echocardiography and magnetic resonance imaging for...
TRANSCRIPT
Echocardiography and
Magnetic Resonance Imaging
for detection of
Coronay Artery Disease
Hans-Marc J. Siebelink MD PhD
Leiden University Medical Center
Cardiology, Non-Invasive Imaging
Leiden, The Netherlands
Ischemic Cascade
Duration Ischemia
Tests: Functional vs Anatomic test?
ImpairedPerfusion
Metabolic changes
Diastolic
dysfunction
Systolic
dysfunction
ECGAngina
Infarction
Echocardiography MRI“working horse”
Available / bed site Not in every practice
Quick Protocol 30-60 min
Easy Technical, processing
Function (syst / diast) Function (syst / diast)
Stress function Stress function
Perfusion Perfusion
Coronary anatomy
First line clinical practiceWall motion assessment
Cerqueira, Circ 2002
Vascular pattern?
2D-echocardiography
Visual function
3D-echocardiography
Automatic border (TomtTec®) detection on 4D volume contrast acquisitions
Echo wall motion abnormality
Global Apical
Idiopathic DCM Aneurysm post infarct
Echo wall motion abnormality
LV thrombus?
Near field artefact
MRI wall motion abnormality
Inferior wall motion abnormality
Inferior infarction?
Regional wall motion abnormality
Suggestive CAD How to prove it?
Tissue characterisation
perfusion echo
delayed enhancement (DE) MRI
Provoke ischemia stress echo / MRI
Perfusion assessment stress echo / MRI
Echo tissue characterizationcontrast perfusion
4 chamber 2 chamber
Antero-apical perfusion defect infarction
MRI tissue characterizationDelayed enhancement (DE)
Kim et al. Cardiovascular MRI and CT. Higgins, de Roos. Eds 2002
Vogel-Claussen, Radiographics 2006
DE MRI Technique
DE MRI
Inferior infarction
Non-transmural?
DE MRI
Inferior infarction
Non-transmural and transmural
Management?
Recovery LV function
Infarct transmurality predictive of recovery
Delayed enhancement MRI
Clinical practice: cutoff 50%
Infarct transmurality %
Kim R, NEJM, 2000
Viability and prognosis
Allman, JACC 2002
Dobutamine stress echo
Recruitment wall motion pos identification
Beta adrenergic stimulation
Biphasic response
Baseline:wall motion abnormalities
Low dose: improvement wall motion viability
(High dose: deterioration wall motion) ischemia
Angina, ECG
Highly operator dependent, image quality
Dobutamine stress echo
No wma no ischemia
Rest
10 γ
40 γ
Recovery
Dobutamine stress echo
Angina, ST , wma Ischemia
Rest 20 γ
10 γrecovery
Recovery
Dobutamine stress MRI
Recruitment wall motion pos identification
Beta adrenergic stimulation
Biphasic response
Baseline:wall motion abnormalities
Low dose: improvement wall motion viability
(High dose: deterioration wall motion) ischemia
Angina, ECG not applicable
Less operator dependent, image quality
basal
mid
apical
protocol: compare cine-series
rest dobutamine
Dobutamine stress MRI
Courtesy PRM van Dijkman
Severe LAD stenosis
Dobutamine 20γ Dobutamine 40 γWorseningwall motion
Mild septalhypokinesia
Dobutamine stress MRIRest: severe hypokinesia anteroseptal region
Courtesy PRM van Dijkman
basal, dobu 30 γ basal, dobu 30 γ
Dobutamine stress MRI
The use of tissue tagging
Courtesy PRM van Dijkman
Echo myocardial perfusion
Rest Adenosine
Perfusion defect apical septal ischemia
basal mid apical
High spatial resolutionAssessment subendocardial and transmural defects
MRI myocardial perfusionnormal study
Courtesy PRM van Dijkman
MRI myocardial perfusion
Courtesy PRM van Dijkman
Basal mid
Transmural perfusion defect mid inferolateral
80%82%Echo perfusion
specsensFunctional tests
87%85%PET perfusion
80%81%Dobu stress echo
96%
86%
91%
87%
68%
95%Dobu stress MRI with Tagging
86%Dobu stress MRI
73%SPECT perfusion
81%MRI perfusion
77%Bicycle exercise stress test
Salerno Circ Im 2009, Marwick Heart 2003, Nagel Circulation 1999
Predictive values detection CAD
MRI coronary angiography
Technically difficult
Time consuming
84% Patients successful
Proximal arteries only
Future high field?!
Ischemic CascadeFunctional tests for CAD
Duration Ischemia
Perfusion
impaired
Metabolic changes
Diastolic
dysfunction
Systolic
dysfunction
ECGAngina
Infarction
Echo
Nuclear
MRI
Nuclear
Echo
Nuclear
MRI
Echo
Nuclear
MRI
Echo
Nuclear
MRI
Resume detection CAD
Echo, MRI and Nuclear all - accurate
- robust.
For your clinical practice:
Choose your modality / modalities
(no need to perform all)
Gain experience
Aim high quality