Case based learning: CMR in Heart Failure Milind Y Desai, MD FACC FAHA FESC Associate Professor of Medicine Heart and Vascular Institute, Cleveland Clinic Cleveland, OH Disclosures: none Use of Gadolinium is off-label for cardiac use in USA
Cardiomyopathies Ischemic Nonischemic Heterogeneous group of primary myocardial diseases with or without associated cardiac dysfunction WHO classification Hypertrophic Dilated Restrictive Arrhythmogenic RV dysplasia Specific Valvular, Hypertensive, Metabolic, Inflammatory, Systemic disorders, Muscular dystrophies, Neuromuscular disorders, Toxic reactions and Peripartum CMP Richardson Circulation 1196;93(5):841-2
WHILE CMR IS EXCELLENT TO ASSESS ICM IN MY OPINION, CMR EARNS ITS MONEY IN ASSESSMENT OF NONISCHEMIC CARDIOMYOPATHIES
CMR and Cardiomyopathies Dynamic CMR For LV/RV mass, volumes and EF Perfusion CMR Rest/stress Phase contrast for regurgitant fraction Tissue characterization LGE for fibrosis T2 weighted imaging for edema T1 mapping for diffuse fibrosis Cine T2-weighted for edema Pre and post contrast T1W LGE Friedrich M et al. JACC 2009, 53:1475 1487
Delayed Hyperenhancement Patterns Ischemic Subendocardial Infarct Mid-wall HE Nonischemic Transmural Infarct Idopathic Dilated Hypertrophic Cardiomyopathy Cardiomyopathy Myocarditis Right ventricular pressure overload (pulmonary HTN) Epicardial HE Global Endocardial HE Sarcoidosis Myocarditis Anderson-Fabry Chagas Disease Amyloidosis Systemic Sclerosis Post Cardiac Transplantation Sarcoidosis Myocarditis Anderson-Fabry Chagas Disease
Case: To do or not to do - - - 61 year old male presents with escalating angina over the last few weeks Has multiple CV risk factors and is on optimal medical therapy Vitals and exam unremarkable Echo reveals suboptimal windows, but LVEF was presumed to be 30-35 % Cath reveals severe 2-vessel disease: proximal LAD and LCX, RCA nondominant with diffuse disease CMR ordered to help decide regarding revascularization vs. ICD/medical Rx
Stress CMR Ischemia seen in LCX territory
Pre-revascularization CMR LVEDD: 203 cc, LVESV: 129 cc, EF: 37% Image courtesy of Veronica Lenge De Rosen, MD
CMR reveals LCX ischemia, no scar and as such, predicted significant functional improvement post-revascularization
3 months post CMR LVEDD: 166 cc, LVESV: 80 cc, EF: 52% Image courtesy of Veronica Lenge De Rosen, MD
Case of mistaken identity 63-year-old woman with coronary artery bypass grafting 3 years ago presented with continued fatigue and mild chest tightness Her resting electrocardiogram showed widespread deep T wave inversions. Coronary angiography revealed occluded grafts to the diagonal and circumflex arteries Left ventriculogram revealed the spade-like configuration of midapical cavity obliteration suggestive of apical hypertrophic cardiomyopathy
EKG and Cath
CMR
Case: Double trouble 57 year old Turkish immigrant presented about 1.5 years ago with progressive dyspnea and chest pain\ Hx of dyslipidemia and mild HTN, well controlled with beta-blockers Initial examination unremarkable, with no murmurs at rest, but a systolic murmur at LUSB with Valsalva EKG: Minimal LVH
Echocardiography
Cine CMR No significant LVH, abnormal bifid hypermobile papillary muscle
LGE Diagnosis: Non-hypertrophied variant of HCM Patient underwent mini-myectomy + papillary muscle reorientation No ICD
Case continued Recovered well post op and was back to baseline for about 1 year Recently (about 3 months ago) started c/o progressive dyspnea, weight gain, abdominal bloating Examination revealed hepatomegaly, ascites, elevated JVP and LE edema EKG: NSR Echo: non diagnostic. No recurrent LVOT gradient.
CMR
Cine CMR
Free breathing Cine CMR Diagnosis: Post op Constrictive pericarditis in the setting of HCM Did not recover and needed pericardial stripping
Inflammatory pericarditis
Case: If you got this, get ready for a rocky road ahead 64 year old male patient referred for progressive shortness of breath and LVH on outside echo PMHx of HTN, mild dyslipidemia, negative family Hx Exam: Basal rales, 1 + LE edema, elevated JVP EKG: NSR, low voltage Echo shows thick walls, LV systolic and diastolic dysfunction
Cine CMR
Delayed Hyper-enhancement High index of suspicion for cardiac amyloidosis EMB confirmed AL type cardiac amyloidosis
Conclusions CMR has invaluable role of imaging techniques in evaluation of patients with CHF and suspected cardiomyopathies More than likely, multimodality imaging useful in arriving at a specific diagnosis Echo still remains the initial test of choice Emerging role of Cardiac MRI and CT for a comprehensive diagnostic approach