Experts "Live" CTO Workshop 2015 Septemper, 18th – 19th , 2014 in Istanbul, Turkey

1. MRI for Ischemia, left ventricular
function, MI and viability, potential for
functional improvement
Dr. Francesca SANGUINETI,
MRI departement - ICPS
Institut Hospitalier Jacques Cartier, MASSY, FRANCE
- BASICS OF CTO PCI -

2. INTRODUCTION
Interesting
Challenging
Complex and Associated with
increased procedural risk
CTO PCI

3. 2 chambers 4 chambers 3 chambers
1. CARDIAC ANATOMY AND FUNCTION

4. •EDI 109 ml (62 ml/m2)
•ESI 41 ml (23 ml/m2)
•SV= 68 ml (40 ml/m2)
•HR= 75/mn
•CO=68x75=5100 ml/mn
•LVEF=(EDI-ESI)/EDI=
63%
•LV Mass(ED)=105 g/m2
1. CARDIAC ANATOMY AND FUNCTION

5. 2. DETECTION OF REVERSIBLE MYOCARDIAL
ISCHEMIA (STRESS CMR)
DOBUTAMINE STRESS CINE MR
 Similar to stress Dobutamine
echocardiography
 Step (3min): 10γ/kg/min +/-
Atropine up to FMT
 2, 3, 4 chambers + short axes
view for each step to detect LV
wall motion abnormalities

6. Dobutamine Stress Cine-MR
62 Y/O male, COPD, suspected CAD
Baseline wall motion
HR 67/mn
30 μg/kg/mn
HR 121/mn

7. Coronary Angio

8. 2. DETECTION OF REVERSIBLE MYOCARDIAL
ISCHEMIA (STRESS CMR)
DOBUTAMINE STRESS CINE MR
 Similar to stress Dobutamine
echocardiography
 Step (3min): 10γ/kg/min +/-
Atropine up to FMT
 2, 3, 4 chambers + short axes
view for each step to detect LV
wall motion abnormalities
STRESS FIRST-PASS MR
MYOCARDIAL PERFUSION
IMAGING
 First pas of gadolinium-based
contrast agent after 3 min
dipyridamole (or Adenosine)
perfusion
 Hypoperfused segments during
stress = hyposignal
 Reversible myocardial ischemia

9. Dipyridamole Stress Perfusion CMR
73 y/o male;
clinical history: stent LAD, chest pain

10. 73 y/o male; clinical history: stent LAD, chest pain
LAD tight stenosis
Dipyridamole Stress Perfusion CMR

11. DIAGNOSTIC VALUE OF PERFUSION CMR TO DETECT
HEMODYNAMICALLY SIGNIFICANT CA STENOSES: CMR vs. FFR
Stress perfusion CMR demonstrates good correlation with the
invasive reference standard FFR in the functional assessment
of coronary stenosis.
An MPRI cut-off value of 1.5 distinguished hemodynamically
significant from non-significant coronary lesions with a
sensitivity of 88% and a specificity of 90%.
Rieber J, et al. Eur Heart J 2006; 27:1465-1471.
FFR<0.75

12. DIAGNOSTIC VALUE OF PERFUSION 3T CMR TO DETECT
HEMODYNAMICALLY SIGNIFICANT CA STENOSES: CMR vs. FFR
Lockie T, et al. J Am Coll cardiol 2010;57:70-75.
Sensitivity and specificity of visual CMR analysis to detect stenoses at
a threshold of FFR<0.75 were 0.82 and 0.94, with an area under the
receiver-operator characteristic curve of 0.92

13. WHAT ABOUT THE STRESS MRI
PROGNOSTIC VALUE?
Normal stress CMR implies excellent
outcome at 3 years
MACE are predicted by AWM, perfusion
deficits, late enhancement
Functional approach rather than
anatomic
Location and extent of myocardial
ischemia
Extent of myocardial ischemia is of
importance for the prediction of MACE
and for therapeutic decision making
Kuijpers D, et al. Circulation 2003;107:1592-7.
Bodi V, et al. J Am Coll Cardiol 2007;50:1174-1179.
Jahnke et al. Circulation 2007;115:1769-1776.

14. Contrast agent has different wash-out in the normal VS pathologic
myocardium
Acquisition 10 mn after gadolinium injection
(inversion time to annul normal myocardium signal)
Can detect with high sensitivity myocardial
infarcts and specify the degree of viability
Often undetected by other techniques
Strong and independent prognostic value
(LGE independently associated with MACE HR 5.98;
2.68-13.3) Kwong RY, et al. Circulation 2006;113:2733-2743.
CONTRAST
ECOCARDIOGRAPHY
3. ASSESSEMENT OF VIABILITY:
LATE ENHANCEMENT TECHNIQUES

15. Kim RJ et al. N Engl J Med 2000;343:1445-1453.
Gd-
DTPA
HOW CAN WE PREDICT A FUNCTIONAL RECOVERY?
Severe hypokinesia but not extended LGE = reversible
dysfunction
Extended LGE before revascularization = contractility of
the wall will not improve after revascularization.

16. PRECISE PREDICTION FOR FUNCTIONAL RECOVERY IN CTO
Combining magnetic resonance viability variables, predict improvement of
myocardial function prior to percutaneous coronary intervention for CTO
Score: Transmural extent of infarction (TEI), contractile reserve,
unenhanced rim thickness and segmental wall thickening of the
unenhanced rim (SWTur) (91% sensibility and 84% specificity) in
predicting improvement of myocardial function.
Kirschbaum, et al. International Journal of
Cardiology 2011.

17. 65 Y/O male, suspected CAD
Post-CTO (8 months later)
Pre-CTO

18. TAKE HOME MESSAGES:
• MRI can provide precise and useful data on LVEF and
Wall Motion anomalies, independently of the patient
characteristics
• Good sensitivity and specificity for ischemia detection
• Excellent in viability quantification

19. CTO with normal
segmental Wall
Motion and LVEF
CTO with MI (by echo,
ventriculography, clinical
history..)
Stress Perfusion to
differentiate Reversible
ischemia from MI
hypoperfusion
Stress MRI to
confirm ischemia
extension
Viability to detect
subendocardial MI
Viability to study
transmural extension
< 50%
CTO PCI
> 50% Dobutamine low
dose MRI for contractile
reserve
CTO PCI