CMR in Ischemic Heart Disease · 2019. 7. 25. · 7/25/2019 1 CMR in Ischemic Heart Disease...
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7/25/2019 1 CMR in Ischemic Heart Disease Wojciech Mazur MD FACC Director, Advanced Cardiac Imaging Professor of Clinical Medicine and Pediatrics Reffelmann T, Kloner R A Heart 2002;87:164[2 ] CMR in Acute Myocardial Infarction Higgins CB, DeRoos A (eds) Cardiovascular MRI&MRA, Philadelphia: Lippincott, Williams, & Wilkins, 2003, p 224,
Transcript of CMR in Ischemic Heart Disease · 2019. 7. 25. · 7/25/2019 1 CMR in Ischemic Heart Disease...
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CMR in Ischemic Heart Disease
Wojciech Mazur MD FACC
Director, Advanced Cardiac Imaging
Professor of Clinical Medicine and Pediatrics
Reffelmann T, Kloner R A Heart 2002;87:164[2]
CMR in Acute Myocardial Infarction
Higgins CB, DeRoos A (eds) Cardiovascular MRI&MRA, Philadelphia: Lippincott, Williams, & Wilkins, 2003, p 224,
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Schematic depicting the multiple mechanisms that contribute to the no-reflow phenomenon at the ultrastructural level
Reffelmann T, Kloner R A Heart 2002;87:164
Chapter: Acute ischaemic heart disease
Author(s): Holger Thiele, Nuno Bettencourt, Michael Salerno, and Erica Dall’ArmellinaFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Basic Cardiac MRI Protocol for AMI Imaging
Multisequence Imaging of Microvascular Obstruction (MO) imaging:
Mather et al. J Cardiovasc Magn Reson 2009;11(1):11–33
First PassEGE LGE T2-STIR
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Time course of MO post-infarction
The presence and persistence of MO can predict how well the LV remodels in the subsequent year !
Ørn S et al. Eur Heart J 2009;30:1978–1985
T2* imaging to improve the differentiation between MO with and without
hemorrhage
O’Regan DP et al. Heart 2010; 96:1885-1891
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Persistent Iron Within the Infarct Core After ST-Segment Elevation Myocardial Infarction
Jaclyn Carberry et al. JIMG 2018;11:1248-1256
Jaclyn Carberry et al. JIMG 2018;11:1248-1256
2018 The Authors
Persistent Iron Within the Infarct Core After ST-Segment Elevation Myocardial Infarctionpredicts LV remodeling , death and heart failure hospitalization
All cause death orHF, HR 3.9
MACEHR 3.3
Smoker
Non Smoker
Current Smoking and infarct morphology
6 m: infarct size: 31.2%LVEDVi 84.8ml/m2
6 m: infarct size: 15.2%LVEDVi 78.4/m2
T2*
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Haig C at al Volume 12, Issue 6, June 2019, Pages 993-1003
Nordlund at al, Circulation: Cardiovascular Imaging. 2016;9
Cardiovascular magnetic resonance images of myocardium at risk (MaR) and infarct
Salvage = MaR-LGE
Ibrahim at al, Radiology, Dec 19, 2009, Vol 254, No 1
Time line of post MI LGE regression
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.
Author(s): Holger Thiele, Nuno Bettencourt, Michael Salerno, and Erica Dall’ArmellinaFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
MI Complications
LV Pseudoaneurysm RV Infarct Papillary Muscle Infarct
MI Complications : LV thrombus
Chapter: Acute ischaemic heart diseaseAuthor(s): Holger Thiele, Nuno Bettencourt, Michael Salerno, and Erica Dall’ArmellinaFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Downloaded from Oxford Medicine Online. © European Society of Cardiology 2018
Use long inversion time T! 450-550 ms for thrombus imaging
Dark Blood LGE in subendocardial LGE
Hansen at al Journal of Cardiovascular Magnetic Resonance201618:77
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Holger Thiele, Nuno Bettencourt, Michael Salerno, and Erica Dall’ArmellinaFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Mapping techniques in acute myocardial infarction
T2 STIR T1 T2 LGE
Prognostic parameters assessed by CMR in acute myocardial infarction.
Holger Thiele, Nuno Bettencourt, Michael Salerno, and Erica Dall’ArmellinaFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Diagnostic algorithm in patients with myocardial infarction with no obstructive coronary atherosclerosis (MINOCA).
Holger Thiele, Nuno Bettencourt, Michael Salerno, and Erica Dall’ArmellinaFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
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Relation between coronary artery stenosis severity and perfusion reserve.
Chapter: Chronic ischaemic heart disease
Author(s): Bernhard L Gerber, Mouaz H Al-Mallah, Joao AC Lima, and Mohammad R OstovanehFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Stress CMR modalities.
Author(s): Bernhard L Gerber, Mouaz H Al-Mallah, Joao AC Lima, and Mohammad R OstovanehFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Perfusion stress protocol.
Bernhard L Gerber, Mouaz H Al-Mallah, Joao AC Lima, and Mohammad R OstovanehFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
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Perfusion stress interpretation.
