Case
<ul><li>80 yo F with PMH of HTN, HLD, DM, CVA with a history of continuous chest pain x 2 weeks.  Patient was found to hav...
 
 
 
 
 
 
Dobutamine CMR <ul><li>Contractile reserve can be assessed using low dose dobutamine stress test </li></ul><ul><ul><li>All...
Contrast Enhancement CMR <ul><li>Regions of myocardial infarct exhibit signal intensity (contrast enhancement) on T1-weigh...
Mahrholdt, et al.  Heart   2007
Use of contrast enhanced MRI to identifify reversible myocardial dysfunction <ul><li>Methods </li></ul><ul><ul><li>50 pati...
Viability post CABG <ul><li>Methods </li></ul><ul><ul><li>60 patients undergoing mutlivessel CABG were studies preoperativ...
Predicting Late Myocardial Recovery and Outcomes in Early hours of STEMI <ul><li>Methods </li></ul><ul><ul><li>104 prospec...
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Cardiac MR and viability

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Cardiac MR and viability

  1. 1. Case
  2. 2. <ul><li>80 yo F with PMH of HTN, HLD, DM, CVA with a history of continuous chest pain x 2 weeks. Patient was found to have a LBBB on unknown duration. Cardiac enzymes were negative. The patient was transferred to WHC for further management. </li></ul>
  3. 9. Dobutamine CMR <ul><li>Contractile reserve can be assessed using low dose dobutamine stress test </li></ul><ul><ul><li>Allows for superior endocardial border definition facilitating more accurate wall motion and wall thickening </li></ul></ul><ul><li>Dobutamine CMR vs PET </li></ul><ul><ul><li>35 patients with mild LV dysfunction </li></ul></ul><ul><ul><li>Sensitivity of 88% and Specificity of 87% for detecting regions of viable myocardium </li></ul></ul><ul><li>Reduced predictive ability with more severe dysfunction is present at rest with specificity in the 80% range, but sensitivity limited to 50% </li></ul><ul><ul><li>If contractile function improves with dobutamine the there is likely viability </li></ul></ul><ul><ul><li>Lack of improvement, however, does may not rule out viability as ischemia may develop at even low levels of dobutamine administration </li></ul></ul>Mahrholdt, et al. Heart 2007
  4. 10. Contrast Enhancement CMR <ul><li>Regions of myocardial infarct exhibit signal intensity (contrast enhancement) on T1-weighted images after administration gadolinium </li></ul><ul><ul><li>Gadolinium passively diffuses into the intracellular space due to rupture of myocyte membranes leading to increased contrast concentration in interstitial space between collagen fibers </li></ul></ul><ul><li>Contrast images are acquired mid-diastole </li></ul><ul><li>The inversion time must be manually selected to null signal from normal myocardial regions </li></ul><ul><ul><li>This varies btw patients as a function of dose and and time after administration of contrast due to varying pharmacokinetics. </li></ul></ul>Mahrholdt, et al. Heart 2007
  5. 11. Mahrholdt, et al. Heart 2007
  6. 12. Use of contrast enhanced MRI to identifify reversible myocardial dysfunction <ul><li>Methods </li></ul><ul><ul><li>50 patients prospectively enrolled </li></ul></ul><ul><ul><ul><li>Of these 41 patient had MRI before and after revascularization </li></ul></ul></ul><ul><ul><li>Inclusion criteria </li></ul></ul><ul><ul><ul><li>Scheduled to undergo revascularization </li></ul></ul></ul><ul><ul><ul><li>Had regional wall motion abnormalities bu ventriculogram or echo </li></ul></ul></ul><ul><ul><li>Exclusion criteria </li></ul></ul><ul><ul><ul><li>Unstable angina </li></ul></ul></ul><ul><ul><ul><li>NYHA Class IV heart failure </li></ul></ul></ul><ul><ul><ul><li>Contraindication for MRI </li></ul></ul></ul><ul><li>Results </li></ul><ul><ul><li>80 percent of patient demonstrated hyperenhancement </li></ul></ul><ul><ul><li>50 percent with q waves on ekg showed hyperenhacement </li></ul></ul><ul><ul><li>Before revascularization, 38 percent of pts had abnormal contractility and 33 percent had some areas of hyperenhancement </li></ul></ul><ul><ul><li>Areas with dysfunctional, but non-hyperenhancing myocardium improved significantly after revascularization </li></ul></ul>Kim et al NEJM , 2000
  7. 13. Viability post CABG <ul><li>Methods </li></ul><ul><ul><li>60 patients undergoing mutlivessel CABG were studies preoperatively, 6 days and 6 months post op </li></ul></ul><ul><ul><li>Patients were also randomized to be off pump and on pump </li></ul></ul><ul><ul><li>Exclusion: age > 75 yo, severe pre-existing LV dysfunction, CKD, typical MRI contraindications </li></ul></ul><ul><li>Results </li></ul><ul><ul><li>Preoporatively 21% of wall segments had abnormal regional function, whereas 14% showed evidence of hyperenhancement </li></ul></ul><ul><ul><li>At 6 months, 57% of wall segments had improved contraction by at least one grade </li></ul></ul><ul><ul><li>Strong correlation between the transmural extent of hyperenhancement and ther recovery of in regional function at 6 months </li></ul></ul>Selvanayagam et al Circulation , 2004
  8. 14. Predicting Late Myocardial Recovery and Outcomes in Early hours of STEMI <ul><li>Methods </li></ul><ul><ul><li>104 prospectively enrolled patients with successfully reperfused STEMI </li></ul></ul><ul><ul><li>Exclusion criteria were recent MI (<6months), shock requiring IABP, respiratory failure, contraindications for MRI </li></ul></ul><ul><ul><li>Subjects were followed prospectively at 33 months and MRI was repeated at 6 months </li></ul></ul><ul><ul><li>Primary endpts were change in LVEF and LV dysfunction at 6 months. </li></ul></ul><ul><ul><ul><li>Secondary endpt was MACE </li></ul></ul></ul><ul><li>Results </li></ul><ul><ul><li>LGE was the best predictor of late LV dysfunction </li></ul></ul><ul><ul><li>LGE > 23% of volume accurately predicted late dysfunction (sensitivity 89%, specificity 74%) </li></ul></ul><ul><ul><li>LGE > 23 % carried a hazard ration of 6.1 percent for adverse events (p<0.0001) </li></ul></ul>Larose et al JACC , 2010
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