Cardiac MR Cardiac CT

Transcription

1 Cardiac MR Cardiac CT A selection of recent articles JN Dacher 1, A Manrique 2 and J Caudron 1 1 Rouen University Hospital - Department of Radiology 2 Caen University Hospital - Cyceron Imaging Centre France Cardio CT MR - Paris - June 2010

2 Delayed enhancement at acute phase of MI White, but not completely dead! Ibrahim T et al. Radiology 2010;254:88-97

3 Acute myocardial infarction: cardiac MR shows a decrease in delayed enhancement during the 1st week after reperfusion 17 patients with successfully reperfused AMI were longitudinally followed-up Correlation with myocardial perfusion SPECT defect: r = 0.84 Ibrahim T et al. Radiology 2010;254:88-97

4 Acute myocardial infarction: cardiac MR shows a decrease in delayed enhancement during the 1st week after reperfusion LGE cardiac MR at 1, 7, 35, and 180 days after reperfusion P <.001 vs. all 18.3% 12.9% 11.3% 11.6% Ibrahim T et al. Radiology 2010;254:88-97

5 Changes of LGE extent in endocardium (red) and epicardium (orange) after AMI Ibrahim T et al. Radiology 2010;254:88-97 * P <.01 for comparison of day 1 and follow-up # P =.03 for comparison of days 7 and 35

6 Inverse relationship (P <.0001) of regional wall thickening on day 180 and transmural enhancement extent on day 7 Ibrahim T et al. Radiology 2010;254:88-97

7 Acute myocardial infarction: cardiac MR shows a decrease in delayed enhancement during the 1st week after reperfusion Conclusion In patients with reperfused AMI, the size of delayed gadolinium enhancement at CE cardiac MR imaging significantly diminished during the first week after infarction. Timing of CE cardiac MR imaging is crucial for accurate measurement ent of myocardial infarct size early after AMI. Ibrahim T et al. Radiology 2010;254:88-97

8 Risk of MACE after MI: Persistent Microvascular Obstruction Six or more than 6 involved segments Cochet. Eur Radiol Sep;19(9): Kelle S. J Am Coll Cardiol Nov 3;54(19):1770-7

9 Prognostic impact of Persistent Microvascular Obstruction (PMO) as assessed by contrast-enhanced CMR in reperfused AMI Methods: 184 patients within the week after successfully reperfused first AMI First-pass MR: extent of MO Late Gd-enhanced images: PMO and infarct size (IS) MACE collected at 1-year 1 follow-up MO and PMO were found in 127 (69%) and 87 (47%) pts MO (first pass) PMO (LGE) Cochet. Eur Radiol Sep;19(9):

10 Prognostic impact of persistent microvascular obstruction as assessed by contrast-enhanced CMR in reperfused AMI Predictors of MACE: Univariate analysis High GRACE risk score: OR: 3.6 [ ], p < Infarct size > 10%: OR 2.7 [ ], p = LVEF < 40%: OR 2.4 [ ], p = presence of MO: OR 3.1 [ ], p = presence of PMO: OR 10 [ ], p < Multivariate analysis Model 1: including MO Model 2: including PMO presence of MO: OR 2.5 [ ], p = presence of PMO: OR 8.7 [ ], p < associated with GRACE score Cochet. Eur Radiol Sep;19(9):

11 Prognostic impact of persistent microvascular obstruction as assessed by contrast-enhanced CMR in reperfused AMI Cochet. Eur Radiol Sep;19(9):

12 Prognostic value of myocardial infarct size and contractile reserve rve using magnetic resonance imaging Methods 177 pts with CAD and scar on LGE MRI LV function at rest and low-dose dobutamine (10 µg/kg bodyweight per minute for 3 min) Results 11 (6.2%) events at follow-up (20.3 ± 13.3 months): 8 (4.4%) cardiac death 2 (1.1%) non cardiac death 1 (0.5%) MI Infarct size = strongest predictor of events for mortality low risk (LGE < 6 sgts, n = 79) high risk patients (LGE 6 sgts, n = 98) Kelle S. J Am Coll Cardiol Nov 3;54(19):

13 Prognostic value of myocardial infarct size and contractile reserve rve using magnetic resonance imaging Incremental prognostic value of LDD in patients with large MI ( 6 sgts) Results In the subgroup of high risk patients: Transmurality of infarct was not a predictor of events Presence of contractile reserve (n = 63) was associated with a higher h number of events (12.7%) compared with no change (6.7%; n = 15; p = 0.008) 08) Kelle S. J Am Coll Cardiol Nov 3;54(19):

