LA RISONANZA MAGNETICA CARDIACA: PRESENTE O … · Figure 2. CMR in Ischemic CardiomyopathyThe...

Pietro Giuliano

Arnas civico, Palermo

LA RISONANZA MAGNETICA CARDIACA:

PRESENTE O FUTURO?

Un nuovo strumento nella

stratificazione del rischio di morte

improvvisa?

Scar is scaring?

Physiopathologic Principles of Gadolinium Imaging

Gadolinium contrast medium has a molecular size that allows it to distribute in the

extracellular space without entering the myocardial cells in normal conditions.

However, under certain pathologic circumstances, either the extracellular space may

increase or the myocardial cell membrane may be disrupted, leading to an increase in

the volume of distribution of gadolinium and, as a consequence, gadolinium

enhancement. In acute myocardial infarction, for instance, cellular necrosis is associated

with cell membrane rupture and increase in gadolinium distribution .

On the other hand, in a scar secondary to a chronic myocardial infarction the

extracellular space will be increased due to collagen deposits

Non-ischemic cardiomyopathies may also exhibit LGE, due to either of the two

mechanisms described above.

Evaluation of Scar

One of the great successes with CMR is its ability to visualize myocardial scar.

Gadolinium (Gd) is injected intravenously and diffuses outside the intravascular space

but cannot cross intact myocardial cellular membrane.

However, in areas with myocardial cell damage, there is increased distribution/unit

volume. Gadolinium alters the T1-relaxation properties of the surrounding tissue, which

appears bright on delayed imaging .

The geographic distribution of LGE helps distinguish different types of cardiomyopathy.

In addition, quantification of LGE is feasible and performed with semi-quantitative or

automated measurements.

The infarcted myocardium can be divided into: 1) core infarct zone; 2) gray or peri-infarct

zone; and 3) total infarct = core + peri-infarct zones.

Nel decennio trascorso numerosi studi randomizzati controllati hanno dimostrato il

grande beneficio offerto dal cardioverter-defibrillatore impiantabile (ICD) per la

prevenzione primaria della morte cardiaca improvvisa aritmica nei pazienti con grave

disfunzione ventricolare sinistra.

Tali studi hanno rappresentato la base per la stesura delle linee guida e hanno contribuito

ad allargare di molto le indicazioni e il numero degli impianti. L’analisi della realtà clinica

quotidiana emersa dai risultati di ampi studi osservazionali ha però evidenziato alcuni

importanti punti critici nell’articolato percorso di selezione-impianto-decorso clinico dei

pazienti trattati con ICD, infatti:

1) circa un quarto degli apparecchi impiantati non è giustificato

dall’evidenza clinica

2) quasi la metà dei pazienti con indicazione non viene realmente

impiantato

3) il beneficio della terapia con ICD non sembra distribuirsi

omogeneamente

4) il bilancio trai vantaggi e gli svantaggi della terapia con ICD è

poco noto.

Figure 2. CMR in Ischemic CardiomyopathyThe figure illustrates cardiac magnetic resonance (CMR) in a patient with acute

myocardial infarction and evidence of transmural late gadolinium enhancement (LGE) (A and B) with microvascular obstruction

(arrows, A). The...

Wael A. AlJaroudi, Scott D. Flamm, Walid Saliba, Bruce L. Wilkoff, Deborah Kwon

JACC: Cardiovascular Imaging, Volume 6, Issue 3, 2013, 392–406

http://dx.doi.org/10.1016/j.jcmg.2012.11.011

Figure 3. CMR in Dilated CardiomyopathyThe figure illustrates cardiac magnetic resonance (CMR) performed on a patient with

nonischemic dilated cardiomyopathy. The left ventricle was dilated with significantly and globally reduced systolic function (cine

images...


<img height="18" border="0" style="vertical-align:bottom" width="36" alt="CME article" title="CME article"

src="http://origin-ars.els-cdn.com/content/image/1-s2.0-S1936878X13000600-cme_o.gif">Role of CMR Imaging in Risk

Stratification for Sudden Cardiac Death JACC: Cardiovascular Imaging, Volume 6, Issue 3, 2013, 392–406


Figure 5. CMR in MyocarditisThe figure illustrates cardiac magnetic resonance (CMR) in a patient with myocarditis with evidence of

significant gadolinium (Gd) uptake (even on cine imaging post-Gd injection, arrows, top row) on late gadolinium enhancement

(LGE)...






