J. Schwitter, MD, FESC Section of Cardiology

J. Schwitter, MD, FESC Section of Cardiology CMR Center of the CHUV University Hospital Lausanne - CHUV Switzerland Centre de RM Cardiaque

J. Schwitter, MD, FESC Section of Cardiology CMR Center of the CHUV University Hospital Lausanne - CHUV Switzerland Stress CMR to Guide Complex Revascularization in Stable CAD ESC Meeting Munich, Germany August 28, 2012 Disclosure: - no conflicts of interest - Gd-based contrast media are not approved for CMR in the US and in some European countries

CMR in Complicated Revascularizations: Examples CABG: yes or no CABG: 1 vs 2 vs 3 grafts PCI vs CABG PCI and complications CABG and concomitant diseases CABG vs drugs/transplantation

septal septal Hibernating Myocardium vs Scar: To Revascularize or Not? LV mass: 205.7g LV scar mass: 46.2g LV scar: 22.5% anterior Subendocardial scar lateral inferior anterior Transmural scar lateral inferior Knuesel et al. Circulation, 2001

Characterization of Dysfunctional Myocardium by PET and MR: Relation to Functional Outcome After Revascularization Baseline Follow-up 3% 2% 2% 3% 10% 71% functional improvement 10% 93% 28% Viability 77% PET/MR +/+ PET/MR -/+ PET/MR -/- PET/MR +/- 29% no functional improvement 7% 27% 38% Scar < 4mm, viable rim > 4 mm Recovery of function Scar > 4mm, viable rim < 4 mm Recovery of function P.R. Knuesel et al. Circulation, 2003

Hibernating Myocardium vs Scar: To Revascularize or Not? High-Risk Patient: pre-interventional assessment Patient E, 49 years EF 34% Patient S, 62 years 22%

Hibernating Myocardium vs Scar: To Revascularize or Not? High-Risk Patient: pre-interventional assessment Large transmural scar No intervention EF 34%

Hibernating Myocardium vs Scar: To Revascularize or Not? High-Risk Patient: pre-interventional assessment Small scar Revascularization indicated EF 22% Knuesel, Schwitter et al. Circ. 2003

Hibernating Myocardium vs Scar: To Revascularize or Not? High-Risk Patient: pre-interventional assessment EF 22% Pre-operative EF 37% 3 months post-operative Knuesel, Schwitter et al. Circ. 2003

CMR in Complicated Revascularizations: Examples CABG: yes or no CABG: 1 vs 2 vs 3 grafts PCI vs CABG PCI and complications CABG and concomitant diseases CABG vs drugs/transplantation

Mortality and outcome of patients stratified by number of vessels treated Mortality in patients undergoing CABGs Multivariate Cox proportion regression model N.H. Lopes et al. Eur J Cardiothorac Surg 2008;33:349-354

Clinical case 1: CMR for viability assessment 57 y.o male Severe mitral regurgitation LVEF 40%, hypokinesia of the infero-lateral wall Ad coronary angiogram prior to mitral valve repair

Clinical case 1: CMR for viability assessment

Clinical case 1: CMR for viability assessment LGE in the inferior wall (100% transmurality)

Clinical case 1: CMR for viability assessment Mitral valve repair CABG LAD CABG CX CABG RCA Time of procedure is reduced

CMR in Complicated Revascularizations: Examples CABG: yes or no CABG: 1 vs 2 vs 3 grafts PCI vs CABG PCI and complications CABG and concomitant diseases CABG vs drugs/transplantation

MR-IMPACT I (18 centers) MR-IMPACT II (33 centers) Perfusion-CMR all SPECT Gated-SPECT 1 1 0.8 0.6 0.8 0.6 * 0.4 0.2 CMR superior to SPECT p=0.013 0.4 0.2 CMR superior to SPECT p=0.0004 0 0 0.2 0.4 0.6 0.8 1 MR 1- Specificity J. Schwitter et al. Eur Heart J 2008;29:480-489 0 0 0.25 0.5 0.75 1 1-Specificity J. Schwitter et al. JCMR 2012, in press