14 Myocardial Perfusion Imaging

15 Validation of MR Myocardial Perfusion Imaging (MPI) with Fractional Flow Reserve (FFR) for the detection of significant coronary heart disease 103 patients with suspected angina MR MPI at 1.5T (IV Adenosine blinded observers (IV Adenosine 140 µg.kg - 1.min - 1 ) Gadolinium (0.1 mmol/kg Omniscan) 1 week later; CA with pressure wire studies FFR performed in all patent major vessels Mean distal coronary artery pressure / Mean aortic pressure FFR considered positive if < 0.75 Watkins S et al. Circulation 2009; 120 :

16 Maximal Hyperemia DS 61.7% Aorta pressure FFR 0.5 LAD pressure Watkins S et al. Circulation 2009; 120 :

17 Validation of MR Myocardial Perfusion Imaging (MPI) with Fractional Flow Reserve (FFR) for the detection of significant coronary heart disease Results Per segment MR MPI scans identified 121 / 300 positive segments 110 were positive by FFR 168/179 normally perfused segments had FFR > 0.75 Se 91%; Sp 94%; PPV 91%; NPV 94% Per patient 76 patients with perfusion defect on MR MPI 74 had at least one vessel with FFR < 0.75 MR MPI scan falsely positive in 2 patients 25 patients with normal MR MPI 21 had FFR > 0.75 in all vessels 4 False negative patients Se 95%; Sp 91%; PPV 97%; NPV 84% Watkins S et al. Circulation 2009; 120 :

18 Aorta

19 Association of Aortic Arch Pulse Wave Velocity with LV mass and lacunar brain infarcts in hypertensive patients Assessment of Aortic Arch Stiffness in hypertensive pts and correlation with cardiac and cerebral end-organ damage Brandts A et al. Radiology 2009; 253 :

20 Brandts A et al. Radiology 2009;253: Aortic arch PWV determination with MR imaging.

21 Brandts A et al. Radiology 2009;253: Aortic arch PWV determination with MR imaging

22 Aortic arch PWV determination with MR imaging. Aortic PWV X/ t (m/sec) Brandts A et al. Radiology 2009;253:

23 Association of Aortic Arch Pulse Wave Velocity with LV mass and lacunar brain infarcts in hypertensive patients Results Aortic Arch PWV (mean 7.3 m/sec) was significantly associated with: LV mass Indexes of systolic function including EF Indexes of diastolic function Lacunar brain infarcts Periventricular and deep white matter hypersignals Could help to stratify the risk of patients with HT Brandts A et al. Radiology 2009; 253 :

24 Box plot for aortic arch PWV in hypertensive patients with and those without lacunar brain infarcts After adjustment for confounding factors: Age Sex Hypertension duration Brandts A et al. Radiology 2009;253:

25 Bicuspid aortic valve: four-dimensional MR evaluation of ascending aortic systolic flow patterns Hope M D et al. Radiology 2010;255:53-61

26 Normal systolic flow in a patient with a TAV and normal thoracic aorta dimensions Hope M D et al. Radiology 2010;255:53-61

27 Images in a patient with a BAV and a focal ascending aortic aneurysm Hope M D et al. Radiology 2010;255:53-61

28 Bicuspid aortic valve: four-dimensional MR evaluation of ascending aortic systolic flow patterns Nested helical flow was seen at peak systole in the ascending aorta of 15 of 20 patients with a BAV but in none of the healthy volunteers or patients with a TAV Fusion of right and left leaflets gave rise to right-handed helical flow and right-anterior flow jets (n = 11), whereas right and noncoronary fusion gave rise to left-handed helical flow with left-posterior flow jets (n = 4) Hope M D et al. Radiology 2010;255:53-61

29 Cardiac CT

30 Prognostic value of 64-Slice Computed Tomography 2 years (06-08) 08) prospective enrollment of 2,076 consecutive pts Excluding revascularization hx., heart transplant and congenital heart disease Results severity of CAD diagnosed from CT increased the prediction of MACE (OR: 3.02; 95% CI ) over clinical factors LVEF had incremental value over CAD severity Total plaque score had incremental value over CAD severity and LVEF Chow BJW et al. JACC 2010; 55 : 1017

