Cardiac CT and MRI. Ashraf Hamdan, MD. Sheba Medical Center. Sheba Medical Center Tel Hashomer. Leviev Heart Center

Transcription

1 Cardiac CT and MRI Ashraf Hamdan, MD Sheba Medical Center Sheba Medical Center Tel Hashomer Leviev Heart Center

2 Spatial resolution Resolution 4x4mm If the object incidentally placed in one pixel high image quality Resolution 4x4mm If the object incidentally placed in more than one pixel larger object with low image quality & low render delineation =partial volume effect

3 Dual Source CT - Rationale Original Image 50 ms 100 ms 250 ms Ideally, motion-free imaging for coronary arteries requires acquisition time to be around 50 ms but the current temporal resolution of MDCT is: ms: temporal resolution for DSCT = 83 msec, for 64CT = 160msec

4 EHJ 2013

5 Pretest probability Low: < 15% - can be managed without further testing Intermediate: 15-85% - stress testing High: > 85% - risk stratification only EHJ 2013 EHJ 2013

6 Anatomical assessment of CAD CCTA? EHJ 2013

7 PPV = TP/(TP + FP) NPV = TN/(TN + FN) Schuetz et al. Systemic Reviews 2013,2:13

8 Effect of BMI on the image quality BMI = 30 kg/m² BMI = 19 kg/m²

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10 CASE I

11 CASE I

12 Case II

13 Case III

14 Case IV In 2010: typical chest pain

15 איתסמיני רץ מרתון מדי פעם גורמי סיכון מאוזנים היטב מעקב שגרתי אקו במאמץ כל 2-3 תקינים שנים

16 2014- מודאג האם התומכן ב LADפתוח איתסמיני מתכונן למרוץ הר לעמק אקו במאמץ-צניחות במקטע ST שלא היו בעבר ללא הפרעה בתנועתיות הדפנות גורמי סיכון מאוזנים היטב מטופל עם סטטין ומטפורמין, אספירין,פלביקס

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18 Case V RVOT Right cusp RV LV Left cusp

19 Coronary anomalies: Malignant criteria Intramural course: - Slit like ostium - acute angle - asymmetrically positioned between aorta & PA Running between PA and aorta Intra- vs. extramuscular: when intramuscular less malignant

20 MRI

21 10 Top MRI Indication 1. Ventricular volumes and function 2. Viability 3. Stress examinations: perfusion and dobutamine stress MRI 4. Cardiomyopathy, myocarditis and infiltrative disease 5. Tumors and Thrombus 6. Pericardial Diseases 7. Magnetic resonance angiography of the great and peripheral vessels 8. Coronary artery imaging 9. Blood flow quantification for shunt sizing and evaluation of valvular heart disease 10. Congenital disease

22 Need for further modalities?

23 Interstudy Reproducibility 200 MRI 200 Echo Mean 1 = 131 Mean 2 = 131 SD = 4.6 Mean 1 = 131 Mean 2 = 131 SD = 18 Bellenger. Pennell. JCMR 2000: 2: 271-8

24 Sample Size Reduction Grothues et al. Am J cardio, 2002; 90-29

25 Enddiastolic Endsystolic CMR-AKADEMIE.com Determination of LV- Function with Simpson s method is reference standard

26 MRI vs. SPECT Spatial resolution MRI ~ 2 x 3 mm SPECT ~ 10 x 10 mm 3-D Imaging No Radiation Wagner A et al. Lancet 2003;9355:

27 Comparison with Dobutamine Stress Echo (DSE) and MRI (DSMR) DSE DSMR P value Sensitivity 74.3% 86.2% < 0.05 Specificity 69.8% 85.7% < 0.05 Pos. predictive value 81.0% 91.3% < 0.05 Neg. predictive value 61.1% 78.3% < 0.05 Accuracy 72.7% 86.0% < Nagel et al. Circulation 1999;99:

28 MRI for the Diagnosis of Coronary Artery Disease Detection of ischemia MRI coronary angiography Perfusion measurements Wall motion analysis

29 Monitoring & Safety Aspects Continuous monitoring of rhythm/heart rate (vector-ecg) blood pressure respiratory control D Physician and Technician must bei experienced in advanced cardiac life support periodically practice rapid patient evacuation (2 staff members, <30 sec)

30 Safety of DSMR Side Effects Safety profiles of DSE and DSMR are virtually identical Wahl et al. Eur Heart J 2004

31 DSMR inducible WMA male, 52 yrs known CAD post multiple interventions of LCX at presentation chest pain, not strictly related to exercise Echo: moderate image quality (esp. endocardial border definition of lateral wall)

32 4-chamber view rest 20 g 40 g

33 Endsystole Enddiastole DSMR-02 rest 10µg 20µg max

34 DSMR-03 inducible, ischemic WMA

35 Late Enhancement Patterns for Ischemic and Nonischemic Disorders Mahrhold EHJ 26:1461

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39 Mechanism of delayed enhancement Normal myocardium Contrast agent molecules (Gadolinium-chelates) extracellular can not cross cell membrane low concentration Myocardial infarct Membrane rupture Gadolinium-chelates Intracellular Increased concentration hyperenhancement Chronic infarct Myocytes replaced by Collagen large interstitial space Increased concentration hyperenhancement intact cell membrane ruptured cell membrane Collagen matrix

40 Case I Male, 17 yrs Medical history: Smoker 7-days history of Fever 38.9, Sore throat, weakness At presentation: acute chest pain and dyspnea Laboratory workup: Troponin-I positive = (33 micg/l); CPK = 1630 IU/L

41 Invasive Angiogram

42 Acute myocarditis 5-months later

43 Acute myocarditis 5-months later

44 Acute myocarditis 5-months later

45 Case II: Gaint cell myocarditis Signal Intensity measurement Myocardium: 164g Scar: 54g, 33% Edema: 68g, 40%

46 Case II ischaemic vs. Non-ischaemic CMP

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50 Acute MI 3 weeks later

51 Case III Male, 56 yrs Medical history: s/p inferior MI (s/p PCI to RCA), Smoker 3-days history of Fever and chest pain Laboratory workup: Troponin-I positive = (25 micg/l); CRP = 190

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56 Case IV

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58 Apical 82% Multicenter study in 207 pts. Midventricular 82% Basal 82% Possible etiology - Inflammation - increased LV wall stress - transient ischemia - myocardial edema Biventricular 34% Eitel et al. JAMA 2011; 306:277

59 Preceding stressful events

60 Case VI Female, 51 yrs Medical history: Smoker, positive family history for CAD At presentation: Non specific chest pain Laboratory workup: Troponin-I positive = (18.9 micg/l); CPK = 785 IU/L

61 Invasive Angiogram

62 MRI

63 ARVD

64 Case V Male, 44y Syncope

65 Sarcoidosis

66 Sarcoma Black blood DE Broad based & large mass - Heterogeneous enhancement corresponding to Necrosis - The most common cardiac malignant tumor Isointense in T1 -The majority of occur in the right atrium - Mean survival 3 months to 1 year TGE without contrast TGE with contrast

67 Lipoma Without fat suppression With fat suppression

68 Lipoma Delayed enhancement Perfusion

69 Lipoma

70 Lipoma

71 Thrombus 5 days after MVR

72 Pericarditis

73 Non compaction