Bernhard L Gerber, Mouaz H Al-Mallah, Joao AC Lima, and Mohammad R OstovanehFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
The prefusion deficit is1. Clearly visible, lasting ≥ 3 phases ( ≥ 3 heartbeats and
≥ 6 heartbeats, respectively, in 1-2 RR acquisitions)2. Extends to ≥ 50% of wall thickness3. Encompasses ≥ 50% of segment4. Matches a coronary artery territory, except CABG patients5. Resides within viable tissue (LGE negative tissue)
Perfusion stress test: multivessel CAD
Perfusion stress test and “splenic switch off “phenomenon to assess adequacy of vasodilatation
“splenic switch off “phenomenon exists with only with adenosine and not with regadeneson!!!
Cardiovasc Imaging Asia. 2018 Apr;2(2):65-75.
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Victory at last! CMT perfusion versus invasive FFR: MR-INFORM Trial
Revascularization ratesCMR: 35.7%FFR: 45.0%
Nagel E at al N Engl J Med 2019; 380:2418-2428, June 20, 2019
Dobutamine stress protocol
Author(s): Bernhard L Gerber, Mouaz H Al-Mallah, Joao AC Lima, and Mohammad R OstovanehFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Interpretation of dobutamine response (ischemia protocol and viability protocol).
Chapter: Chronic ischaemic heart diseaseAuthor(s): Bernhard L Gerber, Mouaz H Al-Mallah, Joao AC Lima, and Mohammad R OstovanehFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Downloaded from Oxford Medicine Online. © European Society of Cardiology 2018
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Diagnostic Performance of Treadmill Exercise Cardiac Magnetic Resonance: The Prospective, Multicenter Exercise
CMR's Accuracy for Cardiovascular Stress Testing (EXACT) Trial, Volume: 5, Issue: 8, DOI:
(10.1161/JAHA.116.003811)
Ex CMR vs AngiographySensitivity: 79%, Specificity: 99%
PPV of 92% and NPV: 96%.
Agreement between treadmill stress CMR and angiography was strong (κ=0.82), and moderate between SPECT and
angiography (κ=0.46) and CMR versus SPECT (κ=0.48).
Exercise CMR stress test
Chronic infarct imaging and viability
WAGNER, AT AL LANCET, VOLUME 361, ISSUE 9355, P374-379, FEBRUARY 01, 2003
PATIENT DATA181 segments with subendocardial infarction, 85 (47%) were not detected by SPECT. On a per patient basis, six (13%) individuals with subendocardial infarcts visible by CMR had no evidence of infarction by SPECT.
Probability of recovery of dysfunction according to preoperative transmurality of LGE.
Kim, et al. The Use of Contrast-Enhanced Magnetic Resonance Imaging to Identify Reversible Myocardial Dysfunction. NEJM 2000; 343(20):1445–53.
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Reporting Viability
Quantification of myocardial late gadolinium enhancement using different techniques for late enhancement delineation
Manual Standard Deviations full-width at half maximum
There was no statistically significant difference between LGE volume by the FWHM, manual, and 6-SD or 5-SD techniquesThe FWHM technique was the most reproducible.Conditions evaluated AMI, CMI, HCMFlett at al JACC, CVIVolume 4, Issue 2, February 2011, Pages 150-156
Author(s): Holger Thiele, Nuno Bettencourt, Michael Salerno, and Erica Dall’ArmellinaFrom: The EACVI Textbook of Cardiovascular Magnetic Resonance
Infarct size and mortality based on quartiles of infarct size
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Scar Burden and risk of VT in ischemic CMP
J Am Coll Cardiol. 2012 Jul 31;60(5):408-20
Yan AT, Circulation. 2006 Jul 4;114(1):32-9. Epub 2006 Jun 26
Beyond the scar: The Gray Zone ( of Death)
Infarct Core, red > 3 SDGray Zone, yellow 2-3 SD
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Infarct Tissue Heterogeneity Assessed With Contrast-Enhanced MRI Predicts Spontaneous Ventricular Arrhythmia in Patients With Ischemic Cardiomyopathy and Implantable
Cardioverter-Defibrillator, Volume: 2, Issue: 3, Pages: 183-190, DOI: (10.1161/CIRCIMAGING.108.826529)
Characterization of the Peri-Infarct (Gray) Zone by Contrast-Enhanced Cardiac Magnetic Resonance Imaging Is a Powerful Predictor of Post–Myocardial Infarction Mortality and ICD Therapies
Dead Meat Don’t Beat: Six-month response rate to cardiac resynchronization therapy (CRT) in ischemic CMP based on pacing region of the left ventricle (LV) or right ventricle (RV)
Bobak Heydari et al. JIMG 2012;5:93-110
Non responder> 50% TM
Responder< 50% TM
Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance.
Levya at al, J Cardiovasc Magn Reson. 2011; 13(1): 29
Pacing scarred (posterolateral) myocardium was associated with
the worst outcome, in terms of both pump failure and sudden
cardiac death!
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Still in doubt what is the best imaging technique in ischemic heart disease?
OR
From DAIC, April 12, 2019 : First Image of a Black Hole Shows Signs of Myocardial Ischemia
Black hole at the center of Messier 87, a massive galaxy in the nearby Virgo galaxy cluster. Distance form detector: 55 million light years
Heart at the center of a patient, Bob 87, not that massive, Distance form detector : 55 cm
Only test with comparable diagnostic accuracy to CMR….