31 Chow BJW et al. JACC 2010; 55 : 1017

32 CT and Chest Pain: forthcoming studies National Heart, Lung and Blood Institute (PROMISE) Prospective Multicenter Imaging Study for Evaluation of Chest Pain Randomized trial of > = 64d MDCT vs. initial functional stress testing in 10,000 low to intermediate risk patients APHP (PEPSI - HEGP) Acute chest pain no ST segment elevation, no cardiac enzymes change A comparison of dobutamine stress echo and 64d MDCT

33 Adenosine induced stress myocardial perfusion imaging using dual source cardiac computed tomography 34 patients included Nuclear stress test, invasive coronary angiography Stress CT / Rest CT / Delayed CT 33 patients were assessable Mean ED of CT: 12.7 msv (close to that of SPECT) Results (per patient adenosine induced stress CT) For detection of > 50% stenosis, CT perfusion results were : Se 92%, Sp 67% For detection of > 70% stenosis, CT perfusion results were : Se 94%, Sp 41% Blankstein Ret al. JACC 2009; 54 : 1072

34 Blankstein Ret al. JACC 2009; 54 : 1072

35 Blankstein Ret al. JACC 2009; 54 : 1072

36 PROTECTION I Study 50 sites, 1965 exams, multi vendor study Mean DLP : 885 mgy.cm (= 600 RP) Range = Hausleiter J et al. JAMA 2009; 301 : 500

37 PROTECTION I Study Independent factors associated with dose Weight (+ 5%) Arrhythmia (+ 10%) DFOV (+ 5%) ECG modulation (-( 25% ; 73% patients) 100 kv (-( 46% ; 5% patients) Prospective ECG synchro. (-78%( ; 6% patients) Experienced operator (-( 1%) CT Type (97% inter institution deviation) Hausleiter J et al. JAMA 2009; 301 : 500

38 Cardiac Failure

39 Heart failure with normal EF: the complementary roles of echocardiography and CMR imaging State of the art paper HFNEF has replaced «diastolic heart failure» This article demonstrates the complementary roles of echo and MR in this field echo Diastolic function Tissue velocity Strain analysis CMR Systolic function (EF) Myocardial mass Fibrosis Tissue characterization Leong DP et al. JACC Cardiovascular Imaging 2010; 3 : 409

40 55 y-o y o pt with massive anterior MI. LAD and RCA occluded on coronary angiography. MRI requested to evaluate viability. Caudron J et al. RadioGraphics January 2011 E A LA volume: normal (104 ml) ; 57 ml/m² Restriction pattern E=77 cm/s, A=7cm/s, E/A=11 Anterior MI, No reflow, Restrictive pattern on TransMitral flow. Systolic and diastolic dysfunction (no dilated LA)

41 Congenital Heart Disease

42 Congenital Heart Disease 3 recent state of the art papers Paul JF, Rohnean A, Sigal-Cinqualbre A. Multidetector CT for congenital heart patients: what a paediatric radiologist should know. Pediatr Radiol 2010;40(6): Babar JL, Jones RG, Hudsmith L, Steeds R, Guest P. Application of o MR Imaging in Assessment and Follow-up of Congenital Heart Disease in Adults. Radio Graphics To Be Published Lapierre C, Dery J, Guerin R, Viremouneix L, Dubois J, Garel L. Segmental approach to imaging of congenital heart disease. Radio Graphics 2010;30(2):

43 Consensus Documents

44 ACCF/ACR/AHA/NASCI/SCMR 2010: expert consensus document on cardiovascular magnetic resonance JACC 2010; published online May 17, 2010 ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT 2010: expert consensus document on coronary CT angiography JACC 2010; published online May 17, 2010 Diagnosis of arrythmogenic RV cardiomyopathy/dysplasia: proposed modification of the task force Criteria Eur Heart J 2010; 31 :

45 Major Criteria (MRI) ARVD Regional RV akinesia or dyskinesia or dyssynchronous RV contraction And 1 of the following EDRV volume/bsa > 110 ml/m 2 in males, 100 in females RVEF < 40% Minor criteria (MRI) Regional RV akinesia or dyskinesia or dyssynchronous RV contraction And 1 of the following 110 > ED RV volume / BSA > 100 ml/m 2 in males, 100 > ED RV volume / BSA > 90 ml/m 2 in females 45%> RVEF > 40% Marcus FI et al. Eur Heart J 2010; 31 :

46 Enjoy your Reading!