Müokardiidid üks haigus, mitu nägu. Juhendajad: Maksim Zagura, Vello Sõgel Raul Õunapuu, II aasta radioloogia resident

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1 Müokardiidid üks haigus, mitu nägu Juhendajad: Maksim Zagura, Vello Sõgel Raul Õunapuu, II aasta radioloogia resident

2 Müokardiit müokardi põletikuline haigus

3 Etioloogia (1,7,9) Viirused (Coxsackie B, adenoviirus, hepatiit C, CMV, echoviirus, influenza,ebv, parvoviirus B19, HHV 6, HIV-1 jne.) Muud patogeenid (bakterid, spiroheedid, riketsiad, seened, algloomad, parasiidid) Ravimid (kemoterapeutikumid, antibiootikumid, diureetikumid, amfetamiin, kokaiin, metüüldopa jne.) Süsteemsed haigused (SLE, sarkoidoos, Kawasaki tõbi, põletikulised soolehaigused, RA, Wegeneri granulomatoos) Muud (radiatsioon, hüpotermia, mürgid, kemikaalid)

4 Epidemioloogia (1,7,9) Esinemissagedus: 1 22 / N = M Keskmine vanus: 42 a.

5 Kliiniline pilt (1,2,8) Asümptomaatiline/subkliiniline haigus Väsimus Rindkere valu (seotud perikardi haaratusega - perikardiit) Rütmihäired Südamepuudulikkus ja kardiogeenne šokk (9 10% esialgu ebaselge etioloogiaga südamepuudulikkuse patsientidest) Surm (kuni 22% alla 30 aastaste patsientide kardiaalsetest äkksurmadest)

6 Diagnostilised uuringud (1,2,8) Lab. analüüsid: leukotsütoos, eosinofiilia, troponiinid, CK-MB, seerumis antikehade tiitrid, NT-proBNP EKG: siinustahhükardia, mittespetsiifilised ST-segmendi ja T-laine muutused, AV-blokk, RBBB, FA, ventrikulaarsed arütmiad Rindkere rö-ülesvõte: KTI, pleuraefusioon, kopsupais Müokardi biopsia: Kuldstandard Sensitiivusus ja spetsiifilisus limiteeritud Tüsistuste sagedus 6%, rasked tüsistused kuni 0,5% (perforatsioon, tamponaad)

7 Radioloogilised uuringud (1,2,8) Ehhokardiograafia: funktsionaalne hindamine, perikardi efusioon, seina paksenemine Südame MRT Nukleaarmeditsiini uuringud: SPECT: ei ole tänapäeval aktiivses kasutuses PET: 18F-FDG PET/MRT hübriidkuvamine tulevik?

8 Müokardi kahjustuse kaskaad Äge faas Alaäge faas Paranemine Krooniline faas T-lümfotsüütide aktivatsioon Tsütokiinide sekretsioon Hüpereemia Turse Müotsüütide nekroos Infiltratsioon makrofaagidega Fibroblastide aktivatsioon Turse taandumine Põletikulise infiltraadi resorptsioon Fibroos Põletiku ägenemine Autoantikehade teke Tihe lümfotsütaarne infiltraat ja müotsüütide nekroos Difuusne lümfotsütaarne infiltraat ja interstitsiaalne fibroos Vähene intesstitsiaalne fibroos Residuaalne lümfotsütaarne infiltraat ja müotsüütide atroofia

9 Südame MRT müokardiidi protokoll Funktsionaalsed seeriad (CINE): perikardi efusiooni ja müokardi kontraktiilsuse hindamine T2 STIR: fokaalsed tõusnud signaaliga alad või difuusne signaali tõus - turse Varajane kontrasteerumine (ERE): intensiivsem (suhteline) varajane kontrasteerumine hüpereemia Hiline kontrasteerumine (LGE): nekroos ja fibroos

10 Südame MRT - CINE Ischemic and non-ischemic cardiomyopathy Wouter van Es, Hans van Heesewijk, Benno Rensing, Jan van der Heijden and Robin Smithuis (

11 Südame MRT T2 STIR Fokaalne tõusnud signaaliga ala või Difuusne müokardi signaali tõus (müokard vs skeletilihas, signaali intensiivsuse suhe > 2.0) 14-aastane tüdruk. Coxsackie viirus infektsioonist tingitud müokardiit. TÜK Turse vasaku vatsakese inferioorses ja lateraaalses seinas.

12 Südame MRT varajane kontrasteerumine (ERE) Kontrasteerumise suhe vs skeletilihas > 4.0 või müokardi absoluutne kontrasteerumine >45% D.H. O'Donnell, S. Abbara, V. Chaithiraphan, et al. Cardiac MR imaging of nonischemic cardiomyopathies: imaging protocols and spectra of appearances Radiology, 262 (2) (2012), pp

13 Südame MRT varajane kontrasteerumine (ERE) Varane kontrasteerumine vasaku vatsakese inferioorses seinas. TÜK

14 Hiline kontrasteerumine (LGE) Nekroos suurenenud gadoliiniumi kogunemine rakusiseselt Fibroos suurenenud gadoliiniumi kogunemine ekstratsellulaarsel LGE esinemine ja/või langenud EF omavad ainukesega (negatiivset) prognostilist väärtust TÜK 19-aastane mees. Müokardi biopsia positiivne HHV6 suhtes.

