Assessment of Ischemia and Viability - European Society of...
Transcript of Assessment of Ischemia and Viability - European Society of...
European Society of Cardiology copyright -All right reserved
1
EAE Teaching CourseBucharest, 2010
Assessment of Ischemia and Viability
Jens-Uwe VoigtDpt. of CardiologyUniversity Leuven
Belgium
JU Voigt, Leuven
resting wall motion
1 2 3 4normal hypokinetic akinetic dyskinetic
Assessment of Ischemia & Viability
Stress Testing needed !
European Society of Cardiology copyright -All right reserved
2
JU Voigt, Leuven
Stress Testing in CAD
Ischemia
JU Voigt, Leuven
exercise test (bicycle, treadmill)
target HR = (220-age) *0.85
rest exercise max rec.
50W
100W
150W
200W
Stress Echocardiography
European Society of Cardiology copyright -All right reserved
3
JU Voigt, Leuven
Stress Echocardiography
dobutamine protocol
viability ischemia
rest dobutamine +atropin rec.
10µ
20µ
30µ
40µ
0,5mg
JU Voigt, Leuven
Stress Echocardiography
dipyridamol / adenosine protocol
rest dipyridamol / adenosine atropin rec.
dipyridamol 0,84 mg/kgadenosin 140 µg/kg
up to1mg
European Society of Cardiology copyright -All right reserved
4
JU Voigt, Leuven
sensitivity / specificity for CAD (stenosis > 50%)
0
20
40
60
80
100Exerc. Dobu Dipy
Fleischmann, JAMA 1998
sensitivity
specificity
Comparison of Protocols
JU Voigt, Leuven
Stress Echocardiography
European Society of Cardiology copyright -All right reserved
5
JU Voigt, Leuven
Stress Echocardiography
baseline stress
normal
ischemic
non-transm. scar
scar
Afridi et al., Circ 1995
regional wall motion
JU Voigt, Leuven
0
20
40
60
80
100
120
center 1 center 2 center 3 center 4 center 5Hoffmann et al., JACC 1996
interinstituional agreement in
stress echo readings(n=150 pts., 5 centers)
negative
positive
Stress Echo Reading
the human factor
European Society of Cardiology copyright -All right reserved
6
JU Voigt, Leuven
0102030405060708090
100
cent. 1 cent. 2 cent. 3 cent. 4 cent. 5 cent. 6
Hoffmann et al., EHJ 2002
negative
positive
the human factor + modern technology ...
interinstituional agreement in
stress echo readings(n=150 pts., 6 centers)
Stress Echo Reading
JU Voigt, Leuven
Regional Ischemic Response
experimental coronary occlusion
Jamal, J Am Soc Echo 2001
European Society of Cardiology copyright -All right reserved
7
JU Voigt, Leuven
baseline 5s ischemia 10s ischemia 20s ischemia
rad.
stra
in [%
]po
st. w
all
Regional Ischemic Response
Jamal, J Am Soc Echo 2001
JU Voigt, Leuven
strainischemicsegment
strainnon-ischemic
segment
rest stress
0
-10
-20
0
-10
-20
0
-10
-20
0
-10
-20
AVC MVO AVC MVO
totalstrain
PSS
Strain Rate Imaging in Stress Echo
ECG
AVC MVO AVC MVO
Voigt et al., Circulation 2003
European Society of Cardiology copyright -All right reserved
8
JU Voigt, Leuven
0
0,2
0,4
0,6
0,8
1
0 0,2 0,4 0,6 0,8 11-specificity
sens
itivi
ty
parameter AUC
PSS 0.90
systolicstrain rate 0.74
systolicstrain 0.65
ROC - Analysis
Quantitative Criteria
Voigt et al., Circulation 2003
JU Voigt, Leuven
Case: Dobutamine Stress Echo, 4CV
European Society of Cardiology copyright -All right reserved
9
JU Voigt, Leuven
Case: Quantitative Assessment
baseline peak stress
JU Voigt, Leuven
sensitivity
specificity
with and without considering SRI
Strain Rate im Stress Echo
47
7381 86
59 59
8289
0
30
60
90
ohne mit ohne mit
[%]
novice expert
Voigt, Circulation 2003
accuracy improvement depends on experience
European Society of Cardiology copyright -All right reserved
10
JU Voigt, Leuven
dobutamine stress, 646 pts., 7 ys. follow up
Björk-Ingul, Circulation 2007
Strain Rate Stress Echo for Prognosis
mSRs -
mSRs +cutoff: -2.0 s-1
p < 0.001
survival
0
10
20
30
40
clinical clin. + WMSI clin + WMSI +mSRs
χ²
p<0.001
p<0.001predictive value
JU Voigt, Leuven
Stress Testing in CAD
Viability
European Society of Cardiology copyright -All right reserved
11
JU Voigt, Leuven
CASS - Study
5 year survival rate:
med. OPEF<35% 54% 68% **EF<26% 43% 63% **
CASS: Alderman et. al.,Circ 1983
Concept of “Viability”
JU Voigt, Leuven
reperfusion therapy
relieves symptomsimproves LV functionimproves prognosis
dysfunction≠ irreversible myocardial damage !
