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Nick Curzen Nick Curzen PhD FRCP FESCPhD FRCP FESC

Wessex Cardiac UnitWessex Cardiac Unit

Why I use MRI in my clinical practiceWhy I use MRI in my clinical practiceWhy I use MRI in my clinical practiceWhy I use MRI in my clinical practice

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Acknowledgements

Dr Charles Peebles

Dr Steve HardenDr Nick Bellenger

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Anatomy

Function

Wall motion Flow quantification

PerfusionViability

PeripheralangiographyCentral

angiography

CoronariesCardiovascular MRICardiovascular MRI

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MRI for Interventional Cardiology: WHY?MRI for Interventional Cardiology: WHY?

LV functionStress induced WM …. Ischaemia & ViabilityExtent of Infarct….. Gadolinium hyperenhancementCoronary Course/ plaquePerfusion

Rest/stress

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Clinically valuable techniques for the interventionist…Clinically valuable techniques for the interventionist…(Or MRI stuff that I Love!)(Or MRI stuff that I Love!)

Gadolinium HyperenhancementGadolinium Hyperenhancement

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CASE

67 yr old male Elective PCI LAD/D1 bifurcation Research study V difficult to stent LAD!! Could not re-access compromised diagonal with balloon……

67 yr old male Elective PCI LAD/D1 bifurcation Research study V difficult to stent LAD!! Could not re-access compromised diagonal with balloon……

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Pre PCIPre PCI Post PCIPost PCI

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Clinically valuable techniques for the interventionist…Clinically valuable techniques for the interventionist…(Or MRI stuff that I Love!)(Or MRI stuff that I Love!)

Detection of ischaemiaDetection of ischaemia

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CASE

34 yr male Presented local hospital with 12 hour history of intermittent chest pain Widespread ST elevation anterior leads Thrombolysed Failed reperfusion diagnosed at 2.5 hrs Transferred to Soton approx 18 hrs after pain onset. Pain free on arrival

Cath………

34 yr male Presented local hospital with 12 hour history of intermittent chest pain Widespread ST elevation anterior leads Thrombolysed Failed reperfusion diagnosed at 2.5 hrs Transferred to Soton approx 18 hrs after pain onset. Pain free on arrival

Cath………

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CASE

52 yr male Presented acute inferior MI Thrombolysed but developed severe R heart failure & cardiogenic shock Decision by non-interventionist to treat medically (?OOPS!)… inotropes & IABP Stormy course: acute RF; trash foot; sepsis Slow recovery… angio 3 weeks after admission but no pain since admission

52 yr male Presented acute inferior MI Thrombolysed but developed severe R heart failure & cardiogenic shock Decision by non-interventionist to treat medically (?OOPS!)… inotropes & IABP Stormy course: acute RF; trash foot; sepsis Slow recovery… angio 3 weeks after admission but no pain since admission

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1.1. Is LAD territory ischaemic?Is LAD territory ischaemic?2.2. Is inferior wall viable?Is inferior wall viable?

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Bellenger N et al. Heart 2006;92:1206.

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dobutaminedobutamine

0 μg/kg/min

10 μg/kg/min

40 μg/kg/min

Bellenger N et al. Heart 2006;92:1206.

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CASE

20 yr male Presented acute pulmonary oedema No chest pain Widespread anterior T wave changes & CK > 500

Extremely difficult to engage LCA at angio…………..

20 yr male Presented acute pulmonary oedema No chest pain Widespread anterior T wave changes & CK > 500

Extremely difficult to engage LCA at angio…………..

Courtesy of Keith Dawkins…Courtesy of Keith Dawkins…

(although I made the diagnosis on my on call ward round!)(although I made the diagnosis on my on call ward round!)

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Keith, I made the diagnosis on my on call ward roundKeith, I made the diagnosis on my on call ward round

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I made the diagnosis on my on call ward roundI made the diagnosis on my on call ward round

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Keith, I made the diagnosis on my on call ward roundKeith, I made the diagnosis on my on call ward round

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CASE

68 yr male Stent to LAD & Cx 2001 Further angio for chest pain… diffuse disease, no lesions > 50% Ongoing exertional chest pain & SOB H/o HT , LVH with strain on ECG Echo: “poor views” shows Good LV function & LVH

Why has he got his symptoms? ? ischaemia…………..

