cardiovascular imaging studies - health.ucdavis.edu · cardiovascular imaging studies to the heart...
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Cardiovascular Imaging StudiesTo the Heart of the Matter
Thomas Smith, MDDepartment of Internal Medicine
Cardiovascular MedicineMay 4, 2013
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Disclosures
I have no financial or professional disclosures pertaining to this presentation.
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Optical Coherence
Tomography
Nuclear Imaging
EchocardiographyTEE/TTE
Cardiac Computed Tomography
Cardiac Magnetic Resonance Imaging
Intravascular Ultrasound
IntracardiacEchocardiography
Anatomy
Function
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Optical Coherence
Tomography
Nuclear Imaging
EchocardiographyTTE
EchocardiographyTEE
Cardiac Computed Tomography
Cardiac Magnetic Resonance
Imaging
Intravascular Ultrasound
IntracardiacEchocardiography
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Simply complex - Advances
• Ability to see region of interest in more detail and less invasively.
• Potential for the same or a more defined diagnosis with less risk to patients.
•
• Ability to communicate images and findings quickly and effectively (procedural/team).
DiagnosisDiagnosis and Guidance (less
invasive)
Invasive Non-Invasive
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• Cardiovascular imaging modalities available and how to utilize them.
– MRI
– Computed Tomography
– Echocardiography
• TTE/TEE/IVUS
– Nuclear Imaging
– Procedural guidance
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CARDIAC MAGNETIC RESONANCE IMAGING
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MRI
Lee Card MRI 2006
Align Protons (always on)
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Cardiac MRI – When is it useful?
• Congenital heart disease• Vascular – Aorta• Diseases of myocardium• Diseases of pericardium• Viability• Left and right ventricular function – gold standard• Shunts
• Cardiac stress testing – dobutamine/adenosine• Coronary artery disease – imaging of coronaries
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MRI• Advantages
– View of whole heart (not limited by bones/etc)– No radiation– Calcium does not cause artifact
• Disadvantages– Magnet (PM-limited, ICDs, clips -> artifacts)– Claustrophobia– Expensive– Long acquisition time – may take hours– Nephrogenic systemic fibrosis (gadolinium)– Long post-processing time– Limited by arrhythmias– Patient must be able to follow breathing instructions
(CT and MRI)-translators if necessary
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Non-contrast. Signal to Noise
Gold standard
LV, RVEF
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Flow through ASD- Phase Contrast
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MRI Stress Test - Normal wall motionRest function
Stress
function
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Normal Rest Perfusion
Gated image during contrast delivery
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Pharmacologic Stress
• Adenosine agonist
– Dipyridamole, Adenosine, Regadenoson
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1
time
1
time
2
Rest
Stress
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1
time
2
Stress
Flow impairing plaque
impairs vessel dilation
Less dilation – less flow
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56 yo F with LAD lesion
stress
rest
Less flow, less blood, less contrast
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Delayed enhancement - Scar
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CHEST MRA
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Whole Heart MRI
• Uses gating of breathing and heart rate.
• No prolonged breath holds.
• Potential for clinical assessment of coronary artery disease – if resolution improved.
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Pacemaker and MRI• Potential risks
– Lead heating
– Unintended cardiac stimulation
– Device interactions
• System includes leads/PM
• No ICDs – yet…
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MRI CT
Conduit from ascending aorta to descending aorta.
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Cardiac CT – When is it useful?
• Chest pain syndrome– Exclude CAD (99% NPV)– CP in Emergency room
• Equivocal stress test• Non-coronary artery cardiac surgery
– Exclude CAD
• Prior bypass surgery
– Determine patency of grafts (not great for severe native disease)
• Congenital anomalies of the coronary circulation
• Coronary or pulmonary venous anatomy
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Cardiac Computed Tomography
• Advantages – Anatomic advantages similar to MRI– High resolution coronary artery angiography– Rapid acquisition time– Pacemakers/ICDs are safe (although with artifact)
• Disadvantages– Ionizing radiation– Patient must be able to follow breathing instructions
(CT and MRI)-translators if necessary– Post-processing required– Potential renal injury– Does not assess flow (yet…)
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Third Generation CT
• Arc of detector elements
• Wider fan beam
• Translation of tube and detector
• Faster scan speed
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01010110101010010000101110101011101011110010101010010101110111100101110101001010101110101010100101010101010101010110101010101010101011010101010010101010
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More coverage with larger detectors
64 x 0.625 = 40mm
128 x 0.625 = 80mm
320 x 0.625 = 200mm
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More coverage with larger detectors
64 x 0.625 = 40mm
128 x 0.625 = 80mm
320 x 0.625 = 200mm
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More coverage with larger detectors
64 x 0.625 = 40mm
128 x 0.625 = 80mm
320 x 0.625 = 200mm
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The average person in the U.S.receives an effective background doseof about 2.5 – 3 mSv per year
0.021.5 2-6 2.5 3
78
910
18
5
10
6-15
12-26
0
5
10
15
20
25
30
Relative Radiation DoseReal World Results Vary Widely
mS
v
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High Pitch Coronary CT ScanningMale patient (183 cm, 78 kg, heart rate 54 b.p.m.).
