27-year-old professionnal rugby player: asymptomatic

Transcription

1 27-year-old professionnal rugby player: asymptomatic

2 Benefits and limits of cardiac MRI in the young athlete with a suspected heart disease. Philippe PAULE Service de Cardiologie, HIA Clermont Tonnerre, Brest. Session Société Française de Médecine des Armées / Société Française de Médecine Aéronautique et Spatiale JESFC, Paris 16 janvier 2014.

3 Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest No conflicts of interest

4 Cine imaging 3 important views: four chambers long axis short axis Cardiac MRI Myocardial non-invasive technique Global regional myocardial function, wall thickness, mass and volumes STIR-imaging (T2) Oedema Late gadolinium enhancement (LGE) Myocardial fibrosis, necrosis Adapted from C. Parsai et al. Journal of Cardiovascular Magnetic Resonance 2012; 14: 54.

5 Suspected heart disease Symptomatic or asymptomatic (sport s permit) patient: «abnormal» ECG abnormalities on stress ECG, Holter abnormalities on TTE other paraclinical exams: CR Benefits of cardiac MRI?

6 Cardiac MRI Adapted from A. La Gerche. J Am Coll Cardiol Img 2013; 6 :

7 Athlete s heart? «abnormal» ECG ventricular arrhythmias athlete s heart? cardiopathy end-diastolic left ventricular diameter (56 70 mm) left ventricular thickness (13-15 mm)

8 Suspected hypertrophic cardiomyopathy (HCM) 24 mm 22-year-old female runner Challenging diagnosis: echography inconclusive (anterolateral wall +++) 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. JACC 2011; 58: e212 e260.

9 Greater accuracy than echocardiography in the diagnosis of hypertrophy. C. Rickers and al. Circulation 2005; 112:

10 Suspected HCM 26-year-old african female runner Challenging diagnosis: apical cardiomyopathy 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. JACC 2011; 58: e212 e260.

11 Suspected HCM LGE: fibrosis (half of patients with HCM) prognosis? 2011 ACCF/AHA guideline for the diagnosis and treatment of hypertrophic cardiomyopathy. JACC 2011; 58: e212 e260.

12 Meta-analysis JJ. Green and al. J Am Coll Cardiol Img 2012; 5:

13 MS. Maron. Journal of cardiovascular magnetic resonance 2012, 14: 13. DF. Waterhouse and al. Br J Sports Med 2012; 46: i Athlete s heart? Utility of cardiac MRI 1 - left ventricle hypertrophy (LVH): symetric - end diastolic wall thickness (EDWT) < 15 mm - LV end diastolic diameter > 45 mm - depends on the type of training:. eccentric (+ LV dimensions) in dynamic exercise. concentric (+ normal LV dimensions) in static exercise - low ratio EDWT LVED volume 2 - wall thickness: after a phase of deconditionning 3 - without LGE Suspected HCM Spatial resolution! in the young athlete, but

14 Suspected arrhythmogenic right ventricle cardiomyopathy (ARVC) 25-year-old male soccer player

15 Suspected ARVC Regional right ventricule dyskinesia (triangle of dysplasia) and RV end-diastolic volume = 100 ml/m²

16 Suspected ARVC Adapted from ER. Valsangiacomo Buechel and al. Eur Heart J 2012; 33; Cardiac MRI: - right ventricle (RV) volume - RV function - regional wall-motion abnormalities (infero-posterior wall +++) - additional abnormalities:. trabeculations Quantitative evaluation. hyperreflective moderator band MRI provides extra information compared to echocardiography H. Tandri and al. Am Heart J 2008; 155 : FI. Marcus and al. EHJ 2010; 31: ER. Valsangiacomo Buechel and al. Eur Heart J 2012; 33;

17 Proposed structural and functionnal criteria for ARVC by Task Force = combined use of echocardiograhy and cardiac MRI Adapted from FI. Marcus and al. EHJ 2010; 31:

18 Suspected ARVC LGE: excellent correlation with histopathology (fibrofatty tissue) and predicts inductible ventricular tachycardia and occurrence of RV dysfunction But fatty infiltrations in T1-weighted sequence: limited diagnostic value H Tandri. J Am Coll Cardiol 2005; 45: FI. Marcus and al. EHJ 2010; 31:

19 FI. Marcus and al. EHJ 2010; 31: T. Luijkx and al. Eur J Cardiovasc Prev Rehabil 2011; 19: DL. Prior, A. La Gerche. Heart 2012; 98: A. La Gerche. Eur Heart J 2012; 33: RV remodelling but proportionate changes in LV and RV: ratio LV end diastolic volume RV end diastolic volume ( in ARVC) 2 - normal right ventricle ejection fraction 3 - normal regional wall-motion 4 - normalization after detraining 5 - without LGE Suspected ARVC Athlete s heart? Utility of cardiac MRI Spatial resolution! in the young athlete, but

20 Suspected dilated cardiomyopathy (DCM) 60 mm Long axe view LV volumes and function (Adapted from ER. Valsangiacomo Buechel and al. Eur Heart J 2012; 33; ). Dilated left + right ventricle (end-diastolic volume) and reduced left ventricle ejection fraction Appropriateness criteria for cardiac magnetic resonance imaging. J Am Coll Cardiol 2006; 48:

21 Suspected DCM LGE LGE mid-wall DE 1/3 of patients predominantely in the septum Aetiologic diagnosis? Presence of mid-wall LGE rules out a coronaropathy (sub-endocardial LGE) C. Parsai and al. Journal of cardiovascular magnetic resonance 2012, 14: 54. DF. Waterhouse and al. Br J Sports Med 2012; 46: i69 77.