68 yr male Stent to LAD & Cx 2001 Further angio for chest pain… diffuse disease, no lesions > 50% Ongoing exertional chest pain & SOB H/o HT , LVH with strain on ECG Echo: “poor views” shows Good LV function & LVH

Why has he got his symptoms? ? ischaemia…………..

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CASE – useful MR even in retrospect

53 yr male HT, FH, hyperchol CABG 1989: LIMA 2 LAD; VGs 2 OM + D1 1996 recurrent angina.. .. Stent to dominant RCA Recurrent angina 2006… local angio Referred ?PCI to ostium of Cx VG Soton colleague “challenging”… MRI ? Ischaemia Cx territory MRI 9/06….. Accepted as elective case BUT admitted after >1 week severe, worsening angina 11/06 Trop –ve on admission Transfer Soton for SBCA

53 yr male HT, FH, hyperchol CABG 1989: LIMA 2 LAD; VGs 2 OM + D1 1996 recurrent angina.. .. Stent to dominant RCA Recurrent angina 2006… local angio Referred ?PCI to ostium of Cx VG Soton colleague “challenging”… MRI ? Ischaemia Cx territory MRI 9/06….. Accepted as elective case BUT admitted after >1 week severe, worsening angina 11/06 Trop –ve on admission Transfer Soton for SBCA

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So…… what do you do?

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CASE

60 yr male Previously fit: has cardiac arrest after jogging Bystander and paramedic CPR Brief ITU stay Trop high but only minor ECG changes (AVL)

Angio shows mild LAD disease only……. IVUS

60 yr male Previously fit: has cardiac arrest after jogging Bystander and paramedic CPR Brief ITU stay Trop high but only minor ECG changes (AVL)

Angio shows mild LAD disease only……. IVUS

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Bellenger N, Peebles C, Curzen N. Eurointervention 2006.

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Bellenger N, Peebles C, Curzen N. Eurointervention 2006.

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Journal of Invasive CardiologyJournal of Invasive Cardiology 2006;18:594-598.2006;18:594-598.

Patients presenting with troponin +ve cardiac-sounding pain who then have no Patients presenting with troponin +ve cardiac-sounding pain who then have no important CAD are relatively commonimportant CAD are relatively common Underlying pathology unknown…. ?”plaque event”; ?myocarditis; ?otherUnderlying pathology unknown…. ?”plaque event”; ?myocarditis; ?other Most are labelled with diagnosis of NSTEMIMost are labelled with diagnosis of NSTEMI Implications for long term Rx + insurance + job medicals etcImplications for long term Rx + insurance + job medicals etc

25 consecutive patients25 consecutive patientsMean age 56Mean age 56++11 yrs11 yrsAll treated with ACS Rx and listed for SBCAAll treated with ACS Rx and listed for SBCAAll had unobstructed coros and well-preserved LV functionAll had unobstructed coros and well-preserved LV function

Patients presenting with troponin +ve cardiac-sounding pain who then have no Patients presenting with troponin +ve cardiac-sounding pain who then have no important CAD are relatively commonimportant CAD are relatively common Underlying pathology unknown…. ?”plaque event”; ?myocarditis; ?otherUnderlying pathology unknown…. ?”plaque event”; ?myocarditis; ?other Most are labelled with diagnosis of NSTEMIMost are labelled with diagnosis of NSTEMI Implications for long term Rx + insurance + job medicals etcImplications for long term Rx + insurance + job medicals etc

25 consecutive patients25 consecutive patientsMean age 56Mean age 56++11 yrs11 yrsAll treated with ACS Rx and listed for SBCAAll treated with ACS Rx and listed for SBCAAll had unobstructed coros and well-preserved LV functionAll had unobstructed coros and well-preserved LV function

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Journal of Invasive CardiologyJournal of Invasive Cardiology 2006;18:594-598.2006;18:594-598.

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16%

32%

52%

Focal HE

Patchy HE

No HE

Journal of Invasive CardiologyJournal of Invasive Cardiology 2006;18:594-598.2006;18:594-598.

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Journal of Invasive CardiologyJournal of Invasive Cardiology 2006;18:594-598.2006;18:594-598.

Do patients require angiography prior toDo patients require angiography prior toICD implantation?ICD implantation?

Do patients require angiography prior toDo patients require angiography prior toICD implantation?ICD implantation?