Achenbach S et al. Eur Heart J 2010;31:340-346
0.89 mSv
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Gated with
contrast
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Plaque visualization
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Acute Chest Pain Syndrome in the ED
• Challenging strain on delivery system
– 8 million visits annually in the US
– ACS diagnosis is made in only 10-15% of these patients
• $10 billion annual cost
• Three recent randomized trials
– CT vs usual care in the ED in CP patients
– Low to intermediate risk patients
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What the studies demonstrated
• CTCA in low-to-intermediate risk patients is safe with similar patient outcomes when compared to currently available testing.
• CTCA use results in faster triage in ED.– Faster discharge/faster diagnosis/faster admit.
• ER costs are reduced.– although no significant overall savings.
• Does not apply to intermediate or high risk patients.
• Safe and quick at about the same cost.
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Copyright © 2012 American Medical
Association. All rights reserved.
From: Diagnostic Accuracy of Fractional Flow Reserve From Anatomic CT Angiography
JAMA. 2012;308(12):1237-1245.
doi:10.1001/2012.jama.11274
The future of coronary CT?
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Structural heart disease
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Structural heart disease
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Structural heart disease
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Structural heart disease
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Single breath-hold. Mechanical valve assessment
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CT prior to EP ablation
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ECHOCARDIOGRAPHYImaging workhorse.
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Ultrasound
• Helmet Hertz – only few years in cardiac imaging. Developed ink-jet technology.
– Advised Seimens Corporation not to enter cardiac ultrasound because there was not a great future
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Echocardiography Methods
• Transthoracic echocardiography
• Transesophageal echocardiography
• Intracardiac echocardiography
• Intravascular echocardiography
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Sector Transducers2D and 3D
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TTE
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TTE
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Transesophageal Echocardiography
– Evaluate for cardiac source of embolism (36%)
– Endocarditis (14%)– Prosthetic valve function
(12%)– Valvular disease, aortic
dissection or aneurysm, tumor, mass or thrombus (6-8% each).
– Congenital heart disease (4%)
– Interventional cardiology guidance
– Intraoperative evaluation cardiothoracic surgery.
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Echocardiography Training
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Intracardiac Echocardiography
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Intracardiac Echocardiography
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Intracardiac echo
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NUCLEAR PERFUSION IMAGING
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Stress Testing
• Multiple possible modalities
• Major use for nuclear cardiac imaging
• Stress tests indicated for
– Initial evaluation of suspected ischemic chest pain
– Significant change in cardiac symptoms
– Prognosis in patients with known disease
• SPECT, PET/Rb
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PET Perfusion Scans
• Higher energy particle (511 keV vs 100). – Less attenuation (goes through
breast/bone/walls/etc).
– May be more reliable in obese patients.
– “easier” to read
• Rb-82.– Stress and rest imaging in 30 minutes.
• Allows non-invasive assessment of coronary blood flow – imaging as Rb is injected.
• Typically uses CT for attenuation correction.
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PET Rb Imaging
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Triple vessel disease
Heart 2012;98:592-600 doi:10.1136/heartjnl-2011-300790
1
2
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CARDIOVASCULAR IMAGINGPROCEDURAL GUIDANCE
Maximizing success with pre and intra-procedural imaging.
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Matching up C-arm angle – reducing contrast and radiation in the cath lab
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Optical Coherence
Tomography
Nuclear Imaging
EchocardiographyTTE
EchocardiographyTEE
Cardiac Computed Tomography
Cardiac Magnetic Resonance
Imaging
Intravascular Ultrasound
IntracardiacEchocardiography
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Conclusions and Future Directions
• More integration across cardiovascular imaging platforms.
• Radiation exposure will continue to decrease.
• More melding of function with anatomy.
• Imaging will play a more robust role in procedural guidance.
• Keep playing your video games.
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Thank you.