assessment of ischemia and viability - european society of...

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EAE Teaching CourseBucharest, 2010

Assessment of Ischemia and Viability

Jens-Uwe VoigtDpt. of CardiologyUniversity Leuven

Belgium

JU Voigt, Leuven

resting wall motion

1 2 3 4normal hypokinetic akinetic dyskinetic

Assessment of Ischemia & Viability

Stress Testing needed !


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JU Voigt, Leuven

Stress Testing in CAD

Ischemia

JU Voigt, Leuven

exercise test (bicycle, treadmill)

target HR = (220-age) *0.85

rest exercise max rec.

50W

100W

150W

200W

Stress Echocardiography


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JU Voigt, Leuven


dobutamine protocol

viability ischemia

rest dobutamine +atropin rec.

10µ

20µ

30µ

40µ

0,5mg

JU Voigt, Leuven


dipyridamol / adenosine protocol

rest dipyridamol / adenosine atropin rec.

dipyridamol 0,84 mg/kgadenosin 140 µg/kg

up to1mg


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JU Voigt, Leuven

sensitivity / specificity for CAD (stenosis > 50%)

0

20

40

60

80

100Exerc. Dobu Dipy

Fleischmann, JAMA 1998

sensitivity

specificity

Comparison of Protocols

JU Voigt, Leuven



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baseline stress

normal

ischemic

non-transm. scar

scar

Afridi et al., Circ 1995

regional wall motion

JU Voigt, Leuven

0

20

40

60

80

100

120

center 1 center 2 center 3 center 4 center 5Hoffmann et al., JACC 1996

interinstituional agreement in

stress echo readings(n=150 pts., 5 centers)

negative

positive

Stress Echo Reading

the human factor


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JU Voigt, Leuven

0102030405060708090

100

cent. 1 cent. 2 cent. 3 cent. 4 cent. 5 cent. 6

Hoffmann et al., EHJ 2002

negative

positive

the human factor + modern technology ...

interinstituional agreement in

stress echo readings(n=150 pts., 6 centers)

Stress Echo Reading

JU Voigt, Leuven

Regional Ischemic Response

experimental coronary occlusion

Jamal, J Am Soc Echo 2001


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JU Voigt, Leuven

baseline 5s ischemia 10s ischemia 20s ischemia

rad.

stra

in [%

]po

st. w

all

Regional Ischemic Response

Jamal, J Am Soc Echo 2001

JU Voigt, Leuven

strainischemicsegment

strainnon-ischemic

segment

rest stress

0

-10

-20

0

-10

-20

0

-10

-20

0

-10

-20

AVC MVO AVC MVO

totalstrain

PSS

Strain Rate Imaging in Stress Echo

ECG

AVC MVO AVC MVO

Voigt et al., Circulation 2003


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JU Voigt, Leuven

0

0,2

0,4

0,6

0,8

1

0 0,2 0,4 0,6 0,8 11-specificity

sens

itivi

ty

parameter AUC

PSS 0.90

systolicstrain rate 0.74

systolicstrain 0.65

ROC - Analysis

Quantitative Criteria

Voigt et al., Circulation 2003

JU Voigt, Leuven

Case: Dobutamine Stress Echo, 4CV


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Case: Quantitative Assessment

baseline peak stress

JU Voigt, Leuven

sensitivity

specificity

with and without considering SRI

Strain Rate im Stress Echo

47

7381 86

59 59

8289

0

30

60

90

ohne mit ohne mit

[%]

novice expert

Voigt, Circulation 2003

accuracy improvement depends on experience


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JU Voigt, Leuven

dobutamine stress, 646 pts., 7 ys. follow up

Björk-Ingul, Circulation 2007

Strain Rate Stress Echo for Prognosis

mSRs -

mSRs +cutoff: -2.0 s-1

p < 0.001

survival

0

10

20

30

40

clinical clin. + WMSI clin + WMSI +mSRs

χ²

p<0.001

p<0.001predictive value

JU Voigt, Leuven

Stress Testing in CAD

Viability


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JU Voigt, Leuven

CASS - Study

5 year survival rate:

med. OPEF<35% 54% 68% **EF<26% 43% 63% **

CASS: Alderman et. al.,Circ 1983

Concept of “Viability”

JU Voigt, Leuven

reperfusion therapy

relieves symptomsimproves LV functionimproves prognosis

dysfunction≠ irreversible myocardial damage !

