164 Value Added Cardiothoracic MRI in the ICU Patient · Value of non-CMRI imaging in ICU patients:...

Science at the heart of medicine

Value Added? Cardiothoracic MRI in the ICU Patient

Narmadan A Kumarasamy, Nima Tishbi, Shey MukundanJeffrey M Levsky, Linda B Haramati

STR Annual MeetingMarch 2016

Relevant Financial Disclosures

• None

| 1Science at the heart of medicine

The Issue

• Anecdotally, we have noticed an increasing number of requests for cardiothoracic MRI (cardiac MRI) in ICU patients

• However, this presents multiple problems:> Inherent risk to an unstable patient when leaving the ICU> Renal impairment precluding IV contrast> Lengthy exam time> Strain on departmental resources> Inability to tolerate a diagnostic exam> Unclear clinical benefit

• We sought to clarify if these MRIs added value to patient care


ACCF/AHA latest recommendations on clinical indications for cardiac MRI


2005 ACCF/AHA clinical indications for cardiac MRI

• Ischemic heart disease: regional and global function, perfusion, viability, and coronary angiography

• Non-ischemic cardiomyopathies> Hypertrophic, Iron Deposition, ARVD, Myocarditis

• Pericardial disease• Valvular disease• Congenital heart disease• Acquired vascular disease


Literature Review


• Number of studies evaluating the added value of cardiac MRI in the ICU patient: Zero

• Limited literature is not directly relevant (see references):> Studies looking at non-ICU patients and value from

cardiac MRI: Several> Studies looking at ICU patients and value from non-

cardiac MRI imaging (e.g. chest x-rays, chest sonography, echo, PET-CT, brain CT, brain MRI, HIDA, V/Q): Innumerable

Project Design

• Retrospective IRB approved study• Study Population: Adult ICU patients scheduled for cardiothoracic MRI 2005-2014

> Exclusion criteria: MRI was performed for research, clinical information missing• Data Collection: RIS Query

> Chart Review• Clinical indications

– Aorta– Myocardial Disease

» Cardiomyopathy/Heart Failure» Arrhythmia/ARVD» Myocarditis» Sarcoid» Pericardial

– Viability


Project Design: Did cardiac MRI ultimately help patient care?


• Chart Review: Pre-specific clinical utility categories:> 1) Useful – Led to Surgical or Invasive Intervention> 2) Useful – Led to Medical Therapy> 3) Not Useful – Did Not Guide Therapy

Results – 62 cardiac MRI cases formed the study population


• 143 cardiothoracic MRIs were requested for ICU patients 2005-2014> 74 cases completed (52%)> 69 cases cancelled (48%)

• Among the 74 completed cases, 12 excluded (16%)> 7 - research > 5 - missing clinical information

Results – Myocardial Disease was the most common clinical indication, followed closely by Aorta


* Other indication was a 21 year old woman with anti-NMDA encephalitis evaluating for malignancy/paraneoplastic syndrome

Clinical Indication Cases %Aorta 24 39%Myocardial Disease 25 40%

Arrhythmia/ARVD 9Cardiomyopathy/Heart Failure 6

Myocarditis 6Sarcoid 3

Pericardial 1Other* 1 2%Viability 12 19%Total 62

Results – Cardiac MRIs were useful in a majority of cases (55%)


# %Useful: led to surgical/invasive intervention 5 8%

Aorta 2 40%Myocardial Disease 3 60%

Useful: led to medical therapy 29 47%Aorta 12 41%

Myocardial Disease 14 48%Other 1 3%

Viability 2 7%Not Useful: did not seem to guide therapy 28 45%

Aorta 10 36%Myocardial Disease 8 29%

Viability 10 36%

• Clinical Utility

Results – Cardiac MRIs were useful for majority of the Myocardial Disease and Aorta cases


• Myocardial Disease and Aorta comprise majority of useful cases (91%)

• Not useful cases are relatively evenly split amongst the three major clinical indications,

suggestive of variability

Clinical Indication Useful %

NotUseful %

Aorta 14 41% 10 36%Myocardial 17 50% 8 29%Viability 2 6% 10 36%Other 1 3% 0 0%Total 34 28 14

17

2

1

10

8

10

0

0% 20% 40% 60% 80% 100%

Aorta

Myocardial Disease

Viability

Other

Useful Not Useful

Clinical Utility by Indication

• Among clinical indications, a majority of the myocardial disease (17/25, 68%) and aorta

(14/24, 58%) cases were useful• A minority of the viability cases were useful

(2/12, 17%)

Results – Arrhythmia/ARVD, Myocarditis clinical indications tended to be useful in Myocardial group


Myocardial DiseaseSubcategories Useful %

NotUseful %

Arrhythmia/ARVD 7 41% 2 25%Cardiomyopathy/Heart Failure 3 18% 3 38%Myocarditis 5 29% 1 13%Pericardial 1 6% 0 0%Sarcoid 1 6% 2 25%Total 17 8

• Useful vs not useful for Myocardial subcategories

Results – Value Added: Types of surgical/invasive procedures among the useful cases


Type of Procedure Cases %Aortic Aneurysm/Dissection Repair 2 40%ICD Implantation 2 40%Pericardectomy 1 20%Total 5

Results – Value Added: Clinical indications for medically useful cases


Cases %Non Surgical Aorta* 13 45%Other** 6 21%ARVD (confirmed) 1 3%ARVD (ruled out) 4 14%Myocarditis (ruled out) 2 7%Myocarditis (confirmed) 3 10%Total 29

* Non Surgical Aorta cases include: ruled out aortic dissection, diagnosed type B aortic dissection, non-surgical aortic aneurysm

** Examples of Other cases: confirmed viability, ruled out cardiac sarcoid, ruled out/diagnosed infiltrative cardiomyopathy

58-year-old man presented with back pain


Axial Pre- (left) and Post-contrast (right) MRI demonstrate a complex type A aortic dissection with arch involvement and peripheral thrombus. There is a moderate left pleural effusion.

