RISQUE RYTHMIQUE ET INSUFFISANCE RISQUE RYTHMIQUE ET INSUFFISANCE CARDIAQUE: ROLE DE L’IMAGERIE CARDIAQUE: ROLE DE L’IMAGERIE Pr. Hubert Cochet Pr. Hubert Cochet University of Bordeaux, France University of Bordeaux, France Email: hubert.cochet@chu Email: hubert.cochet@chu- -bordeaux.fr bordeaux.fr
DISCLOSURES Shareholder: Co-founder of inHEART Grant/Research Support: Siemens Healthineers Guerbet Medtronic Speaker/Consultant fees: Siemens Healthineers Biosense Webster Boston Scientific Abbott Fineheart Farapulse
RATIONAL Etiologies of lethal arrhythmias Albert CM. Circulation. 1996;93:1170-1176
RATIONAL Ursell PC et al. Wagner A et al. Circ Res . 1985;56:436-51 Lancet . 2003;361:374-9
IMAGING & VENTRICULAR ARRHYTHMIAS
CLINICAL ISSUE OF SUDDEN CARDIAC DEATH • > 4 millions/yr worldwide (1/5 of all deaths…) • 70% due to arrhythmias • 90% of arrhythmias occur on a substrate visible on CMR CURRENT PREVENTION ICDs in LVEF <35% Covers only a small minority of SCDs (<10%) Most implanted pts do not need ICDs (2/3)
PROGNOSTIC ROLE OF LGE CMR IN ISCHEMIC HEART DISEASE n pixels Signal intensity Watanabe, E., et al. Circ. Cardiovasc. Imaging. 2014; 7: 887–894
PROGNOSTIC ROLE OF LGE CMR IN NON-ISCHEMIC DCM Meta-analysis 2948 patients LVEF<35% Prospective study 399 patients LVEF>40% Di Marco A, et al. B.P. Halliday,et al. JACC Heart Fail. 2017 Jan;5(1):28-38. Circulation, 135 (2017), pp. 2106-2115
PROGNOSTIC ROLE OF LGE CMR IN HCM Prior SCD Prior SCD Spontaneous sustained VT Spontaneous sustained VT Family history of SCD Family history of SCD Unexplained syncope Unexplained syncope Non-sustained VT on Holter Non-sustained VT on Holter Abnormal exercise blood pressure Abnormal exercise blood pressure LV thickness 30 mm LV thickness 30 mm
PROGNOSTIC ROLE OF LGE CMR IN HCM d d e e t s t s a a e e m m i d i d i i u t u Prior SCD t s t s t s e s e r e r e e e v v v i v Spontaneous sustained VT t i o t c o c e e w V w V p p P o s o P s l N o l Family history of SCD N o s o s r o r n t n t t e y t o e y o V r f i r V f i i t y t i t P a y t P s a Unexplained syncope s b c b P u c P u i j i l j p l p o o m m t t o Non-sustained VT on Holter o c c & & s s Abnormal exercise blood pressure t t s s o o c c LV thickness >30 mm
PROGNOSTIC ROLE OF LGE CMR IN HCM Prospective study 1293 patients Chan RH, et al. Circulation. 2014 Aug 5;130(6):484-95.
PROGNOSTIC ROLE OF LGE CMR ONGOING TRIALS
RISK STRATIFICATION ROLE OF T1 MAPPING? Prospective study 130 ICM&DCM patients, LVEF<35% Chan RH, et al. Circulation. 2014 Aug 5;130(6):484-95.
IMAGING & VENTRICULAR ARRHYTHMIAS
IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY 157 pts with VT or VF CMR alters diagnosis in 38% of pts with no history of SHD negative echo & angio Hennig et al. Eur Heart J Cardiovasc Imaging 2017
IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY 44 yo man with monomorphic sustained VT of RBBB morphology Negative TTE & coronary angiography ED ES LGE CARDIAC SARCOID
IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY 34 yo man with VT of unknown morphology Negative TTE. Non-specific T wave changes on ECG. ED ES LGE APICAL FORM OF HCM
IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY 58 yo women with sustained VT of RBBB morphology Negative TTE & coronary angiography ED ES LGE CHURG-STRAUSS VASCULITIS
IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY 35 yo man with frequent PVCs and sustained VT. Negative coronary CTA. TTE: mild dilatation suggesting arrhythmia-induced cardiomyopathy ED ES LGE LAMINOPATHY
IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY 62 yo. Woman with symptomatic PVCs & negative T waves V1-V3 ARVC
THE SMALLER THE PIXEL THE BETTER CONVENTIONAL LGE HIGH-RES LGE => better detection of SHD HIGH-RES LGE => better detection of SHD (17% à 38%, P<0.001). (17% à 38%, P<0.001). HIGH-RES. LGE Hennig et al. Eur Heart J Cardiovasc Imaging 2017
IMAGING & VENTRICULAR ARRHYTHMIAS
SUBSTRATE MAPPING FROM MRI: LATE GADOLINIUM ENHANCEMENT n pixels Ursell. Circ Res . 1985 Signal intensity
SUBSTRATE MAPPING FROM CT: MULTI-PARAMETRIC ARTERIAL Wall thinning Fat Calcification LATE Late iodine enhancement
SUBSTRATE MAPPING FROM CT: POST-INFARCTION CT arterial CT late Fusion MRI Scar CT Scar MRI
EXAMPLE: POST-MI VT (CT/MRI) CT-thickness CT-fat CT-late iodine MR-late gadolinium mm Dense scar Dense scar < 1 < 2 Grey zone Grey zone < 3 < 4 < 5
PROCEDURAL INTEGRATION Improved efficacy Shorter procedures Simpler & more standardized procedures
IMPACT ON OUTCOME OVERALL SURVIVAL VT-FREE SURVIVAL Hendriks. EP Europace. 2017 Jun;19(3):483.
IMAGE INTEGRATION STRATEGY CURRENT: IMAGING TO GUIDE MAPPING Improved anatomy and substrate definition - Impact on procedure time + - Impact on efficacy + SOON: IMAGING TO DEFINE ABLATION TARGETS Dedicate the entire procedure to ablation - Impact on procedure time +++ - Impact on efficacy +++ - Simplification / standardization of procedures +++
PERSPECTIVE IMAGE-BASED SIMULATION 57 yo man with prior infarct in LAD territory Multiple ICD shocks on monomorphic VT 0mm Thickness 5mm HD VT map Simulation endo Simulation epi Nicolas Cedilnik et al. Europace 2018
CONCLUSIONS IMAGING & VENTRICULAR ARRHYTHMIAS ablation guidance CT/MR for enhanced definition of substrate/anatomy identifying structures at risk (coronaries, phrenic) direct definition of ablation targets perspective fully non-invasive cardiac ablation
TAKE HOME MESSAGES Patient considered for ICD implantation for primary prevention? Patient considered for ICD implantation for primary prevention? Use MRI to measure LVEF: gold standard + LGE data in case of future shocks Use MRI to measure LVEF: gold standard + LGE data in case of future shocks Ventricular arrhythmia without known structural heart disease? Ventricular arrhythmia without known structural heart disease? Get an MRI even if echo and angio are negative Get an MRI even if echo and angio are negative Patient referred for VT ablation? Patient referred for VT ablation? Develop a close collaboration between EP & imaging teams Develop a close collaboration between EP & imaging teams Seek for image processing solutions to get optimal imaging information in the lab Seek for image processing solutions to get optimal imaging information in the lab
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