HEART AND AORTA

Zbigniew Serafin

CARDIAC CT

CT

diagnostic value

Dewey M (ed.): Cardiac CT. Springer 2010: 36.

diagnostic value

64-row Philips, 128-slice Siemens, 64-row GE

retrospective gating vs. prospective triggering

nitroglycerine, β-blockers

arrhytmia

electrodes

sensitivity specificity PPV NPV

Stein PD, et al. 64-slice CT for diagnosis of coronary artery disease: a

systematic review. Am J Med. 2008;121: 715–25. 98% 88% 8,0 0,10

Miller JM, et al. Coronary CT angiography using 64 detector rows: methods

and design of the multi-centre trial CORE-64. Eur Radiol. 2009;19:816 –28. 85% 90% 8,5 0,17

Budoff MJ, et al. Diagnostic performance of 64-multidetector row coronary

computed tomographic angiography for evaluation of coronary artery stenosis

in individuals without known coronary artery disease: results from the

prospective multicenter ACCURACY (Assessment by Coronary Computed

Tomographic Angiography of Individuals Undergoing Invasive Coronary

Angiography) trial. J Am Coll Cardiol. 2008;52:1724 –32.

95% 82% 5,6 0,07

Meijboom WB, et al. Diagnostic accuracy of 64-slice computed tomography

coronary angiography: a prospective, multicenter, multivendor study. J Am

Coll Cardiol. 2008;52: 2135–44. 99% 64% 2,7 0,02

diagnostic value

stenosis ≥ 50%

sensitivity specificity

LM 100% 99%

LAD 93% 95%

LCX 88% 95%

RCA 90% 96%

Stein PD, et al. 64-slice CT for diagnosis of coronary artery disease: a systematic review.

Am J Med. 2008;121: 715–25.

diagnostic value

Dewey M (ed.): Cardiac CT. Springer 2010: 36.

indications

exclusions of CAD in patients with low-to-intermediate pretest probability

evaluation of CAD when no consent for angiography

suspicion of CAD with inconclusive exercise/stress test

acute chest pain with positive enzymes and negative ECG

CABG follow-up

imaging of coronary anomalies

electrophysiology planning and follow-up

____________________________________________

LV functional assessment, chamber morphology, cardiac tumors

valve morphology

____________________________________________

PTCA follow-up

pericardial calcifications

triple rule-out

Calcium Score, Calcium Mass

contraindications

„allergy” do contrast media

arrhythmia (e.g. atrial fibrillation)

dyspnoe

____________________________________________

hyperthyroidism (TSH, endocrinologist)

CKD (serum creatinine ≥ 2,0 mg/dl)

metformine (off for 48 h before exam)

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contraindications to NTG (intollerance, Viagra, low BP, aortic stenosis, obstructive cardiomyopathy)

contraindications to β-blockers (intollerance, asthma, bradycardia, AV block II/III)

____________________________________________

stents, electrodes

massive calcifications

stents

Maintz D, et al. Update on multidetector coronary CT angiography of coronary stents: in vitro evaluation of 29 different stent types with dual-source CT.

Eur Radiol. 2009 Jan;19(1):42-9.

anatomy

0% 10% 20% 30% 40%

90% 80% 70% 60% 50%

anatomy

coronaries

tt. wieńcowe

tt. wieńcowe

coronaries

coronaries

coronaries

coronaries

CABG

tumors

tumors

valves

LV function

0% 10% 20% 30% 40%

90% 80% 70% 60% 50%

LV function

czynność

LV function

wall

motion

wall

thickenning

ED wall

thickness

EP planning

EP planning

EP planning

EP planning

Perforacja prawej komory

RV perforation

RV perforation

Seegers J et al. Clin Res Cardiol 2009

RV perforation

RV perforation

CARDIAC MR

MRI

Coronary artery disease is the leading cause of

morbidity and mortality.

Assessment of viability of dysfunctional myocardium

in patient with coronary artery disease is of great

clinical importance.

Revascularization of dysfunctional but viable

myocardium may improve left ventricular function

and long-term survival.

Intro

One stop shop

- Provide information on morphology, function, physiology & tissue characterization in single examination.

Non-operator dependent – accurate & reproducible result.

Non-patient dependent.

Large FOV, 3D capability.

Non-invasive; no ionizing radiation.

Advantages of MRI

Indications

cardiac failure size and morphology of chambers, LV mass, contractility, viability

CAD anomalies of corinaries, stenosis (?)

IHD size and location of ischemia, stress tests

infarct, scar size and location of necrosis and scar, viability, thrombus

cardiomyopathies size and morphology of chambers, LV mass, contractility,

amyloidosis, ARVD

valvular disease ventricular morphology, velocities, gradient estimation

tumors morphology, vascularity, infiltration, differentiation with thrombi

pericardial disease morphology, thickness, LV sizing

congenital disease chamber morphology, leaks

aorta dissection, intramural hematoma, anomalies

Contraindications

ferromagnetic foreign bodies

stimulators (cardio-, neuro-, oto-)

claustrophobia

poor contact

____________________________________________

arrhythmias

ferromagnetic implants (orthopedic, vascular, dental)

ferromagnetic valves

tatoo

1st trimester of pregnancy

CKD

Safety

Safety

Safety

cardiac stents safe / conditional safety

MRI at any time

peripheral stents safe / conditional safety

MRI at any time or after 6 mo.

aortic stent-grafts safe / conditional safety / unsafe

valves safe / conditional safety

MRI at any time

ocluders safe / conditional safety

MRI at any time or after 6 mo.

stimulators cardiowerters

unsafe

MRI in life-threating conditions

MRI-compatible devices (FDA clearance)

Safety

w w w. m r i s a f e t y. c o m / l i s t _ s e a r c h . a s p

Safety

symptoms after 2-3 mo.

pain

edema

erythema

skin thickening

fibrosis of skin, muscles,

heart, lungs, liver

risk factors:

eGFR < 60 ml/min./1,73 m2

dialysis

insufficiency of kidneys and

liver

Safety

MRI scanner – 1.5 T or above.

