MRI ACS-ben. Tamás Simor MD, PhD, Med Hab. University of Pécs, Heart Institute

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1 MRI ACS-ben Tamás Simor MD, PhD, Med Hab Time Course of Changes in Infarct Size, Viable Myocardium, and LV Mass After Reperfused and Nonreperfused MI Blue lines denote reperfused myocardial infarction (MI), and dashed red lines show nonreperfused MI. Within the first few days after MI, infarct size can substantially increase because of the addition of edema and cellular elements within the necrotic zone. Thereafter, infarct volume can shrink to 25% of its initial size over the next 4 to 6 weeks as edema is resorbed and necrotic myocytes are replaced by scar tissue. After 6 weeks, infarct size is relatively stable. The volume of viable myocardium (e.g., noninfarcted LV mass) correspondingly declines initially, but may increase over the course of infarct healing because of myocyte hypertrophy. Changes in total LV mass reflect the sum of changes occurring in infarcted and viable myocardium. J Am Coll Cardiol 2010;55:1 16 1

2 MRI ISZB - ben ACS Funkció A(8), A(8), A(8), U(6) Életképesség A(9), A(9), A(9), A(4), U(4) Perfúzió A(7), U(6) A, CMR methods for assessment of ACS. Short-axis views (of different patients) illustrate the different imaging techniques used (rows 1 and 2), their morphological correlates (row 3), and main clinical application (row 4). B, These methods can be integrated into a CMR protocol in the sequence indicated to provide a comprehensive assessment of ACS patients. Such a study can be performed in less than 1 hour. Gd indicates gadolinium. ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging JACC 48, 7, 2006 Globális bal kamra funkció EF=(EDV-ESV)/EDV*100 Bazális és Középső harmad Regionális bal kamra funkció Falvastagodás = 100*(Ds-Dd) / Dd Bal kamra: 17 szegmentum Csúcsi harmad Csúcs 6 6 szegmentum inferoseptalis anteroseptalis anterior anterolateralis inferolateralis Inferior 4 szegmentum Septalis Anterior Lateralis Inferior 1 szegmentum LAD RCA CX Bal kamra izomtömeg = BK izomzat volumen * 1,05 2

3 Koronária ellátási területek Myocardial infarct remodeling 3 rd day 180 th day Heart function T2/T1 weighted SSFP short axis Myocardial infarct area at risk 3 rd day 180 th day Myocardial infarct necrosis 3 rd day 180 th day Oedema in heart muscle T2 acquisition short axis Viability T1 wighted acquisition short axis 3

4 ACS MVO NSTEMI-ACS CMR images taken 24 hours after primary percutaneous intervention in a patient with a lateral ST-elevation MI. A,The T2-weighted images reveal a large area of edema that representst he region of threatened myocardium and is clearly larger that the area of late gadolinium enhancement (D). B, Resting first-pass perfusion shows a region of MVO in the subendocardial region at the infarct core that closely correlates with the early gadolinium-enhanced images (C). ECG, cardiac magnetic resonance (CMR), ultrasound, and angiographic findings are shown in a 69-year-old woman with chest and epigastric pain that had resolved by the time she presented to the emergency department. Her ECG was a concern for injury (A), and initial troponin was mildly elevated at 0.14 ng/ml. However, because of the lack of symptoms by the time of presentation, invasive angiography was deferred to the following morning. T2-CMR in vertical-long axis (B) and horizontal long-axis (C) planes showed increased signal intensity in apical myocardium, beyond T2 increase in the stagnant apical blood. Apical dyskinesis was also evident (end-diastolic [D and E] and end-systolic [F and G] frames), and late gadolinium enhancement (H and I) showed a large area of signal enhancement in the apical myocardium as well as thrombus in the apical left ventricle (LV). Echocardiography without contrast (J) was also concerning for LV apical thrombus. Invasive coronary angiography (K) showed serial nonobstructive plaques in the left anterior descending coronary artery. Circ Cardiovasc Imaging. 2012;5: ACS Myocarditis ACS - Takosubo CMR images from a 49-year-old woman presenting with chest pain and breathlessness. Cardiac serum biomarkers were raised, and an ECG showed widespread T-wave inversion. Coronary angiography showed normal coronary arteries with no evidence ofcoronary atheroma. CMR shows a regional wall motion abnormality predominantly in the inferior segments (A, diastole; B, systole). Late gadolinium enhancement images (C) show extensive epicardial hyperenhancement in the inferior and near-transmural enhancement in the lateral segments. Based on all available results, a clinical diagnosis of myocarditis was made. The patient declined cardiac biopsy. CMR images from a 52-year-old woman presenting with an episode of severe chest pain associated with marked anterior ST elevation and raised serum biomarkers. Coronary angiography revealed normal coronary arteries with no atheromatous disease. An LV angiogram showed a marked apical wall motion abnormality, raising the suspicion of takotsubo syndrome. CMR confirmed the typical diastolic apical ballooning on cine images (A, B) and the absence of scar on late gadolinium-enhanced images (C). 4