Case 2: CMR for Ischemia Assessment Patient history: Hypertension, high cholesterol CABG x 3 for stable angina 16 years ago LIMA to mid-lad / 2 nd diagonal branch VG to 1 st diagonal branch VG to intermediate branch and 1 st OM branch

Case 2: CMR for Ischemia Assessment Recurrence of exertional angina since summer 2009, CCS II Resting ECG normal Stress ECG (bicycle) at 227 W (=10 METs): no angina no ECG changes Sent to private clinic for coronary angiogram

Case 2: CMR for Ischemia Assessment Coronary angiogram LIMA graft patent 2 vein grafts occluded LAD: proximally occluded LCX: severe proximal and mid-vessel stenosis RCA: distal 70% stenosis and 70% stenosis of the PLV branch, gives collaterals to LCX and intermediate branch LV-angiogram: LVEF 73%

Case 2: CMR for Ischemia Assessment Atrial branch Intermediate LCx Graft OM1

Case 2: CMR for Ischemia Assessment Mr R.W. 63 yo

Case 2: CMR for Ischemia Assessment Mr R.W. 63 yo First cardiology opinion: CABG re-do because of the lesion complexity, despite good functioning LIMA graft Bifurcation stenosis of the RCA which gives collaterals to the left system Occlusion of the intermediate branch Long and complex lesion of the LCx Sent for second opinion

Case 2: CMR for Ischemia Assessment CMR 1 Cine: LVEF 58%

Case 2: CMR for Ischemia Assessment

LGE PEAK PRE Case 2: CMR for Ischemia Assessment BASE APEX

Case 2: CMR for Ischemia Assessment Cine: LVEF 58% LGE: small basal-mid anterior subendocardial scar Perfusion: extensive defect in the anterior, anteroseptal and lateral wall No perfusion defect in the RCA territory No need for RCA revascularisation Aim for lateral wall revascularisation Remaining graft between OM1 and intermediate should improve anterior wall perfusion PCI is a suitable option

Case 2: CMR for Ischemia Assessment Mr R.W. 63 yo Sent for PCI to LCX only LCX angioplasty with stenting of the mid-vessel stenosis Dilatation of the LMS with rotablator, then stenting to the LM-ostial LCX

Case 2: CMR for Ischemia Assessment

Case 2: CMR for Ischemia Assessment Repeat CMR 1 month after intervention Patient symptom free

Case 2: CMR for Ischemia Assessment Mr R.W. 63 yo Cine: LVEF 64% LGE: unchanged small basal anterior scar

Case 2: CMR for Ischemia Assessment Mr R.W. 63 yo BASE APEX

Case 2: CMR for Ischemia Assessment Mr R.W. 63 yo Take home messages Simple ECG stress test is probably insufficient for ischemia assessment after CABG. Stress imaging is recommended. Accurate assessment of myocardial viability and of the distribution of inducible perfusion defects with CMR is of great value, especially in case of complex coronary lesions It adds a functional assessment to the morphologic angiographic picture, and allows to better targeting PCI (and to avoid unnecessary, potentially dangerous re-op)

CMR in Complicated Revascularizations: Examples CABG: yes or no CABG: 1 vs 2 vs 3 grafts PCI vs CABG PCI and complications CABG and concomitant diseases CABG vs drugs/transplantation

Case 3: CMR for Complications Assessment 59 y.o male art. hypertension, DM, positive family history known CTO of the RCA Ad PCI of the RCA Failure of anterograde recanalisation of the RCA Locca et al., Circulation, 2007

Case 3: CMR for Complications Assessment Retrograde approach via the septal collaterals Implantation of 4 DES TIMI flow 3 at the end of the procedure Locca et al., Circulation, 2007