15 Hiliskontrasteerumise mustrid Subendokardiaalne Müokardiinfarkt Müokardi keskosa Hüpertroofiline KMP Müokardi keskosa Dilatatiivne KMP Subepikardiaalne Müokardiit Transmuraalne Müokardiinfarkt Subepikardiaalne Sarkoidoos Sõlmeline Sarkoidoos Difuusne subendokardiaalne Amüloidoos

16 17 segmendi mudel Ischemic and non-ischemic cardiomyopathy Wouter van Es, Hans van Heesewijk, Benno Rensing, Jan van der Heijden and Robin Smithuis (

17 Südame MRT "Lake Louise Criteria"

18 Südame MRT "Lake Louise Criteria" CINE - toetav informatsioon Müokardiidi diagnoosimiseks või välistamiseks peaks olema täidetud 2 kriteeriumit 3-st: (diagnostiline täpsus 78%) T2 STIR (turse) Varajane kontrasteerumine (hüpereemia) Hiline kontrasteerumine (nekroos ja fibroos)

19 Diagnostic performance of CMR compared with EMB Study group Sensitivity Specificity PPV NPV Accuracy Group 1 (n=70), symptoms 14 days ER gre LGE of 3 approach Group 2 (n=62), symptoms >14 days ER gre LGE of 3 approach Lurz P et al. JACC Cardiovasc Imaging. 2012; 5:

20 Südame MRT sensitiivsus sõltub kliinilisest pildist 57 patsienti, kellel müokardiit kinnitatud müokardi biopsial Südame MRT sensitiivsus Lake Louise kriteeriumeid kasutades: 80% in infarct-like pattern (I) 57% in cardiomyopathic pattern (II) 40% in arrhytmic pattern (III) Number of necrotic myocytes Francone M et al. JACC Cardiovasc Imaging 2014 ; 7:

21 18F-FDG PET-MRT hübriidkuvamine T2 LGE 18F-FDG PET + LGE White JA, Rajchl M, Butler J, Thompson RT, Prato FS, Wisenberg G. Active cardiac sarcoidosis: first clinical experience of simultaneous positron emission tomography magnetic resonance imaging for the diagnosis of cardiac disease. Circulation. 2013;127:e

22 HAIGUSJUHT: 66-aastane naine Tekkinud rõhuv valu rinnaku taga, mis paratsetamooliga ei möödunud Järgmisel päeval valu süvenes, lisandus higistamine ja iiveldustunne EMOs valu kupeerus nitroglütseriini ja petidiiniga EKG: negatiivne T-sakk avl-is TnT 328 ng/l (N <14 ng/l) CK-MBm 16,8 μg/l (N <4,88 μg/l) WBC 7,98 x 10 9 /L (N 4-10 x 10 9 /L) PERH Radioloogiakeskus

23 66-aastane naine Ehhokardiograafia: Normaalse õõne suuruse ja kergelt hüpertrofeerunud seinaga vasak vatsake. Üldine süstoolne funktsioon on kergelt langenud, EF 45-50%. Esineb kontraktsioonihäire kõigis keskmistes ja anterioorsetes basaalsetes segmentides. Koronarograafia: D A(010) C(10). LAD keskosas on sujuvate kontuuridega kuni 25%-line ahenemine, mujal pärgarterites veel väiksemad muutused. PERH Radioloogiakeskus

24 66-aastane naine Hüpokinees eesseina basaalses ja keskmises segmendis PSIR Vähene hiliskontrasteerumine septumis müokardi keskel ja südame tipus subepikardiaalsel PSIR EDV/BSA 82 ml/m 2 (N ml/m 2 ) ESV/BSA 39 ml/m 2 (N ml/m 2 ) EF 53% (N 57-81%) PSIR phase-sensitive inversion recovery PERH Radioloogiakeskus

25 66-aastane naine TIRM T1 map T2 map T1 aeg septumis on 1460 ms (N ms) T2 aeg septumis on 56,8 ms (N 34,9 43,3 ms) Vasaku vatsakese müokardis ulatuslik, suhteliselt difuusne signaalimuutus kõikides seintes TIRM turbo inversion recovery magnitude PERH Radioloogiakeskus

26 Kasutatud kirjandus 1. Friedrich MG, Sechtem U, Schulz-Menger J, et al.. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. J Am Coll Cardiol 2009;53(17): The Role of Cardiovascular MRI for Diagnosis and Prognosis in Acute Myocarditis - Dr. James White. The Stephenson Cardiac Imaging Centre's Ongoing Educational Lecture Series from Sept. 22, Ischemic and non-ischemic cardiomyopathy Wouter van Es, Hans van Heesewijk, Benno Rensing, Jan van der Heijden and Robin Smithuis. ( 4. Luetkens JA, Doerner J, Thomas DK, Dabir D, Gieseke J, Sprinkart AM, et al. Acute Myocarditis: Multiparametric Cardiac MR Imaging. Radiology. 2014; D.H. O'Donnell, S. Abbara, V. Chaithiraphan, et al. Cardiac MR imaging of nonischemic cardiomyopathies: imaging protocols and spectra of appearances Radiology, 262 (2) (2012), pp White JA, Rajchl M, Butler J, Thompson RT, Prato FS, Wisenberg G. Active cardiac sarcoidosis: first clinical experience of simultaneous positron emission tomography magnetic resonance imaging for the diagnosis of cardiac disease. Circulation. 2013;127:e Wai Hong Wilson Tang, MD. Myocarditis. ( 8. Leslie T Cooper, Jr, MD. Clinical manifestations and diagnosis of myocarditis in adults ( 9. Leslie T Cooper, Jr, MD. Etiology and pathogenesis of myocarditis. (

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