THE NEW PLACE OF CARDIAC MRI IN AERONAUTICAL FITNESS

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1 88 th ASMA ANNUAL SCIENTIFIC MEETING DENVER - CO April 30- May 4, 2017 THE NEW PLACE OF CARDIAC MRI IN AERONAUTICAL FITNESS S. BISCONTE (1), J. MONIN (2), N. HUIBAN (3), G. GUIU (2), S. NGUYEN (1), O. MANEN (2), E. PERRIER (2). (1) Aeromedical Center, Robert Picqué Military Hospital, Bordeaux, France (2) Aeromedical Center, Percy Military Hospital, Clamart, France (3) Aeromedical Center, Sainte Anne Military Hospital, Toulon, France

2 Disclosure Information 88 th AsMA Annual Scientific Meeting Sebastien BISCONTE I have no financial relationships to disclose. I will not discuss off-label use or investigational use in my presentation.

3 Cardiological diseases are one of the first causes of in- flight incapacity. Limited tools: Declared medical history, cardiovascular risk factors, clinical examination, electrocardiogram Fitness context: Often: asymptomatic, athletic, no treatment, no medical history, normal examination, Atypical ECG!early diagnosis!!! Prognosis depends on the underlying cardiopathy! First intention medical investigations sometimes limited What is the real place of Cardiac MRI (CMR) in aeronautical fitness?

4 Case report 1-21 yo class 1 applicant - No medical history - No symptom - Normal clinical examination ECG: Premature Ventricular Beats "Frequent "Isolated, monomorphic "Long coupling interval "LBBB morphology

5 Case report 1 " Blood test: No ionic disorder No thyroid disorder No inflammation "Signal average ECG: ( 3+/3) late ventricular potential - 21 yo class 1 applicant - No medical history - No symptom - Normal clinical examination -ECG: PVB! Temporary unfit for explorations

6 Case report 1 " Blood test: No ionic disorder No thyroid disorder No inflammation "Signal average ECG: ( 3+/3) late ventricular potential ARVD? Myocarditis? - 21 yo class 1 applicant - No medical history - No symptom - Normal clinical examination -ECG: PVB " Normal echocardiography " 24h ambulatory Holter: PVB/24h, no repetitive form " Maximal negative exercise test - Disappearance of PVBs during test! Diagnosis?! Next investigation?

7 Case report 2 40 yo Air traffic controller No family history No symptom Normal clinical examination Follow up from 2000! Repolarization abnormalities V4! V6 Normal echography EF = 60%, Stress test : normalisation, no ischemia 24h ambulatory Holter: No rhythm disturbance HCM? DCM? Myocarditis? Evaluation every year First line investigations every two years 2016: no normalisation under stress and 1200 PVBs Continue monitoring? Other investigation?

8 What kind of investigation do we need? Excellent sensitivity Good specificity Performing in early diagnosis Wide range of indications Non invasive Easy to compare Fast to realize Good availability Prognosis elements Many studies CMR?

9 CMR and Arrythmogenic Right Ventricular Dysplasia (Case report 1) " Family history " ECG abnormalities ARVD criteria " Tissue characterization of wall (EMB)

10 CMR and Arrythmogenic Right Ventricular Dysplasia (Case report 1) " Family history " ECG abnormalities ARVD critéria " Tissue characterization " of wall (EMB) Epsilon wave?

11 CMR and Arrythmogenic Right Ventricular Dysplasia (Case report 1) " Family history " Tissue characterization ARVD of wall (EMB) critéria " ECG abnormalities " Arrhythmias " Global or regional dysfunction and structural abnormalities - Trabeculated RV +++! Reference imaging - Hypokinesia - Late gadolinum enhancement (fibrosis)! Prognosis

12 CMR

13 CMR and Hypertrophic Cardiomyopathy (Case report 2) TTE Can miss the diagnosis Can underestimate wall thickness Can miss APICAL HCM! CMR Diagnosis Positive Differential Athlete s Heart, hypertensive cardiomyopathy, metabolic and infiltrative cardiomyopathies LV wall Thickness Apical hypertrophy or aneurysm Potential SD risk factors LGE