Figure 8. CMR in Postpartum CardiomyopathyThe figure illustrates focal wall motion abnormality at end-systole (ES) of the basal

inferoseptal wall (asterisk) as compared to end-diastole (ED) (A and B) with corresponding area of late gadolinium enhancement (C).

...






Figure 4. CMR in HCMThe figure illustrates cardiac magnetic resonance (CMR) in a symptomatic patient with hypertrophic

cardiomyopathy (HCM) with asymmetrical hypertrophy and interventricular septal wall thickness of 3.2 cm (top row, asterisk) and

significant s...






Figure 6. CMR in Chagas DiseaseThis is a patient from South America presenting with heart failure and found to have Chagas

disease: cardiac magnetic resonance (CMR) demonstrates wall motion abnormality in the basal inferolateral wall (A and asterisk, B)

and la...






Figure 7. CMR in Infiltrative and Neuromuscular CardiomyopathyCardiac magnetic resonance imaging demonstrating different types

of cardiomyopathy: 1) patient with known pulmonary sarcoidosis presenting with arrhythmia and found to have cardiac involvement

(note...






One of the critical factors predisposing individuals with structural heart

disease to life-threatening ventricular arrhythmias is the presence of substrate.

Although the pathophysiology of VF may be complex,

in patients with coronary artery disease(CAD), the substrate for VT is

characterized by an infarct scar that creates an opportunity for re-entry.

For a number of historical and practical reasons, the LVEF has become an

indirect index of this substrate.

Yet, the sensitivity of LVEF for identifying patients at risk of SCD is limited .

Incremental Prognostic Value of Myocardial Fibrosis

in Patients With Non–Ischemic Cardiomyopathy

Without Congestive Heart FailureCLINICAL

PERSPECTIVE

by Pier Giorgio Masci, Constantinos Doulaptsis, Erika Bertella, Alberico Del Torto, Rolf

Symons, Gianluca Pontone, Andrea Barison, Walter Droogné, Daniele Andreini,

Valentina Lorenzoni, Paola Gripari, Saima Mushtaq, Michele Emdin, Jan Bogaert, and

Massimo Lombardi

Circ Heart Fail

Volume 7(3):448-456

May 20, 2014

Copyright © American Heart Association, Inc. All rights reserved.

Study protocol.

Pier Giorgio Masci et al. Circ Heart Fail. 2014;7:448-456


Kaplan–Meier curves for composite end point.



Kaplan–Meier curves for the development of congestive heart failure.



Multivariate analyses showing the incremental value of late gadolinium enhancement (LGE) in

predicting outcome when compared with models, including clinical data alone (age and

duration of cardiomyopathy) or in combination with cardiovascular magnetic resonance

(CMR) parameters of left ventricular (LV) remodeling and function (LV volumes, mass, and

ejection fraction).



A prospective longitudinal study to investigate the yet unknown clinical significance of myocardial

fibrosis in patients with non-ischemic cardiomyopathy without history of congestive heart failure

(CHF).

METHODS AND RESULTS:

At 3 tertiary referral centers, 228 patients with non-ischemic cardiomyopathy without history of CHF were studied with cardiovascular magnetic

resonance for late gadolinium enhancement (LGE) detection and quantification and prospectively followed up for a median of 23 months.

The end point was a composite of cardiac death, onset of CHF, and aborted sudden cardiac death. LGE was detected in 61 (27%) patients.

Thirty-one of 61 (51%) patients with LGE reached combined end point when compared with 18 of 167 (11%) patients without LGE (hazard ratio,

5.10 [2.78-9.36]; P<0.001).

Patients with LGE had greater risk of developing CHF than patients without LGE (hazard ratio, 5.23 [2.61-10.50]; P<0.001) and higher rate of

aborted sudden cardiac death (hazard ratio, 8.31 [1.66-41.55]; P=0.010).

Multivariate analysis showed that LGE was associated with high likelihood of composite end point independent of other prognostic determinants,

including age; duration of cardiomyopathy; and left ventricular volumes, mass, and ejection fraction (hazard ratio, 4.02 [2.08-7.76]; P<0.001).

Improvement χ(2) analysis disclosed that LGE addition to models, including clinical data alone or in combination with parameters of left

ventricular remodeling and function, yielded an improvement in outcome prediction (P<0.001).

