La Risonanza Magnetica Nella Prima Diagnosi Di Scompenso Cardiaco

Gaetano Nucifora MD, PhD, FESC

Division of Cardiology

University Hospital “Santa Maria della Misericordia”, Udine, Italy

Il Laboratorio di Cardiac Imaging Nello Scompenso CardiacoInnovazione e CoworkingTrieste – 30-31/10/2015

Il sottoscritto GAETANO NUCIFORA

DICHIARA

che negli ultimi 2 anni NON ha avuto rapporti anche di finanziamentocon soggetti portatori di interessi commerciali in campo sanitario

Fun

ctio

nEd

em

aN

ecrosis

Mycro

vascular

dam

age

Magnetic Resonance and Heart Failure

Identification of Underlying Etiology

Risk stratification

Therapeutic implications3

1

2

Magnetic Resonance and Heart Failure

Identification of Underlying Etiology

Risk stratification

Therapeutic implications3

1

2

1. Delayed wash-in and wash-out kinetics of nonviable tissue;

2. Acute and chronic disarrangement of interstitium;

3. Different volumes of distribution of Gd in viable and nonviable tissue;

4. Inversion Recovery technique with prepulse delay (250 to 350 msec) to null myocardial signal intensity .

Non viablemyocardium

Viablemyocardium

Identification of Underlying EtiologyLate Gadolinium Enhancement Imaging

LGE PATTERN

Mahrholdt et al. EHJ 2005

Identification of Underlying Etiology

Non-IschemicCardiomyopathy Ischemic

Cardiomyopathy

Heart Failure With Reduced Ejection Fraction

Felker et al. JACC 2002

1921 pts with symptomatic HFLVEF<40%

Ischemic etiology: independent predictor of mortality after correction for age, gender, diabetes, NYHA class and LVEF<40%

3-vessel CADEF < median (27%)ESVI > median (79 ml/m2)

Panza et al. JACC 2015

Identification of Underlying Etiology

Ischemic CM

Non-Ischemic CM

59%28%

13%

No LGE Mid-wall LGE Subendocardial LGESubendocardial/Transmural LGE

100%

No CAD by Cath CAD by Cath

McCrohon et al. Circulation 2003

Identification of Underlying Etiology

Non-IschemicCardiomyopathy Ischemic

Cardiomyopathy

Heart Failure With Reduced Ejection Fraction

90 patients with heart failure and LV systolic dysfunction

Regional or global myocardial SI increase in T2-W images

Increased global myocardial early gadolinium enhancement ratio between myocardium and skeletal muscle in gadolinium enhanced T1-W images

≥1 focal lesion with non-ischemic regional distribution in IR gadolinium-enhanced T1-W images (LGE)

Heart Failure With Reduced Ejection Fraction

Identification of Underlying Etiology

Myocarditis

Identification of Underlying EtiologyHeart Failure With Reduced Ejection Fraction

Myocarditis

Friedrich et al. JACC 2009

Identification of Underlying EtiologyHeart Failure With Reduced Ejection Fraction

Myocarditis

Francone et al. JACC Imaging 2014

Suspected Acute Myocarditis

Suspected Chronic Myocarditis

Lurz et al. JACC Imaging 2012

Identification of Underlying EtiologyHeart Failure With Reduced Ejection Fraction

Bohnen et al. Circ Imaging 2015

T2 of ≥60 ms: 94%sensitivity, 60%specificity, 77%accuracy, 90%negative and 71%positive predictivevalue for activemyocarditis

Radunski et al. JACC Imaging 2014

Identification of Underlying EtiologyHeart Failure With Preserved Ejection Fraction

HTN

Rudolph et al. JACC 2009Nucifora et al. Am J Physiol Heart Circ 2014

Nucifora et al. Int J Cardiovasc Imaging 2015

HC

MA

mylo

id

Identification of Underlying EtiologyHeart Failure With Preserved Ejection Fraction

Longhi et al. JACC Imaging 2015

Magnetic Resonance and Heart Failure

Identification of Underlying Etiology

Risk stratification

Therapeutic implications3

1

2

Gerber et al. JACC 2012

Kwon et al. Circulation 2012

Risk Stratification/Prognosis AssessmentIschemic Cardiomyopathy

Pegg et al. JCMR 2010

Gulati et al. JAMA 2013

Risk Stratification/Prognosis AssessmentNon-ischemic Cardiomyopathy

472 patients with dilated cardiomyopathyFollow-up: median 5.3 years

Midwall fibrosis: 142 patients (30%)73 deaths

162 patients with non-ischemic cardiomyopathyFollow-up: mean 29 months

LGE: 81 patients (50%)51 events (CV death/ICD shocks)

Neilan et al. JACC Imaging 2013

Risk Stratification/Prognosis Assessment

1293 patients with HCMFollow-up: median 3.3 years

LGE: 548 patients (42%)37 (3%) events (SCD/ICD therapy)

Chan et al. Circulation 2014

Austin et al. JACC Imaging 2009

Banypersad et al. EHJ 2015

Risk Stratification/Prognosis Assessment

Magnetic Resonance and Heart Failure

Identification of Underlying Etiology

Risk stratification

Therapeutic implications3

1

2

Klem et al. JACC 2012

Therapeutic Implications

137 patients with ischemic/non-ischemic CMP (53/47%)Follow-up: 24 months

39 events (death/ICD intervention)Scar >5% independent predictor of events

Adding scar >5% to EF reclassified 32% of patients in low/high risk

Rijnierse et al. AJC 2015

Delgado et al. Circulation 2011

Therapeutic Implications

Leyva et al. JCMR 2011

Ajmone Marsan et al. Eur Heart J 2009

Therapeutic Implications

Abbasi et al. JCMR 2013

CONCLUSIONSComprehensive information of morphology, function, tissuecharacterization

Differentiation between ischemic and non-ischemic heart failure and of differentetiologies of non-ischemic heart failure

Risk stratification of HF patients with incremental value over classical clinicalparameter, regardless of etiology

Improvement of clinical decision making, and selection of CRT and ICD candidates

Thank you for your kind attention!