“viable myocardium”
Concept of “Viability”
European Society of Cardiology copyright -All right reserved
12
JU Voigt, Leuven
Concept of “Viability”
stunning: contractile dysfunction after short ischaemia despite restored perfusionHeyndrickx et al., J Clin Invest 1975(to render sb. senseless or dizzy)
restitutio ad integrum
JU Voigt, Leuven
stunning: contractile dysfunction after short ischaemia despite restored perfusionHeyndrickx et al., J Clin Invest 1975(to render sb. senseless or dizzy)
restitutio ad integrum
hibernation: reduced contractile function withproportionally reduced perfusionDiamond et al., Am Heart J 1978(to lethargically pass the winter)
restitutio ad integrum ?
Concept of “Viability”
European Society of Cardiology copyright -All right reserved
13
JU Voigt, Leuven
Decision to Revascularize
CABG in pat. with LV dysfunction
Haas et al., JACC 1997
with proof of viability
clinicaldecision only
months post OP
prob
abili
ty o
f sur
viva
l
n = 76 pat.EF ca. 30%
JU Voigt, Leuven
CABG without proof of viability
more adverse events due toperioperative mortality (11-15% !)
worse prognosis than with med. therapy
(Haas et al., JACC 1997)(Anselmi et al., Am J Cardiol 1998)(Pasquet et al., Circ 1999)(Senior et al., J Am Coll Cardiol 1999)
Decision to Revascularize
European Society of Cardiology copyright -All right reserved
14
JU Voigt, Leuven
scintigraphy: SPECT, PETperfusion / metabolism mismatch
echocardiography: dobutamine stressinotropic stimulation
MRI: dobutamine stressinotropic stimulation
contrast MRIdelayed enhancement
How to Test for Viability ?
JU Voigt, Leuven
Stress Echocardiography
dobutamine protocol
viability ischaemia
BL dobutamine +atropine Rec
10µ
20µ
30µ
40µ
2mg
European Society of Cardiology copyright -All right reserved
15
JU Voigt, Leuven
Stress Echocardiography
baseline low dose high dosedobutamine
normal
ischemic
viable
viable+ischemic
scar
Afridi et al., Circ 1995
regional wall motion
JU Voigt, Leuven
Case: Low Dose Dobutamine
biphasic response
baseline lowdose peak
European Society of Cardiology copyright -All right reserved
16
JU Voigt, Leuven
echocardiography
scintigraphy
meta-analysisdata from
studies with direct comparison
of methods
11 studies
325 patients
Bax et al., Curr Probl Cardiol 2001
DSE vs. Scintigraphy
JU Voigt, Leuven
“delayed enhancement” vs. histology
Viability in MRT
% area histology
% a
rea
late
enh
ance
men
t
Kim, Circulation 1999
European Society of Cardiology copyright -All right reserved
17
JU Voigt, Leuven Kaandorp et al., Am J Cardiol 2004
contractile reserve vs. transmurality of scar
n= 48 patients
late enhancement vs.dobutamin - MRT
w/o
w
transmurality of scar0% 1-25% 26-50% 51-75% >75%
% s
egm
ents
contractile reserve
Viable Rimb
JU Voigt, Leuven
Which Test for Viability ?
ESC Study Group Report
modality Scinti Echo MRI (stress) MRI (contrast)indication class 1 1 1 1
Underwood et al., Eur Heart J 2004
European Society of Cardiology copyright -All right reserved
18
JU Voigt, Leuven
Case
M.Pf., m, 67 yerasdecompensated HF, NYHA III-IV
Hx silent posterior infarctionHx PTA of A. femoralisrisik faktors: hypertension
diabetes mellitus IIhyperlipidaemiaex smoker
EF ca. 25%LAD occluded, CX and RCA stenotic
JU Voigt, Leuven
Case: Multimodality Approach
European Society of Cardiology copyright -All right reserved
19
JU Voigt, Leuven
transmuralinfarction
dobu 2.5 dobu 5 dobu 10
AVC AVC AVC AVC
hibernatingmyocardium
AVC
baseline dobu 20
radial strain during low dose dobutamineafter non-transmural / transmural infarction
Weidemann et al., Circulation 2003
Strain for Viability Testing ?
JU Voigt, Leuven
layer specific assessment
Rösner et al., JASE 2010
Strain for Viability Testing ?
European Society of Cardiology copyright -All right reserved
20
JU Voigt, Leuven
EAE Consensus Statement
Sicari et al., EHJ 2008