Imaging in Ischemic Heart Disease: Role of Cardiac MRI

Transcription

1 Imaging in Ischemic Heart Disease: Role of Cardiac MRI Chiara Bucciarelli Ducci MD, PhD, FESC, FRCP Consultant Senior Lecturer Cardiologist Bristol Heart Institute, University of Bristol, UK Chair elect, Cardiac MRI European Association Cardiovascular Imaging (EACVI) European Society of Cardiology (ESC)

2 Cardiovascular MR Function Infarct size Microvascular obstruction Inducible ischaemia Myocardial oedema

3 Spectrum of Ischemic Heart Disease ACUTE CHEST PAIN ACUTE MYOCARDIAL INFARCTION CHRONIC CHEST PAIN CHRONIC MYOCARDIAL INFARCTION

4 CMR in Ischemic Heart Disease Infarction Transmurality, Viability, Hibernation Inducible myocardial ischemia LV thrombus Left ventricular remodeling Microvascular obstruction Myocardial Edema

5 CMR in Ischemic Heart Disease Infarction Transmurality, Viability, Hibernation Inducible myocardial ischemia LV thrombus Left ventricular remodeling Microvascular obstruction Myocardial Edema Chronic MI Stable Angina

6 Spectrum of Ischemic Heart Disease ACUTE CHEST PAIN ACUTE MYOCARDIAL INFARCTION CHRONIC CHEST PAIN CHRONIC MYOCARDIAL INFARCTION

7 Cardiovascular MR Function Infarct size Microvascular obstruction Inducible ischaemia Myocardial oedema

8 Gadolinium chelates contrast agents Kim RJ, Cardiovascular MRI and MRA, Higgins and de Roos ed. LWW 2003

9 Histological validation Kim RJ et al, Circulation 1999

10 Myocardial Infarction Bright is dead Kim & Judd 2000 Bright is bad Bucciarelli-Ducci, JACC 2014 Kim RJ et al, Circulation 1999

11 Contrast Enhancement NSTEMI HCM STEMI MYOCARDITIS DCM AMYLOID

12 Building Evidence for Myocardial Viability time Simonetti et al. Radiology, 2001 Wagner A et al. Lancet, 2003 HIggins et al. Circulation, 1983 Kim et al. Circulation, 1999 Bright is dead

13 Transmurality: MRI vs SPECT Transmural Infarct Subendocardial Infarct Wagner A and Bonow RO, Lancet 2003

14 Q waves and Transmural Infarct Moon J, JACC 04

15 Q waves and Subendocardial infarct Moon J, JACC 04

16 Non Q-waves and Transmural Infarct Moon J, JACC 04

17 Functional Recovery after Revascularization Recovery of contracttility (%) Transmural Extension of Late Enhancement Kim RJ, NEJM 2000

18 Case 1 Apex and Anterior Wall: Viable or Non-Viable?

19 Viability Study

20 Post-PCI

21 Recovery of LV Function Before PCI After PCI

22 From: Prevalence of Regional Myocardial Thinning and Relationship With Myocardial Scarring in Patients With Coronary Artery Disease JAMA. 2013;309(9): doi: /jama Date of download: 8/30/2015

23 Survival, CMR Viability and Revasc Gerber et al, JACC 2012

24 Risk of 3-Year Death Gerber et al, JACC 2012

25 STICH Trial- Viability and Survival in LV Dysfunction No significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause Flaws in Study Design: <50% had viability testing Viability testing not randomised Viability defn changed throughout the trial Viability definition differed in SPECT and DSE Viability sub-study was underpowered (only 114pts deemed non viable Viability testing was not blinded (influenced treatment decisions in the trial) What s next? Bonow et al, NEJM 2011

26 Infarction and Inducible VT LGE compared with EF to predict EPS inducible VT Bello J Am Coll Cardiol 2005; 45:

27 Schmidt Circulation 2007; 115: 2006

28 CRT and non responders Bax et al, Circulation 2006

29 Implications for CRT Posterolateral Scar associated with increased events rates regardless of extent of scar CV deaths, hospitalisation for heart failure Mean follow-up : 741 days Pacing over postero-lateral scar is associated with increased events rates Chalil et al PACE 2007;30:1201-9

30 LGE and Differential Diagnosis Mahrholdt H et al, EHJ 2005; 26:

31 Etiology of heart failure Case 2 Case 3

32 Case 2 Ischemic cardiomyopathy

33 Case 3 Dilated Cardiomyopathy

34 Left ventricular thrombus

35 Silent Infarct

36 Kwong RY et al, Circulation 2006

37 Spectrum of Ischemic Heart Disease ACUTE CHEST PAIN ACUTE MYOCARDIAL INFARCTION CHRONIC CHEST PAIN CHRONIC MYOCARDIAL INFARCTION

38 Perfusion CMR SPATIAL RESOLUTION SPECT PET CMR ~ 8 10mm ~4 7 mm ~2 mm Contrast first pass perfusion technique Transmural / Subendocardial extent of perfusion defect

