New Modalities for Imaging the Failing Heart: How Do They Help?

Paul J. Kim, MD, FACCAssistant Clinical Professor of MedicineDivision of CardiologyUniversity of California, San Diego

18th Annual San Diego Heart Failure SymposiumJanuary 19-20, 2018

• Grant/Research Support: Astellas Pharma

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Disclosures

We will review in this session:

1. Cardiac imaging modalities available

2. Choosing the appropriate cardiac imaging modality

3. Nonbiopsy diagnosis of cardiac amyloid

4. Imaging for cardiac sarcoidosis

5. Other advanced cardiac imaging techniques

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Learning Objectives

• Echocardiogram• Nuclear cardiac imaging• Cardiac MRI• Cardiac CT

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Non-invasive Cardiac Imaging Modalities

• Essential tool that provides structure, function and assessment of intracardiac hemodynamics.

• No radiation, relatively quick exam with reasonable spatial and excellent temporal resolution.

• Limited acoustic windows (obesity) and myocardial tissue characterization.

• Significant advancements with 3D acquisition and contrast echocardiography.

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Echocardiogram

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Echocardiogram

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Echocardiogram

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Echocardiogram

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3D Echocardiogram

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3D Echocardiogram

• Widespread cardiac imaging modality that provides function (not structure), perfusion, and viability.

• Newer advancements for evaluation of sarcoid and amyloid cardiomyopathies.

• Does not evaluate valvular disease, pericardium or intracardiachemodynamics.

• Patients are exposed to ionizing radiation.

• Shortages in technetium-99m in the late 2000s.

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Nuclear cardiac imaging

• SPECT/CT

• Perfusion (99mTc-sestamibi, 99mTc-tetrosfosmin, 201Tl)

• Viability (201Tl)

• ATTR amyloid (99mTc-PYP, 99mTc-DPD)

• PET/CT

• Perfusion ([82Rb]-Rubidium, [13N]-Ammonia)

• Viability ([18F]-FDG)

• Sarcoid ([18F]-FDG)

• MUGA

• Function (99mTc-red blood cell)

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Nuclear cardiac imaging

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SPECT myocardial perfusion imaging

Heller and Hendel. Handbook of Nuclear Cardiology 2013.

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PET viability

Heller and Hendel. Handbook of Nuclear Cardiology 2013.

• Advanced cardiac imaging technique with high spatial and temporal resolution.

• No radiation and gadolinium contrast can be used without concern for acute kidney injury.

• Provides high resolution structure, function and myocardial perfusion. Can demonstrate myocardial viability.

• Limited by longer time for acquisition (narrow bore) and arrhythmias at time of exam.

• Excellent for myocardial tissue characterization and pericardial evaluation.

• Cannot estimate intracardiac pressures and does not provide enough spatial resolution to evaluate for coronary artery disease.

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Cardiac MRI

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Myocardial infarction with Cardiac MRI

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Late gadolinium enhancement shows nonviable myocardium

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Cardiac MRI is excellent for characterization of myocardial mass

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Late gadolinium enhancement in cardiac sarcoma

• Advanced cardiac imaging technique with high spatial resolution but lower temporal resolution.

• Of all the modalities, provides the highest spatial resolution consistently. Can provide detailed evaluation of coronary anatomy.

• Provides high quality anatomical structure (great for cardiac masses), function.

• Great tool for prognostication (CAC).

• Does not provide evaluation for valvular regurgitation, intracardiachemodynamics and limited myocardial tissue characterization. Patients are exposed to ionizing radiation and iodinated contrast.

• Able to diagnose other causes of chest pain (e.g. pulmonary embolism, aortic dissection).

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Cardiac CT

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Coronary CTA

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Cardiac CT

• Structure

• Cardiac CT• Cardiac MRI

• Echo

• Function – Echo or Cardiac MRI• Myocardial tissue characterization

• Cardiac MRI• PET; Tc 99m pyrophosphate SPECT

• Ischemia

• CMR, FFR-CT, PET, SPECT, stress echocardiogram

• Viability

• Cardiac MRI, PET, Thallium23

Choosing the “right” cardiac imaging

Ischemic

• CCT

• Stress

• Echo

• MRI

• Nuclear

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Another paradigm for choosing a cardiac imaging test

Non-ischemic

• MRI

• Sarcoid – PET

• Amyloid – 99m Tc PYP

or MRI

• Nuclear imaging with bone seeking tracers shows high sensitivity (91%) and specificity (92%) for ATTR cardiac amyloid1.

• A positive Tc 99m pyrophosphate scan without evidence of an abnormal monoclonal protein can diagnose ATTR cardiac amyloid without the need for biopsy2.

• Cardiac MRI can demonstrate late gadolinium enhancement that can provide early diagnosis and offer prognostic value3.

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Nonbiopsy diagnosis of Cardiac Amyloid

1. Castano et al. JAMA Cardiol 2016.2. Castano et al. Current Cardiovascular Risk Reports 2017.3. Fontana et al. Circulation 2015.

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Nonbiopsy diagnosis of Cardiac Amyloid

• HFpEF• LVH (>1.3 cm), biatrial enlargement

and restrictive filling pattern

• Tc 99m pyrophosphate scan• SPEP, UPEP, immunofixation,

kappa & lambda light chains

• Cardiac MRI

Tc 99m PYP + - -

Monoclonal protein

- + -

Cardiac MRI + + +

ATTR AL Other

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99mTc pyrophosphate imaging for TTR cardiac amyloid

Bokhari et al. J Nucl Cardiol 2016.

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99mTc pyrophosphate imaging for TTR cardiac amyloid

Castano et al. JAMA Cardiol 2016.

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MRI in Cardiac Amyloid

Fontana et al. Circulation 2015.

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Transmural late gadolinium enhancement predicts death in Cardiac Amyloid

Fontana et al. Circulation 2015.

• FDG-PET shows high sensitivity to detect active cardiac sarcoidosis1.

• Following treatment, degree of FDG uptake reduces or resolves with good response to treatment2.

• Cardiac MRI is also a useful diagnostic tool to determine cardiac involvement with excellent sensitivity (>90%)3. However, cardiac MRI has not been demonstrated to follow treatment response.

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Imaging of Cardiac Sarcoidosis

1. Mc Ardle et al. Circ Cardiovascular Imaging 2013.2. Osborne et al. J Nucl Cardiol Off Publ Am soc Nucl Cardiol 2014.3. Smedema et al. JACC 2005.

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FDG-PET positive in Cardiac Sarcoidosis

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Serial PET with treatment of cardiac sarcoid

1. Osborne et al. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol 2014.

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4D Flow with Cardiac MRI

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Aortic regurgitant fraction

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Repaired Tetralogy of Fallot

Repaired Tetralogy of Fallot

Net flow: 4.835 L/minRegurgitant fraction: 48%

Regurgitant volume: 4.433 L/min

Excess volume loading

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FFR-CT

1. Koo et al. JACC 2011.2. Douglas et al. Eur Heart J 2015.

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Quantitative Perfusion Cardiac MRI

• Which question are you asking:

• Structure? Echo, Cardiac CT or MRI

• Function? Echo or Cardiac MRI

• Myocardial tissue characterization? Cardiac MRI

• Coronary disease? Cardiac CT

• Viability? Cardiac MRI or PET

• Non-biopsy diagnosis of amyloid can be obtained with:

• Tc 99m PYP scan AND SPEP/UPEP with immunofixation and kappa/lambda ratio.

• For cardiac sarcoid, refer for FDG PET with sarcoid protocol

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Summary

Questions?

Paul J. Kim, M.D.cell: 310-490-7217pjk017@ucsd.edu