the role of cmr in cardio oncology
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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


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

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

  3. Breadth of Scope

  4. Position Paper 2016

  5. 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

  6. 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

  7. The Value of CMR Pennell D et al. EHJ 2004

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

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

  14. Heart Failure Ventricular Function

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

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

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

  18. Heart Failure Fibrosis (focal)

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

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

  21. Heart Failure Diffuse Fibrosis/ECV

  22. 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])

  23. 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

  24. 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

  25. 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

  26. Heart Failure Amyloidosis/Infiltration

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

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

  29. Coronary Artery Disease ACS/Infarction

  30. Infarction MVO Normal Small Large

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

  32. Coronary Artery Disease Ischaemia

  33. CMR Adenosine Stress Perfusion Small Gross

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

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

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

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

  38. Valvular Disease

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

  40. Pulmonary Hypertension

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

  42. Pericardial Disease

  43. 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

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

  45. Pericardial constriction Ventricular coupling Short Axis 4 Chamber

  46. Delivery

  47. 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

  48. 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

  49. Conclusion

  50. 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

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

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

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