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Longwood Area Non-invasive Cardiac Imaging Seminar:

OverviewLV/RV Anatomy and Function

Warren J. Manning, MDBeth Israel Deaconess Medical Center, Boston, MA

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Disclosures

• Research Grant Support: – Philips Medical Systems– NIH, NHLBI– Lantheus Medical Inc.

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Seminar Conception - 2004

• Training in echocardiography (TTE, Stress, TEE) was relatively mature.

• Exposure to other imaging modalities [CMR, CCT] was less developed

• Clinical exposure to CMR and Nuclear Cardiology by cardiology and radiology residents/fellows is high at the BIDMC– formal training/lectures in CMR, CCT, is more limited

• Fulfill new COCATS training recommendations for Level I training in CMR, CCT

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Outline – Year 7

• 1 hour weekly “seminar” style series• Monday, noon-1pm

• West Campus, Baker 4 - CV library• ~45-50 min presentation by Longwood attending staff• 5-10 minute questions• Internal [CMR] Web posting of presentations• Didactic • CME credit for attending staff

• Clinical cases - 1 hour case based conference (2nd/4th Friday at 12:30pm) initiated 2007

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Outline

• Modalities: • January - June

• Cardiovascular Magnetic Resonance (CMR)• July – August

• CMR Physics [Monday noon-1pm; EAST Campus]• September – October

• Nuclear Cardiology (Tom Hauser)• November-December

• Cardiac Computed Tomography (CCT) (Tom Hauser)

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Outline

• Primarily for cardiology fellows and radiology residents/fellows

• also open to interested medical students, medicine residents, sonographers, nuclear med trainees, CMR/MR technologists, CT technologists, nurses, attendings, etc.).

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Outline

• Boston area staff/teaching resources, inclusive of fellows within and outside Longwood Medical Area:

• Longwood: BIDMC, BWH, Children’s Hospital

• Boston: Boston Medical Center, Tufts Medical Center

• Outside 128 (new for 2009/10)

• Lahey Clinic, UMass-Memorial

• Participation via web: cardiacmr.webex.com

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3 “Pillars” of Cardiology

1. Interventional/Invasive Cardiology1. Interventional/Invasive Cardiology

2. Electrophysiology2. Electrophysiology

3. Non-invasive Cardiac Imaging3. Non-invasive Cardiac ImagingBeller JACC 2006; Thomas JACC 2009Beller JACC 2006; Thomas JACC 2009[WJM: Enter from Cardiology or Radiology][WJM: Enter from Cardiology or Radiology]

Echo (TTE, TEE, Stress, ICE, 3D)Echo (TTE, TEE, Stress, ICE, 3D)Nuclear Cardiology/PET (PET-CT)Nuclear Cardiology/PET (PET-CT)Cardiovascular Magnetic ResonanceCardiovascular Magnetic ResonanceCardiac Computed TomographyCardiac Computed Tomography

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CardiologyCardiology

AnesthesiaAnesthesia* Feroze Mahmood, MD* Feroze Mahmood, MD* Achi Grinberg, MD* Achi Grinberg, MD

RadiologyRadiology**Neil Rofsky, MD**Neil Rofsky, MD***Mel Clouse, MD***Mel Clouse, MD***V. Raptopoulos, MD***V. Raptopoulos, MD

TEETEE TTE*TTE*

TTETTECathCathNuclearNuclearPETPETCMR**CMR**CCT***CCT***

BIDMC Non-invasive Cardiovascular Imaging - TrainingBIDMC Non-invasive Cardiovascular Imaging - Training

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CMR Teaching StaffBIDMC:

Evan Appelbaum, MDEli Gelfand, MDRobert Greenman, PhDYuchi Han, MDThomas H. Hauser, MDKraig V. Kissinger, RTRobert Lenkinski, MD Warren J. Manning, MDReza Nezafat, PhDIvan Pedrosa, MDDana C. Peters, PhDNeil M. Rofsky, MDMartin Smith, MDSusan B. Yeon, MD

