22. raman Raman debate Pro...Fibrosis Is Substrate for HF, Arrhythmias GulatiAet al. JAMA 2013....
Transcript of 22. raman Raman debate Pro...Fibrosis Is Substrate for HF, Arrhythmias GulatiAet al. JAMA 2013....
Dis clos ure s
Re s e a rch s upport from S ie me ns
Off-la be l us e of ga dolinium-ba s e d contra s t
Etiologies tha t you may be certa in of a fte r his tory,exam, bas ic labs :
• Ane mia
• Me ta bolic dis orde rs
• Toxins
• Etc.
Why is Ca rdia c MRI He lpful?
Tis s ue cha ra cte riza tion
Tis s ue cha ra cte riza tion
Tis s ue cha ra cte riza tion
P re cis ion in qua ntifying function, flow
Myoca rd itisCa rd ia c
Am yloidos isNon-is che m ic
Ca rd iom yopa thyIn fa rc t S ca r
S igna ture s of Myoca rdia l Dis e a s e :Late Gadolinium Enhancement (LGE) CMR
Circ 2003.
Angiogra m or LGE-CMR for HF Etiology?
90 HF pa tie nts cla s s ified by a ngiogra m a s :
ICM if ≥50% stenos is
DCM/NICM if no coronary s tenos is
100% of pa tie nts with ICM ha d infa rct s ca r
DCM pa tie nts ha d 1 of 3 pa tte rns :
LGE-nega tive (59%)
Midwall enhancement (28%)
Infarc t s car (13%)
LGE: P rognos tic Va lue Acros s Etiologie s
JACC 2012.
MYOCARDITIS
Su
rviv
al
LGE-neg
LGE-pos
JAMA 2012.
Unknown MI
Known MI
No MI
Mo
rta
lity
INFARCT SCAR
0 1 2 3 4 5 6 y
fre
ed
om
fro
mS
CD
Adjus ted HR 1.46@10% in LGE
Circ 2014.
LGE neg
≤ 10%
≤ 15%
≥ 20%
HCM
SARCOIDOSIS
Circ 2009.
Fibros is Is S ubs tra te for HF, Arrhythmia s
Gulati A et a l. JAMA 2013.
Recent meta -ana lys is of 19 s tudies , >2800 pa tients , 24% with events :
OR for a rrhythmic events if LGE+ 4.5 [3.2 - 6.3] for EF >30%
Nega tive like lihood ra tio 0.13 [0.06 – 0.30]
Disertori M et a l. JACC Im 2016.
T1 Mapping & Myocardia l Extrace llula r Volume (ECV)
Diffus e fibros is e xpa nds the e xtra ce llula r s pa ce
P re - a nd pos t-contra s t T1 ma ps ECV:
myo blood)
LGE ‘nega tive’ T1 maps abnormal
Edwards e t a l. Orphanet J Rare Dis 2015. Kammerlande r e t a l. JACC Im 2015.
r = 0.493, p = 0.002
“Na tive ” (Noncontra s t) Myoca rdia l T1
T1
(ms
)
Fa b ry HTN HCM AS AL Am ylo id
Sa do e t a l. Circ Im 2013.
Moon J , EHJ 2015
P rognos tic Va lue of ECVPatients referred for CMR
Wong T, Schelbert E, Circula tion 2012
Amylo id pa tien ts
Diabe tic pa tients
Wong T, Schelbert E, EHJ 2014
• NICM
• Va lvula r dis e a s e
• HFpEF
Afib Recurrence Pos t PVI
Neilan, Kwong, JACCImaging, 2014
Courtesy Karolina Zareba , MD
Infla mma tory Myoca rdia l Dis e a s e
Thavendira nathan P e t a l. Circ Im 2012.
More Extens ive T2 vs . LGE in myocarditis
Crouser ED et a l. AJRCCM 2013.
Sarcoidos is : Arrhythmia Subs tra te , Biomarker of Tx Response
6 m s
5.1 m g Fe/ g
3 m s
8.6 m g Fe/ g
n o rm a l T2*:
>20 m s
T2*-CMR in the right patient:57 y/o F with myelodysplas ia & new-onse t HF
Outline
Tis s ue cha ra cte riza tion
Tis s ue cha ra cte riza tion
Tis s ue cha ra cte riza tion
P re cis ion in qua ntifying function, flow
Cine CMR: LV, RV size & function
Breath-hold, ECG-gated
Real-time, free-breathing, no gating
Grothues F et a l.Am J Cardiol2002.
0
10
20
30
40
50
60
CMR1 CMR2 CMR3
Tim e
LV
ES
VI
0
10
20
30
40
50
60
Meas 1 Meas 2 Meas 3
Tim e
LV
ES
VI
Does Precis ion Matter Clinically?
LV
ES
VI
Cine CMR: Gold S ta nda rd for Qua ntifica tion
Cardiomyopa thy Due to Mitra l Regurgita tion
r=0.85p<.0001
r=0.32p=.1
Uretsky S et a l. JACC 2015.
Cines(whole heart)
Flow Quantifica tion(ascending aorta )
LV S S V
MR re gurgita nt volume
mild: <30 mL
mode ra te : 30-60 mL
s e ve re : ≥60 mL
Why Wouldn’t You Want to Know What You’reDealing With?
The pa tie nt doe s n ’t wa nt to know (why? )
Ris k of finding out > be ne fits of knowing
Ke e p in mind:
What you don ’t know in HF can hurt you
Assumptions may be incorrect
“MRI is S o Expe ns ive ”
Zip code
Insured or Uninsured
CPT code
http://www.fa irhea lthconsumer.org/medica lcos tlookup
Test CPT Code Charge Reimbursement
MPI-SPECT, rest &stress
78452 428 300
Transthoracicechocardiogram
93306 955 668
CardiacMRI withcontrast
75561 1078 755
Invasive coronaryangiogram
93454 3748 2623
Zip code 90210
Not knowing what you’re t r eat ing isn’t cheap
“MRI Is a Difficult Te s t for HF P a tie nts ”
Ha rd wa re
Larger, shorte r bore (eas ie r)
Para lle l imaging (fas te r)
Low fie ld (lower cos t)
S o ftwa re
Rea l-time (no brea thholding)
S ingle hea rtbea t scans (no ga ting)
Noncontras t MRA (less risk)
0.35 Tes la (Courtesy O. S imonetti, PhD)
Conclus ions
Mos t pa tie nts with HF of unce rta in e tiology s houldha ve ca rdia c MRI
If you know what you ’re trea ting (and trea tment ise ffective ), grea t!
If you don ’t (or it’s not), CMR
Ma na ge me nt informe d by tis s ue cha ra cte ris ticsne e ds to ca tch up