CARDIOMYOPATHY IN CT Hans- Christoph Becker Professor of Radiology 1
Cardiomyopathy Heart muscle disease Deterioration of the heart function, heart failure Dyspnea, peripheral edema Risk of arrhythmia, sudden cardiac death
Cardiomyopathy Classification
Primary/Intrinsic CM Genetic HOCM, ARVD, NCC, Mitochondrial Myopathy Mixed DCM, RCM Loeffler endocarditis Acquired Peripartum Takotsubo
Secondary/Extrinsic CM Metabolic Amyloidosis, hemachromatosis Inflammatory Viral, Chagas disease Endocrine Diabetes, hyperthyroidism, acromegaly Toxic CTx, alcohol Neuromuscular Muscular dystrophy Other Ischemic, nutritional
Cardiac CT Scan Modes Retrospective Spiral Prospective Sequence Single Heart Beat Heart rate Any Any <60 bmp Rhythm Any Sinus Sinus Radiation <20 msv <4 msv <1 msv Function Yes Optional No
Williams Clinical Radiology 2008 normal LV thickness 7-11 mm
anterior LAD posterior RCA lateral LCx
Myocardial Perfusion CTA MBV MBF
Dilated Cardiomyopathy (DCM) Most common non ischemic CM, predominant African-Americans Viral (Coxsackie B, enterovirus) myocarditis, Chagas disease Peripartum CM Alcohol, chemotherapy (doxorubicin) Thyroid disease, chronic uncontrolled tachycardia (Autoimmune)
Dilated Cardiomyopathy non apposition in end systolic phase Williams Clinical Radiology 2008
Dilated Cardiomyopathy (DCM) Breathlessness (pulmonary edema), syncope, angina Left ventricular remodeling, increase of ED & ES, decline of EF Death due to congestive heart failure, tachy- or bradyarrhythmia ACE inhibitor, diuretics, digitalis, anticoagulation Pacemaker, cardioverter defibrillator, HTX
Andreini JACC 2007
MDCT in DCM 132 consecutive DCM patients 2 patients (1.5%) MDCT not feasible (AF) 88 normal and 42 diseased coronary arteries in MDCT & ICA Except for 1 all correctly classified by MDCT 1-vessel (11), 2-vessel (13), and 3-vessel (18) disease Andreini Circ Cardiovasc Imaging 2009
ischemic ideopathic Andreini JACC 2007
MDCT for the DD of DCM 61 DCM versus 139 patients with normal function 10 complications associated with conventional angiography No MDCT-related complications Coronary artery visualization was 97.2% Interference from a hypertrophic cardiac venous system MDCT is feasible, safe, and accurate for identification of idiopathic versus ischemic DCM, and may represent an alternative to coronary angiography. Andreini JACC 2007
Ischemic Cardiomyopathy acute MI chronic MI Nikolaou JCAT 2004
Late Myocardial Enhancement First Pass Late Enhancement Late Enhancement Mahnken Eur Radiol 2006
CT post Coronary Interventions Habis JACC 2007
Restrictive Cardiomyopathy Aras Int J Cardiovasc Imaging 2006
Myocardial Calcification Deranged Ca 3 (PO 4 ) 2 Chronic renal failure Hyperparathyreoidism Myocardial infarction Normal Ca 3 (PO 4 ) 2 Myocarditis (Tbc, Streptococcus, ) Endomyocardial fibrosis Irradiation Rare cardiac tumors
a b 47 YOM end stage renal disease hemodialysis, refractory laboratory values, poor dietary compliance Matsui Cardiorenal Medicine 2012 1 year 1 month prior presentation
Metastatic Myocardial Calcification a a b b Matsui Cardiorenal Medicine 2012
Hypertrophic (Obstructive) CM HCM/HOCM Incidence 0.2-0.5% Autosomal dominant disease (mutation of sarcomeric genes) Myofibrillar disarray with patchy areas of necrotic tissue Dyspnoe, chest pain, palpitations, syncope, sudden cardiac death 2/3 asymmetric septal hypertrophy Myectomy, septal alcohol ablation, ventricular pacing, HTX
Hypertrophic Obstructive Cardiomyopathy Systolic anterior movement SAM Ghersin Circulation 2011
Septal Alcohol Ablation Ghersin Circulation 2011
Alcohol Septal Ablation Mitsutake IJC 2008
Non Compaction Cardiomyopathy Kirsch IJC 2007 (NCCM)
Non Compaction Cardiomyopathy Congenital genetic cardiomyopathy Incidence 0.12/100,000 (underdiagnosed) Spongelike meshwork of myocardial fibers (NC:C = 2:1) Breathlessness, swelling of ankles, limited physical capacity Tachyarrhythmia, sudden death, clotting of blood ACE inhibitor, beta-blocker, aspirin, valve surgery, HTX
Myocardial Non Compaction Williams Clinical Radiology 2008
Arrhythmogenic Right Ventricular Dysplasia (ARVD) Autosomal dominant CM of the desmosomes (cell link) (Fibro)fatty replacement of the RV myocardium with arrhythmia Incidence 1 (US) - 40 (I) /10,000, 17% of sudden death in young Palpitations, syncope, lower extremity edema, liver congestion, sudden death Beta-blocker, amiodarone, warfarin, catheter ablation, defibrillator, HTX
Arrhythmogenic Right Ventricular Dysplasia
Criteria for ARVD Diagnosis Major Minor RV dysfunction Severe RV dilation/reduced EF Localized RV aneurysm Severe segmental RV dilatation Mild global RV dilatation/reduced EF Mild segmental RV dilatation Regional RV hypokinesia Tissue characterization Fibrofatty replacement by biopsy - Conduction abnormalities Epsilon waves, QRS prolongation Inverted T, VT, frequent pvc Family history Confirmed by autopy Sudden death <35 years
Takotsubo Cardiomyopathy Transient vasospasm, microvascular dysfunction Chest pain, dyspnea Pathognomonic wall motion abnormality (apical ballooning) Intra-aortic balloon pump, fluids, beta blocker, calcium channel blockers LV function normalizes within 2 months
Takotsubo CM
Cardiomyopathies in CT Dilated cardiomyopathy Coronary CT angiography Porcelain/pottery heart, non compaction CM Prospectively ECG triggered HOCM, ARVD, Takotsubo CM, DCM Retrospectively ECG gated 16