Boston Medical CenterFrederick Ruberg, MD

Children’s HospitalTal Geva, MDAndrew Powell, MDAnne Marie Valente, MD

BWHRaymond Kwong, MD

Tufts NEMCMartin S. Maron, MD

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TOPICS [Web site]

LV function/massRV functionMyocardial infarctionCMR stressCMR viabilityCardiomyopathiesPericardiumCongenital heart diseaseValvular heart disease

MRA – aorta, renal,peripheral, carotid

MR venographyCoronary MRINon-cardiac thoracic pathologyPulmonary vein MRAInterventional

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Schedule

1. E-mail notification every Friday• Let me know if you are not on list (or on list…)

2. Every Monday through the end of June, noon-1pm • Except

• Holidays (MLK/Washington’s BDay, Patriot’s Day)• Cardiology Fellowship interviews

(2/22, 3/22, 3/29, 4/26, 5/3)• Research retreat (2/1)

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Additional Resources

• S Drive– BIDMC cases (topic; MRN, images, report)– CMR Physics

• R. Nezafat, DC Peters [BIDMC – slides]• Robert Judd (Duke - video)

• CMR Fellows– Francesca Delling, MD– Airley Fish, MD– Susie Hong, MD– Ali Mahajerin, MD– Nisha Parikh, MD– Ali Rahimi, MD

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Multimodality Imaging in Cardiology

• Critical that training cross technology boundries

• Efficiencies of multimodality imaging program

Thomas JACC 2009

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Level 1 – Basic training required of all trainees to be competent consultant cardiologists. This level makestrainees conversant with all imaging modalitiesalong with their clinical utility. It provides superficial exposure to performance and interpretation….

Didactic Activities: Duration 1 monthPerform 0 cases/Exposed to interpretation of 25 casesLectures and self-study in CMR

• Clinical CMR reading [East] during Echo months [2nd yr] 5 cases/wk x 16 wks = 80 cases• Monday noon CMR seminar• Tuesday am clinical conference• Friday 12:30pm case based imaging conference

•No “hands on” experience necessaryJACC 2002

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Level 2 – Additional training that enables the cardiologistto interpret cardiovascular imaging studies independently

Didactic Activities: 3-6 months under Level 2 or Level 3 (preferred)Supervised interpretation of 150+ cases

(Up to 50 may come from a training set)Primary interpretation of 50+ cases

Lectures and Self Study – more advanced

JACC 2002

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Level 3 – Advanced training that enables a cardiologist toperform, interpret, and train others to perform andinterpret specific imaging studies at the highestskill level. This is the expertise expected fordirectors of imaging laboratories.

Didactic Activities: 6 (clinical) or 12 (academic) mo training under Level 3

Supervised interpretation of 300+ cases(Up to 100 may come from a training set)

Primary interpretation of 100+ casesLectures and Self Study – more advanced Summer Physics series, Monday, noon-1pm Mon-Friday 11am-noon clinical readout

3-4 mo clinical CMR fellowFocused research, publications

JACC 2005

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Modality Level Mo Multimodality Multimodal CasesSingle Total/Unshared (Perf Interpret)

Echo 1 3 3/2 75 150 2 6 6/4 150 300 3 12 12/6 300 750

Nuclear 1 2 2/1 35 100 2 4-6 4/3 35 300 3 12 10/5 35 600

CMR 1 1 1/0 0 25 2 3-6 3/2 50 150 3 6-12 10/5 100 300

CCT 1 - 1/0 0 50 2 2 2/1 50 150 3 6 6/3 100 300

Multimodality Training – JACC 2009

Thomas JACC 2009

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Maintenance of Skills SCMR 2006 ACCF/AHA

(JCMR 2006) (JACC 2005)

Level IICME 20 hours/2yr 30 hours/3yrCases 100/2yr 50/yr

Level IIICME 40 hours/2yr 60 hours/3yrCases 200/2yr 100/yr

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• RADIOLOGIST• ACR Diagnostic Modality Accreditation Program

• Stereotactic Breast Biopsy Accreditation• Breast ultrasound Accreditation• Ultrasound Accreditation• Magnetic Resonance Imaging Accreditation