14 CMR and Hypertrophic Cardiomyopathy (Case report 2)! CMR > Echocardiography

15 CMR and Hypertrophic Cardiomyopathy (Case report 2)! CMR > Echocardiography! Prognosis : LGE clinical cardiac events

16 CMR and Hypertrophic Cardiomyopathy (Case report 2)! CMR > Echocardiography! Prognosis : LGE clinical cardiac events! Early identification of HCM For the evaluation of heart muscle disease In patients with suspected HCM who have inadequate echocardiographic windows in order to confirm the diagnosis Class I I Level B C 2016 In patients fulfilling diagnostic criteria for HCM, to assess cardiac anatomy, ventricular function, and the presence and extent of myocardial fibrosis. in patients with suspected apical hypertrophy or aneurysm. IIa IIa B Level C

17 CMR and myocarditis Only exam for non-invasive diagnosis " Diagnosis: Lake louise criteria 2009 ^ - Oedema (B) - LGE in non-ischemic regional distribution (C-D) - Early Gadolinium enhancement # Myocarditis infarction lesion # Very good correlation with EMB " High resolution localisation " Complication: pericarditis (A), LV dysfunction " Monitoring +++ Friedrich MG, Sechtem U, Schulz-Menger J et al., «Cardiovascular magnetic resonance in myocarditis: A JACC White Paper», J Am Coll Cardiol., n o 53, 2009, p

18 CMR and Dilated Cardiomyopathy Diagnosis = ventricular dilatation + dysfunction Differential diagnosis: athletic heart syndrom CMR approach: " Dilatation: volumes (only diameter by echography) LV > 140 ml ; RV> 150 ml

19 CMR and Dilated Cardiomyopathy Diagnosis = ventricular dilatation + dysfunction Differential diagnosis: athletic heart syndrom CMR approach: " Dilatation: volumes (only diameter by echography) LV > 140 ml ; RV> 150 ml " Dysfunction : Reference standard for LVEF Inter/ intra observer variability <5% Wood and al. Left Ventricular Ejection Fraction and Volumes: it Depends on the Imaging Method. Echocardiography :

20 CMR and Dilated Cardiomyopathy Diagnosis = ventricular dilatation + dysfunction Differential diagnosis: athletic heart syndrom CMR approach: " Dilatation: volumes (only diameter by echography) LV > 140 ml ; RV> 150 ml " Dysfunction : Reference standard for LVEF Inter/ intra observer variability <5% " Prognosis : LGE = fibrosis coronary artery disease (localization of LGE) athletic heart syndrome (no LGE) Predictive value +++ Kuruvilla S and al. Late gadolinium enhancement on cardiac magnetic resonance predicts adverse cardiovascular outcomes in nonischemic cardiomyopathy: a systematic review and meta-analysis. Circ. Cardiovasc. Imaging 2014: 7,

21 Other indications of CMR Valvular function Vessels disease Congenital heart disease Cardiac mass Amylosis Pericardial disease Restrictive cardiomyopathy Non compaction Cardiac sarcoïdosis Thrombus Coronary origin Haemochromatosis

22 Stress CMR in aeronautical fitness Evaluation of coronary artery disease Necrosis Ischemia Vanzetto G et al. Circulation, 1999 Cardiac function Chest pain Rhythm disturbances Flight safety

23 Stress CMR in aeronautical fitness

24 Stress CMR in aeronautical fitness CMR > SPECT in detection European multicenter, multivendor Study Schwitter et al EHJ 2013, JCMR 2012

25 Stress CMR in aeronautical fitness CMR > SPECT in prognosis CE-MARC; Greenwood et al, Annals of internal medicine 2016

26 CMR Strong prognosis information Multianalysis : Anatomy analysis and Function evaluation Less operator dependant than echography No exposure to radiation High resolution detection of ischemia and infarction Contraindications Cerebral clips, pacemaker, implanted stimulator, metal shrapnel, claustrophobia No exercise stress testing No anatomical evaluation of coronary arteries Price Fast - just one scan time Availability

27 Take home message CMR is a mature technology in cardiology CMR is in way to become a gold standard second intention investigation in aviation medicine! Performant Polyvalent: morphology, fonction, stress Early diagnosis Prognosis elements No invasive Helpfull for follow up In progress for its aviability and coronary arteries evaluation

28 Thank you for your attention

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