka R et al Circ Cardiovasc Imaging May;8(5)

26 3D perfusion vs FFR multicentre study Sensitivity 85% Specificity 91% AUC 0.91 Apex Mid LV Base Manka R et al Circ Cardiovasc Imaging May;8(5)

27 Quantitative analysis Semi-quantitative analysis Quantitative analysis Perfusion Phantom Chiribiri, MRM 2013 Transmural Perfusion Gradients Pixel-wise Analysis Hautvast, MRM 2011; Chiribiri, ijacc 2013 Clinical Translation Perfusion Dyssynchrony Chiribiri, EHJCVI 2015 Heart Failure Hypertrophic Cardiomyopathy (HCM) Zarinabad and Chiribiri, MRM 2012 Sammut, JCMR 2015; Villa JCMR 2016 Courtesy A Chiribiri, KCL London

28 Utility of quantitative analysis N=128 pts randomly selected from CE-MARC Original visual read Stress and rest MBF (Fermi deconvolution) Stress MBF vs visual (P=0.82) MPR vs visual (P=0.63) No added value from quantitation No added value from a rest scan Unpublished data

29 Outcome data for perfusion CMR n=561 Meta-analysis 19 studies 11,636 patients Mean follow-up of 32 months Events rates: - 4.9% for a positive - 0.8% for negative stress CMR (p<0.0001) - OR 6.5 (p<0.0001) Jahnke C, et al. Circulation. 2007;115: Lipinski MJ, et al. J Am Coll Cardiol May 29.

30 New Long prognostic term follow-up evidence No comparative, prospective, prognostic data from CMR and MPS-SPECT in the same patients with suspected CHD All patients recruited to CE-MARC scheduled for annual FU for a minimum of 5 years (>99%FU) to assess the occurrence of MACE CV death, ACS/AMI, unscheduled revascularisation or hospital admission for CV cause) MCRC LICAMM LEEDS

31 New evidence Both independent Both independent predictors predictors of MACE: of MACE: CMR (HR CMR 2.77 (HR ( ); 2.77 ( ); p<0.0001) p<0.0001) SPECT SPECT (HR 1.63 (HR ( ); 1.63 ( ); p=0.013) p=0.013) Normal CMR & SPECT hard event rate: 0.12%/year vs. 0.36%/year Only CMR remained a significant predictor after adjustment for CV risk factors Compared to SPECT, CMR appears to be a stronger predictor of risk of MACE ANNALS INTERNAL MEDICINE 2016, 165(1):1-9. MCRC LICAMM LIGHT LEEDS

32 New evidence Hypothesis: 3T CMR-guided management of patients with suspected CHD, is superior to current best clinical practice (NICE & AHA appropriateness criteria), both in terms of avoiding unnecessary coronary angiography and for patient outcome (MACE) UK, multi-centre/vendor, RCT 1200 patients with suspected CHD and PTL 10-90% 1EP: reduction of unnecessary angiography as defined by FFR (>0.8)

33 New evidence Hypothesis: MR perfusion imaging is non-inferior to FFR in guiding therapy of patients with stable angina International RCT 16 centers (UK, Germany, Portugal, Australia) 918 patients Primary endpoint: Occurrence of MACE: Death MI Repeat revascularisation Completed Aug 2015 MR-INFORM Study Population Stable Angina (CCS>2) and/either 2 risk factors for CAD or positive exercise ECG Enrolment (918 Patients) and 1:1 Randomization FFR INFORMED BASELINE CMR (blinded) INVASIVE ANGIOGRAPHY PLUS FFR STENOSIS <30% or FFR >0.8 STENOSIS >95% or FFR <0.8 MR-INFORMED BASELINE CMR (on-site read) NO SIGNIFICANT ISCHAEMIA SIGNIFICANT ISCHAEMIA (transmural or >2 segments or 2 slices) OMT REVASCULARIZATION AND OMT OMT REVASCULARIZATION AND OMT Follow up (6 months and 1 year) ACC (Washington) Friday 17 th March: late breaking clinical trial

34 Conclusions High-field (3T) High-resolution (1.5T and/or 3T) 3D perfusion (coverage) New quantitative techniques benefit to be proven clinically New clinical efficacy data through CER DA, cost effectiveness, prognosis (CE-MARC; MR-IMPACT II) Reduction in downstream resource utilisation (CE-MARC 2) Guiding revascularisation (MR-INFORM) Remember: we already have an excellent technique. MCRC - LICAMM - LEEDS

35 Free - CMR App. try it App developed by Eltjo Hasselhoff