• not CMR specific• Nuclear Medicine and PET Accreditation• Computed Tomography Accreditation• Radiography/Fluoroscopy Accreditation

Physician Credentialing in CMR

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• Board certified radiologist• Supervised and interpreted >75 CMR cases in past 36 mo

• Completed >40 hours of CME (or equivalentsupervised experience)

• >75 examinations every 3 years to maintain skills

• No specific CMR CME requirement

Physician Credentialing in CMR

Radiology 2005;235:723

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CMR Texts (NOT required)

*WJM editor (if interested – see me)

                                            

www.acc.orgwww.scmr.orgwww.scmr.org

**Warren J. Manning -

Dudley J. Pennell

MANNINGPENNELL

Second

Edition

SECONDEDITION

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J Cardiovasc Magn ResonanceJ Cardiovasc Magn Resonance – www.jcmr-online.com – www.jcmr-online.com

1.1. Original Original ArticlesArticles

2.2. How toHow to3.3. ReviewsReviews4.4. Case Case

ReportsReports

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If you want to learn more.....*

Society for CardiovascularMagnetic Resonance*

www.scmr.org

13th Annual Scientific SessionsJanuary 21-January 24, 2010

Phoenix, AZ

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CMR – “New Kid” on the blockNon-invasive Imaging – 2008 (estimate)

0

20

40

60

80

100

Millions

CT MRI Echo Nuclear CCT CMR

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0

5

10

15

20

25

Echo Nuclear CCT CMR

# of ClinicalStudies (millions)

Cardiac imaging is frequently performed!

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0

0.5

1

1.5

2

2.5

Echo Nuclear 64 CT Dual/256CCT

1.5TCMR

3T CMR PET

EquipmentCost ($mil)

Non-invasive Imaging – Equipment Cost

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Advantages of Cardiovascular MR (CMR)

1. Excellent soft tissue contrast2. Non-invasive, no ionizing radiation3. High (<1mm) in-plane spatial resolution4. Multiplane, true tomographic imaging5. Dynamic/cine imaging (2D echo)6. Exogenous contrast usually not needed

[CMR agents are less toxic than iodinated preparations]7. Blood flow/volume – quantitative8. Minimal post-processing9. Potential for tissue characterization [fat, iron]10. Thoracic skeleton and pulmonary parenchyma

do not interfere with imaging11. “Comprehensive” CMR examination

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Advantages of Cardiovascular MR (CMR)

1. Much cardiac hardware is safe…

a. Mechanical and bioprosthetic valvesb. Post-sternotomy sternal wiresc. CABG clips/markersd. Coronary stentse. ? ”Modern” PCM/ICDs [Circ 2004, 2006]

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Local artifacts fromsternal wires and coronary

artery bypass graft markers.

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Is it safe for patients with prostheticheart valves to have an MRI?

YES!

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Prosthetic Valves

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IntracoronaryStents

1. Scott & Pettigrew AJC 19942. Strohm JCMR 19993. Hug Radiology 20004. Kramer JCMR 20005. Powell SCMR 20016. Gerber JACC 2003

ACS Multi-link RX Duet (3)

ACS RX Multi-link (3)

AVE (2,4)

Micro Stent (3)

BeStent (2,3)

Crown (4)

Giantourco-Roubin (1,2)

Giantourco-Roubin II (3)

InFlow (2,3)

InFlow Gold (3)

JoStent (2)

MAC-Stent (3)

Multilink (2,4)

Palmaz-Schatz (1,2,3)

R-Stent (3)

Seaquence (3)

Strecker (1)

Tenax-Stent (2)

Wallstent (2,3)

Wiktor (1)

Wiktor GX (3)

No local heatingMinimal force/No device migrationSmaller artifacts with TSE (vs. GRE)

imaging

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CMR Coronary Stent SafetyCMR Coronary Stent Safety

StudyStudy

Gerber Gerber [JACC ‘03][JACC ‘03]

Schroeder Schroeder [JCMR ‘00][JCMR ‘00]

Kramer Kramer [JCMR ‘00][JCMR ‘00]

Syed Syed [ACC ‘04][ACC ‘04]

