HEART AND AORTA - Collegium Medicum UMK · 2015-01-07 · aorta _____ valves, leaks stress tests...
Transcript of HEART AND AORTA - Collegium Medicum UMK · 2015-01-07 · aorta _____ valves, leaks stress tests...
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
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LV functional assessment, chamber morphology, cardiac tumors
valve morphology
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PTCA follow-up
pericardial calcifications
triple rule-out
Calcium Score, Calcium Mass
contraindications
„allergy” do contrast media
arrhythmia (e.g. atrial fibrillation)
dyspnoe
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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)
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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
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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