RISQUE RYTHMIQUE ET INSUFFISANCE RISQUE RYTHMIQUE ET INSUFFISANCE - - PowerPoint PPT Presentation

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RISQUE RYTHMIQUE ET INSUFFISANCE RISQUE RYTHMIQUE ET INSUFFISANCE - - PowerPoint PPT Presentation

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RISQUE RYTHMIQUE ET INSUFFISANCE RISQUE RYTHMIQUE ET INSUFFISANCE CARDIAQUE: ROLE DE LIMAGERIE CARDIAQUE: ROLE DE LIMAGERIE Pr. Hubert Cochet Pr. Hubert Cochet University of Bordeaux, France University of Bordeaux, France Email:

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  • 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

RISQUE RYTHMIQUE ET INSUFFISANCE CARDIAQUE: ROLE DE L’IMAGERIE RISQUE RYTHMIQUE ET INSUFFISANCE CARDIAQUE: ROLE DE L’IMAGERIE

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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

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RATIONAL

Albert CM. Circulation. 1996;93:1170-1176

Etiologies of lethal arrhythmias

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SLIDE 4

RATIONAL

Ursell PC et al. Circ Res. 1985;56:436-51 Wagner A et al.

  • Lancet. 2003;361:374-9
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IMAGING & VENTRICULAR ARRHYTHMIAS

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  • > 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)

CLINICAL ISSUE OF SUDDEN CARDIAC DEATH

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PROGNOSTIC ROLE OF LGE CMR IN ISCHEMIC HEART DISEASE

Watanabe, E., et al. Circ. Cardiovasc. Imaging. 2014; 7: 887–894 Signal intensity n pixels

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PROGNOSTIC ROLE OF LGE CMR IN NON-ISCHEMIC DCM

Di Marco A, et al. JACC Heart Fail. 2017 Jan;5(1):28-38.

Meta-analysis 2948 patients LVEF<35% Prospective study 399 patients LVEF>40%

B.P. Halliday,et al. Circulation, 135 (2017), pp. 2106-2115

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PROGNOSTIC ROLE OF LGE CMR IN HCM

Prior SCD Spontaneous sustained VT Family history of SCD Unexplained syncope Non-sustained VT on Holter Abnormal exercise blood pressure LV thickness 30 mm Prior SCD Spontaneous sustained VT Family history of SCD Unexplained syncope Non-sustained VT on Holter Abnormal exercise blood pressure LV thickness 30 mm

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PROGNOSTIC ROLE OF LGE CMR IN HCM

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Prior SCD Spontaneous sustained VT Family history of SCD Unexplained syncope Non-sustained VT on Holter Abnormal exercise blood pressure LV thickness >30 mm

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PROGNOSTIC ROLE OF LGE CMR IN HCM

Prospective study 1293 patients

Chan RH, et al.

  • Circulation. 2014 Aug 5;130(6):484-95.
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PROGNOSTIC ROLE OF LGE CMR ONGOING TRIALS

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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.
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SLIDE 14

IMAGING & VENTRICULAR ARRHYTHMIAS

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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

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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

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34 yo man with VT of unknown morphology Negative TTE. Non-specific T wave changes on ECG.

APICAL FORM OF HCM

ED ES LGE

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

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58 yo women with sustained VT of RBBB morphology Negative TTE & coronary angiography

CHURG-STRAUSS VASCULITIS

ED ES LGE

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

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SLIDE 19

35 yo man with frequent PVCs and sustained VT. Negative coronary CTA. TTE: mild dilatation suggesting arrhythmia-induced cardiomyopathy

LAMINOPATHY

ED ES LGE

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

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62 yo. Woman with symptomatic PVCs & negative T waves V1-V3

ARVC

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

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HIGH-RES LGE => better detection of SHD (17% à 38%, P<0.001). HIGH-RES LGE => better detection of SHD (17% à 38%, P<0.001).

THE SMALLER THE PIXEL THE BETTER

CONVENTIONAL LGE HIGH-RES. LGE Hennig et al. Eur Heart J Cardiovasc Imaging 2017

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IMAGING & VENTRICULAR ARRHYTHMIAS

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Signal intensity n pixels

  • Ursell. Circ Res. 1985

SUBSTRATE MAPPING FROM MRI: LATE GADOLINIUM ENHANCEMENT

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Fat Wall thinning Calcification

ARTERIAL

Late iodine enhancement

LATE

SUBSTRATE MAPPING FROM CT: MULTI-PARAMETRIC

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CT arterial CT late Fusion Scar CT MRI Scar MRI

SUBSTRATE MAPPING FROM CT: POST-INFARCTION

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CT-thickness CT-fat CT-late iodine MR-late gadolinium

< 5 < 4 < 3 < 2 < 1 mm Dense scar Grey zone Dense scar Grey zone

EXAMPLE: POST-MI VT (CT/MRI)

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PROCEDURAL INTEGRATION

Improved efficacy Shorter procedures Simpler & more standardized procedures

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  • Hendriks. EP Europace. 2017 Jun;19(3):483.

VT-FREE SURVIVAL OVERALL SURVIVAL

IMPACT ON OUTCOME

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IMAGE INTEGRATION STRATEGY

Improved anatomy and substrate definition

  • Impact on procedure time +
  • Impact on efficacy +

CURRENT: IMAGING TO GUIDE MAPPING

Dedicate the entire procedure to ablation

  • Impact on procedure time +++
  • Impact on efficacy +++
  • Simplification / standardization of procedures +++

SOON: IMAGING TO DEFINE ABLATION TARGETS

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57 yo man with prior infarct in LAD territory Multiple ICD shocks on monomorphic VT

Nicolas Cedilnik et al. Europace 2018

HD VT map Simulation endo Simulation epi

Thickness

5mm 0mm

PERSPECTIVE IMAGE-BASED SIMULATION

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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

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TAKE HOME MESSAGES

Ventricular arrhythmia without known structural heart disease?

Get an MRI even if echo and angio are negative

Ventricular arrhythmia without known structural heart disease?

Get an MRI even if echo and angio are negative

Patient considered for ICD implantation for primary prevention?

Use MRI to measure LVEF: gold standard + LGE data in case of future shocks

Patient considered for ICD implantation for primary prevention?

Use MRI to measure LVEF: gold standard + LGE data in case of future shocks

Patient referred for VT ablation?

Develop a close collaboration between EP & imaging teams Seek for image processing solutions to get optimal imaging information in the lab

Patient referred for VT ablation?

Develop a close collaboration between EP & imaging teams Seek for image processing solutions to get optimal imaging information in the lab