CARDIAC MULTIMODALITY IMAGING: Informing better decisions - or just costly pictures?

Transcription

1 CARDIAC MULTIMODALITY IMAGING: Informing better decisions - or just costly pictures? Jonathan P. Christiansen MBChB, MD, FRACP, FACC, FCSANZ Consultant Cardiologist, North Shore Hospital, Auckland

2 Overview Preoperative evaluation Current evidence for imaging in preoperative risk assessment New modalities: Cardiac MRI CT coronary angiography Echocardiography Portability and IV contrast

3 Preoperative evaluation CARDIAC REVIEW?STRESS IMAGING YES HIGH PATIENT EMERGENCY ACTIVE CARDIAC ISSUES PATIENT RISK FACTORS NO NO HIGH SURGERY RISKS YES LOW INT LOW INT OPERATE Redrawn from: Priebe H-J. British J Anaes. 2011;107(1):83-96

4 Imaging for risk usage? DECREASE II CARP Lee et al RCRI Mangano 1995 DECREASE V POBBLE DIPOM POISE?

5 Stress Imaging - Echo Rest Stress Rest Stress NORMAL ISCHAEMIA

6 Stress perfusion - SPECT Stress Rest Stress Rest NORMAL ISCHAEMIA

7 Death or MI per Year (%) Event rates: SPECT and Echo 2.0 SPECT ECHO Men Women Metz LD et al. JACC 2007;49:227-37

8 Events per Year (%) Event rates: known CAD Death Death+ nonfatal MI yrs 3-6 yrs Schinkel AF et al. Am J Cardiol 2006;97:1-6

9 Cardiac Death Rate (%/year) Adding LV function EF > 50% EF 30-50% Normal Mild/Mod Large Perfusion Defect Sharir T et al J Nuc Med 2001;42: patients

10 Cardiac Death Rate (%/year) Revascularisation - Ischaemic Burden [10,627 patients] Medical Revasc % % 5-10% 11-20% >20% % Total Myocardium Ischaemic Hachamovitch: Circulation 2003;107(23):

11 Cardiac Imagining

12 (%) Does imaging predict events? % 98.7% PPV NPV 50 12% 15% 0 SPECT ECHO Summarised from: Fleisher et al. Circulation 2009;120:e (ACCF/AHA Update)

13 Can we change outcomes? McFalls et al - CARP. N Engl J Med 2004;351:2795

14 Courage! For the COURAGE Investigators. NEJM 2007;356:1053

15 Events (%) Imaging-guided revascularisation Death Death+ nonfatal MI DSE-guided Revascularisation No Revascularisation Poldermans D et al. DECREASE V Pilot Study. J Am Coll Cardiol 2007;49;1763-9

16 Ischaemia, obstruction & events Galal W et al. Anesthesiology 2010;112:557-66

17 Cardiac MRI A o L A L V

18 Stress Perfusion - CMR DELAYED ENHANCEMENT STRESS REST A B

19 % CMR vs SPECT and ECHO Echo Nuclear 81 MRI 50 0 Sensitivity Specificity Schinkel, A.F.L et al. Eur Heart J 2003;24: Nandalur KR et al. JACC 2007;50:

20 Death or MI per Year (%) Event rates: SPECT and CMR Nuclear MRI Normal Abnormal Iskander S, Iskandrian AE. J Am Coll Cardiol 1998;32:57-62 Hanke et al. Circulation 2007;115:1769

21 Dobutamine stress MRI REST STRESS

22 Death or MI or CHF (%) Preoperative use of DS-CMR 20 20% % Normal Abnormal Rerkpattanapipat P et al. Am J Cardiol 2002;90:

23 CMR - Summary No radiation Comprehensive Efficient Accuracy/resolution Prognostic Quantitative (if required) Viability assessed Minimal preoperative data Pharmacologic stress only CMR limitations Claustrophobia Devices pacemakers etc End stage renal disease Expertise limited Scanner availability

24 CT Coronary Angiography NORMAL MILD SEVERE

25 CTCA analysis

26 CTA diagnostic performance Meijboom et al. J Am Coll Cardiol 2008;52:2135

27 Anatomy vs function? QCA vs FFR Fischer J et al. Am J Cardiol 2006;97:1-6

28 % CCTA & SPECT: predicting ischaemia % 84% PPV NPV 50 44% 43% 0 Di Carli Schuijf Di Carli M et al. Circulation 2007;115:

29 CTCA - Prognosis Min J et al. CONFIRM Registry. J Am Coll Cardiol 2011;58:849-60

30 Plaque Imaging Motoyama et al. J Am Coll Cardiol 2007;50:319

31 Preoperative CTCA Well established for assessment of CAD in non-coronary cardiac surgery Only two studies in non-cardiac surgery Liver transplant Observational ESC Guidelines for pre-operative cardiac risk assessment. Eur Heart J 2009;30: Russo V, et al Heart 2007;93: Jodocy et al. Eur J Radiol 2011;In press on line 12 th June

32 CTCA as gatekeeper? Hachamovich R et al. J Nucl Med 2011;52(7)

33 CTCA - Summary Outstanding negative predictive value Accuracy Prognostic?Plaque imaging Radiation dose reducing now Minimal preoperative data No functional information on stenosis severity CTCA limitations Renal failure Arrhythmia Obesity Expertise limited Scanner availability

34 Obesity issues SPECT ECHO CTCA CMR Gugliotti D et al. Obesity Surgery 2008;18:

35 Portability - not! CMR CTCA

36 Portable Echo

37 Microbubble Contrast Agents Shell: 1. Albumin 2. Lipid 3. Polymer Gas: 1. Perfluorocarbon 2. Air

38 Left ventricular opacification

39 Contrast - safety issues 2007 FDA Black Box warning Safety data now extensive: ijacc (2009) 26,774 patients, stress echo Contrast = non contrast for adverse events 1:10,000 acute anaphylactoid reaction

40 Echo extras? 3D Speckle and strain

41 Conclusions Echo remains the core imaging modality Cardiac CT has the greatest potential to be a disruptive technology The majority of patients will not benefit from additional imaging for preoperative risk assessment