Echocardiographie ou IRM dans la cardiomyopathie dilatée? Olivier Huttin
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1 Echocardiographie ou IRM dans la cardiomyopathie dilatée? Olivier Huttin
2 Disclosure Statement of Financial Interest I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company :
3 Definition of DCM Hypokinetic cardiomyopathy Dilated cardiomyopathy - LV or biventricular global systolic (LVEF< 45%) - not explained by abnormal loading conditions or coronary artery disease ± - LV dilatation is defined by LV enddiastolic volumes or diameters - >2SD from normal according to normograms (Z scores ) corrected by BSA v v Taille (cm) Poids (Kgs) Age (Yrs) DTD(mm) BSA (m2) LVEDDPred (mm) LVEDD (%) ,56 44,53 125, ,01 49,4 115,3 Early DCM Atheletes Heart
4 Clinical spectrum of DCM ND or D : non-dilation/dilation or NH or H : non-hypokinetic/hypokinetic on two distinct occasions preferably echocardiography or CMR Yigal M. Pinto et al. Eur Heart J 2016
5 IMAGING DCM PHENOCOPIES 21% 29% 28% 26% CAUSES? RECOVERY? CLINICAL STATUS? RISK?
6 Cardiac Imaging Functionnal analysis Tissu characterisation Systolic function Morphology and motion Diastolic function Couplage VA Oedema Scar Fibrosis (Diffuse, focal) Myocardial performance, synchronisation and deformation
7 TTE CMR LV REMODELING AND FUNCTION ETIOLOGY - VIABILITY VENTRICULAR AND SCD PREDICTION HEART FAILURE CRT Therapy Diastolic - LA function RV function SCREENING AND EARLY EVALUATION REPEATIBILTY FEASABILITY Echogenicity SV / V arryhtmia Heamodynamic instability Unable to perform apnea COUNTER INDICATION Device incompatibility - ICD. ACCESSIBILITY - CENTER EXPERTISE
8 PART 1 : EVALUATION OF LV FUNCTION AND REMODELING 1. Precise quantification of cardiac chambers volume and LVEF calculation 2. Evaluation of LV remodeling Initial status Adverse remodeling Reverse remodeling Follow-up and serial evaluation
9 Biventricular volumes and ejection fraction TTE CMR high temporal resolution Improves spatial accuracy high spatial resolution Multiplanar imaging excellent delineation of the blood myocardium interface Contrast agents Automated delineation Multi-plan 3D Full volume
10 2D echo versus CMR Marzia Rigolli et al. Open Heart 2016
11 TTE CMR LV REMODELING AND FUNCTION LV function LVEF LV Remodeling repeatbility?
12 PART 2: IMAGING AND EVALUATION FOR ETIOLOGY OF DCM VENTRICULAR DILATION AND DEPRESSED MYOCARDIAL CONTRACTILITY ISCHEMIC CARDIOMYOPATHY dilation and depressed contractility caused by ischemia or infarction HYPERTENSION, VALVULAR, CONGENITAL RHYTHMIC ETIOLOGY NON-ISCHEMIC CARDIOMYOPATHY Inflammatory / Autoimmune (myocarditis) Infiltrative (Amyloidois) Toxic (alcohol, chemtherapy) Toxic (alcohol, chemtherapy) genetic basis (neuromuscular D ; laminopathy
13 MYOCARDIAL FIBROSIS NO FIBROSIS DIFFUSE FIBROSIS FOCAL FIBROSIS Stress induce Infiltrative Alan G. JACC, 2016
14 INFARCT SIZING ON LGE MRI SEMI-QUANTITATIVE MANUAL FWHM AND N-SD METHOD SUB-ENDOCARDIAL -INTERMEDIATE TRANSMURAL
