La Risonanza Magnetica Cardiaca: quando usarla come gold standard G. - PowerPoint PPT Presentation

Università di Messina Dipartimento Clinico Sperimentale di Medicina e Farmacologia XV Congresso nazionale SIEC 2011 Uso dell’ Imaging nella pratica clinica: dalla diagnosi alla tecnologia La Risonanza Magnetica Cardiaca: quando usarla come gold standard G. Di Bella (Messina) Napoli, 16 Aprile 2011

CMR CMR: Advantages • No Ionizing Radiation==>Virtually Safe • Multiplanarity • Flow and Velocity Measurement • Not conditioned by presence of Bone CMR: Disadvantages • Controindications (PM dependent,device, Claustrophobia..) • Long time of execution • Need for Cardiac Gating • Need for Compatible instrument

CMR as gold standard Accuracy Differential diagnosis Reserch tool

CMR: left ventricular function High spatial and temporal resolution standardization of acquisition high quality images no geometric assumptions high accuracy good inter and intra-observer reproducibility Relative high costs Not available at bed side of patients

CMR: left ventricular function Starting from a horizzontal long axis view using planes orthogonal to major left ventricular axis (from center of mitral valve to apex) SSFP cine MRI : 10-16 slices, 8 mm thickness, no spacing (or 2 mm gap), R-R: 30 phases, QUANTITATIVE ASSESSMENT

CMR: left ventricular function Phase 1 Phase 10 Post-processing • End-diastolic frame and end-systolic frame for each slice • Trace left ventricular endocardial contour • Trace left ventricular epicardial contour • Trace right ventricular endocardial contour

CMR: left ventricular function Ventricular volume is the sum of single volume from each slice (cavity area x slice thickness) Stroke volume = EDV-ESV EF = Stroke Volume/EDV x 100 Ventricular mass = (epicardial volume - cavity volume) x 1.05 g/cm 3 By G.D Aquaro. IFC

CMR: left ventricular function Maceira et al JCMR 2006

ARVC/D

ARVC/D

Event-free Survival curve of RVA vs no-RVA no-RVA 100 98 Event-free Survival(%) 96 94 RVA 92 90 88 P<0.0001 86 0 200 400 600 800 1000 1200 Time (days) Aquaro GD et al JACC 2010

Event-free Survival curve: no-RVA, Intermediate group, ARVC/D group 100 no-RVA P<0.003 RVA-1 group 98 Event-free Survival(%) 96 94 P<0.0001 RVA 92 RVA-2 group 90 88 86 0 200 400 600 800 1000 1200 Time (days) Aquaro GD et al JACC 2010

Additive data from strain imaging Echocardiography 2010

Semiautomatic Quantification of Left Ventricular Function by 2D Feature Tracking Imaging Echocardiography. A Comparison Study with Cardiac Magnetic Resonance Imaging Gianluca Di Bella, M.D., Ph.D ., Concetta Zito, M.D., *Michele Gaeta, M.D., Maurizio Cusmà Piccione, M.D., *Fabio Minutoli, M.D., *Rocco Donato, M.D., Antonino Recupero, M.D., Antonio Madaffari, M.D., Sebastiano Coglitore, M.D., Scipione Carerj M.D. Echocardiography 2010

Di Bella G, et Al. Echocardiography

CMR: left ventricular function Stroke volume can be assessed also by measuring total flow across ascending aorta or pulmonary trunk in one heartbeat

CMR: left ventricular function Absolute Flow 86 ml/beat Stroke volume can be assessed also by measuring total flow across Retrograd Flow 32 ml/beat ascending aorta or pulmonary Regurgitant fraction 37% trunk in one heartbeat

CMR: left ventricular function Quantitative assessment of absolute aortic flow (LV stroke volume) Quantitative assessment of absolute pulmonary flow (RV stroke volume) QP/QS

CMR: Flow measurements Clinical Implication…………………….. Congenital heart diseases Study of Left Ventricle volume and mass: EndDiastolic Volume: 210 ml EndSystolic Volume: 94ml REAL EF=SV/EDVx 100% Stroke volume: 115 ml 73.5/210x100 EF 55% EF 35% Mass: 175 g Phase Contrast at Ascending Aorta Real Stroke volume 73.5 ml Regurgitant Volume= Mitral regurgitation 115 ml-73.5 ml= 41.5 ml

CMR as gold standard Identification and extent of scar tissue

Scar tissue in myocardial infarction Scar tissue in myocarditis

Noninvasive Gold for Infarct Imaging ? necrosis as small as 1g can be detected with CE-IR-MRI <=> 10 g with SPECT A. Wagner et al. Lancet 2003

CE-IR MRI rationale: scarred myocardium strongly enhances after Gd-DTPA administration, and can be used to determine presence, extent, and transmurality, and to differentiate with normal myocardium likelihood of segmental recovery of function paralles infarct transmurality (Kim et al. N Engl J Med, 2000)