“viable myocardium”



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JU Voigt, Leuven


stunning: contractile dysfunction after short ischaemia despite restored perfusionHeyndrickx et al., J Clin Invest 1975(to render sb. senseless or dizzy)

restitutio ad integrum

JU Voigt, Leuven

stunning: contractile dysfunction after short ischaemia despite restored perfusionHeyndrickx et al., J Clin Invest 1975(to render sb. senseless or dizzy)

restitutio ad integrum

hibernation: reduced contractile function withproportionally reduced perfusionDiamond et al., Am Heart J 1978(to lethargically pass the winter)

restitutio ad integrum ?



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Decision to Revascularize

CABG in pat. with LV dysfunction

Haas et al., JACC 1997

with proof of viability

clinicaldecision only

months post OP

prob

abili

ty o

f sur

viva

l

n = 76 pat.EF ca. 30%

JU Voigt, Leuven

CABG without proof of viability

more adverse events due toperioperative mortality (11-15% !)

worse prognosis than with med. therapy

(Haas et al., JACC 1997)(Anselmi et al., Am J Cardiol 1998)(Pasquet et al., Circ 1999)(Senior et al., J Am Coll Cardiol 1999)

Decision to Revascularize


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JU Voigt, Leuven

scintigraphy: SPECT, PETperfusion / metabolism mismatch

echocardiography: dobutamine stressinotropic stimulation

MRI: dobutamine stressinotropic stimulation

contrast MRIdelayed enhancement

How to Test for Viability ?

JU Voigt, Leuven


dobutamine protocol

viability ischaemia

BL dobutamine +atropine Rec

10µ

20µ

30µ

40µ

2mg


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JU Voigt, Leuven


baseline low dose high dosedobutamine

normal

ischemic

viable

viable+ischemic

scar

Afridi et al., Circ 1995

regional wall motion

JU Voigt, Leuven

Case: Low Dose Dobutamine

biphasic response

baseline lowdose peak


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JU Voigt, Leuven

echocardiography

scintigraphy

meta-analysisdata from

studies with direct comparison

of methods

11 studies

325 patients

Bax et al., Curr Probl Cardiol 2001

DSE vs. Scintigraphy

JU Voigt, Leuven

“delayed enhancement” vs. histology

Viability in MRT

% area histology

% a

rea

late

enh

ance

men

t

Kim, Circulation 1999


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JU Voigt, Leuven Kaandorp et al., Am J Cardiol 2004

contractile reserve vs. transmurality of scar

n= 48 patients

late enhancement vs.dobutamin - MRT

w/o

w

transmurality of scar0% 1-25% 26-50% 51-75% >75%

% s

egm

ents

contractile reserve

Viable Rimb

JU Voigt, Leuven

Which Test for Viability ?

ESC Study Group Report

modality Scinti Echo MRI (stress) MRI (contrast)indication class 1 1 1 1

Underwood et al., Eur Heart J 2004


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JU Voigt, Leuven

Case

M.Pf., m, 67 yerasdecompensated HF, NYHA III-IV

Hx silent posterior infarctionHx PTA of A. femoralisrisik faktors: hypertension

diabetes mellitus IIhyperlipidaemiaex smoker

EF ca. 25%LAD occluded, CX and RCA stenotic

JU Voigt, Leuven

Case: Multimodality Approach


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JU Voigt, Leuven

transmuralinfarction

dobu 2.5 dobu 5 dobu 10

AVC AVC AVC AVC

hibernatingmyocardium

AVC

baseline dobu 20

radial strain during low dose dobutamineafter non-transmural / transmural infarction

Weidemann et al., Circulation 2003

Strain for Viability Testing ?

JU Voigt, Leuven

layer specific assessment

Rösner et al., JASE 2010

Strain for Viability Testing ?


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JU Voigt, Leuven

EAE Consensus Statement

Sicari et al., EHJ 2008

assessment of ischemia and viability - european society of...

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