Dis clos ure s

Re s e a rch s upport from S ie me ns

Off-la be l us e of ga dolinium-ba s e d contra s t

Etiologies tha t you may be certa in of a fte r his tory,exam, bas ic labs :

• Ane mia

• Me ta bolic dis orde rs

• Toxins

• Etc.

Why is Ca rdia c MRI He lpful?

Tis s ue cha ra cte riza tion

Tis s ue cha ra cte riza tion

Tis s ue cha ra cte riza tion

P re cis ion in qua ntifying function, flow

Myoca rd itisCa rd ia c

Am yloidos isNon-is che m ic

Ca rd iom yopa thyIn fa rc t S ca r

S igna ture s of Myoca rdia l Dis e a s e :Late Gadolinium Enhancement (LGE) CMR

Circ 2003.

Angiogra m or LGE-CMR for HF Etiology?

90 HF pa tie nts cla s s ified by a ngiogra m a s :

ICM if ≥50% stenos is

DCM/NICM if no coronary s tenos is

100% of pa tie nts with ICM ha d infa rct s ca r

DCM pa tie nts ha d 1 of 3 pa tte rns :

LGE-nega tive (59%)

Midwall enhancement (28%)

Infarc t s car (13%)

LGE: P rognos tic Va lue Acros s Etiologie s

JACC 2012.

MYOCARDITIS

Su

rviv

al

LGE-neg

LGE-pos

JAMA 2012.

Unknown MI

Known MI

No MI

Mo

rta

lity

INFARCT SCAR

0 1 2 3 4 5 6 y

fre

ed

om

fro

mS

CD

Adjus ted HR 1.46@10% in LGE

Circ 2014.

LGE neg

≤ 10%

≤ 15%

≥ 20%

HCM

SARCOIDOSIS

Circ 2009.

Fibros is Is S ubs tra te for HF, Arrhythmia s

Gulati A et a l. JAMA 2013.

Recent meta -ana lys is of 19 s tudies , >2800 pa tients , 24% with events :

OR for a rrhythmic events if LGE+ 4.5 [3.2 - 6.3] for EF >30%

Nega tive like lihood ra tio 0.13 [0.06 – 0.30]

Disertori M et a l. JACC Im 2016.

T1 Mapping & Myocardia l Extrace llula r Volume (ECV)

Diffus e fibros is e xpa nds the e xtra ce llula r s pa ce

P re - a nd pos t-contra s t T1 ma ps ECV:

myo blood)

LGE ‘nega tive’ T1 maps abnormal

Edwards e t a l. Orphanet J Rare Dis 2015. Kammerlande r e t a l. JACC Im 2015.

r = 0.493, p = 0.002

“Na tive ” (Noncontra s t) Myoca rdia l T1

T1

(ms

)

Fa b ry HTN HCM AS AL Am ylo id

Sa do e t a l. Circ Im 2013.

Moon J , EHJ 2015

P rognos tic Va lue of ECVPatients referred for CMR

Wong T, Schelbert E, Circula tion 2012

Amylo id pa tien ts

Diabe tic pa tients

Wong T, Schelbert E, EHJ 2014

• NICM

• Va lvula r dis e a s e

• HFpEF

Afib Recurrence Pos t PVI

Neilan, Kwong, JACCImaging, 2014

Courtesy Karolina Zareba , MD

Infla mma tory Myoca rdia l Dis e a s e

Thavendira nathan P e t a l. Circ Im 2012.

More Extens ive T2 vs . LGE in myocarditis

Crouser ED et a l. AJRCCM 2013.

Sarcoidos is : Arrhythmia Subs tra te , Biomarker of Tx Response

6 m s

5.1 m g Fe/ g

3 m s

8.6 m g Fe/ g

n o rm a l T2*:

>20 m s

T2*-CMR in the right patient:57 y/o F with myelodysplas ia & new-onse t HF

Outline

Tis s ue cha ra cte riza tion

Tis s ue cha ra cte riza tion

Tis s ue cha ra cte riza tion

P re cis ion in qua ntifying function, flow

Cine CMR: LV, RV size & function

Breath-hold, ECG-gated

Real-time, free-breathing, no gating

Grothues F et a l.Am J Cardiol2002.

0

10

20

30

40

50

60

CMR1 CMR2 CMR3

Tim e

LV

ES

VI

0

10

20

30

40

50

60

Meas 1 Meas 2 Meas 3

Tim e

LV

ES

VI

Does Precis ion Matter Clinically?

LV

ES

VI

Cine CMR: Gold S ta nda rd for Qua ntifica tion

Cardiomyopa thy Due to Mitra l Regurgita tion

r=0.85p<.0001

r=0.32p=.1

Uretsky S et a l. JACC 2015.

Cines(whole heart)

Flow Quantifica tion(ascending aorta )

LV S S V

MR re gurgita nt volume

mild: <30 mL

mode ra te : 30-60 mL

s e ve re : ≥60 mL

Why Wouldn’t You Want to Know What You’reDealing With?

The pa tie nt doe s n ’t wa nt to know (why? )

Ris k of finding out > be ne fits of knowing

Ke e p in mind:

What you don ’t know in HF can hurt you

Assumptions may be incorrect

“MRI is S o Expe ns ive ”

Zip code

Insured or Uninsured

CPT code

http://www.fa irhea lthconsumer.org/medica lcos tlookup

Test CPT Code Charge Reimbursement

MPI-SPECT, rest &stress

78452 428 300

Transthoracicechocardiogram

93306 955 668

CardiacMRI withcontrast

75561 1078 755

Invasive coronaryangiogram

93454 3748 2623

Zip code 90210

Not knowing what you’re t r eat ing isn’t cheap

“MRI Is a Difficult Te s t for HF P a tie nts ”

Ha rd wa re

Larger, shorte r bore (eas ie r)

Para lle l imaging (fas te r)

Low fie ld (lower cos t)

S o ftwa re

Rea l-time (no brea thholding)

S ingle hea rtbea t scans (no ga ting)

Noncontras t MRA (less risk)

0.35 Tes la (Courtesy O. S imonetti, PhD)

Conclus ions

Mos t pa tie nts with HF of unce rta in e tiology s houldha ve ca rdia c MRI

If you know what you ’re trea ting (and trea tment ise ffective ), grea t!

If you don ’t (or it’s not), CMR

Ma na ge me nt informe d by tis s ue cha ra cte ris ticsne e ds to ca tch up