39 Building Evidence for CMR Stress Perfusion M z 2010: Multicentre, multivendor MR-IMPACT II n= : Multicentre, Tissue multivendor 2 MR-IMPACT I n= : Multicentre, single vendor 2003: White single centre, single vendor 2001: Single centre - validation 2012: Single centre, randomized CE-MARC n=752 time MR: subendocardial (87%/85%/0.91) 0.2 MR: transmural (83%/67%/0.84) Specificity Sensitivity Adequate Quality Score <4 Central 3 Slices Specificity Akintson et al. Radiology, 1990 Schwitter et al. Circulation, 2001 Nagel et al. Circuation, 2003 Giang et al. Eur Heart J, 2004 Schwitter et al. Eur Heart J, 2008 Schwitter et al. JCMR 2012

40 How to do CMR Perfusion

41 Perfusion Slices and Coronary Territories

42 CMR Perfusion Protocol ECG BP Cine BP Stress perfusion LGE BP Rest perfusion

43 CMR Perfusion Protocol ECG BP Cine BP Stress perfusion LGE BP Rest perfusion

44 CMR Perfusion Protocol ECG BP Cine BP Stress perfusion LGE BP Rest perfusion

45 CMR Perfusion Protocol ECG BP Cine 5-10min BP Stress perfusion Total scan duration: 50-60min (cine, stress/rest, viability 5-10min 15-20min LGE BP Rest perfusion

46 CMR Perfusion vs Angio and PET Schwitter, Circulation 2001

47 CMR Stress Perfusion vs FFR Lockie T et al, JACC 2011

48 Case 1 Before angioplasty After angioplasty

49 Case example 2 Reversible myocardial ischemia in the RCA territory

50 Case example 2 Pre PCI Post PCI

51 Resolution of Inducible Ischemia Before PCI 1 month after PCI

52 Case 2 51 yo caucasian female Hypertension, hypercholesterolemia Episode of chest discomfort

53 Stress Perfusion MRI basal mid cavity apical STRESS REST

54 Stress Perfusion MRI basal mid cavity apical STRESS discrete inducible perfusion defect in the mid cavity and apical anterior wall (white arrows) (likely corresponding to a large D1 territory)

55 Angio Severe stenosis ostional diagonal branch Moderate LAD disease but pressure wire was within normal limits

56 Greenwood et al Lancet 2012

57 CE-MARC: Gender Substudy Greenwood J et al, Circulation 2014

58 CE-MARC: Gender (single- multivessel) Greenwood et al.circulation 2014 in press

59 Design N=1,200 patients UK multi-centre, multi-vendor, randomised 3T CMR stress guided care vs. current best clinical practice Patients with suspected CHD Hypothesis 3T CMR-guided management of patients with suspected CHD is: Superior to current best clinical practice* avoiding unnecessary coronary angiography patients outcome *defined by NICE guidelines & AHA appropriateness criteria Greenwood J et al, JAMA 2016

60 MR Perfusion Imaging to Guide the Management of Patients with Stable Coronary Artery Disease Randomization Baseline MRI FFR INFORMED MR INFORMED Main Hypothesis MR perfusion imaging is non-inferior to FFR in guiding therapy of patients with stable angina FFR -ve Medic Rx FFR +ve Revas c MR -ve Medic Rx MR +ve Revas c Primary endpoint Occurrence of Major Adverse Cardiac Events (MACE): Death / Heart attack / Need for repeat revascularisation Cost analysis 6 Months FU 12 Months FU Primary Endpoint MACE: Death / AMI / Urgent TVR Cost analysis Nagel E et al. Recruitment completed in Jun 2015

61 International Study of Comparative Health Effectiveness with Medical and Invasive Approaches Patients: Moderate-Severe Ischemia and EF >35% Hypothesis: Initial invasive strategy of cath + optimal revasc (PCI or CABG) + OMT is superior to a conservative strategy of OMT alone Composite Primary Endpoint: CV death or MI Sample Size: 8,000 Follow-up: ~4 years Core Lab Inclusion criteria SPECT Echo RWMA CMR Perfusion 10% LV 3/16 segments Stress hypo/akinesia 12.5% LV

62 Syndrome X Painting Pennell, NEJM 2002

63 Perfusion CMR MPR MBF Myocardial perfusion reserve Myocardial blood flow

64 Prognosis Adenosine stress CMR Patients with known or suspected CAD Jahnke C et al, Circulation 2007

65 Dobutamine Stress vs Adenosine Perfusion Jahnke C, Circulation 2007

66 Bristol - Stress CMR Referrals + 480% in 4 years Stress CMR Referrals Financial Years

67 2010 NICE Guidelines

68 2014

69 CMR Perfusion and Viability Facts Validated technique High resolution, radiation free No balanced ischemia 1h scan Clinical evidence accumulating Myths? Standardized perfusion protocol? 3D perfusion? Quantitative analysis? No devices YES, most? Clautrophobia Ready to be used clinically

70 EuroEcho Imaging December 2016 Leipzig, GERMANY

71 ESC CMR Level 1 certificate *** Special Track**** (free, included in conference registration fees) CMR level 1 is considered the basic knowledge for European Cardiologists SAVE THE DATE European s main clinical CMR meeting 2.5 days of science and clinical training 800+ delegates from 40+ countries 300+ abstract submitters 35+ scientific sessions 90+ international speakers Abstract, posters and cases sessions The opportunity to get CMR level 1 certified

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