new applications in echocardiography and cardiovascular mri
TRANSCRIPT
New Applications in Echocardiography and
Cardiovascular MRI Karima Addetia, MD
University of Chicago, Chicago, IL
What do the 2015 guidelines tell us.?
“In labs with experience, 3D measurement of LV volumes is recommended when feasible”
“In labs with experience, 3D measurement of RV
volumes is recommended”
• STE-derived strain of LV and RV is feasible
• Data available on clinical applicability of LV strain
Why 3D?
0Improved accuracy: validation against CMR
• Ahmad M, et al. J Am Coll Cardiol 2001; 37:1303-9 • Qin JX, et al. J Am Coll Cardiol 2000; 36:900-7 • Arai K, et al. Am J Cardiol 2004; 94:552-8 • Jenkins C, et al. J Am Coll Cardiol 2004; 44:878-86 • Kuhl HP, et al. J Am Coll Cardiol 2004; 43:2083-90. • Gutierrez-Chico JL, et al. Am J Cardiol 2005; 95:809-13
EDV, ESV
Excellent
correlation (r²>0.85)
Why 3D? 0Improved accuracy: validation against CMR
• Jacobs LD, et al. Eur Heart J 2005; 27:460-8 • Sugeng L, et al. Circulation 2006; 114:654-61 • Jenkins C, et al. J Am Soc Echocardiogr 2007; 20:962-8 • Soliman OI, et al. Am Soc Echocardiogr 2007; 20:1042-9
EDV, ESV
Excellent
correlation (r²>0.85)
but 3DE
underestimates
volumes
Mor-Avi V. et al, JACC Cardiovasc Img 2008: 1: 413-423
Sources of error: 3D
Small difference between the 2 boundaries resulted in an 11% difference in the measured volume of the 3D shell!
Egg-shaped phantom
Limitations to integration of 3D into clinical routine
• Time-consuming • Expertise needed for image acquisition • Expertise needed for image analysis • Accuracy varies with expertise • Reproducibility varies among
individuals • Reproducibility varies among
institutions
Anatomical Intelligence in Chamber Quantification
Align &
Orient
Model
Adjust
Local
Borders
Automatically
corrects
foreshortening
Avoids
Geometric
Assumptions
Anatomical intelligence: Comparison with CMR
Correlation Bias LOA (1SD)
LVEF,%
Model No CC 0.85 -2 9 Model with CC 0.91 -2 8 LVEDV, ml
Model No CC 0.93 -24 25
Model with CC 0.95 -10 22
LVESV, ml
Model No CC 0.93 -13 29
Model with CC 0.95 -4 23
Anatomical intelligence: Variability
Automated 3D Mode Measurement
3DE-Manual
Measurement
Test- Retest
without CC
Test-retest
with CC
inter-observer
with CC
Intra- observer-
Inter-observer
Intra-observer
MRI
LV EDV 6±6% 5±5% 9±4% 10±4% 15±12% 4±6%
LV ESV 8±7% 9±9% 10±4% 12±4% 18±18% 8±8%
LV EF 8±9% 8±8% 9±6% 11±2% 21±8% 8±7%
Female LVEF = 61-65%
LVEDVi = 39-58 mL/m2
LVESVi = 15-23 mL/m2
Male LVEF = 57-62%
LVEDVi = 41-66 mL/m2
LVESVi = 16-29 mL/m2
Normal values for the LV (3D)
Right ventricular anatomy
Infundibulum
Apex Inflow tract
Tricuspid valve
Membranous septum
Pulmonary valve
3D RV Analysis correlates with CMR
MuraruD…BadanoLPet.al.EHJCardiovascularImaging2015
MedvedofsyD,AddetiaK…LangRMet.al.JASE2015
r Bias LOA r Bias LOA
EDV 0.92 -15mL ±45mL 0.95 -11mL ±40mL
ESV 0.93 -4mL ±28mL 0.96 -0.3mL ±31mL
RVEF 0.86 1.4% ±9.7% 0.83 -3.3% ±15%
Regional Shape analysis: Curvature
Curvature: “amount by which a surface deviates from being flat”
Addetia K, Maffessanti F. et. al. European Heart Journal Cardiovascular Imaging 2016
Salgo IS et. al. J Am Soc Echocardiogr 2012
Curvature = 0 Curvature < 0 Curvature > 0
Concavity Convexity Curvature
= 0
PAH vs. Normal right ventricles
Pulmonaryarterial
hypertension
4-chamber Sagi alCoronal
Normalsubject
Addetia K, Maffessanti F. et. al. European Heart Journal Cardiovascular Imaging 2016
Curvature maps to describe shape Normal PAH
Fre
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surf
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Normal PAH
Fre
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Addetia K, Maffessanti F. et. al. European Heart Journal Cardiovascular Imaging 2016
Normal PAH
Fre
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all s
urfa
ce
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all s
urfa
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-0.5
0.0
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-0.5
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Normal PAH
Fre
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ac
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0.0
0.5
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-0.5
0.0
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Normal PAH
Fre
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all
surf
ac
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all
surf
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0.0
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1.0
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-0.5
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Severe pulmonary
artery hypertension
Normal healthy subject
Free-wall Free-wall
Septum Septum
What about the left atrium: Volumes
N = 317 patients in normal sinus rhythm
Tsang et. al. J Am Coll Cardiol 2006; 47:1018 –23
Left atrial phasic volumes
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 4 , N O . 7 , 2 0 1 1
Reservoir function
Conduit function
Booster function
Left atrial remodeling/shape!