15 40 yo male hospitalization for HF BNP 2000
16
17 DIFFERENTIATION OF HF RELATED TO DCM AND CAD Understand the LV dysfunction and assess Viability Rule out non obstructive Coronaropathy J.A. McCrohon Circulation. 2003;108:54-59 Giampaolo Niccoli et al. Eur Heart J 2015
18 + 5 0 STRETCH PST ECHO AND TISSUE CHARACTERISATION AVC -5 Strain (%) POST SYSTOLIC εε POST SYSTOLIC εε PSI NORMAL SEGMENT ABNORMAL SEGMENT -30 PLS Time (ms)
19 Apical Lateral Apical Inferior Apical Septum Apical Anterior Mid Lateral Mid Inferolateral Mid Inferior Mid Septum Mid Anteroseptal Mid Anterior Basal Lateral Basal Inferolateral Basal Inferior Basal Septum Basal Anteroseptal Basal Anterior PLS (%) NC thickness (mm) Tarando F, Int J Cardiovasc Imaging Huttin et al. Int J Card and Heart Vessels 2015 Huttin O. et al.clin research 2016
20 VENTRICULAR DILATION AND DEPRESSED MYOCARDIAL CONTRACTILITY ISCHEMIC CARDIOMYOPATHY dilation and depressed contractility caused by ischemia or infarction HYPERTENSION, VALVULAR, CONGENITAL RTYHMIC ETIOLOGY NON-ISCHEMIC CARDIOMYOPATHY Inflammatory / Autoimmune (myocarditis) Infiltrative (Amyloidosis) Toxic (alcohol, chemotherapy) Post partum Genetic (neuromuscular;laminopathy)
21 DCM WITH FIBROSIS 1. Midwall (IVS) 2. Patchy (RV insertion) 3. Others wall
22 DCM WITH NO FIBROSIS?
23 T1 mapping Ambale-Venkatesh, B. & Lima, J. A. C Nat. Rev. Cardiol. 2014
24 DIFFUSE MYOCARDIAL FIBROSIS T1-MAPPING EF 1. Precedes functional impairment 2. Determines prognosis 3. Potential therapeutic target LGE T1 Valentina JACC Cardiovascular Imaging, Volume 9, Issue 1, 2016
25 TTE LV REMODELING AND FUNCTION CMR ETIOLOGY - VIABILITY
26 PART 3: NOVEL RISK PREDICTION TOOLS FOR SCD in DCM LV markers of mortality and ventricular arrhythmias - In preclinical phase (normal LVEF) - Indication for Primary prevention (LVEF<35%??) How can we identify those high-risk patients? Lars Kober N Engl J Med 2016; 375:
27 One ICD = One CMR 1. LGE has a predictive value for VT/SCD in both ischaemic and non-ischaemic cardiomyopathy. 2. Thrombus? 3. Spatial scar characteristics : VT inducibility / ablation? Sujith Kuruvilla Circ Cardiovasc Imaging D. Voilliot C Dechillou CIC-IT Nancy
28 ECHO PREDICTORS OF VENTRICULAR ARRHYTHMIAS in EARLY PHASE of DCM Mechanical dispersion HR =1.20 P = Haugaa et al. JACC Cardiovasc Imaging 2015
29 TTE LV REMODELING AND FUNCTION CMR ETIOLOGY - VIABILITY VENTRICULAR AND SCD PREDICTION
30 PART 4 : DCM - HEART FAILURE and PROGNOSIS PRECLINICAL CLINICAL CRT-D? MR? LVAD? Japp, a,g et al G. JACC, 2016
31 VENTRICULAR DYSSYNCHRONY
32 2D STRAIN Dilated Cardiomyopathy 200 Non ischemic DCM Follow up 17 months readmission for heart failure or cardiac death Cho GY et al. J Am Coll Cardiol 2009
33 SELECTION OF PATIENTS RESPONDING TO CRT Substrates Of Mechanical Discoordination RADIAL STRAIN Yu Circ 2004;110:66 - Dohi AJC 2005 SEPTAL DEFORMATION PATTERN Joost Lumens et al. Circ Cardiovasc Imaging Marechaux et al. J Am Soc Echocardiogr Menet A Eur Heart J Cardiovasc Imaging. 2016
