Noninvasive Cardiac Imaging in Myocardial Infarction Sangchol Lee Sungkyunkwan University Samsung Medical Center
Current Guidelines for Diagnosis of AMI Chest pain ST change on EKG Cardiac Enzymes
Do We Need Imaging for AMI Management? Confusing results on EKG Time needed d for enzymes to rise Chest pain - typical? atypical? Measurement of infarct size Post-PCI PCI complications Assessment of residual viable myocardium
Current Noninvasive Imaging Modalities for AMI Diagnosis Echocardiography Radionuclide perfusion scan Cardiac CT Cardiac MRI
Conventional Echocardiography Global LV function Regional wall motion for diagnosis i Complications of MI Myocardial area at risk Myocardial viability - stress echo
1.0 0.8 Survival of Patients with Acute MI Prognosis EF 40% EF >40% E/e 15 1.0 0.8 E/e 15 1 Surviva al 06 0.6 0.4 E/e >15 06 0.6 0.4 E/e >15 0.2 0.2 0.0 0 6 12 18 24 0.0 0 6 12 18 24 Follow-up (months) Follow-up (months) No. at risk 72 52 29 11 4 178 143 84 38 11 Hillis et al: JACC 43(3):360, 2004 CP1141593-3
Prognostic Value of E/E' After Acute MI In DTBT <90 1.0 1.0 E/e' 15 In DTBT 90 E/e' 15 h) al (death Surviva 0.9 0.8 0.7 P=0.06 E/e' >15 h) al (death Surviva 0.9 0.8 0.7 E/e' >15 P<0.0001 0.6 0.6 0.5 0 200 400 600 800 Follow-up (days) 0.5 0 200 400 600 800 Follow-up (days) Park SJ, Ting H, Oh JK Unpublished CP1302151-7
Unconventional Echocardiography Myocardial strain imaging Contrast t echocardiography h
Strain Imaging Strain: Deformation of an object, relative to its original length = L - L 0 L = L0 L 0 L 0 L 0 If 10 cm original length is shortened to 7.5 cm, strain is (-) 25 %. Normal strain is > 20 %. CP1237840-8
2D Speckle Tracking Image Normal Radial strain (SAX) K.Ogawa, T.Hozumi et al. AJC 2006 Transversal strain (A4) Aplio (SSA-770A, Toshiba Japan)
Longitudinal strain: normal case Display 4C 2C Lengthening APLAX Shortening Bull s Eye
Bull s Eye Mapping of Strain +20% Lengthening g -20% Shortening Anteroseptal MI (LAD) Inferolateral MI (LCX) Inferior MI (RCA)
Contrast Echocardiography h Perfusion Defect in the apical segments
Contrast Perfusion Echo for Viability 2 patients with Anterior STEMI and PCI Baseline Follow up
Is there apical thrombus?
CT for Myocardial Imaging Coronary CT angiography Arterial phase myocardial imaging i Myocardial motion interpretation Viability imaging with delayed enhancement
Role of CCT in AMI Evaluation of acute chest pain Myocardial viability
Quantification of Infarct Size
Myocardial Viability
Dual-Phase CT
Dual-Phase CT
CMR: Delayed Enhancement
Two Patients with Inferior STEMI Soon after PCI
Two Patients with Inferior STEMI After PCI and Follow-up
Two Patients with Inferior STEMI Follow-up Echo and Baseline MRI Small DE by Gd Large DE by Gd
Myocardial Function and DHE Transmural extent of infarction and contractility Marholdt, JACC 2003
All Dysfunctional Segments Segments with Severe Hypokinesia, Akinesia, i or Dyskinesia i Segments with Akinesia i or Dyskinesia i ility (% %) ontract oved co Impro 100 80 60 40 20 0 (12 of 12) (128 of 148) (23 (256 of 28) of 329) (56 of (109 86) of 183) (45 of (29 of (9 of 20) 110) 68) (13 of (10 of 124) 103) (4 (1 of (0 of of 54) (0 of 58) 57) 46) 76-100 51-75 26-50 1-25 0 76-100 51-75 26-50 1-25 0 76-100 51-75 26-50 1-25 0 Transmural extent of hyperenhancement (%) R. Kim et al NEJM 2000 CP1302210-5
Prognosis Associated with DHE Chest pain without known OMI Post-STEMI Kwong, Circ 2006 Wu, Heart 2008
Additional Information: Microvascular Obstruction Sakuma, JMRI 2007
Functional Recovery after AMI and MO Nijveldt, JACC 2008
MO and Prognosis Wu, Circulation 1998
AMI with Edema Sakuma, JMRI 2007
T2WI for Edema in MI T2WI-triple IR Myoview Scan
Acute MI with Swelling T2WI
With a Newer Sequence Acute MI Chronic MI Kellman, Magn Reson Med 2007
Peri-Infarct Zone Enhancement (The Grey Zone) 2-3 SD >3 SD Yan AT et al. Circulation 2006;114;32-39.
STEMI? Chest and left arm pain for 1 hr. Increased Troponin
65 year old woman with chest pain
Cine Delayed Enhancement Courtesy of Siemens Med. Systems
Cardiac MRI New Technology Diffusion Tensor Imaging g Myocardial Strain Imaging
Evaluation of Chest Pain Prognosis Viability Imaging CAD Function Infarct size Unstable Hemodynamics and dc Complications CP1210291-8