A more spherical LA shape was independently associated with an increased risk for embolic events, adding incremental value beyond age and LA function (LA emptying fraction)
Nunes et. al. JACC: CARDIOVASCULAR IMAGING, VOL. 7, NO. 5, 2014
3D TEE and mechanism of mitral regurgitation
P1
P2 P3
A1
A2 A3 CL CM
Lang RM, Tsang W, Weinert L, Mor-Avi V, Chandra S. JACC 2011
November 1;5 8(19):1933-1944.
3D TEE and mechanism of mitral regurgitation
Bhave NM, Addetia K et. al. JACC: Cardiovascular Imaging. 2013
3D TEE in mitral regurgitation
84 yo female, status post mitral valve surgery 6 months
prior, began experiencing
increasing shortness of breath.
Finally she was unable to perform daily activities. A
TEE was organized.
Case History
4chamber Long axis 900 view
4chamber Long axis
Tricuspid valve disorders
Primary
(or “Organic”)
Secondary
(or “Functional”)
Intrinsic abnormality
of the valve apparatus
TR due to RV and/
or TV annular dilation
70-85%* of TR 15-30%* of TR
Antunes MJ, Barlow JB, Heart 2007
1. Rheumatic #1
2. Tricuspid atresia
3. RA tumors
4. Carcinoid
5. RV inflow obstruction
6. Endomyocardial fibrosis
7. TV vegetations
8. Pacemaker
9. Extracardiac tumors
Primary (organic) TR – PM/ICD 72 year-old man with a history of rheumatic heart disease status post AVR and ICD placement. Now presenting with moderate prosthetic stenosis, severe MS and severe TR. He was taken to the OR.
Pre-op
Post-op
Addetia K et. al. J Am Soc Echocardiogr 2014;27(11):1164-75
Primary (organic) TR – PM/ICD
Postero-septal
Septal
Posterior
Anterior
PS + Malcoaptation
Two leads
Mediratta A, Addetia K, et. al. JACC Cardiovasc Imaging. 2014 Apr;7(4):337-47
Tricuspid regurgitation – not benign
Nath et. al. J Am Coll Cardiol. 2004;43(3):405-409. doi:10.1016/j.jacc.2003.09.036
• KM survival curves for patients with TR
• Survival worse in moderate and severe TR
Tricuspid valve disorders
Primary
(or “Organic”)
Secondary
(or “Functional”)
Intrinsic abnormality
of the valve apparatus
TR due to RV and/
or TV annular dilation
70-85%* of TR 15-30%* of TR
Antunes MJ, Barlow JB, Heart 2007
1. Rheumatic #1
2. Tricuspid atresia
3. RA tumors
4. Carcinoid
5. RV inflow obstruction
6. Endomyocardial fibrosis
7. TV vegetations
8. Pacemaker
9. Extracardiac tumors
Functional tricuspid regurgitation Secondary
(or “Functional”)
TR due to RV and/
or TV annular dilation
70-85%* of TR
Antunes MJ, Barlow JB, Heart 2007
Dreyfus, G.D. et al. J Am Coll Cardiol. 2015; 65(21):2331–6
Dreyfus et al. ATS 2005
THE ACC/AHA 2014 GUIDELINES
ACC/AHA Guidelines for management of VHD JACC 2014
ESC/EACTS Guidelines for management of VHD EHJ 2012
TAVR and 3D Echocardiography
0Accurate assessment of
annular size is critical
0Underestimation
0PVR
0Valve migration,
embolism
0Overestimation
0 Incomplete deployment
(valvular and PVR)
0Annular rupture
Piazza Circ Cardiovasc Intervent. 2008
TAVR and 3D Echocardiography
69 yo man • Severe symptomatic AS • LVEF 68% • Concomitant history of
COPD on home O2 (4L), OSA, DM and previous CABG
• Admitted for TAVI • BAV 1 month prior AVA
0.68 to 1.5cm2
Annulus = 24 mm
Valvuloplasty
Holmes DR et. al. ACCF/AATS/SCAI/ STS expert consensus document on TAVR. J Am Coll Cardiol. 2012
TAVR and 3D Echocardiography
Deployment of Edwards Sapien 26 mm
Post deployment
Post deployment – Moderate AI?
