Perfusion myocardique en IRM · Manisty et al. Splenic Switch-off: A Tool to Assess Stress Adequacy...
Transcript of Perfusion myocardique en IRM · Manisty et al. Splenic Switch-off: A Tool to Assess Stress Adequacy...
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Perfusion myocardique en IRMcorrélations avec la FFR
Alain Nchimi MD, PhD
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6.7 ml/’/100g
10.3 ml/’/100g
25/07/2018
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Myocarde normal IM Aigu
[Gd] = Faible
Membranes Intactes
[Gd] = élevée
Rupture de membranes
[Gd] = élevée
Matrice Collagène
K K
KK
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KKK
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Na
Na Na
Gd
Gdd
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NaNa
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GdGd
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Gd
GdGd
GdGd Gd
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GdNa
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Cicatrice
Principe du rehaussement tardif: [Gd] élevé = T1raccourci
Kim RJ, Choi KM, Judd RM. In Cardiovascular MRI and MRA, Higgins and DeRoos editors
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Myo-péricardite SarcoïdoseInfarctus chronique
HCM DCM
% rehaussement tardif% of récupération fonctionnelle
0 78
1-25 67
26-50 56
51-75 35
> 75 5
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Quantification
TTP
AUC
Slope
FWHM
Slope
Peak
LV (AIF)
Myocardium
Peak
Impulse response
(Eg: Fermi function)
LV and myocardial TIC parameters
Myocardium
=
(Convolved)
AIF
MBF
Tissue input is a function of the arterial input:
i(x) = Ø A i(x)25/07/2018 5
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Autres méthodes Marquage de spins/Relaxométries
Kober F et al. Myocardial arterial spin labeling. J Cardiovasc Magn Reson. 2016 Apr 12;18:22.
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Autres méthodes Marquage de spins/Relaxométries
Liu A et al.. Adenosine Stress and Rest T1 Mapping Can Differentiate Between Ischemic, Infarcted, Remote, and Normal Myocardium Without the Need for Gadolinium Contrast Agents. JACC Cardiovasc Imaging. 2016 Jan;9(1):27-36.
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Performance diagnostique
Nandalur et al, JACC 2007; Études 1990 -2007 :
IRM perfusion stress pour coronaropathie (50% sténose diamétre) &
Coronarographie = standard de référence
24 études (1,516 patients)
Sens 0.91 (95% IC 0.88 à 0.94)
Spec of 0.81 (95% IC 0.77 à 0.85) par patient
Prévalence 57.4%
Perfusion IRM > SPECT
Greenwood et al. CE-MARC study. Lancet 2012.
Schwitter et al. MR-IMPACT II study. Eur Heart J 2013
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Pièges diagnostiques
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Pièges diagnostiques
Nchimi et al. Myocardial dynamic contrast-enhanced MR: vascular diseases and beyond. JBR-BTR 2014
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Pièges diagnostiques
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Pièges diagnostiques
Manisty et al. Splenic Switch-off: A Tool to Assess Stress Adequacy in Adenosine Perfusion Cardiac MR Imaging. Radiology 2015 12
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Vasodilatateurs en physiologie cardiaque
• Dipyridamole (Gould 1978)
• Papavérine (Wilson 1986)
• Adénosine (Wilson 1990)
• ATP (De Bruyne 2003)
• Nitroprusside (Kern 2004)
• Nicorandil (Kang 2006)
• Regadenoson (Nair 2011)
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Pièges diagnostiques
– Artéfacts
– Maladie poly-vasculaire
– Ischémie, infarctus sous-jacent
– Stress inapproprié
– Standard de référence
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Performance diagnostique
• 5-10% FN/FP vs coronarographie
• Étude Dan-NICAD
– Sens 41% [28-54]
– Spec 84% [75-91]
– VPP 62% [45-78]
– VPN 68% [58-76]
• Coronaro >90% diamètre ou FFR <0.80)
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Corrélations FFR-IRM
• Rieber J et al. Eur Heart J 2006 • Kuhl HP et al. Am J Cardiol 2007 • Chiribiri A et al. , JACC cardiovasc
Imaging 2013 • Kirschbaum SW et al. Int J Cardiol 2011 • Lockie T et al. JACC 2011Corrélations modérées-bonnes (valeurs r
0.4-0.7)• Pathologie microcirculatoire?• Collatérales?
