what’s new in cardiac mri...disclosures •no financial disclosures •use of gadolinium for...
TRANSCRIPT
What’s New in Cardiac MRI
Katie M. Hawthorne, MD
Director, Cardiac MRI
Main Line Health
Philadelphia Cardiovascular Summit
November 18, 2017
Disclosures
• No financial disclosures
• Use of gadolinium for cardiovascular MRI is off-label use and not
FDA approved
2 Cardiac MRI: Disclosure
Objectives
• Review (briefly) the indications for cardiac MRI
• Discuss new guidelines that include cardiac MRI
• Discuss new technology
3 CMR: Objectives
CMR: Indications • Complex congenital heart disease: including anomalous coronary origin, great vessels, cardiac chambers, and
valvular disease.
• Quantify shunt: Qp:Qs; as well as precise cardiac chamber size
• Evaluate left/right ventricular systolic function (*gold standard)
• Myocardial viability
• Evaluation of specific cardiomyopathies:
– Hypertrophic cardiomyopathy
– Infiltrative: sarcoid, hemochromatosis, amyloidosis
– Arrhythmogenic ventricular cardiomyopathy (ARVC)
– Cardiotoxic therapy
• Evaluation of cardiac masses (suspected tumor or thrombus)
• Myocarditis
• Pericardial disease: acute/chronic pericarditis, constrictive pericarditis
• Ventricular tachycardia: evaluate for areas scar to aid ablation
• Valvular disease: quantify regurgitation volume, planimetry valve area
• Aortic pathology
• Pulmonary veins/anomalies
• Inadequate Echo images TDS or discrepancy between clinical scenario and echocardiogram (moderate aortic regurgitation by echo, symptoms suggesting severe)
• Appropriateness criteria OLD
Appropriateness Criteria for CCT/CMRJACC Vol. 48, No. 7, 2006
Title is 24 pt Arial and can continue onto 2 lines
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JASE 2017 30(4): 303-371
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JASE 2017 30(4): 303-371
Valvular Regurgitation
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JASE 2017 30(4): 303-371
Valvular Regurgitation
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JASE 2017 30(4): 303-371
Valvular Regurgitation: Key Points
• CMR is an excellent modality for evaluating native
valvular regurgitation. While echocardiography
remains the first-line modality, CMR is indicated when:
– Echo images are suboptimal
– Discordance exists between 2D echocardiographic features
and Doppler findings
– Discordance exists between clinical assessment and severity
of regurgitation by echocardiography
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Valvular Regurgitation: Key Points
• CMR may also provide
additional information about
the mechanism of
regurgitation and myocardial
viability, both of which may
have implications for surgical
intervention.
• CMR importantly provides
quantitative evaluation of
chamber size, regurgitant
volume and fraction.
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Mahrhold et al: Eur Heart J 2005 (26): 1461
Myocardial Characterization
Hypertrophic Cardiomyopathy
• Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disorder, with an estimated prevalence of 1:500 in the general population
• Diagnosis of HCM requires confirmation with cardiac imaging of phenotypic expression: unexplained increase in LV wall thickness (≥15 mm in adults) associated with a nondilated LV chamber
• More recently, CMR has emerged as a powerful complementary tool due to its unique strengths of tomographic imaging and enhanced spatial resolution, which affords better characterization of the complex HCM phenotype.
• CMR provides an opportunity to provide more precise LV wall thickness measurements, find atypical hypertrophy patterns and characterization of the LVOT, papillary muscle and subvalvular anatomy.
J Am Coll Cardiol. 2014;64(1):83-99
Hypertrophic Cardiomyopathy
Kaplan-Meier unadjusted estimates of freedom from
reaching combined primary end point (cardiovascular
death, unplanned cardiovascular admission,
sustained ventricular tachycardia or ventricular
fibrillation, appropriate implantable cardioverter-
defibrillator discharge) in 217 hypertrophic
cardiomyopathy (HCM) patients according the
presence or absence of fibrosis J Am Coll Cardiol. 2010;56(11):867-874.
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Circulation 2017 136(19): e273-e344
Hypertrophic Cardiomyopathy
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Circulation 2017 136(19): e273-e344
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JACC: CV Imaging 2017 10(10):1180-1193
JACC 2012 60(5): 408-420
Nonischemic Cardiomyopathy
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Nonischemic Cardiomyopathy EF>35%
Circulation 2017 135:2106-2115
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Circulation 2017 136(19): e273-e344
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Circulation 2017 136(19): e273-e344
Sarcoidosis
• Patients with LGE had a ninefold
higher rate of major adverse events
(17.2 versus 1.9 percent per year)
and 11.5-fold higher rate of cardiac
death (11.5 versus 1.0 percent per
year) as compared to patients
without LGE.
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Circulation. 2009;120(20):1969
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Tissue Characterization: New Advances
Journal of CMR 2017 19:75
Advancing Technology
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Questions?
Thank you!