TAVR and 3D Echocardiography
Post deployment Severe central AI?! Angiographic confirmation of AI severity
TAVR and 3D Echocardiography
CT MD = 30 mm CT Area = 741 mm2
CT Perimeter =99 mm
3D TEE MD = 26 mm 3D TEE Area = 554 mm2
3D TEE Perimeter = 94 mm
TAVR and 3D Echocardiography
CT MD = 30 mm CT Area = 741 mm2
CT Perimeter =99mm
3D TEE MD = 26 mm 3D TEE Area = 554 mm2
3D TEE Perimeter = 94 mm
Paravalvular leak closure and 3D Echo
Lázaro et al. Imaging in paravalvular leaks Cardiovasc Diagn Ther 2014;4(4):307-313
CMR: Myocarditis/Pericarditis A 57-year-old teacher was seen in the ER 6 months prior with symptoms and EKG findings consistent with acute pericarditis. Ibuprofen was started resulting in resolution of symptoms. Since that time, she experienced several exacerbations for which she was treated with bursts of high dose corticosteroids. During exacerbations she had documented serositis. LVEF was normal. 2 weeks prior to CMR the pleuritic chest pain recurred with palpitations and fevers of 101F.
CMR: Myocarditis/Pericarditis 0Pericarditis: pericardial thickening,
inflammation, fibrosis
0Myocarditis: hyperemia and edema, necrosis/scar, contractile dysfunction and pericardial effusion
0Constriction
0Prognosis
0 Edema without necrosis/scar can predict functional recovery
0 Necrosis/scar as detected by LGE has been associated with higher mortality
JCMR 2009; 11:14
Inspiration
Expiration
Friedrich MG. Circ Cardiovasc Imaging. 2013;6:833-839
Cardiac sarcoidosis Definition: Cardiac sarcoidosis is a systemic inflammatory condition associated with the formation of non-caseating granulomas in the lungs, reticuloendothelial system and skin. Cardiac involvement in patients with systemic sarcoidosis is seen in approximately 30-50% of postmortem cases. It is associated with worse prognosis.
Regional wall thickening
Patchy wall motion changes
Cardiac sarcoidosis Class IIa: ICD implantation is reasonable for patients with cardiac sarcoidosis... (Level of Evidence: C)
The importance of LGE
Murtagh G… Addetia K…..Patel AR Circ Cardiovasc Imaging. 2016;9:e003738
Cardiac sarcoidosis
Among our population of sarcoid patients with nonspecific symptoms, presence of… LGE was the best independent predictor of potentially lethal events, as well as other adverse events. Cox HR of 31.6 and of 33.9, respectively.
N = 155 consecutive patients with systemic sarcoidosis who underwent CMR for workup of suspected cardiac involvement
Greulich S. J Am Coll Cardiol Img 2013;6:501–11
Hypertrophic cardiomyopathy 0Myocardial fibrosis or scaring detected by CMR
occurs in up to 33-86% of patients with HCM
The importance of LGE
Maron Journal of Cardiovascular Magnetic Resonance 2012, 14:13
Hypertrophic cardiomyopathy 0 Myocardial fibrosis or scaring detected
by CMR occurs in up to 33-86% of
patients with HCM
The importance of LGE
Follow-up (years)
Chan RH. Circulation. 2014;130:484-495
10 prevention • Family history of HCM SD • Unexplained syncope • Multiple, repetitive NSVT • Abnormal exercise BP
response • Massive LVH • LGE ≥ 15% LV
Maron MS. Circulation. 2015;132:292-298
Cardiac amyloidosis 0Echo initial diagnostic
test of choice 0Findings: 0“Speckling” 0LVH 0RVH 0Bi-atrial enlargement 0Thickening of IAS 0Thickening of valves 0 Increased PASP 0Abnormal diastology
Cardiac amyloid – T1 Mapping
A 54 year-old woman with AL amyloidosis (bone marrow biopsy positive) and renal dysfunction was referred for cardiac MRI to rule out cardiac amyloidosis. She had an echo which revealed an LVEF of 65-70% with moderate LVH. No significant valvulopathy. No “apical sparing” of strain. GFR = 27.
Cardiac amyloid – T1 Mapping A 54 year-old woman with AL amyloidosis (bone marrow biopsy positive) and renal dysfunction was referred for cardiac MRI to rule out cardiac amyloidosis. She had an echocardiogram which revealed an LV ejection fraction 65-70% and moderate LVH. No significant valvulopathy. No apical sparing of strain. GFR = 27.
Mean native T1 reference values 950 ± 21 msec at 1.5 T 1052 ± 23 msec at 3 T
T1 time in this patient: 1150