Imaging Saves Lives: An Evidence-Based Choice of Modality Magnetic Resonance Imaging Oliver Bruder Department of Cardiology Elisabeth Hospital Essen Germany
Growth of CV Imaging Shaw; JACCi 2010
Novel Paradigm for CV Imaging Research Diagnostic Accuracy Clinical Utility Patient Outcomes Societal Outcomes Technical quality Reliability Reproducibility Sensitivity/ specificity Impact on MD decision making: i)diagnostic ii)therapeutic Impact on patient management Increase survival +quality of life Comparative Effectiveness of imaging-driven clinical pathways Cost effectiveness
Does the patient live longer or better due to the imaging procedure...? Shaw SCMR Phoemix 2010
Benefits / Risks of CV Imaging - Avoid Invasiveness
Benefits / Risks of CV Imaging - Avoid Radiation
CMR in Clinical Routine Evidence from routine CMR in 11,040 patients. EuroCMR registry an initiative of the ESC WG CMR Bruder; JACC 2009
Late Gadolinium Enhancement SPECT CMR Histology Wagner; Lancet 2003
LGE detects subendocardial infarction 50% 57% 77 % 100% Wagner; Lancet 2003
How does it work? Normal Acute Damage Scar Na Na Na Na Na K K Na Na Na Na Na K Na K K K K Na Na Na Na Na Na Na K K K Na Na Na Intact Cell Membran Ruptured Cell Membran Collagen Matrix Mahrholdt; EHJ 2005
Ischemic Wavefront: Subendocardial LGE in CAD! < 2 Hours 2-6 Hours > 6 Hours Reimer; Circulation 1977, Mahrholdt; EHJ 2005
CMR Infarct Transmurality Predicts Recovery of Function Kim; NEJM 2000
Viability, Intervention, and Prognosis Allman; JACC 2002
Suspected CAD Impact of Unrecognized SCAR LGE present n=44 195 patients with suspected CAD referred for CA, no hx of myocardial infarction, no infarct scar on ECG Kwong; Circ 2006
Perspective T2 Imaging Friedrich; JACC 2008
T2 CMR Myocardial Salvage in Retrospection Salvageable myocardium = T2 area - LGE infarct size (1 week following infarction) Carlsson; JACC Imaging 2009
CAD or DCM: Two Patients with New Onset Heart Failure Patient A (45 yr., male) Patient B (57 yr., male) Courtesy H. Mahrholdt Stuttgart
Two similar Patients Patient A Patient B Courtesy H. Mahrholdt Stuttgart
Two similar Patients Patient A Patient B Contrast CMR Courtesy H. Mahrholdt Stuttgart
Mid-wall LGE in DCM McCrohon; Circulation 2003
Mid-wall LGE in DCM Prognostic Significance Assomull; JACC 2006
Contrast CMR in HCM A B Roberts & Roberts Patient 2 Basso et al. Patient 5 Mahrholdt; EHJ 2005
LGE in HCM Prognostic Significance Bruder; JACC 2010
Contrast CMR in Amyloidosis NECROPSY HISTOLOGY CMR LAX CMR SAX Mahrholdt; EHJ 2005
Contrast CMR in Sarcoidosis NECROPSY CMR LAX CMR SAX Mahrholdt; EHJ 2005
Contrast CMR in Myocarditis EXVIVO Shirani et al. A B CMR Mahrholdt et al. Mahrholdt; EHJ 2005
Clinical Implication CMR Guides EMB Mahrholdt; Eur Heart J 2005, Mahrholdt; Circulation 2006
Contrast CMR Algorithm Mahrholdt; Eur Heart J 2005
CMR Stress Perfusion Stress perfusion RV contrast LV contrast Myocardium
65 female suspected CAD
Perfusion-Enhancement Algorithm for Suspected CAD LGE (1) infarct scar, CAD (2) exclusion (3) ischemia, CAD (4) exclusion, artefact (dark rim) CAD STRESS + REST - CAD Klem; JACC 2006, Mahrholdt; Heart 2007
CMR or SPECT - Suspected CAD MR-IMPACT: double blinded, randomized, multicenter, multivendor trial, 241 p undergoing cath. CMR perfusion superior to SPECT for multivessel disease. Schwitter; Eur Heart Journal 2008
SPECT: Prognostic Evidence from Large Patient Cohorts n = 5381 Hachamovitch; Circulation 1998
Stress CMR - Prognosis n = 513 MRP - Adenosine stress perfusion DSMR - Dobutamine stress CMR < 1% annual mortality rate with a normal stress CMR Jahnke; Circulation 2007
Impact of routine CMR on Patient Management Bruder; JACC 2009
Impact - Age Bruder; JACC 2009
Procedures NOT Performed Following CMR Bruder; JACC 2009
Summary CMR provides combined information on morphology, function, perfusion and non invasive tissue characterization CMR is superior to competing imaging modalities with many clinical indications CMR has a strong prognostic impact CMR guided therapy warrants further scientific evaluation
What we need! Megatrials with clinical questions meaningful to large parts of the population (suspected CAD, heart failure) Registries (EuroCMR registry) Comparative clinical effectiveness studies Comparing imaging-guided clinical pathways (ISCHEMIA trial)
EuroCMR Registry Goals Bruder; JACC 2009
www.eurocmr-registry.com
Imaging Saves Lives: An Evidence-Based Choice of Modality Magnetic Resonance Imaging