34 PREDICTIVE VALUE OF RV DYSFUNCTION in HF RVEF <35/38% TAPSE <14mm S <7.3 cm/s RVFAC<35% RVEF <45% Vizzardi et al. Echocardiography 2012 Polak et al. JACC 1983 Ghioet al.eurj of HeartFailure 2013 Juillière et al. Eur Heart J Murninikas et al. J Cardiac Failure 2014 Aronson et al. J Cardiac Fail 2013 Bistola et al. Am J Cardiol 2010 Vizzardiet al. HellenicJ Cardiol2014 Gulati et al. Circulation 2013 STE cut off -15% Park et al. JACC imaging Motoki et al JASE 2014
35 FUNCTIONAL MITRAL REGURGITATION and ATRIAL FUNCTION Rutger J. van Bommel et al. Circulation Pellicori P Eur Heart J. 2015
36 TTE CMR LV REMODELING AND FUNCTION ETIOLOGY - VIABILITY VENTRICULAR AND SCD PREDICTION HEART FAILURE CRT Therapy -MR Diastolic - LA function RV function
37 PART 5: EARLY DETECTION and MONITORING CARDIAC FUNCTION Early detection of PRE-DCM PHENOTYPE Serial changes in LV function and repeat evaluation of HF Follow-Up Response to heart failure therapy Prediction of LV function recovery Change in LVEF from baseline at 6 months and 1 year = strongest predictors of mortality
38 DIAGNOSTIC OF PRE-SYMPTOMATIC HF Relatives DCM screening <5% meet criteria for DCM but 15% to 25% exhibit LV dilatation 10% to 20% progress to overt DCM 5 years Chemotherapy-related cardiac dysfunction 5% to <55% with HF symptoms or Asymptomatic decrease of LVEF 10% to <55% Atheltes Thavendiranathan P et al J Am Coll Cardiol Mousavi N et al. Eur Heart J Cardiovasc Imaging. 2015
39 SERIAL CHANGES IN LV FUNCTION AND REPEAT EVALUATION OF HF Male 58 yo Resistant Chronic myeloid leukemia PONATINIB : multi-targeted tyrosine-kinase inhibitor (start in sept 2011) 2011 Pretherapeutic TTE March 2012 Congestive HF
40 PLS (%) LVEF (%) ,2-6, ,8-11,7-10,1-8 -7,1-8, TT PONATINIB PONATINIB PONATINIB SCA+HF SHF
41 PREDICTION OF LV FUNCTIONAL RECOVERY Feb 2013 March 2014 July 2016 AT LEAST 3 MONTHS of optimal medical therapy prior to formal evaluation for an ICD LV FUNCTIONAL RECOVERY? may continue well beyond 3 months risk of unnecessary implantation REVERSIBLE ETIOLOGY? alcohol-related peripartum acute inflammatory cardiomyopathy
42 INFLAMMATORY CARDIOMYOPATHY Combination of myocardial inflammation and H/D SPONTANEOUS IMPROVEMENT IN UP TO 70% DCM 14% to 52% D Ambrosio A, Heart. 2001
43 FUNCTION > REMODELING > ETIOLOGY > SCD? > HEART FAILURE? > RECOVERY? 2000 Ratio 1,49 Number of segments Normal = Ratio 1.2 GS endo GS epi Multilayer GS (%) Multilayer deformation longitudinal profil
44 TTE CMR LV REMODELING AND FUNCTION ETIOLOGY - VIABILITY VENTRICULAR AND SCD PREDICTION HEART FAILURE SCREENING AND EARLY EVALUATION
45 TTE CONCLUSION CMR LV REMODELING AND FUNCTION ETIOLOGY - VIABILITY ECHOCARDIOGRAPHY OR CMR IN DCM? : BOTH VENTRICULAR AND SCD PREDICTION COMPLEMENTARITY: ADVANTAGE and LIMIT OF EACH IMAGING INTERCHANGEABLE: REPEATIBILTY - FEASABILITY - ACCESSIBILITY HEART FAILURE SCREENING AND EARLY EVALUATION
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