The Role of CMR in Cardio-Oncology Dr Mark Westwood Consultant - PowerPoint PPT Presentation

The Role of CMR in Cardio-Oncology Dr Mark Westwood Consultant Cardiologist Barts Heart Centre

CMR + Cardio-Oncology • ESC position paper • 9 Pillars – What can CMR offer • Future directions

Breadth of Scope

Position Paper 2016

The 9 Pillars of Cardio-Oncology • Myocardial dysfunction/heart failure (HF) • Coronary artery disease (CAD) • Valvular disease • Arrhythmias (esp. QT-prolonging drugs) • Arterial hypertension • Thromboembolic disease • Peripheral vascular disease and stroke • Pulmonary hypertension • Pericardial complications

The Value of CMR: UK Data 70000 60000 50000 40000 15% Year on Year Growth 30000 20000 10000 0 2008 2009 2010 2011 2012 2013 Total scans Courtesy, David Ripley

The Value of CMR Pennell D et al. EHJ 2004

The 9 Pillars of Cardio-Oncology • Myocardial dysfunction/heart failure (HF) • Coronary artery disease (CAD) • Valvular disease • Arrhythmias (esp. QT-prolonging drugs) • Arterial hypertension • Thromboembolic disease • Peripheral vascular disease and stroke • Pulmonary hypertension • Pericardial complications

The 9 Pillars of Cardio-Oncology • Myocardial dysfunction/heart failure (HF) • Coronary artery disease (CAD) • Valvular disease • Arrhythmias (esp. QT-prolonging drugs) • Arterial hypertension • Thromboembolic disease • Peripheral vascular disease and stroke • Pulmonary hypertension • Pericardial complications

The 9 Pillars of Cardio-Oncology • Myocardial dysfunction/heart failure (HF) • Coronary artery disease (CAD) • Valvular disease • Arrhythmias (esp. QT-prolonging drugs) • Arterial hypertension • Thromboembolic disease • Peripheral vascular disease and stroke • Pulmonary hypertension • Pericardial complications

The 9 Pillars of Cardio-Oncology • Myocardial dysfunction/heart failure (HF) • Coronary artery disease (CAD) • Valvular disease • Arrhythmias (esp. QT-prolonging drugs) • Arterial hypertension • Thromboembolic disease • Peripheral vascular disease and stroke • Pulmonary hypertension • Pericardial complications

The 9 Pillars of Cardio-Oncology • Myocardial dysfunction/heart failure (HF) • Coronary artery disease (CAD) • Valvular disease • Arrhythmias (esp. QT-prolonging drugs) • Arterial hypertension • Thromboembolic disease • Peripheral vascular disease and stroke • Pulmonary hypertension • Pericardial complications

The Value of CMR Anatomy Function Ischaemia (Perfusion) Fibrosis (Focal) Fat Vascularity Oedema Flow

Heart Failure Ventricular Function

Ventricular Function: Evidence Base • Cavity Volumes –12 patients –R=0.99 Longmore D et al. Lancet 1985

Ventricular Function: Evidence Base Grothues F et al. AJC 2002

Ventricular Function: Feature tracking Radial Circumferential Longitudinal Courtesy, Steffen Petersen

Heart Failure Fibrosis (focal)

Focal Fibrosis: DCM Normal Mid Wall LGE Infarction Mc Crohon J D et al. Circ. 2003

Focal Fibrosis DCM: Prognosis Assomull R et al. JACC 2006

Heart Failure Diffuse Fibrosis/ECV

Diffuse Fibrosis: T1 Mapping • The true T1 of myocardium can be measured – Tricky but possible – Combination of intra/extracellular components of myocardium • Many process cause diffuse as well as focal fibrosis – Drugs – Infiltration • Can calculate Extracellular Volume – Just need FBC – Haematocrit – Extracellular component only – ECV= ( Δ [1/T1 myo ] / Δ [1/T1 blood ]) * [1-haematocrit])

Diffuse Fibrosis: Anthracyclines: 3yr change Native T1 and ECV are BEFORE and also 3 years after Anthracycline Chemotherapy in Heart Failure CHECK THIS Native T1 ECV Raised BEFORE Raised only and AFTER AFTER Chemotherapy Chemotherapy Jordan J et al. Circ. CV Imaging 2016

