EAE Teaching Course Bucharest, 2010 Assessment of Ischemia and Viability Jens-Uwe Voigt Dpt. of Cardiology University Leuven Belgium Assessment of Ischemia & Viability resting wall motion Stress Testing needed! 1 2 3 4 normal hypokinetic akinetic dyskinetic 1
Stress Testing in CAD Ischemia Stress Echocardiography exercise test (bicycle, treadmill) 200W 150W 100W 50W rest exercise max rec. target HR = (220-age) *0.85 2
Stress Echocardiography dobutamine protocol 40µ 30µ 20µ 10µ 0,5mg rest dobutamine +atropin rec. viability ischemia Stress Echocardiography dipyridamol / adenosine protocol dipyridamol 0,84 mg/kg adenosin 140 µg/kg up to 1mg rest dipyridamol / adenosine atropin rec. 3
Comparison of Protocols sensitivity / specificity for CAD (stenosis > 50%) 100 Exerc. Dobu Dipy 80 60 40 sensitivity specificity 20 0 Fleischmann, JAMA 1998 Stress Echocardiography 4
Stress Echocardiography regional wall motion normal ischemic non-transm. scar scar baseline stress Afridi et al., Circ 1995 Stress Echo Reading the human factor 120 100 80 60 40 20 0 center 1 center 2 center 3 center 4 center 5 interinstituional agreement in stress echo readings (n=150 pts., 5 centers) negative positive Hoffmann et al., JACC 1996 5
Stress Echo Reading the human factor + modern technology... 100 90 80 70 60 50 40 30 20 10 0 cent. 1 cent. 2 cent. 3 cent. 4 cent. 5 cent. 6 interinstituional agreement in stress echo readings (n=150 pts., 6 centers) negative positive Hoffmann et al., EHJ 2002 Regional Ischemic Response experimental coronary occlusion Jamal, J Am Soc Echo 2001 6
Regional Ischemic Response baseline 5s ischemia 10s ischemia 20s ischemia rad. strain [%] post. wall Jamal, J Am Soc Echo 2001 Strain Rate Imaging in Stress Echo rest stress strain ischemic segment strain non-ischemic segment 0-10 -20 0-10 AVC MVO AVC MVO 0-10 -20 AVC MVO AVC MVO 0-10 total strain PSS ECG -20-20 Voigt et al., Circulation 2003 7
Quantitative Criteria sensitivity 1 0,8 0,6 0,4 0,2 ROC - Analysis parameter AUC PSS 0.90 systolic strain rate 0.74 systolic strain 0.65 0 0 0,2 0,4 0,6 0,8 1 1-specificity Voigt et al., Circulation 2003 Case: Dobutamine Stress Echo, 4CV 8
Case: Quantitative Assessment baseline peak stress Strain Rate im Stress Echo accuracy improvement depends on experience 90 [%] 60 30 novice 73 59 59 47 expert 86 81 82 89 sensitivity specificity with and without considering SRI 0 ohne mit ohne mit Voigt, Circulation 2003 9
Strain Rate Stress Echo for Prognosis dobutamine stress, 646 pts., 7 ys. follow up χ² 40 30 predictive value p<0.001 survival msrs - msrs + cutoff: -2.0 s -1 p < 0.001 20 10 p<0.001 0 clinical clin. + WMSI clin + WMSI + msrs Björk-Ingul, Circulation 2007 Stress Testing in CAD Viability 10
Concept of Viability CASS - Study 5 year survival rate: med. OP EF<35% 54% 68% ** EF<26% 43% 63% ** CASS: Alderman et. al.,circ 1983 Concept of Viability reperfusion therapy relieves symptoms improves LV function improves prognosis dysfunction irreversible myocardial damage! viable myocardium 11
Concept of Viability stunning: contractile dysfunction after short ischaemia despite restored perfusion Heyndrickx et al., J Clin Invest 1975 (to render sb. senseless or dizzy) restitutio ad integrum Concept of Viability stunning: hibernation: contractile dysfunction after short ischaemia despite restored perfusion Heyndrickx et al., J Clin Invest 1975 (to render sb. senseless or dizzy) restitutio ad integrum reduced contractile function with proportionally reduced perfusion Diamond et al., Am Heart J 1978 (to lethargically pass the winter) restitutio ad integrum? 12
Decision to Revascularize CABG in pat. with LV dysfunction probability of survival n = 76 pat. EF ca. 30% with proof of viability clinical decision only months post OP Haas et al., JACC 1997 Decision to Revascularize CABG without proof of viability more adverse events due to perioperative mortality (11-15%!) worse prognosis than with med. therapy (Haas et al., JACC 1997) (Anselmi et al., Am J Cardiol 1998) (Pasquet et al., Circ 1999) (Senior et al., J Am Coll Cardiol 1999) 13
How to Test for Viability? scintigraphy: echocardiography: SPECT, PET perfusion / metabolism mismatch dobutamine stress inotropic stimulation MRI: dobutamine stress inotropic stimulation contrast MRI delayed enhancement Stress Echocardiography dobutamine protocol 40µ 30µ 20µ 10µ 2mg BL dobutamine +atropine Rec viability ischaemia 14
Stress Echocardiography regional wall motion normal ischemic viable viable+ ischemic scar baseline low dose high dose dobutamine Afridi et al., Circ 1995 Case: Low Dose Dobutamine biphasic response baseline lowdose peak 15
DSE vs. Scintigraphy echocardiography scintigraphy meta-analysis data from studies with direct comparison of methods 11 studies 325 patients Bax et al., Curr Probl Cardiol 2001 Viability in MRT delayed enhancement vs. histology % area late enhancement % area histology Kim, Circulation 1999 16
Viable Rimb contractile reserve vs. transmurality of scar % segments n= 48 patients late enhancement vs. dobutamin - MRT w/o w contractile reserve 0% 1-25% 26-50% 51-75% >75% transmurality of scar Kaandorp et al., Am J Cardiol 2004 Which Test for Viability? ESC Study Group Report modality Scinti Echo MRI (stress) MRI (contrast) indication class 1 1 1 1 Underwood et al., Eur Heart J 2004 17
Case M.Pf., m, 67 yeras decompensated HF, NYHA III-IV Hx silent posterior infarction Hx PTA of A. femoralis risik faktors: hypertension diabetes mellitus II hyperlipidaemia ex smoker EF ca. 25% LAD occluded, CX and RCA stenotic Case: Multimodality Approach 18
Strain for Viability Testing? radial strain during low dose dobutamine after non-transmural / transmural infarction baseline dobu 2.5 dobu 5 dobu 10 dobu 20 hibernating myocardium AVC AVC AVC AVC AVC transmural infarction Weidemann et al., Circulation 2003 Strain for Viability Testing? layer specific assessment Rösner et al., JASE 2010 19
EAE Consensus Statement Sicari et al., EHJ 2008 20