Addition of LGE to age and left ventricular ejection fraction improved risk stratification for composite end point (net reclassification improvement,

29.6%) and onset of CHF (net reclassification improvement, 25.4%; both P<0.001)

CONCLUSIONS:

In patients with non-ischemic cardiomyopathy without history of CHF,

myocardial fibrosis is a strong and independent predictor of outcome, providing

incremental prognostic information and improvement in risk stratification

beyond clinical data and degree of left ventricular dysfunction. © 2014 American Heart Association, Inc.

HCMHCM

it's not all a bed of roses

scar Ma a cosa ci serve?

La presenza di LGE è un tool

LA CMR E’ UNO STRUMENTO RIVOLUZIONARIO

In Sicilia sono soltanto sei i centri che attualmente

fanno cardiorisonanza.

Nessun centro è terziario ( la RNM è di

competenza e gestione della radiologia),

mediamente ogni centro non fa più di dieci esami a

settimana.

Siamo attrezzati per il futuro?

Scar is scaring?

Scar is a tool, never less never more.

Scar is the newest tool for the future.

Good job, good luck

Friends….

Thanks..

Scar Characteristics for Prediction of VentricularArrhythmia in Ischemic Cardiomyopathy

SHERIF GOUDA, M.SC.,* AMIR ABDELWAHAB, M.D.,* MOHAMED SALEM, M.D.,†

and MAGDY ABDEL HAMID, M.D.*

From the *Department of Cardiovascular Medicine, Cairo University, Cairo, Egypt; and †Department of

Radio-Diagnosis, Cairo University, Cairo, Egypt

Background: Better risk-stratification tools are needed to identify the best candidates for implantable

cardioverter defibrillator implantation. Infarct characterization by cardiac magnetic resonance (CMR) has

become an evolving potential tool for risk stratification.

Objective: We assessed the ability of scar characteristics by CMR in patients with postinfarction left

ventricular (LV) dysfunction to predict sustained monomorphic ventricular tachycardia (SMVT).

Methods: Forty-eight patients with postinfarction LV dysfunction underwent CMR study. Twenty-four

patients had history of SMVT and the other 24 were control group and underwent electrophysiological

study to assess SMVT inducibilty. Various scar characteristics were assessed in the spontaneous SMVT

group and were compared with the inducible and noninducible SMVT groups.

Results: Only six patients in the control group had inducible SMVT. In univariable analysis, total scar

(absolute and as percent of LV), scar core (absolute and as percent of LV), peri-infarct zone (absolute and

as percent of LV), mean infarct transmurality, and number of segments with late gadolinium enhancement

(LGE) were statistically significant predictors of spontaneous SMVT experience and SMVT inducibility. In

multivariable analysis, total infarct as percent of LV mass was the only significant independent predictor of

spontaneous SMVT experience (odds ratio [OR] 1.33 per% change, 95% confidence interval [CI] 1.12–1.6,

P = 0.001) and SMVT inducibility (OR 1.3 per% change, 95% CI 1.1–1.6, P = 0.004).

Conclusion: Characterization of myocardial infarct by LGE-CMR, specifically total infarct size, is better

predictor of spontaneous SMVT experience and SMVT inducibility than LV ejection fraction. (PACE 2015;

38:311–318)

The indications for implantable cardioverter-defibrillator (ICD) therapy for the prevention of sudden cardiac death in patients with severe left

ventricular dysfunction have rapidly expanded over the last 10 years on the basis of the very satisfying results of the numerous randomized

clinical trials that have provided the framework for guidelines. However, the analysis of clinical practice in the real world has highlighted some

important criticisms in the complex process of selection-management of those patients candidates for ICD therapy: 1) approximately one fourth of

all ICD implantations is not justified by clinical evidence, 2) approximately one half of patients with an indication for ICD therapy do not undergo

implantation, 3) the benefits from ICD therapy do not apply uniformly to all patients, 4) the relationship between the lifesaving benefit and the

potential for harm of ICD therapy is still scarcely known. The main reason for this clinical scenario can be ascribed to the guideline

recommendations that are based only on few standard cut-off criteria and therefore too generic and insufficiently detailed. This does not help

cardiologists in their decision-making process, and results in fear, uncertainty, and sometimes emotional choices.

The aim of this consensus document is to discuss current guideline recommendations and to provide the Italian cardiologists with the most

updated information to optimize the selection of patients with severe left ventricular dysfunction who should receive ICD therapy.

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