Diffuse Fibrosis: Anthracyclines: 3m change Baseline 3 Months p=0.04 1100 30 p=0.04 Extracellular Volume (%) 1090 29 p=0.04 1080 28 Changes are early (3 months) Native T1 (ms) p=0.1 1070 27 1060 26 1050 25 1040 24 1030 23 1020 22 1010 21 1000 20 All LV LV All LV LV Segments Septum Segments Septum Melendez G et al. JACC CV Imaging in press

Diffuse Fibrosis: Anthracyclines: maybe not BC n=98 CMR changes baseline-FU Δ EDVi, ml/m 2 -2.9 ± 7.4 Δ ESVi, ml/m 2 1.5 ± 3.3 -4.7 ± 5.1 Δ SVi, ml/m 2 -3.7 ± 4.2 Δ EF, % 0.97 ± 5.3 Δ Massi, mg/m 2 Courtesy, Charlotte Manisty

Heart Failure Amyloidosis/Infiltration

Fibrosis and Infiltration: T1 Mapping HCM Hypertension Fabry’s Amyloid Disease Courtesy, Charlotte Manisty

Fibrosis and Infiltration: T1 Mapping HIGH T1 Courtesy, Charlotte Manisty

Coronary Artery Disease ACS/Infarction

Infarction MVO Normal Small Large

Infarction: LGE/MVO Wu K et al. Circ. 1998

Coronary Artery Disease Ischaemia

CMR Adenosine Stress Perfusion Small Gross

CMR Vs SPECT: Animal Work Lee D et al. Circ. 2003

CE-MARC: Results Greenwood J et al. Lancet 2012

CMR Perfusion: CMR Meta Analysis Lipinski M et al. JACC 2013

CE-MARC: Long Term Follow Up SPECT CMR/Angio Greenwood J et al. Annals Int Med 2016

Valvular Disease

Valvular Disease: Planimetry/Flow/4D Flow mapping 4D techniques Planimetry Courtesy, Vivek Muthurangu

Pulmonary Hypertension

Pul HT: ‘M-Mode’ RV function M-mode Correlates with PAP RV systole - LV diastole Septal curvature Correlates with PAP Courtesy, Dan Knight

Pericardial Disease

CMR: Assessment of the Pericardium Echo CT CMR Angio Visualising the Pericardium +/- +++ +++ - Thickening - +++ - ++ Calcification + +++ +++ - Masses + ++ +++ - Mass composition Flow/Functional changes +++ + + - Restrictive myocardial changes +++ + ++ - Static +++ - +++ - Respiratory Haemodynamic changes + - - +++ Static - - - +++ Respiratory

Pericardial constriction T1 T1 Fat Sat Identify cleavage planes T2 STIR Resting Function LGE

Pericardial constriction Ventricular coupling Short Axis 4 Chamber

Delivery

Delivery: Needs a large CMR service • Cardio-Oncology is: high quality/swiftly delivered – Imaging interleaved with service • Twice weekly dedicated outpatients – Tuesday (Manisty/Westwood/Woldman) – Friday (Crake/Ghosh) – Friday MDT • Imaging – Echo (Tuesday, Friday) – CMR - scan and result in 7 days – Future will be same day CMR

Delivery: A Growing Network • Cardio-oncology, a growing UK network – Belfast – Queen’s University Hospital – Birmingham – Queen Elizabeth Hospital – Edinburgh – Edinburgh Royal Infirmary – Newcastle – Freeman Hospital – Leeds – Leeds General Infirmary – Liverpool – Liverpool Heart and Chest – London – Barts Heart Centre – Guys and St Thomas – Kings College Hopsital – The Royal Brompton Hospital – University College Hospital – Manchester – University Hospitals South Manchester

Conclusion

Conclusion • Myocardial dysfunction/heart failure (HF) • Coronary artery disease (CAD) • Valvular disease • Arrhythmias (esp. QT-prolonging drugs) • Arterial hypertension • Thromboembolic disease • Peripheral vascular disease and stroke • Pulmonary hypertension • Pericardial complications

Conclusion • ESC position paper • 9 Pillars – What can CMR offer • Future directions

Thanks to …… • Barts Heart Centre Cardio-Oncology team – Dr Charlotte Manisty (Lead Consultant) – Dr Arjun Ghosh – Dr Tom Crake – Dr Simon Woldman