Pt TypePt Type

CADCAD

AMIAMI

AMIAMI

AMIAMI

NN

112112

4747

3030

133133

CMRCMR(days)(days)2121++1717

166166

33++11

22++22

F/UF/U(days)(days)

3030

2121++55

220220++6060

133133++6060

+CMR+CMREventsEvents

5%5%

35%35%

8%8%

6%6%

-CMR-CMREventsEvents

38%38%

29%29%

22%22%

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Disadvantages of CMR

1. Most physicians did not enjoy or don’t remember much physics…. 2. Set-up is complex, many options (compared with other technologies)3. CMR image interpretation is not always “intuitive”4. ECG gating is “absolute” requirement yet soimetimes difficult5. Claustrophobia, ?Exclusion [PCM, ICD]6. Real and perceived $$

• Perceived cost is high [echo < Nuclear << CMR]• Reimbursement is relatively low [echo < CMR << Nuclear]• Investment is high [echo << Nuclear << CMR]

7. Other technologies are established (echo, nuclear, CT)What is true value CMR?

New information that impacts/changes patient care

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Non-invasive Imaging – Reimbursement/study

0

1000

2000

3000

ECG ETT Echo CCT CMR Nuclear PET

$$

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Disadvantages of CMR

Powerful magnet that is “always on”Intracranial clipsTENSCochlear implants….stethescopepensID badge clips…

CMR is not portable

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Disadvantages of CMRNephrogenic Systemic Fibrosis - NSF

• Systemic fibrosis (skin, lungs, muscles, heart)• subacute swelling of distal extremities

followed by severe skin induration pain, loss of skin flexibility• onset of symptoms 2 days to 18 mo from exposure• 2006 [Grobner Nephrol Dial Transplant 2006]• >200 cases reported – all with exposure to Gd-based contrast• ?Preference for specific Gd-agent [>80% Omniscan]• Underlying renal dysfunction (many on dialysis)

• CrCl >60 ml/min/1.73m2 = “no” risk• FDA advisory December 2006

• BIDMC: Creatinine clearance estimate prior to Gd-DTPA exposureChoyke questionnaire

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Pacemakers/AICD

• Heating (leads)• Threshold changes in a minority of patients• Isolated leads without PCM generator may be more concerning

• PCM program changes• Devices manufactured after 2000 may be “safer”

• FDA: potential risks and data do not justify routine MRI in patientsWith pacemakers/ICD

• ?IRB protocol at BIDMC• Monitoring of patients• No PCM dependent patients

Levine et al. Safety of MRI in patients with Levine et al. Safety of MRI in patients with Cardiovascular Devices. Circulation 2007;116:2878-91.Cardiovascular Devices. Circulation 2007;116:2878-91.

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wwwwww..

www.scmr.orgOr link from…

Intranet.bidmc.harvard.eduCardiac MRREFERENCES

Or link from…

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Importance of LV Anatomy/Function

• LV mass is independent risk factor for adverse cardiovascular events– hypertrophy (HTN, aortic stenosis/regurgitation)

• Global LV volumes are important in monitoring of patients with valvular disease (AR, MR)

• Global LVEF provides prognostic information– many therapeutic strategies are based on LVEF thresholds (ACE

inhibitors p-MI)

• LV regional function (CAD)• Cardiologists are “intensely quantitative”

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Echocardiography

Parasternal Long Axis

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ECG

EDD ESEcho LVMeasures

Septum [nl<11] End-diasolic Dimension [nl<56mm] Inferolateral [nl<11] End-systolic Dimension

Ant Sept

Inferolateral

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M-Mode Echo Estimates

LVVol: Teichholz Formula: EDV=7D3/(2.4+D)

LVEF: Fractional shortening = (EDD - ESD)/(EDD) [nl>0.30]

Vol (sphere) R3/3FS = 0.33 ED radius = 3; ES radius =2

LVEF = (Rd3 - Rs

3) / Rd3

= 33 - 23 / 33

= 27 – 8 / 27 = 0.70 2D visual / “eye ball method”

(15-20% of cases - cannot see all the segments)

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M-Mode Echo Estimates

LV MASS Penn-Cube Method: LVM = [(S+IL+EDD) 3 - EDD3 ])*1.05*0.8 - 13.6 LV MASS (ASE Method): LVM = [(S+IL+EDD) 3 - EDD3 ])*1.05*0.8 + 0.6

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2D Echo Estimates

Apical 4 Chamber view

Truncated ElipsoidBiplane Simpson’s Rule

a

bd

LV mass = 1.05 (b+t)2 [2/3(a+t) + d - (d3/d(a+t)2 -b2 [2/3a +d - d3/3a2 ]

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Advantages of Cardiovascular MR (CMR)

1. Excellent soft tissue contrast2. Non-invasive, no ionizing radiation3. High (<1mm) in-plane spatial resolution4. Multiplane, true tomographic imaging5. “Volumetric imaging” – no geometric assumptions6. Dynamic/cine imaging with high temporal resolution(2D echo)7. Exogenous contrast usually not needed

[MR agents are less toxic than iodinated preparations]8. Blood flow/volume - quantitative9. Potential for tissue characterization10. Thoracic skeleton and pulmonary parenchyma

do not interfere with imaging

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Coronal or Transverse Scout – Single Shot

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SSFP ECG gated Cine Acquisitions

12 frames/R-R interval12 frames/R-R interval

UngatedUngated

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2Ch & 4Ch Breath-hold Cine MR

LALV

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Short Axis Cines from Base to Apex

Base

Apex

1234567

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LV EDV/ESV - Practical Points

• End-diastolic phase is 1st phase in SA dataset• End systolic phase is phase of minimum area• End-systolic phase is defined on a mid-ventricular level.

– Phase of minimum area is then used as “end-systolic phase” for all slices in dataset

1 10 20 30 Phases

1

10

Slice #

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ES

ED3D Assessment of LV/RV Volumes

Isolated Aortic/Mitral Regurgitation

LVEDV 236 ml LVESV 134 mlSVLV 102 ml

RVEDV 186 ml RVESV 102 mlSVRV 84 ml

Regurgitant Volume 18 ml

EDA*Thsl = EDVESA* Thsl = ESVSV = EDV – ESV

EF = SV/EDV

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Why CMR for LV Mass/Volumes?

• Summation of discs– Volumetric No geometric assumptions

• Enhanced Accuracy (Chuang JACC 2000;35:477)

• Superior Reproducibility– Changes more reliable for serial evaluation in patients with LVH,

valvular disease – Reduces sample size for research studies

• High temporal (30ms) and spatial (1.4mm) resolution

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Volumetric vs. Biplane Methods

Chuang JACC 2000;35:477

Limits of agreementbetween volumetric MRI, biplane MRI, volumetric Echoand biplane echo

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Inter and Intraobserver LVEF Reproducibility

Chuang JACC 2000;35:477

Interobserver Variability (%) Mean +/- SD (%) SEE r2

Intraobserver Variability (%) Mean +/- SD (%) SEE r2

VolumetricCMR

3.60.5+1.5

1.60.99

5.1-1.1+2.1

2.10.99

BiplaneCMR

13.4-1.4+5.9

4.30.94

13.0-2.0+5.6

5.40.91

Volumetric/3DEcho

8.3-0.1+3.8

3.70.96

6.9-0.4+3.1

3.30.97

BiplaneEcho

17.8-1.3+8.8

9.20.82

13.4-0.9+6.8

6.70.90

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Interstudy SD: 2D Echo vs CMR

24

10 9.3

16

5.6

8.26.6

2.9 2.4

36

6.5

10

0

5

10

15

20

25

30

35

40

LVEDV (ml) LVESV (ml) LVEF (%) LVM (g)

EchoCMR NlCMR CM

Otterstad EurHeartJ 1997;18:507 Bellenger JCMR 2000:2:271

SD

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Sample Size Calculations: 10% Change*

LV-EDD 2D EchoLV-EDD CMR

LVM 2D echo (Teicholz)LVM 2D echo (biplane)LVM CMR

LVEF 2D echoLVEF CMR

Sample Size509261

244389835

69891

<0.05

<0.01<0.001

<0.001

*Strohm JMRI 2001;13:367; Grothues AJC 2002;90:29

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Comparative Sample Sizes2D Echo vs CMR [Power 80%, P<0.05]

Change Echo CMR

LVEDV 8.3 mL 250 46 (18%)

LVESV 5.5 mL 250 34 (14%)

LVEF 2.3% 250 50 (20%)

LVM 12.7 g 250 8 (3%)

Bellenger JCMR 2000:2:271.

