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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
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 - - 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
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SLIDE 3
Breadth of Scope
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Position Paper 2016
SLIDE 5
- 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
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The Value of CMR: UK Data
10000 20000 30000 40000 50000 60000 70000 2008 2009 2010 2011 2012 2013 Total scans
Courtesy, David Ripley
15% Year on Year Growth
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The Value of CMR
Pennell D et al. EHJ 2004
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- 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
SLIDE 9
- 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
SLIDE 10
- 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
SLIDE 11
- 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
SLIDE 12
- 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
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The Value of CMR
Anatomy Fibrosis (Focal) Ischaemia (Perfusion) Oedema Fat Flow Vascularity Function
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Heart Failure
Ventricular Function
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Ventricular Function: Evidence Base
- Cavity Volumes
–12 patients –R=0.99
Longmore D et al. Lancet 1985
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Ventricular Function: Evidence Base
Grothues F et al. AJC 2002
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Ventricular Function: Feature tracking
Radial Circumferential Longitudinal
Courtesy, Steffen Petersen
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Heart Failure
Fibrosis (focal)
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Focal Fibrosis: DCM
Normal Mid Wall LGE Infarction
Mc Crohon J D et al. Circ. 2003
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Focal Fibrosis DCM: Prognosis
Assomull R et al. JACC 2006
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Heart Failure
Diffuse Fibrosis/ECV
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- 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/T1myo] / Δ[1/T1blood]) * [1-haematocrit])
Diffuse Fibrosis: T1 Mapping
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Diffuse Fibrosis: Anthracyclines: 3yr change
Jordan J et al. Circ. CV Imaging 2016
Native T1 and ECV are BEFORE and also 3 years after Anthracycline Chemotherapy in Heart Failure CHECK THIS
Raised BEFORE and AFTER Chemotherapy Raised only AFTER Chemotherapy
Native T1 ECV
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Diffuse Fibrosis: Anthracyclines: 3m change
Melendez G et al. JACC CV Imaging in press
Native T1 (ms) Extracellular Volume (%)
1000 1010 1020 1030 1040 1050 1060 1070 1080 1090 1100 20 21 22 23 24 25 26 27 28 29 30
Baseline 3 Months
All LV Segments All LV Segments LV Septum LV Septum
p=0.04 p=0.1 p=0.04 p=0.04
Changes are early (3 months)
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Diffuse Fibrosis: Anthracyclines: maybe not
Courtesy, Charlotte Manisty
BC n=98
CMR changes baseline-FU ΔEDVi, ml/m2 ΔESVi, ml/m2 ΔSVi, ml/m2 ΔEF, % ΔMassi, mg/m2
- 2.9±7.4
1.5±3.3
- 4.7±5.1
- 3.7±4.2
0.97±5.3
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Heart Failure
Amyloidosis/Infiltration
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Fibrosis and Infiltration: T1 Mapping
HCM Amyloid Hypertension Fabry’s Disease
Courtesy, Charlotte Manisty
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Fibrosis and Infiltration: T1 Mapping HIGH T1
Courtesy, Charlotte Manisty
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Coronary Artery Disease
ACS/Infarction
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Infarction
Normal Small Large MVO
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Infarction: LGE/MVO
Wu K et al. Circ. 1998
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Coronary Artery Disease
Ischaemia
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CMR Adenosine Stress Perfusion
Small Gross
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CMR Vs SPECT: Animal Work
Lee D et al. Circ. 2003
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CE-MARC: Results
Greenwood J et al. Lancet 2012
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CMR Perfusion: CMR Meta Analysis
Lipinski M et al. JACC 2013
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CE-MARC: Long Term Follow Up
Greenwood J et al. Annals Int Med 2016
SPECT CMR/Angio
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Valvular Disease
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Valvular Disease: Planimetry/Flow/4D
Courtesy, Vivek Muthurangu
Flow mapping Planimetry 4D techniques
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Pulmonary Hypertension
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Pul HT: ‘M-Mode’
Courtesy, Dan Knight
RV function Septal curvature
RVsystole - LVdiastole Correlates with PAP
M-mode
Correlates with PAP
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Pericardial Disease
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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
- +++
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Pericardial constriction
T1 T1 Fat Sat T2 STIR LGE Resting Function
Identify cleavage planes
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Pericardial constriction
4 Chamber Short Axis Ventricular coupling
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Delivery
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- 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: Needs a large CMR service
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- 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
Delivery: A Growing Network
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Conclusion
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- 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
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Conclusion
- ESC position paper
- 9 Pillars
– What can CMR offer
- Future directions
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Thanks to……
- Barts Heart Centre Cardio-Oncology team