Il valore prognostico additivo dell’integrazione funzione/necrosi 237 pts con infarto miocardico pregresso con e senza disfunzione ventricolare sinistra Eventi: n=19 (morte cardiaca, arresto resuscitato, scarica DEF appropriata HR P de=1 & wm=0 vs de=0 & wm=0 2,285 ns de=0 & wm=1 vs de=0 & wm=0 2,129 ns de=1 & wm=1 vs de=0 & wm=0 7,784 0.007 de=1 & wm=1 vs de=1 & wm=0 3,347 0.05 Di Bella et al. de=1 & wm=1 vs de=0 & wm=1 3,407 0.05 Submitted

Acute Myocarditis Immagini T2 pesate Immagini T2 pesate Delayed Enhancement Fase acuta Fase cronica Fase cronica

CMR as gold standard Tissue characterization

MIXOMA

ANGIOSARCOMA Di Bella G et al. Rev Esp Cardiol. 2010;63(11):1383-9

Di Bella G et al. Circulation 2008

CMR as gold standard Tissue characterization (scar tissue) Myocarditis Viability Cardiac tumors Cardiomyopathies Cardiac Morphology andFunction RV function Congenital heart diseases

CMR is gold standard in Right ventricular function Identification of scar tissue in MI and Myocarditis Tissue caracterization of cardiac tumors and in other many cardiomyopaties

University of Messina Clinical and Experimental Department of Medicine and Pharmacology PhD course on Cardiovascular Imaging Methodologies and Techniques Grazie Gianluca Di Bella

Post-Infarction Ventricular Arrhythmia • Characterization of the peri-infarct zone by CE-MRI is a powerful predictor of post-myocardial infarction mortality (Yan AT et al. Circulation 2006;114:32) • Presence and extent of tissue heterogeneity in the peri-infarct zone increases susceptibility to ventricular arrhythmias in patients with prior LV infarction and LV dysfunction (Schmidt A et al. Circulation 2007;115:2006)

RV infarction

Grasso e Displasia aritmogena VD “Un caso senza sospetti” Immagini T1 pesate Immagini T1 pesate Delayed enhancement con fat suppression

By G.D Aquaro. IFC CMR: left ventricular function

CMR: left ventricular function Epidemiologic data • 2% of population < 65 years • 10% of population > 65 years have reduction of LV systolic function

CMR: left ventricular function SSFP TE Minimun In base TR freq.cardiaca FLIP ANGLE 45 ° RBw 125 kHz FOV ~40 THICKNESS 8 mm SPACING 0.0 NEX 1 N ° Phase 30 View per segm. 8-16 R-R 1

Tagging RM E1: ispessimento sistolico E2: accorciamento circonferenziale Alfa: angolo di deformazione della direzione di E1 rispetto alla direzione radiale sistole E1 diastole Alfa E2

CMR as gold standard in function Clinical Implication …………………… • LV • >>>>>> RV • Global function • >>> regional function

MRI tagging Con una sequenza di impulsi viene generata una modulazione spaziale di magnetizazzione. Le righe generate si muovonoi con il tessuto e si analizza il movimento delle righe (deformazione) su più immagini

MRI: STUDIO DI FUNZIONE TAGGING La sequenza di impulsi in CINE viene preceduta da una modulazione spaziale di magnetizzazione (demagnetizzazione)  Le righe generate (tags) si muovono con il tessuto  viene analizzato la deformazione delle tags line nelle fasi del ciclo cardiaco  mappe di deformazione del miocardio

ECO vs RM ECO RM Fattibilità +++ ++ Sicurezza +++ ++ Acc Diagnostica ++ +++ Costi + +++ Tempo Esame + +++ Risol. Temporale +++ ++ Risol. Spaziale ++ +++ “Val. Quantitativa ++ +++

CMR: Flow measurements Clinical Implication…………………….. Study of Left Ventricle volume and mass: EndDiastolic Volume: 210 ml EndSystolic Volume: 94ml REAL EF=SV/EDVx 100% Stroke volume: 115 ml 73.5/210x100 EF 55% EF 35% Mass: 175 g Phase Contrast at Ascending Aorta Real Stroke volume 73.5 ml Regurgitant Volume= Mitral regurgitation 115 ml-73.5 ml= 41.5 ml

Semiautomatic Quantification of Left Ventricular Function by 2D Feature Tracking Imaging Echocardiography. A Comparison Study with Cardiac Magnetic Resonance Imaging Di Bella G, et Al. In press Echocardiography

MR in VALVULOPATIE Effective aortic SV (156-77) = 81 ml; EDV: 328 ml; ESV: 140 ml; ejection fraction: 57%; mass: 195 g EF= 188/328*100= 57% Real EF= 81/328*100= 25% Regurgitation flow volume: 77 ml; regurgitation fraction: 46%.