22 Suspected DCM fibrosis = potential risk factor for adverse events: - all cause of mortality - cardiac death - ventricular tachycardia or sudden cardiac death - hospitalization for heart failure but, LGE: - simple marker of advanced cardiac remodelling or - independent marker of severity RG. Assomul and al. J Am Coll Cardiol 2006; 48: TF. Ismail and al. Heart 2012; 98:

23 Suspected DCM Athlete s heart? Utility of cardiac MRI 1 - no excessive dilatation of cardiac chambers (+ hypertrophic LV) due to exercise Spatial resolution! 2 - normal LV ejection fraction (normal stroke volume) 3 - without LGE in the young athlete, but DF. Waterhouse and al. Br J Sports Med 2012; 46: i69 77.

24 Other cardiopathies 30-year-old male triathlete: asthenia

25 Other cardiopathies LGE (mid-wall and sub-epicardial) cardiac biopsy: sarcoidosis

26 Sarcoidosis cardiac MRI more sensitive for detection compared to SPECT LGE = higher rate of: - left ventricle diastolic dysfunction - reduced right ventricle ejection fraction - non-sustained ventricular tachycardia C. Parsai and al. Journal of cardiovascular magnetic resonance 2012, 14: 54.

27 Acute myocarditis (AM) / Acute coronary syndrome (ACS) 28-year-old male soccer player: chest pain Normal coronary arteries

28 AM / ACS short axis view: T2 hyperintensity

29 AM / ACS short axis view: sub epicardial LGE (sparing the sub-endocardium)

30 AM / ACS «Lake Louise criteria» for myocarditis diagnosis (2 of the following criteria): - regional or global myocardial T2 hyperintensity - early myocardial enhancement (T1-weighted images) - sub epicardial LGE (at least 1 focal lesion) + left ventricular dyfunction + pericardial effusion reliable criteria for AM diagnosis and rule out an ACS MG. Friedrich and al. J Am Coll Cardiol 2009; 53:

31 persistence of LGE in a short axis view in the same patient at 3-month follow-up Prognosis?

32 AM / ACS Median follow-up = 4,7 years LGE is an independent predictor of all-cause mortality and of cardiac mortality encourages to provide a more rigorous long term follow-up : problem in the athlete? RG. Assomul and al. J Am Coll Cardiol 2006; 48 : S. Grün and al. J Am Coll Cardiol 2012; 59:

33 Abnormal implantation of coronary artery aorta pulmonary trunk Malignant course of the RCA 28-year-old male athlete (adapted from NH. Prakken Int J Cardiovasc Imaging 2010; 26: ). Appropriateness criteria for cardiac magnetic resonance imaging. J Am Coll Cardiol 2006; 48:

34 Systematic MRI for all athletes? = to identify those at risk of sudden death Problem of atypical findings: - cardiac dimensions - small isolated LGE (extreme physical training) in asymptomatic well-trained athletes = meaning? unknown prognosis uncertainty for the athlete and clinician consequences on sporting career A. La Gerche. J Am Coll Cardiol Img 2013; 6 :

35 DL. Prior, A. La Gerche. Heart 2012; 98: Evaluation of the athlete s heart a second-line screening tool

36 Limits: Cardiac MRI - availability of this advanced imaging - prolonged exam - severe claustrophobia - first trimester of pregnancy - frequent ventricular prematures complexes - follow-up of patients with ICD or pacemaker - numerous echocardiographic criteria but not many MRI values available for investigating the athlete s heart

37 Take home messages 1 - non invasive cardiac imaging 2 - better assessment than echocardiography with good reproducibility and spatial resolution: evaluation of myocardium +++ combined strategy 3 - cardiomyopathies:. diagnosis (HCM, ARVC). prognosis 4 - «acute coronary syndrome»:. diagnosis. + prognosis after coronarography Cardiac MRI = a second-line screening tool!

38 Normal cardiac MRI 27-year-old professionnal rugby player

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40 Symptomatic patients: ventricular prematures complexes (VPC) Patients with frequent VPC (left bundle branch morphology): normal ECG, echocardiogram and negative maximal exercise test 3 year-mean follow-up: But no LGE in this study! Systematic cardiac MRI for prognosis in this situation? GD. Aquaro. J Am Coll Cardiol 2010; 56: