Echocardiography and

Magnetic Resonance Imaging

for detection of

Coronay Artery Disease

Hans-Marc J. Siebelink MD PhD

Leiden University Medical Center

Cardiology, Non-Invasive Imaging

Leiden, The Netherlands

Ischemic Cascade

Duration Ischemia

Tests: Functional vs Anatomic test?

ImpairedPerfusion

Metabolic changes

Diastolic

dysfunction

Systolic

dysfunction

ECGAngina

Infarction

Echocardiography MRI“working horse”

Available / bed site Not in every practice

Quick Protocol 30-60 min

Easy Technical, processing

Function (syst / diast) Function (syst / diast)

Stress function Stress function

Perfusion Perfusion

Coronary anatomy

First line clinical practiceWall motion assessment

Cerqueira, Circ 2002

Vascular pattern?

2D-echocardiography

Visual function

3D-echocardiography

Automatic border (TomtTec®) detection on 4D volume contrast acquisitions

Echo wall motion abnormality

Global Apical

Idiopathic DCM Aneurysm post infarct

Echo wall motion abnormality

LV thrombus?

Near field artefact

MRI wall motion abnormality

Inferior wall motion abnormality

Inferior infarction?

Regional wall motion abnormality

Suggestive CAD How to prove it?

Tissue characterisation

perfusion echo

delayed enhancement (DE) MRI

Provoke ischemia stress echo / MRI

Perfusion assessment stress echo / MRI

Echo tissue characterizationcontrast perfusion

4 chamber 2 chamber

Antero-apical perfusion defect infarction

MRI tissue characterizationDelayed enhancement (DE)

Kim et al. Cardiovascular MRI and CT. Higgins, de Roos. Eds 2002

Vogel-Claussen, Radiographics 2006

DE MRI Technique

DE MRI

Inferior infarction

Non-transmural?

DE MRI

Inferior infarction

Non-transmural and transmural

Management?

Recovery LV function

Infarct transmurality predictive of recovery

Delayed enhancement MRI

Clinical practice: cutoff 50%

Infarct transmurality %

Kim R, NEJM, 2000

Viability and prognosis

Allman, JACC 2002

Dobutamine stress echo

Recruitment wall motion pos identification

Beta adrenergic stimulation

Biphasic response

Baseline:wall motion abnormalities

Low dose: improvement wall motion viability

(High dose: deterioration wall motion) ischemia

Angina, ECG

Highly operator dependent, image quality

Dobutamine stress echo

No wma no ischemia

Rest

10 γ

40 γ

Recovery

Dobutamine stress echo

Angina, ST , wma Ischemia

Rest 20 γ

10 γrecovery

Recovery

Dobutamine stress MRI

Recruitment wall motion pos identification

Beta adrenergic stimulation

Biphasic response

Baseline:wall motion abnormalities

Low dose: improvement wall motion viability

(High dose: deterioration wall motion) ischemia

Angina, ECG not applicable

Less operator dependent, image quality

basal

mid

apical

protocol: compare cine-series

rest dobutamine

Dobutamine stress MRI

Courtesy PRM van Dijkman

Severe LAD stenosis

Dobutamine 20γ Dobutamine 40 γWorseningwall motion

Mild septalhypokinesia

Dobutamine stress MRIRest: severe hypokinesia anteroseptal region

Courtesy PRM van Dijkman

basal, dobu 30 γ basal, dobu 30 γ

Dobutamine stress MRI

The use of tissue tagging

Courtesy PRM van Dijkman

Echo myocardial perfusion

Rest Adenosine

Perfusion defect apical septal ischemia

basal mid apical

High spatial resolutionAssessment subendocardial and transmural defects

MRI myocardial perfusionnormal study

Courtesy PRM van Dijkman

MRI myocardial perfusion

Courtesy PRM van Dijkman

Basal mid

Transmural perfusion defect mid inferolateral

80%82%Echo perfusion

specsensFunctional tests

87%85%PET perfusion

80%81%Dobu stress echo

96%

86%

91%

87%

68%

95%Dobu stress MRI with Tagging

86%Dobu stress MRI

73%SPECT perfusion

81%MRI perfusion

77%Bicycle exercise stress test

Salerno Circ Im 2009, Marwick Heart 2003, Nagel Circulation 1999

Predictive values detection CAD

MRI coronary angiography

Technically difficult

Time consuming

84% Patients successful

Proximal arteries only

Future high field?!

Ischemic CascadeFunctional tests for CAD

Duration Ischemia

Perfusion

impaired

Metabolic changes

Diastolic

dysfunction

Systolic

dysfunction

ECGAngina

Infarction

Echo

Nuclear

MRI

Nuclear

Echo

Nuclear

MRI

Echo

Nuclear

MRI

Echo

Nuclear

MRI

Resume detection CAD

Echo, MRI and Nuclear all - accurate

- robust.

For your clinical practice:

Choose your modality / modalities

(no need to perform all)

Gain experience

Aim high quality