HEART AND AORTA. Zbigniew Serafin

Transcription

1 HEART AND AORTA Zbigniew Serafin

2 CARDIAC CT

3 CT

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

5 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: % 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: % 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: Meijboom WB, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol. 2008;52: % 82% 5,6 0,07 99% 64% 2,7 0,02

6 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:

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

8 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

9 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) 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

10 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 Jan;19(1):42-9.

11 anatomy 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

12 anatomy

13 coronaries

14 tt. wieńcowe

15 tt. wieńcowe

16 coronaries

17 coronaries

18 coronaries

19 coronaries

20 CABG

21 tumors

22 tumors

23 valves

24 LV function 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

25 LV function

26 czynność

27 LV function wall motion wall thickenning ED wall thickness

28 EP planning

29 EP planning

30 EP planning

31 EP planning

32 Perforacja prawej komory

33 RV perforation

34 RV perforation

35 RV perforation Seegers J et al. Clin Res Cardiol 2009

36 RV perforation

37 CARDIAC MR

38 MRI

39 Intro 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.

40 Advantages of MRI 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.

41 Indications cardiac failure size and morphology of chambers, LV mass, contractility, viability CAD anomalies of corinaries, stenosis (?) IHD infarct, scar cardiomyopathies valvular disease tumors pericardial disease congenital disease aorta size and location of ischemia, stress tests size and location of necrosis and scar, viability, thrombus size and morphology of chambers, LV mass, contractility, amyloidosis, ARVD ventricular morphology, velocities, gradient estimation morphology, vascularity, infiltration, differentiation with thrombi morphology, thickness, LV sizing chamber morphology, leaks dissection, intramural hematoma, anomalies

42 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

43 Safety

44 Safety

45 Safety cardiac stents peripheral stents safe / conditional safety MRI at any time safe / conditional safety MRI at any time or after 6 mo. aortic stent-grafts safe / conditional safety / unsafe valves ocluders stimulators cardiowerters safe / conditional safety MRI at any time safe / conditional safety MRI at any time or after 6 mo. unsafe MRI in life-threating conditions MRI-compatible devices (FDA clearance)

46 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

47 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 m 2 dialysis insufficiency of kidneys and liver

48 Safety

49 Cardiac MR - Equipment 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.

50 Cardiac MR - Equipment ECG leads for monitoring of patient s condition & gating.

51 Cardiac MR - Equipment

52 Performing Cardiac MR 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.

53 Performing Cardiac MR

54 Performing Cardiac MR

55 Performing Cardiac MR

56 Performing Cardiac MR

57 Left ventricular function Left Ventricular Function Patient s LV parameter Reference value (mean± SD)* End Diastolic Volume (EDV in cc) ± 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) ± 20.0 Heart Rate (bpm)

58 anatomy

59 anatomy

60 anatomy

61 Cardiac MR in CAD 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

62 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.

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

64 64/58 function.

65 65/58 function.

66 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.

67 Myocardial Perfusion MR Ref: MRI clinics of North America 2003.

68 68/58 perfusion.

69 perfusion

70 Myocardial viability Reversible LV contraction impairment Stunning persistent contractile impairment after complete return of blood flow. Hibernation concomitant reduction of perfusion and contractility.

71 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.

72 Myocardial viability Ref: Kaul S. Assessing the myocardium after attempted reperfusion: should we bother? Circulation 1998; 98:625-7.

73 Myocardial viability - LGE - Increase in interstitial space late Gd hyperenhancement (infarcted myocardium, infiltration, fibrosis)`bright is dead

74 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.

75 Myocardial viability - LGE Ref: Wagner A et al. Lancet 2003; 361:

76 LGE for Myocardial Viability

77 Standardized Myocardial Segmentation & Nomenclature for Tomographic Imaging of the Heart Ref: Circulation 2002; 105:

78 LGE

79 late enhancement

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

81 valves

82 valves.

83 valves

84 valves

85 Cardiac Mass - Apical Clot

86 86/58 tumor.

87 tumor

88 aneurysm

89 Cardiomyopathies 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:

90 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.

91 cardiomyopathies

92 cardiomyopathies.

93 cardiomyopathies

94 Perspectives

95 Perspectives

96 Perspectives

97 Perspectives

98 Perspectives

99 Perspectives

100 summary coronaries CABG chamber anatomy, LV mass tumors, aneurysms functional analysis (LV, RV, LA, RA) EP planning great vessels valvular morphology stress tests viability CT MRI infarct, viability qualification for CABG cardiomyopathies chamber anatomy, LV mass tumors, aneurysms, thrombi functional analysis (LV, RV) aorta valves, leaks stress tests molecular imaging

101 summary MR TK zawał, ocena żywotności kardiomiopatie anatomia jam guzy tętniaki pomiary czynnościowe, masa aorta zastawki, przecieki test z adenozyną tt. wieńcowe anatomia jam guzy multimodality approach pomiary czynnościowe planowanie elektrofizjologii wielkie naczynia morfologia zastawek