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Jul 16, 2023 27 likes •600 views

Universit 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

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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

Università di Messina

Dipartimento Clinico Sperimentale di Medicina e Farmacologia

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CMR: Advantages

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

CMR: Disadvantages

CMR

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CMR as gold standard

Accuracy Differential diagnosis Reserch tool

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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

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SSFP cine MRI: 10-16 slices, 8 mm thickness, no spacing (or 2 mm gap), R-R: 30 phases,

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)

QUANTITATIVE ASSESSMENT

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  • 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

Phase 1 Phase 10

Post-processing

CMR: left ventricular function

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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/cm3

By G.D Aquaro. IFC

CMR: left ventricular function

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Maceira et al JCMR 2006

CMR: left ventricular function

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ARVC/D

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ARVC/D

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Event-free Survival(%)

0 200 400 600 800 1000 1200

Event-free Survival curve of RVA vs no-RVA Time (days) no-RVA RVA P<0.0001

100 98 96 94 92 90 88 86

Aquaro GD et al JACC 2010

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Event-free Survival(%)

no-RVA

RVA

100 98 96 94 92 90 88 86

Event-free Survival curve: no-RVA, Intermediate group, ARVC/D group

0 200 400 600 800 1000 1200

Time (days)

RVA-1 group RVA-2 group

P<0.0001 P<0.003

Aquaro GD et al JACC 2010

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Echocardiography 2010

Additive data from strain imaging

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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

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Di Bella G, et Al. Echocardiography

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Stroke volume can be assessed also by measuring total flow across ascending aorta or pulmonary trunk in one heartbeat

CMR: left ventricular function

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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 Retrograd Flow 32 ml/beat Regurgitant fraction 37%

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Quantitative assessment of absolute aortic flow (LV stroke volume)

CMR: left ventricular function

Quantitative assessment of absolute pulmonary flow (RV stroke volume) QP/QS

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CMR: Flow measurements

Clinical Implication…………………….. Congenital heart diseases

Study of Left Ventricle volume and mass: EndDiastolic Volume: 210 ml EndSystolic Volume: 94ml Stroke volume: 115 ml EF 55% Mass: 175 g

Phase Contrast at Ascending Aorta

Real Stroke volume 73.5 ml REAL EF=SV/EDVx 100%

73.5/210x100 EF 35%

Regurgitant Volume= 115 ml-73.5 ml=41.5 ml

Mitral regurgitation

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CMR as gold standard

Identification and extent of scar tissue

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Scar tissue in myocardial infarction

Scar tissue in myocarditis

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  • A. Wagner et al. Lancet 2003

necrosis as small as 1g can be detected with CE-IR-MRI <=> 10 g with SPECT

Noninvasive Gold for Infarct Imaging ?

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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 (Kim et al. N Engl J Med, 2000)

likelihood of segmental recovery of function paralles infarct transmurality

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Il valore prognostico additivo dell’integrazione funzione/necrosi

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 de=1 & wm=1 vs de=0 & wm=1 3,407 0.05

Di Bella et al. Submitted

237 pts con infarto miocardico pregresso con e senza disfunzione ventricolare sinistra Eventi: n=19 (morte cardiaca, arresto resuscitato, scarica DEF appropriata

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

Acute Myocarditis

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CMR as gold standard

Tissue characterization

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MIXOMA

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

ANGIOSARCOMA

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Di Bella G et al. Circulation 2008

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CMR as gold standard

Tissue characterization (scar tissue)

Myocarditis Viability Cardiac tumors Cardiomyopathies

Cardiac Morphology andFunction

RV function Congenital heart diseases

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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

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Gianluca Di Bella

Grazie

University of Messina

Clinical and Experimental Department of Medicine and Pharmacology PhD course on Cardiovascular Imaging Methodologies and Techniques

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Post-Infarction Ventricular Arrhythmia

  • Characterization of the peri-infarct zone by CE-MRI is a powerful predictor
  • f 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)

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RV infarction

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Grasso e Displasia aritmogena VD “Un caso senza sospetti”

Immagini T1 pesate Immagini T1 pesate con fat suppression Delayed enhancement

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CMR: left ventricular function

By G.D Aquaro. IFC

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Epidemiologic data

  • 2% of population < 65 years
  • 10% of population > 65 years

have reduction of LV systolic function CMR: left ventricular function

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

CMR: left ventricular function

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diastole sistole

Tagging RM

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

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Clinical Implication……………………

  • LV
  • >>>>>> RV
  • Global function
  • >>> regional function

CMR as gold standard in function

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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

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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

MRI: STUDIO DI FUNZIONE

TAGGING

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ECO RM Fattibilità +++ ++ Sicurezza +++ ++ Acc Diagnostica ++ +++ Costi + +++ Tempo Esame + +++

  • Risol. Temporale

+++ ++

  • Risol. Spaziale

++ +++ “Val. Quantitativa ++ +++

ECO vs RM

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Study of Left Ventricle volume and mass: EndDiastolic Volume: 210 ml EndSystolic Volume: 94ml Stroke volume: 115 ml EF 55% Mass: 175 g

Phase Contrast at Ascending Aorta

Real Stroke volume 73.5 ml REAL EF=SV/EDVx 100%

73.5/210x100 EF 35%

Regurgitant Volume= 115 ml-73.5 ml=41.5 ml

CMR: Flow measurements

Mitral regurgitation

Clinical Implication……………………..

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Di Bella G, et Al. In press Echocardiography

Semiautomatic Quantification of Left Ventricular Function by 2D Feature Tracking Imaging Echocardiography. A Comparison Study with Cardiac Magnetic Resonance Imaging

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MR in VALVULOPATIE

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%. Effective aortic SV (156-77) = 81 ml;