Uploaded byMasahiro Terashima
Cvic tmdu 071913_share
1) Cardiac MRI provides a comprehensive assessment of cardiac structure and function through techniques such as cine imaging, perfusion imaging, late gadolinium enhancement (LGE), and coronary magnetic resonance angiography (MRA) in a single exam without radiation exposure. 2) LGE can identify myocardial scar from prior myocardial infarction (MI), myocarditis, and non-ischemic cardiomyopathies. The detection of unexpected scarring by LGE has important prognostic implications. 3) Combining cardiac CT for assessment of coronary artery calcium with cardiac MRI can help identify patients with prior "unrecognized" MI missed by other testing due to small scars or absence of symptoms.
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- 1. Current Applications ofCardiac MRI Masahiro Terashima, MD, PhD CV Imaging Clinic (CVIC) Iidabashi Whole-Heart Coronary MRA
- 2. Today’s Agenda • CardiacMRI in Japan – Recent trends of cardiac MRI in Japan • Cardiac MRI@CVIC – Ischemic – Non-ischemic • Combination of cardiac CT and MRI – Calcified lesions – Unrecognized MI
- 3. Today’s Agenda • CardiacMRI in Japan – Recent trends of cardiac MRI in Japan • Cardiac MRI@CVIC – Ischemic – Non-ischemic • Combination of cardiac CT and MRI – Calcified lesions – Unrecognized MI
- 4. Trends of CoronaryCTA and Cardiac MRI in Japan 27,131 86,256 150,309 218,053 273,370 346,412 360,275 25,593 17,975 20,900 21,670 20,452 24,511 27,128 0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 2004 2006 2007 2008 2009 2010 2011 Coronary CTA Cardiac MRI 日本循環器学会：循環器疾患診療実態調査
- 5. Cardiac MRI inJapan CVIC 冠動脈CT 月間250件 3,000/year CVIC 心臓MRI (Share 10%) 月間200件 2,400/year 日本循環器学会：循環器疾患診療実態調査
- 6. Today’s Agenda • CardiacMRI in Japan – Recent trends of cardiac MRI in Japan • Cardiac MRI@CVIC – Ischemic – Non-ischemic • Combination of cardiac CT and MRI – Calcified lesions – Unrecognized MI
- 7. Cardiac MRI: FullStudy Full Study: One-Stop Shop Wall motion (5min) Perfusion (Stress→Rest) (10min) Stress Rest LGE (15min) Coronary MRA (10min) 4ch SA No contrast No radiation T2W (3min) T2W
- 8. Whole-Heart Coronary MRA RCA LAD LCX ID-193 Kato,et al. J Am Coll Cardiol 2010;56:983–91 127/138 (92%) (9.5+/-3.5 min)
- 9. Today’s Agenda • CardiacMRI in Japan – Recent trends of cardiac MRI in Japan • Cardiac MRI@CVIC – Ischemic – Non-ischemic • Combination of cardiac CT and MRI – Calcified lesions – Unrecognized MI
- 10. Pattern of LateGadolinium Enhancement (LGE) Mahrholdt H, et al. EHJ. 2005:26:1461 PET MRI
- 11. Assessment of MyocardialViability by MRI Kim RJ, et al. NEJM. 2000;343:1445 • 12 segments model • % of HE area = 100 x area A ÷ (area A + area B) N=50 Transmural extent of hyperenhancement
- 12. Mechanism of DelayedHyperenhancement Gd diffuses rapidly from the intravascular to the extracellular space. Expanded volume of distribution of Gd in scar tissue. Ruptured cell membrane increases the potential interstitial volume. Higgins, CB. Cardiovascular MRI and MRA. 2002
- 13. Myocardial Thinning andScarring in CAD JAMA. 2013;309(9):909-918 end-diastolic wall thickness<5.5 mm N=201/1055 (wall thinning) Limited scar burden (<50%): 37/201 (18%) Repeated CMR (n=42)
- 14. Improved LV Functionin Patients with Thinning and Limited Scar Burden JAMA. 2013;309(9):909-918
- 15. Case Presentation • Asymptomatic •ECG: V1~V3 poor R (Normal in 2008) • Coronary Risk Factor: HLP, HT, Smoking 67M ID-67 6/25/2008 7/6/2009
- 16. LV function (ShortAxis) HypokinesisHypokinesis ID-67
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- 18. LGE (Late GadoliniumEnhancement) 2ch 4ch ID-67
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- 21. Multiparametric CMR vs.SPECT CE-MARC: n=752, 39% had significant CHD by CAG Greenwood JP, et al. Lancet 2012; 379: 453–60 Sensitivity Specificity CMR 86.5 83.4 SPECT 66.5 82.6 Multiparametric CMR: Cine, Adenosine stress perfusion, LGE, and coronary MRA “Real world evaluation of CMR”
- 22. Today’s Agenda • CardiacMRI in Japan – Recent trends of cardiac MRI in Japan • Cardiac MRI@CVIC – Ischemic – Non-ischemic • Combination of cardiac CT and MRI – Calcified lesions – Unrecognized MI
- 23. Pattern of LGE MahrholdtH, et al. EHJ. 2005:26:1461
- 24. 54M Coronary Risk Factor:HT, DM (IGT?), Smoking Case Presentation ID-193
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- 26. Late Gadolinium Enhancement 2chamber view Delayed Enhancement Cine MRI ID-193
- 27. Cine MRI Late GadoliniumEnhancement (LGE) LGE ID-193 T2W
- 28. T2W MRI ofHCM: Myocardial Edema Our case LGE T2W （Abdel-Aty H, et al. JMRI. 2008;28:242） LGE T2W Poor blood suppression
- 29. Stress Perfusion MRIin HCM ID-193 Diffuse perfusion defect (Microvascular dysfunction?)