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What is Normal CMR LV Anatomy?

Salton and Yeon AHA 2006• 606 adults subjects in FHS Offspring Cohort

• all free of clinical CV disease• No history of HTN or antihypertensive meds• No SBP >140mmHg or DBP >90mmHg

• SSFP cine MR • 30-40ms temporal resolution• contiguous 10mm slices• Short axis stack (Simpson’s Rule)

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Normal CMR LV Anatomy

Variable

LV EDV (ml)LV EDV/HT (ml/m)LV EDVI (ml/m2)LV ESV (ml)LV ESVI (ml/m2)

LVM (g)LVMI (g/m2)

LVEF (%)

MenMean + SD

144 + 2681 + 1471 + 1251 + 1425 + 7

123 + 2261 + 10

0.65 + 0.05

WomenMean + SD106 + 19*71 + 12*61 + 9*25 + 7*20 + 5*

81 + 14*47 + 7*

0.67 + 0.05*

Salton AHA 2006 *p<0.001 vs. men

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Comparison of CMR* vs. LV gram

Variable

LVEDVI (ml/m2)

LVESVI (ml/m2)

LVEF (%)

Men-CMRMean (95%)

71 + 1225 + 7

0.65 + 0.05

Women-CMRMean (95%)

61 + 9*20 + 5*

0.67 + 0.05*

LV GramRange 50-9015-3050-80

* Salton AHA 2006

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Normal Aging - MEN (n=239)*

* Yeon AHA 2006

SBP (mmHg)SBP (mmHg)DBP (mmHg)DBP (mmHg)LVEDDI (mm/m2)LVEDDI (mm/m2)LVEDVI (ml/m2)LVEDVI (ml/m2)LVESVI (ml/m2)LVESVI (ml/m2)LVMI (g/m2)LVMI (g/m2)LVEF (%)LVEF (%)

Q1Q1114.5114.574.774.726.626.676.676.627.427.462.162.10.640.64

Q2Q2116.4116.4

747425.825.869.369.324.424.461.661.60.650.65

Q3Q3118.4118.474.474.425.825.869.469.424.024.059.459.40.660.66

Q4Q4119.6119.670.970.925.525.567.367.323.623.658.958.90.650.65

TrendTrend0.0030.0030.0050.0050.0490.049

<0.001<0.0010.0020.0020.0340.0340.2160.216

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Normal Aging - WOMEN (n=367)*

* Yeon AHA 2006

SBP (mmHg)SBP (mmHg)DBP (mmHg)DBP (mmHg)LVEDDI (mm/m2)LVEDDI (mm/m2)LVEDVI (ml/m2)LVEDVI (ml/m2)LVESVI (ml/m2)LVESVI (ml/m2)LVMI (g/m2)LVMI (g/m2)LVEF (%)LVEF (%)

Q1Q1109.7109.771.471.427.927.964.464.421.821.847.347.30.660.66

Q2Q2114.2114.272.272.227.627.661.861.820.620.646.446.40.670.67

Q3Q3114.4114.470.470.427.427.459.859.819.619.645.645.60.670.67

Q4Q4117.3117.368.168.127.927.957.757.718.318.346.946.90.690.69

TrendTrend<0.001<0.0010.0010.0010.800.80

<0.001<0.001<0.001<0.001

0.510.510.0010.001

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LV Mass/Volume and CHD (MESA)(216 events in 5098 participants)

* Bluemke JACC 2008

LVM (10%)LVM (10%)LV volume (10%)LV volume (10%)LVM/vol (g/ml)LVM/vol (g/ml)LVM/volLVM/vol 11stst quartile quartile 22ndnd quartile quartile 33rdrd quartile quartile 44thth quartile quartile