Outcome: Operative repair of Type A Dissection

Case Example: Led to surgical intervention

39-year-old man with chronic eosinophilic pneumonia presented with chest pain and fevers Other Studies: Echo - diffuse LV hypokinesis with LVEF< 30%

Cath - clean coronaries; Endocardial biopsy - negative


Late gadolinium enhanced long (left) and short (right) axis images show multifocal left ventricular delayed enhancement in a non-vascular distribution

Outcome: Medical therapy (steroids) for eosinophilic myocarditis

Case Example: Led to medical therapy

54-year-old woman with ventricular tachycardia. Endocardial biopsy - giant cell myocarditis. MRI revealed extensive disease.


A: Axial postcontrast MR shows marked thinning of the intraventricular septum and bilateral pleural effusions B: Late gadolinium enhanced short axis image shows marked predominantly transmural delayed enhancement involving the septum and multiple myocardial segments Outcome: Medical therapy (steroids), listed for cardiac transplant.

A B

Case Example: Led to medical therapy

82-year-old man with known thoracic aortic aneurysm presented with back pain. Initial noncontrast chest CT performed.


Axial noncontrast CT shows an intimal flap in an aneurysmal ascending aorta consistent with Type A dissection

Axial pre- axial and coronal post-contrast MRI better delineates the ascending aorta aneurysm with Type A dissection and a partially thrombosed false lumen.

Deemed a poor operative candidate and expired

Case Example: Did not guide therapy

Discussion

• 52% of cardiac MRI cases from the ICU were completed, 48% were cancelled

• Myocardial disease was the most common clinical indication (40%), followed by Aorta (39%) and Viability (19%)


Discussion

• Cardiac MRI was useful in a majority of cases (55%)> 8% Led to surgical/invasive intervention> 47% Led to medical therapy

• When broken down among clinical indications:> Cardiac MRI was useful in a majority of Myocardial Disease

(68%) and Aorta cases (58%)• Among the Myocardial Disease cases, cardiac MRI was

more useful in the Arrhythmia/ARVD, Pericardial and Myocarditis sub-categories

> Cardiac MRI was useful in a minority of Viability cases (17%)


Discussion

• Examples of value added:> Led to a surgical/interventional procedure:

• OR for Aortic Aneurysm/Dissection Repair• ICD Implantation• Pericardectomy

> Led to medical therapy:• Type B Aortic Dissection• Medical Management of Aortic Aneurysm• Confirming or Ruling Out:

– ARVD– Myocarditis


Conclusion

• Over half of requested cardiothoracic MRIs in an ICU population were successfully completed

• Cardiothoracic MRI added value most often for Myocardial Disease and Aorta clinical indications

• Feasibility and potential clinical value should be assessed on a case-by-case basis


Thanks

• Ariel Shiloh, MD• Daniel Spevack, MD• Disraeli De Costa• Anna Santelia


References• Budoff MJ, Cohen MC, Garcia MJ, et al: ACCF/AHA clinical competence statement on cardiac imaging with computed tomography and magnetic resonance: A report of the american

college of cardiology Foundation/American heart Association/American college of physicians task force on clinical competence and training. J Am Coll Cardiol 46:383-402, 2005 • Kramer CM, Budoff MJ, Fayad ZA, et al: ACCF/AHA 2007 clinical competence statement on vascular imaging with computed tomography and magnetic resonance. A report of the

american college of cardiology Foundation/American heart Association/American college of physicians task force on clinical competence and training. J Am Coll Cardiol 50:1097-1114, 2007

Value of CMRI in non-ICU patients:• Abbasi SA, Ertel A, Shah RV, et al: Impact of cardiovascular magnetic resonance on management and clinical decision-making in heart failure patients. J Cardiovasc Magn Reson 15:89-

429X-15-89, 2013 • Arai AE: New insights from major prospective cohort studies with cardiovascular magnetic resonance (CMR). Curr Cardiol Rep 17:46-015-0599-3, 2015 • Bruder O, Wagner A, Lombardi M, et al: European cardiovascular magnetic resonance (EuroCMR) registry--multi national results from 57 centers in 15 countries. J Cardiovasc Magn

Reson 15:9-429X-15-9, 2013 • Campbell F, Thokala P, Uttley LC, et al: Systematic review and modelling of the cost-effectiveness of cardiac magnetic resonance imaging compared with current existing testing pathways

in ischaemic cardiomyopathy. Health Technol Assess 18:1-120, 2014 • Chellamuthu S, Smith AM, Thomas SM, et al: Is cardiac MRI an effective test for arrhythmogenic right ventricular cardiomyopathy diagnosis? World J Cardiol 6:675-681, 2014 • Hatabu H, Stock KW, Sher S, et al: Magnetic resonance imaging of the thorax. past, present, and future. Radiol Clin North Am 38:593-620, x, 2000• Rajwani A, Stewart MJ, Richardson JD, et al: The incremental impact of cardiac MRI on clinical decision-making. Br J Radiol 89:20150662, 2016 • Yilmaz A, Ferreira V, Klingel K, et al: Role of cardiovascular magnetic resonance imaging (CMR) in the diagnosis of acute and chronic myocarditis. Heart Fail Rev 18:747-760, 2013

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Author Contact Information

• Narmadan Kumarasamy• [email protected]


164 Value Added Cardiothoracic MRI in the ICU Patient · Value of non-CMRI imaging in ICU patients:...

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