Case 3: CMR for Complications Assessment unchanged ECG before/after PCI 24h after PCI: - Peak troponin I: 1.19 g/l (0.04) - CK-MB: 7.8 g/l (0 6) 48h 48h Edema Necrosis Locca et al., Circulation, 2007

Case 3: CMR for Complications Assessment unchanged ECG before/after PCI 24h after PCI: - Peak troponin I: 1.19 g/l (0.04) - CK-MB: 7.8 g/l (0 6) 48h Edema Necrosis Perforation Locca et al., Circulation, 2007

Case 3: CMR for Complications Assessment unchanged ECG before/after PCI 24h after PCI: At 24 hours after PCI - Peak troponin I: 1.19 g/l (0.04) - CK-MB: 7.8 g/l (0 6) 48h 8 w Edema No Edema Locca et al., Circulation, 2007

Spontaneous Dissection of LCX Not Requiring PCI 70 60 50 40 30 20 10 0 80 70 60 50 40 30 20 10 0 80 70 70 60 60 50 50 R. Van 40 40Heeswijk, JACC Cvimaging, in press 30 30

CMR in Complicated Revascularizations: Examples CABG: yes or no CABG: 1 vs 2 vs 3 grafts PCI vs CABG PCI and complications CABG and concomitant diseases CABG vs drugs/transplantation

Case 4: CMR for Assessment of Coronary Circulation in Congenital Heart Disease 4 year-old boy S/p Switch operation Ostial stenosis of the LCX at the RCA sinus JCMR 2008 E. Valsangiacomo et al.

Case 4: CMR for Assessment of Coronary Circulation in Congenital Heart Disease JCMR 2008 E. Valsangiacomo et al.

Case 4: CMR for Assessment of Coronary Circulation in Congenital Heart Disease

Case 4: CMR for Assessment of Coronary Circulation in Congenital Heart Disease Systole forward Flow (black) Diastole retrograde Flow (bright)

Flow (L/min) Case 4: CMR for Assessment of Coronary Circulation in Congenital Heart Disease LCX: Diameter ~1.5mm PCI CABG + Replacement of pulmonary valve in aortic position 70 50 30 10-10 -30-50 HR: 72 bpm RF: 46% 1 3 5 7 9 11 13 15 17 19 21 # image

Case 4: CMR for Assessment of Coronary Circulation in Congenital Heart Disease Perfusion Pre-CABG LCX: Diameter ~1.5mm Perfusion Post-CABG PCI CABG + Replacement of pulmonary valve in aortic position

CMR in Complicated Revascularizations: Examples CABG: yes or no CABG: 1 vs 2 vs 3 grafts PCI vs CABG PCI and complications CABG and concomitant diseases CABG vs drugs/transplantation

July 2011 Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP? 62 y.o male History of inferior MI - RF: DM, HT, hypercholesterolemia, smoking Dyspnea NYHA II On echo: ischemia of anterior and infero-septal wall EF 22% X-ray coronary angiography

July 2011 Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP?

July 2011 Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP? Ischemia? Ischemia?

Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP? Diastole Systole

LV-EF: 14% LVEDVI 365 ml Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP?

Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP? Diastole Systole

Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP?

Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP? Pre-contrast Peak First Pass Scar

Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP? Pre-contrast Peak First Pass Ischemia? Scar

Occlusion Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP? PCI

Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP?

LV-EF: 20% LVEDV: 372 ml LV Function post-revascularization

Case 5: CMR for Assessment of Viability and Ischemia CAD vs dil CMP? 14 g of scar tissue do not explain a LV-EF of 20% The combination of CAD and dil CMP most likely explain the reduced EF, i.e. the heart failure symptoms in this patient No Revascularization Transplantation to discuss (or CRT?)

CABG: yes or no CABG: 1 vs 2 vs 3 grafts PCI vs CABG CMR in Complicated Revascularizations PCI and complications CABG and concomitant diseases CABG vs drugs/transplantation CMR can help in decision making by assessing viability, ischemia, and concomitant diseases such as dilative CMP, valvular heart disease etc.