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(In)Déterminants FFR
• Sévérité de la sténose
• Étendue du territoire irrigué
• Collatérales
• Pathologie microvasculaire
• Maladie diffuse
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Hypothèse
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Tester IRM de perfusion relative!
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Eligible patients with intermediate-grade stenoses on coronary CTA and adenosine perfusion CMR from Hospital databases (n=81 patients)
Quantitative coronary angiography (n=76 patients)
Patients excluded (n=5)
➢transmural myocardial infarct
Patients excluded with previous stenting, motion artefacts or misregistration on coronary CT (n=9)
Invasive FFR measurement (n=46 patients)
Patients excluded (n= 30)
➢< 40% diameter stenosis (n=12)➢> 70% diameter stenosis (n=12)
➢More than one intermediate-grade stenosis on the same vessel (n=3)➢Stenosis >70% on a different artery (n=3)
FFRCT, adenosine stress CMR and invasive FFR
(n=37 patients; 39 intermediate-grade stenoses)25/07/2018 19
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Analyse IRM
• Segment/segment
• Pente endocardique au-delà de la sténose & dans une zone saine– Pente normalisée au stress
– Rapport à la zone saine (relative)
– Rapport au repos (réserve)
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IRM vs FFR
Az = 0.69
Az = 0.67
Az = 0.88
Ghekiere et al. Value of relative myocardial perfusion on cardiac magnetic resonance for fractional flow reserve-defined ischemia. A pilot study. Soumis EHJcv
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Coronary artery
stenosis (n= 49)TP TN FP FN Sensitivity Specificity PPV NPV LR+ LR- Accuracy
Stress upslope 22 11 4 12(22/34)
65% [63-67]
(11/15)
73% [69-77]
(22/26)
85% [82-86]
(11/23)
48% [45-51]
2.43
[2.36-2.50]
0.48
[0.47-0.49]
(33/49)
67% [66-
69]
Perfusion reserve 17 12 3 17(17/34)
50% [48-52]
(12/15)
80% [75-83]
(17/20)
85% [81-87]
(12/29)
41% [39-44]
2.50
[2.42-2.59]
0.62
[0.62-0.63]
(29/49)
59% [58-
61]
Relative perfusion 31 12 3 3(31/34)
91% [89-92]
(12/15)
80% [75-83]
(31/34)
91% [89-92]
(12/15)
80% [73-83]
4.56
[4.41-4.71]
0.11
[0.11-0.11]
(43/49)
88% [86-
89]
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Eligible patients with intermediate-grade stenoses on coronary CTA and adenosine perfusion CMR from Hospital databases (n=81 patients)
Quantitative coronary angiography (n=76 patients)
Patients excluded (n=5)
➢transmural myocardial infarct
Patients excluded with previous stenting, motion artefacts or misregistration on coronary CT (n=9)
Invasive FFR measurement (n=46 patients)
Patients excluded (n= 30)
➢< 40% diameter stenosis (n=12)➢> 70% diameter stenosis (n=12)
➢More than one intermediate-grade stenosis on the same vessel (n=3)➢Stenosis >70% on a different artery (n=3)
FFRCT, adenosine stress CMR and invasive FFR
(n=37 patients; 39 intermediate-grade stenoses)25/07/2018 23
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FFRct vs IRM vs IRMrel
Ghekiere et al. FFRCT and stress perfusion CMR are equally reliable alternatives to invasive FFR measurement in functional significance of intermediate-grade coronary artery stenosis. Soumis Eur Radiol.
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r = 0.67 r = 0.15 r = -0.63
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Discussion
FFR Standard de référence
• iFR (Instantaneous wave free ratio)
• Valeur seuil débattue (0.80-075, zone grise)
• Le seuil idéal serait plus bas encore
• L’indice de perfusion relative en IRM est la meilleure alternative non invasive
IRM standard de référence
• Hussain ST et al. Design and rationale of the MR-INFORM study: stress perfusion CMR to guide the management of patients with stable coronary artery disease
• (IRM>FFR)
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Johnson NP et al. Prognostic value of fractional flow reserve: linking physiologic severity to clinical outcomes. JACC 2014;64(16):1641-54
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Conclusion
• ! différences conceptuelles entre les techniques de mesure et les indices de perfusion myocardique
• L’IRM/stress offre une mesure globale des l’atteinte épicardique et microcirculatoire– Perfusion relative proche de la FFR
– Perfusion « absolue » différente de la FFR, mais valeur clinique à déterminer
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25/07/2018 ESCR 2018, Geneva 27