HR(95% CI)HR(95% CI)1.1 (1.0-1.2)1.1 (1.0-1.2)0.9 (0.8-0.9)0.9 (0.8-0.9)5.5 (3.3-9.1)5.5 (3.3-9.1)

1.0 (ref)1.0 (ref)2.0 (1.0-4.0)2.0 (1.0-4.0)2.0 (1.0-4.1)2.0 (1.0-4.1)

5.3 (2.9-10.0)5.3 (2.9-10.0)

PP0.050.05

0.0020.002<0.001<0.001

0.050.050.050.05

<0.001<0.001

HR (95% CI)HR (95% CI)1.0 (0.9-1.1)1.0 (0.9-1.1)0.9 (0.8-1.0)0.9 (0.8-1.0)2.1 (1.1-4.1)2.1 (1.1-4.1)

1.0 (ref)1.0 (ref)1.5 (0.7-3.0)1.5 (0.7-3.0)1.3 (0.6-2.6)1.3 (0.6-2.6)2.3 (1.2-4.4)2.3 (1.2-4.4)

PPNSNS0.090.090.020.02

NSNSNSNS0.010.01

UnadjustedUnadjusted Adjusted*Adjusted*

*age, sex, race, smoking, lipids, BP, DM*age, sex, race, smoking, lipids, BP, DM

WJM 01/10

Regional Assessment17 Segment Model of LV

(Echo, CMR, Nuclear, Invasive Cardiology)

AS

IS

I IL

AL

A AS

IS

I

LAL

A

S

Apex ILI

A

Base Mid Apical

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RV Anatomy

• True RV short axis is not parallel with the short-axis SA of LV

• ?Define normal population

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RV End-Diastolic Volume*

Men(n=340)

Women(n=512)

P Value

RV EDV (ml) 155.2 + 32.2 110.2 + 22.9 <0.0001

RV EDV / ht (ml/m) 88.1 + 17.3 67.9 + 13.3 <0.0001

RV EDV / ht2.7 (ml/m) 33.7 + 6.6 29.8 + 5.7 <0.0001

RV EDV / BSA (ml/m²) 76.3 + 14.6 63.2 + 11.8 <0.0001

RV EDV / BMI (ml) 5.7 + 1.3 4.3 + 1.0 <0.0001

* G Arora AHA 2009

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RV End Systolic Volume*

Men(n=340)

Women (n=512) P Value

RV ESV (ml) 84.0 + 22.5 52.61 + 14.4 <0.0001

RV ESV / ht (ml/m) 47.8 + 12.3 32.4 + 8.6 <0.0001

RV ESV / ht2.7 (ml/m) 18.3 + 4.7 14.2 + 3.7 <0.0001

RV ESV / BSA (ml/m²) 41.5 + 10.5 30.2 + 7.9 <0.0001

RV ESV / BMI (ml) 3.1 + 0.9 2.1 + 0.6 <0.0001

* G Arora AHA 2009

WJM 01/10* G Arora AHA 2009

RV Ejection Fraction*

Men(n=340)

Women(n=512)

P Value

RVEF (%) 45.8 + 9.7 52.2 + 9.2 <0.0001

WJM 01/10

Normal RV Mass*

Men(n=340)

Women(n=512)

P Value

RVM (g) 28.3 + 6.3 21.6 + 4.3 <0.0001

RVM / ht (g/m) 16.1 + 3.4 13.3 + 2.5 <0.0001

RVM / ht2.7 (g/m) 6.2 + 1.3 5.9 + 1.1 0.0027

RVM / BSA (g/m²) 13.9 + 3.0 12.4 + 2.4 <0.0001

RVM / BMI (g) 1.1 + 0.3 0.9 + 0.2 <0.0001

* G Arora AHA 2009

WJM 01/10

Next Week:

Dr. Thomas HauserViability

WJM 01/10

If you want to learn more.....*

Society for CardiovascularMagnetic Resonance*

www.scmr.org

13th Annual Scientific SessionsJanuary 21-January 24, 2010

Phoenix, AZ

WJM 01/10

Thank you!