What’s New in Cardiac MRI
Katie M. Hawthorne, MD
Director, Cardiac MRI
Main Line Health
Philadelphia Cardiovascular Summit
November 18, 2017
Disclosures
• No financial disclosures
• Use of gadolinium for cardiovascular MRI is off-label use and not
FDA approved
2 Cardiac MRI: Disclosure
Objectives
• Review (briefly) the indications for cardiac MRI
• Discuss new guidelines that include cardiac MRI
• Discuss new technology
3 CMR: Objectives
CMR: Indications • Complex congenital heart disease: including anomalous coronary origin, great vessels, cardiac chambers, and
valvular disease.
• Quantify shunt: Qp:Qs; as well as precise cardiac chamber size
• Evaluate left/right ventricular systolic function (*gold standard)
• Myocardial viability
• Evaluation of specific cardiomyopathies:
– Hypertrophic cardiomyopathy
– Infiltrative: sarcoid, hemochromatosis, amyloidosis
– Arrhythmogenic ventricular cardiomyopathy (ARVC)
– Cardiotoxic therapy
• Evaluation of cardiac masses (suspected tumor or thrombus)
• Myocarditis
• Pericardial disease: acute/chronic pericarditis, constrictive pericarditis
• Ventricular tachycardia: evaluate for areas scar to aid ablation
• Valvular disease: quantify regurgitation volume, planimetry valve area
• Aortic pathology
• Pulmonary veins/anomalies
• Inadequate Echo images TDS or discrepancy between clinical scenario and echocardiogram (moderate aortic regurgitation by echo, symptoms suggesting severe)
• Appropriateness criteria OLD
Appropriateness Criteria for CCT/CMRJACC Vol. 48, No. 7, 2006
Title is 24 pt Arial and can continue onto 2 lines
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JASE 2017 30(4): 303-371
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JASE 2017 30(4): 303-371
Valvular Regurgitation
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JASE 2017 30(4): 303-371
Valvular Regurgitation
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JASE 2017 30(4): 303-371
Valvular Regurgitation: Key Points
• CMR is an excellent modality for evaluating native
valvular regurgitation. While echocardiography
remains the first-line modality, CMR is indicated when:
– Echo images are suboptimal
– Discordance exists between 2D echocardiographic features
and Doppler findings
– Discordance exists between clinical assessment and severity
of regurgitation by echocardiography
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Valvular Regurgitation: Key Points
• CMR may also provide
additional information about
the mechanism of
regurgitation and myocardial
viability, both of which may
have implications for surgical
intervention.
• CMR importantly provides
quantitative evaluation of
chamber size, regurgitant
volume and fraction.
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Mahrhold et al: Eur Heart J 2005 (26): 1461
Myocardial Characterization
Hypertrophic Cardiomyopathy
• Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disorder, with an estimated prevalence of 1:500 in the general population
• Diagnosis of HCM requires confirmation with cardiac imaging of phenotypic expression: unexplained increase in LV wall thickness (≥15 mm in adults) associated with a nondilated LV chamber
• More recently, CMR has emerged as a powerful complementary tool due to its unique strengths of tomographic imaging and enhanced spatial resolution, which affords better characterization of the complex HCM phenotype.
• CMR provides an opportunity to provide more precise LV wall thickness measurements, find atypical hypertrophy patterns and characterization of the LVOT, papillary muscle and subvalvular anatomy.
J Am Coll Cardiol. 2014;64(1):83-99
Hypertrophic Cardiomyopathy
Kaplan-Meier unadjusted estimates of freedom from
reaching combined primary end point (cardiovascular
death, unplanned cardiovascular admission,
sustained ventricular tachycardia or ventricular
fibrillation, appropriate implantable cardioverter-
defibrillator discharge) in 217 hypertrophic
cardiomyopathy (HCM) patients according the
presence or absence of fibrosis J Am Coll Cardiol. 2010;56(11):867-874.
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Circulation 2017 136(19): e273-e344
Hypertrophic Cardiomyopathy
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Circulation 2017 136(19): e273-e344
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JACC: CV Imaging 2017 10(10):1180-1193
JACC 2012 60(5): 408-420
Nonischemic Cardiomyopathy
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Nonischemic Cardiomyopathy EF>35%
Circulation 2017 135:2106-2115
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Circulation 2017 136(19): e273-e344
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Circulation 2017 136(19): e273-e344
Sarcoidosis
• Patients with LGE had a ninefold
higher rate of major adverse events
(17.2 versus 1.9 percent per year)
and 11.5-fold higher rate of cardiac
death (11.5 versus 1.0 percent per
year) as compared to patients
without LGE.
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Circulation. 2009;120(20):1969
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Tissue Characterization: New Advances
Journal of CMR 2017 19:75
Advancing Technology
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Questions?
Thank you!
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