- 30. LGE of HCM •LGE (+) in 50% of HCM patients. (Harris SR, et al. Magn Reson Imaging Clin N Am. 2008;16:165) • Most frequent in RV insertion points (73%) (Rubinshtein R. Circ Heart Fail. 2010;3:51) （Adabag SA. JACC. 2008;51:1369） Our case Bruder O, et al. JACC.2010;56:875 Teraoka K, et al. MRI. 2004;22: 155
- 31. Case Presentation 57M CHF dueto AR DCM (First diagnosed in 1995) ID-5
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- 33. LGE of DCM •LV Mid-wall enhancement in DCM • RV Mid-wall ID-5
- 34. Midwall Fibrosis inCMR and Histology SCD Tx Small amounts of perivascular fibrosis Extensive replacement fibrosis JAMA. 2013;309(9):896-908
- 35. Prognostic Significance of MidwallEnhancement N=472 DCM patients N=142 (30%) midwall LGE+, 38 deaths (26.8%) N=330 (70%) LGE-, 35 deaths (10.6%) Hazard ratio=2.96 JAMA. 2013;309(9):896-908
- 36. Case Presentation 40M CHF, s/oDCM, History of cardiac arrest ID-416
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- 38. Cine MRI LGE ID-416 LGE andT2WBB LV short axis T2WBB
- 39. CMR of Myocarditis FriedrichMG, et al. JACC2009;53:1475Cocker M, et al. Curr Cardiol Rep (2010) 12:82–89 23M LGE T2W LGE pattern of myocarditis
- 40. Today’s Agenda • CardiacMRI in Japan – Recent trends of cardiac MRI in Japan • Cardiac MRI@CVIC – Ischemic – Non-ischemic • Combination of cardiac CT and MRI – Calcified lesions – Unrecognized MI
- 41. Case Presentation 71M • Jawpain early in the morning (rest and effort) • Coronary Risk Factor: HT, HLP
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- 44. LGE ID-6176 12/1 EmergentCAG@Tokyo Univ. LMT#5-99%, LAD#6-100%, #11-99% Moderate AS (AV flow=2.7m/s) IABP insertion 12/3 Urgent CABG with AVR
- 45. CAG ID-6176 LCA (Missing LAD)RCA (Collateral to LAD)
- 46. Today’s Agenda • CardiacMRI in Japan – Recent trends of cardiac MRI in Japan • Cardiac MRI@CVIC – Ischemic – Non-ischemic • Combination of cardiac CT and MRI – Calcified lesions – Unrecognized MI
- 47. Unrecognized MI byContrast-Enhanced MRI • 44/195 (23%) pts had positive on DEMRI. • Even a very small scar (<2% mean LV mass) was associated with a >7- fold increase in MACE hazards. Kwong RY, et al. Circulation. 2006;113:2733 73M, DM, 3VD, SCD at 8 mo later 68M, UAP at 12 mo later (LAD and RCA)
- 48. Unrecognized MI morecommon, dangerous in older adults than previously suspected. Schelbert EB, et al. JAMA. 2012;308(9):890-897 陳旧性心筋梗塞 無症候性心筋梗塞 無症候性心筋梗塞 死亡率に差は無し 73% 17% 10% No MI Unrecognized MI Recognized MI Older adults (n=936, age: 67-93y.o.) • ECGではUMIの5%しか検出できず。 • UMIはDM+で21%、DM-で14% UMI: Aspirin 50%, Beta-blockers 45%, Statin 36%
- 49. Cardiac MRI: FullStudy Full Study: One-Stop Shop Wall motion (5min) Perfusion (Stress→Rest) (10min) Stress Rest LGE (15min) Coronary MRA (10min) 4ch SA No contrast No radiation T2W (3min) T2W
Editor's Notes
- #5 日本循環器学会の循環器疾患診療実態調査の結果より年次ごとの冠動脈CTA、心臓MRI検査件数の推移を示す。