Dedicated phase array cardiac surface

coil – allow use of parallel imaging

technique, at least 4 channels at

anterior & posterior chest wall.

Cardiac MR - Equipment

Cardiac MR - Equipment

ECG leads for monitoring of patient’s condition & gating.

Cardiac MR - Equipment

ECG gating.

• Placement of ECG leads – Ensure optimal contact. Remove moisture & oil, may need to shave male patient.

• ECG may be degraded by electrical interference from MR.

Performing Cardiac MR

Performing Cardiac MR

Performing Cardiac MR

Performing Cardiac MR

Performing Cardiac MR

Left Ventricular Function Patient’s LV parameter

Reference value (mean± SD)*

End Diastolic Volume (EDV in cc) 116.5 ± 18.4

End Systolic Volume (ESV in cc) 36.5 ± 7.0

Stroke Volume (cc) 80.0 ± 14.9

Ejection Fraction(EF)% 68.5 ± 4.4

Cardiac Output (L/min) 4.8 ± 1.0

LV Mass (g) 129.1 ± 20.0

Heart Rate (bpm)

Left ventricular function

anatomy

anatomy

anatomy

1. Dobutamine-stress MR

- ischemia & viability

2. Myocardial Perfusion MR

- perfusion defect indicating hemodynamically significant

stenosis.

3. Late Gadolinium Enhancement (LGE) MR

- myocardial viability.

4. Coronary MR Angiography.

- anatomy

Cardiac MR in CAD

Dobutamine-Stress MR

- Detection of myocardial ischemia & viability.

- Assess regional wall motion abnormality (WMA).

- Low dose (10 ug/kg/min) & high dose (40 ug/kg/min)

protocol.

Improvement in WMA with low dose

dobutamine viable myocardium.

- Ischemia is defined as a new WMA or a biphasic

response.

- Superior image quality compare to echo.

Myocardial Perfusion MR

- use of pharmacologic vasodilator (adenosine or dipyridamole) to improve the sensitivity for detection of ischemia.

function 64/58

.

function 65/58

.

Myocardial Perfusion MR

Myocardial perfusion is directly correlated to myocardial oxygenation, thus can be used to assess myocardial ischemia.

With significant stenosis, coronary blood flow cannot increase adequately with stress perfusion defect in affected coronary artery territory.

IV adenosine and IV gadolinium were given.

Myocardial Perfusion MR

Ref: MRI clinics of North America 2003.

perfusion 68/58

.

perfusion

Reversible LV contraction impairment

Stunning – persistent contractile impairment after complete return of blood flow.

Hibernation – concomitant reduction of perfusion and contractility.

Myocardial viability

Myocardial viability

- Revascularization of dysfunction but viable

myocardium improve LV function & long term

survival.

- Revascularization of non-viable myocardium

carry a risk of higher rate of death & non-fatal

events.

Myocardial viability

Ref: Kaul S. Assessing the myocardium after attempted reperfusion:

should we bother? Circulation 1998; 98:625-7.

Myocardial viability - LGE

- Increase in interstitial space late Gd

hyperenhancement (infarcted myocardium, infiltration, fibrosis)`bright is dead’

Myocardial viability - LGE

In patient with chronic MI, increasing transmural extent of delayed hyperenhacement is correlated with poor recovery of contractile function after revascularization.

CMR can quantify and predict the likelihood of myocardial functional recovery after MI.

Myocardial viability - LGE

Ref: Wagner A et al. Lancet 2003; 361: 374-379.

LGE for Myocardial Viability

Standardized Myocardial Segmentation & Nomenclature for

Tomographic Imaging of the Heart

Ref: Circulation 2002; 105: 539-542.

LGE

late enhancement

late enhancement

Slavich M, Florian A, Bogaert J - Insights Imaging (2011)

valves

valves .

valves

valves

Cardiac Mass - Apical Clot

tumor 86/58

.

tumor

aneurysm

Pattern of LGE is helpful in distinguishing infarction scar and non-infarct related disease.

If LGE omit SE layer, nonischemic disease have to be considered.

AJR 2005: 184:1420-1426.

Cardiomyopathies

Coronary MRA

technically demanding

current clinical utility of coronary CMR is limited to visualization of proximal coronary artery anatomy diagnosis of anomalous coronary artery (class I indication).

grading of coronary artery stenosis: coronary angiography.

unable to identify coronary calcification.

cardiomyopathies

cardiomyopathies .

cardiomyopathies

Perspectives

Perspectives

Perspectives

Perspectives

Perspectives

Perspectives

summary

infarct, viability

qualification for CABG

cardiomyopathies

chamber anatomy, LV mass

tumors, aneurysms, thrombi

functional analysis (LV, RV)

aorta

__________________________

valves, leaks

stress tests

molecular imaging

coronaries

CABG

chamber anatomy, LV mass

tumors, aneurysms

functional analysis (LV, RV, LA,

RA)

EP planning

great vessels

valvular morphology

__________________________

stress tests

viability

MRI CT

summary

zawał, ocena żywotności

kardiomiopatie

anatomia jam

guzy

tętniaki

pomiary czynnościowe, masa

aorta

__________________________

zastawki, przecieki

test z adenozyną

tt. wieńcowe

anatomia jam

guzy

pomiary czynnościowe

planowanie elektrofizjologii

wielkie naczynia

morfologia zastawek

MR TK

multimodality approach