Eurointervention 2006;2:371-4

ProblemProblem: : No way of telling…….. No way of telling…….. (a)(a) how many were ischaemic how many were ischaemic (b)(b) How many had angiographyHow many had angiography(c)(c) How many had revascHow many had revasc

Problem 3Problem 3: : Evidence against benefit of routineEvidence against benefit of routineangiography & revascularisationangiography & revascularisation

New Engl J Med 1997

67 yr old maleMI 9 yrs agoCABG x 3 1999Poor LV (EF 30%)Admitted with symptomatic VT & pulmonary oedemaNo recent h/o angina/chest pain/chest heaviness/chest tightness/etc!Troponin 0.15LBBB

Rx: iv diuretics/nitratesRx: aspirin + clopidogrel + aceiEP opinion…….. “Needs SBCA”

NC interventionist on call………………………………………………..

……………………………………!………………?……………………….

………………what’s the indication for revascularisation???

CURZEN’S CASE 1

““Extensive area of anteroapical infarction with no viability or ischaemia”Extensive area of anteroapical infarction with no viability or ischaemia”““Extensive area of anteroapical infarction with no viability or ischaemia”Extensive area of anteroapical infarction with no viability or ischaemia”

STRESS MRI WITH HYPERENHANCEMENTSTRESS MRI WITH HYPERENHANCEMENT

(a)(a) Angio & revasc anyway (to teach the interventionist a lesson)Angio & revasc anyway (to teach the interventionist a lesson)

(b)(b) Get on with the ICD (& stop messing about)Get on with the ICD (& stop messing about)

(c)(c) When’s lunch?When’s lunch?

(a)(a) Angio & revasc anyway (to teach the interventionist a lesson)Angio & revasc anyway (to teach the interventionist a lesson)

(b)(b) Get on with the ICD (& stop messing about)Get on with the ICD (& stop messing about)

(c)(c) When’s lunch?When’s lunch?

Which patients being considered for ICD therapy shouldWhich patients being considered for ICD therapy shouldundergo revascularisation?undergo revascularisation?

Change in Care Pathway & Research RegistryChange in Care Pathway & Research Registry

Patients being considered for ICDPatients being considered for ICD

Exclude those with obvious angina/established objective evidence of ischaemia-Exclude those with obvious angina/established objective evidence of ischaemia-NOT including ETT!!NOT including ETT!!

Exclude those with good story of MI this time – Exclude those with good story of MI this time – NOT including troponin rise only!!NOT including troponin rise only!!

All undergo stress MRI with LHE gadoliniumAll undergo stress MRI with LHE gadolinium

Revasc for ischaemia +/- viability ONLY: not necessarily as in patientRevasc for ischaemia +/- viability ONLY: not necessarily as in patient

Persuade your CEO that this will save bed days so that he funds the MRI scansPersuade your CEO that this will save bed days so that he funds the MRI scans

Write up as observational series – become rich & famous. Retire and be happy!!Write up as observational series – become rich & famous. Retire and be happy!!

Patients being considered for ICDPatients being considered for ICD

Exclude those with obvious angina/established objective evidence of ischaemia-Exclude those with obvious angina/established objective evidence of ischaemia-NOT including ETT!!NOT including ETT!!

Exclude those with good story of MI this time – Exclude those with good story of MI this time – NOT including troponin rise only!!NOT including troponin rise only!!

All undergo stress MRI with LHE gadoliniumAll undergo stress MRI with LHE gadolinium

Revasc for ischaemia +/- viability ONLY: not necessarily as in patientRevasc for ischaemia +/- viability ONLY: not necessarily as in patient

Persuade your CEO that this will save bed days so that he funds the MRI scansPersuade your CEO that this will save bed days so that he funds the MRI scans

Write up as observational series – become rich & famous. Retire and be happy!!Write up as observational series – become rich & famous. Retire and be happy!!

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ED

ES

• CMR is robust, versatile and reproducibleCMR is robust, versatile and reproducible• Non-invasiveNon-invasive• No radiationNo radiation• Time consumingTime consuming

• Helps to tailor revascularisation therapyHelps to tailor revascularisation therapy• Likely to save money!Likely to save money!

• Important research tool Important research tool

ConclusionsConclusions

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Acknowledgements

My computer Charles Peebles The pupil at my son’s school who gave him this…..

Keith Dawkins, Huon Gray Nick Bellenger Steve Harden Paul Roberts & John Morgan Staff in Wessex Cardiac Unit MRI Suite