5 MRI Coron &FFR ACS Complications CMR images from a patient with previous stents in the right coronary arteryand left anterior descending coronary artery 2 years earlier who presented to the emergency room withtroponin-negativechest pain. CMR was performed within 24 hours of admission. A, Inferiorand anterior ischemiaon adenosine-stressperfusionimaging. B, Late gadolinium-enhanced images with a region of subendocardial gadolinium enhancement in the inferior wall suggesting old MI that was previously unknown. T2-weighted images were normal (not shown). Subsequent coronary angiography revealed tight in-stent restenosis in the right coronary artery and significant flow-limiting disease in the left anterior descending coronary artery (C) as assessed by a pressure wire during hyperemic conditions (fractional flow reserve, 0.69). Both lesions were stented successfully, and the patient was discharged home. CMR images in the 4-chamber orientationfrom a patient with previous anteroseptal MI. A, The diastolic frame from a cine CMR study shows thinning of the interventricular septum with a mass lesion at the endocardial surface (arrow). B, Early gadolinium-enhanced images show that the lesion does not take up contrast. C, Late gadoliniumenhanced images delineate the extent of MI (blackarrow) as hyperenhancement and show that the lesion remains unenhanced (white arrow), suggesting an LV thrombus. ACS RV Infarct High resolution perfusion CMR images from a patient with acute non-stemi, evidenced by a rise in cardiac enzymes and nonspecific ST-segment changes on an ECG. Invasive coronary angiography revealed 3-vessel CAD with an occluded proximal RV branch of the right coronary artery. A cine CMR image (A) in systole shows a subtle wall motion abnormality in the anterior RV free wall (arrow). The T2-weighted image (B) shows high signal in this area with corresponding high signal on the late gadolinium-enhanced image (C). There is no evidence of scar in the left ventricle, suggesting isolated RV infarction 47-year-old male with previous inferior myocardial infarction, in whom subsequent coronary angiography showed chronic total occlusion of the right coronary artery and a patent proximal left anterior descending artery stent. The top row shows adenosine stress myocardial perfusion images at peak myocardial contrast enhancement, the middle row the corresponding late-gadolinium enhanced images and the bottom row matching frames from the cine data sets. An infero-basal scar with thinning of the myocardium can be seen in all images. Perfusion images show peri-infarct ischaemia extending circumferentially outside the scar at the basal level (arrows). In addition, there is ischaemia in the viable apical inferior segments. The correlation of the cardiac magnetic resonance components is facilitated by their identical orientation and spatial resolution. European Heart Journal (2008) 29,

6 Ischemia no Infarct Myocardial perfusion CMR was performed in a 43 year-old female to evaluate exertional chest pressure. Perfusion images obtained during intravenous infusion of adenosine (A) demonstrate severe hypoenhancement of the septum, anterior wall, and apex that is not present on resting perfusion imaging (B). Late gadolinium enhancement acquisitions are negative for Hyperenhancement (C); together, these findings suggest severe myocardial ischemia in the distribution of the left anterior descending coronary artery without infarction. (D) Invasive coronary angiography confirms high-grade serial stenoses in the left anterior descending coronary artery. Journal of Cardiovascular Magnetic Resonance 2008, 10:18 Thanks! 6