Cardiac CT and MRI Ashraf Hamdan, MD Sheba Medical Center Sheba Medical Center Tel Hashomer Leviev Heart Center
Spatial resolution Resolution 4x4mm If the object incidentally placed in one pixel high image quality Resolution 4x4mm If the object incidentally placed in more than one pixel larger object with low image quality & low render delineation =partial volume effect
Dual Source CT - Rationale Original Image 50 ms 100 ms 250 ms Ideally, motion-free imaging for coronary arteries requires acquisition time to be around 50 ms but the current temporal resolution of MDCT is: 80-200ms: temporal resolution for DSCT = 83 msec, for 64CT = 160msec
EHJ 2013
Pretest probability Low: < 15% - can be managed without further testing Intermediate: 15-85% - stress testing High: > 85% - risk stratification only EHJ 2013 EHJ 2013
Anatomical assessment of CAD CCTA? EHJ 2013
PPV = TP/(TP + FP) NPV = TN/(TN + FN) Schuetz et al. Systemic Reviews 2013,2:13
Effect of BMI on the image quality BMI = 30 kg/m² BMI = 19 kg/m²
CASE I
CASE I
Case II
Case III
Case IV In 2010: typical chest pain
2006-2013 איתסמיני רץ מרתון מדי פעם גורמי סיכון מאוזנים היטב מעקב שגרתי אקו במאמץ כל 2-3 תקינים שנים
2014- מודאג האם התומכן ב LADפתוח איתסמיני מתכונן למרוץ הר לעמק אקו במאמץ-צניחות במקטע ST שלא היו בעבר ללא הפרעה בתנועתיות הדפנות גורמי סיכון מאוזנים היטב מטופל עם סטטין ומטפורמין, אספירין,פלביקס
Case V RVOT Right cusp RV LV Left cusp
Coronary anomalies: Malignant criteria Intramural course: - Slit like ostium - acute angle - asymmetrically positioned between aorta & PA Running between PA and aorta Intra- vs. extramuscular: when intramuscular less malignant
MRI
10 Top MRI Indication 1. Ventricular volumes and function 2. Viability 3. Stress examinations: perfusion and dobutamine stress MRI 4. Cardiomyopathy, myocarditis and infiltrative disease 5. Tumors and Thrombus 6. Pericardial Diseases 7. Magnetic resonance angiography of the great and peripheral vessels 8. Coronary artery imaging 9. Blood flow quantification for shunt sizing and evaluation of valvular heart disease 10. Congenital disease
Need for further modalities?
Interstudy Reproducibility 200 MRI 200 Echo 180 180 160 160 140 140 120 120 100 100 80 1 2 80 1 2 Mean 1 = 131 Mean 2 = 131 SD = 4.6 Mean 1 = 131 Mean 2 = 131 SD = 18 Bellenger. Pennell. JCMR 2000: 2: 271-8
Sample Size Reduction Grothues et al. Am J cardio, 2002; 90-29
Enddiastolic Endsystolic CMR-AKADEMIE.com Determination of LV- Function with Simpson s method is reference standard
MRI vs. SPECT Spatial resolution MRI ~ 2 x 3 mm SPECT ~ 10 x 10 mm 3-D Imaging No Radiation Wagner A et al. Lancet 2003;9355:
Comparison with Dobutamine Stress Echo (DSE) and MRI (DSMR) DSE DSMR P value Sensitivity 74.3% 86.2% < 0.05 Specificity 69.8% 85.7% < 0.05 Pos. predictive value 81.0% 91.3% < 0.05 Neg. predictive value 61.1% 78.3% < 0.05 Accuracy 72.7% 86.0% < 0.005 Nagel et al. Circulation 1999;99:763-770
MRI for the Diagnosis of Coronary Artery Disease Detection of ischemia MRI coronary angiography Perfusion measurements Wall motion analysis
Monitoring & Safety Aspects Continuous monitoring of rhythm/heart rate (vector-ecg) blood pressure respiratory control D Physician and Technician must bei experienced in advanced cardiac life support periodically practice rapid patient evacuation (2 staff members, <30 sec)
Safety of DSMR Side Effects Safety profiles of DSE and DSMR are virtually identical Wahl et al. Eur Heart J 2004
DSMR inducible WMA male, 52 yrs known CAD post multiple interventions of LCX at presentation chest pain, not strictly related to exercise Echo: moderate image quality (esp. endocardial border definition of lateral wall)
4-chamber view rest 20 g 40 g
Endsystole Enddiastole DSMR-02 rest 10µg 20µg max
DSMR-03 inducible, ischemic WMA
Late Enhancement Patterns for Ischemic and Nonischemic Disorders Mahrhold EHJ 26:1461
Mechanism of delayed enhancement Normal myocardium Contrast agent molecules (Gadolinium-chelates) extracellular can not cross cell membrane low concentration Myocardial infarct Membrane rupture Gadolinium-chelates Intracellular Increased concentration hyperenhancement Chronic infarct Myocytes replaced by Collagen large interstitial space Increased concentration hyperenhancement intact cell membrane ruptured cell membrane Collagen matrix
Case I Male, 17 yrs Medical history: Smoker 7-days history of Fever 38.9, Sore throat, weakness At presentation: acute chest pain and dyspnea Laboratory workup: Troponin-I positive = (33 micg/l); CPK = 1630 IU/L
Invasive Angiogram
Acute myocarditis 5-months later
Acute myocarditis 5-months later
Acute myocarditis 5-months later
Case II: Gaint cell myocarditis Signal Intensity measurement Myocardium: 164g Scar: 54g, 33% Edema: 68g, 40%
Case II ischaemic vs. Non-ischaemic CMP
Acute MI 3 weeks later
Case III Male, 56 yrs Medical history: s/p inferior MI (s/p PCI to RCA), Smoker 3-days history of Fever and chest pain Laboratory workup: Troponin-I positive = (25 micg/l); CRP = 190
Case IV
Apical 82% Multicenter study in 207 pts. Midventricular 82% Basal 82% Possible etiology - Inflammation - increased LV wall stress - transient ischemia - myocardial edema Biventricular 34% Eitel et al. JAMA 2011; 306:277
Preceding stressful events
Case VI Female, 51 yrs Medical history: Smoker, positive family history for CAD At presentation: Non specific chest pain Laboratory workup: Troponin-I positive = (18.9 micg/l); CPK = 785 IU/L
Invasive Angiogram
MRI
ARVD
Case V Male, 44y Syncope
Sarcoidosis
Sarcoma Black blood DE Broad based & large mass - Heterogeneous enhancement corresponding to Necrosis - The most common cardiac malignant tumor Isointense in T1 -The majority of occur in the right atrium - Mean survival 3 months to 1 year TGE without contrast TGE with contrast
Lipoma Without fat suppression With fat suppression
Lipoma Delayed enhancement Perfusion
Lipoma
Lipoma
Thrombus 5 days after MVR
Pericarditis
Non compaction