NPC 07
Nick Curzen Nick Curzen PhD FRCP FESCPhD FRCP FESC
Wessex Cardiac UnitWessex Cardiac Unit
Why I use MRI in my clinical practiceWhy I use MRI in my clinical practiceWhy I use MRI in my clinical practiceWhy I use MRI in my clinical practice
NPC 07
Acknowledgements
Dr Charles Peebles
Dr Steve HardenDr Nick Bellenger
NPC 07
NPC 07
Anatomy
Function
Wall motion Flow quantification
PerfusionViability
PeripheralangiographyCentral
angiography
CoronariesCardiovascular MRICardiovascular MRI
NPC 07
MRI for Interventional Cardiology: WHY?MRI for Interventional Cardiology: WHY?
LV functionStress induced WM …. Ischaemia & ViabilityExtent of Infarct….. Gadolinium hyperenhancementCoronary Course/ plaquePerfusion
Rest/stress
NPC 07
Clinically valuable techniques for the interventionist…Clinically valuable techniques for the interventionist…(Or MRI stuff that I Love!)(Or MRI stuff that I Love!)
Gadolinium HyperenhancementGadolinium Hyperenhancement
NPC 07
CASE
67 yr old male Elective PCI LAD/D1 bifurcation Research study V difficult to stent LAD!! Could not re-access compromised diagonal with balloon……
67 yr old male Elective PCI LAD/D1 bifurcation Research study V difficult to stent LAD!! Could not re-access compromised diagonal with balloon……
NPC 07
Pre PCIPre PCI Post PCIPost PCI
NPC 07
Clinically valuable techniques for the interventionist…Clinically valuable techniques for the interventionist…(Or MRI stuff that I Love!)(Or MRI stuff that I Love!)
Detection of ischaemiaDetection of ischaemia
NPC 07
CASE
34 yr male Presented local hospital with 12 hour history of intermittent chest pain Widespread ST elevation anterior leads Thrombolysed Failed reperfusion diagnosed at 2.5 hrs Transferred to Soton approx 18 hrs after pain onset. Pain free on arrival
Cath………
34 yr male Presented local hospital with 12 hour history of intermittent chest pain Widespread ST elevation anterior leads Thrombolysed Failed reperfusion diagnosed at 2.5 hrs Transferred to Soton approx 18 hrs after pain onset. Pain free on arrival
Cath………
NPC 07
NPC 07
NPC 07
CASE
52 yr male Presented acute inferior MI Thrombolysed but developed severe R heart failure & cardiogenic shock Decision by non-interventionist to treat medically (?OOPS!)… inotropes & IABP Stormy course: acute RF; trash foot; sepsis Slow recovery… angio 3 weeks after admission but no pain since admission
52 yr male Presented acute inferior MI Thrombolysed but developed severe R heart failure & cardiogenic shock Decision by non-interventionist to treat medically (?OOPS!)… inotropes & IABP Stormy course: acute RF; trash foot; sepsis Slow recovery… angio 3 weeks after admission but no pain since admission
NPC 07
1.1. Is LAD territory ischaemic?Is LAD territory ischaemic?2.2. Is inferior wall viable?Is inferior wall viable?
NPC 07
Bellenger N et al. Heart 2006;92:1206.
NPC 07
dobutaminedobutamine
0 μg/kg/min
10 μg/kg/min
40 μg/kg/min
Bellenger N et al. Heart 2006;92:1206.
NPC 07
CASE
20 yr male Presented acute pulmonary oedema No chest pain Widespread anterior T wave changes & CK > 500
Extremely difficult to engage LCA at angio…………..
20 yr male Presented acute pulmonary oedema No chest pain Widespread anterior T wave changes & CK > 500
Extremely difficult to engage LCA at angio…………..
Courtesy of Keith Dawkins…Courtesy of Keith Dawkins…
(although I made the diagnosis on my on call ward round!)(although I made the diagnosis on my on call ward round!)
NPC 07
Keith, I made the diagnosis on my on call ward roundKeith, I made the diagnosis on my on call ward round
NPC 07
I made the diagnosis on my on call ward roundI made the diagnosis on my on call ward round
NPC 07
Keith, I made the diagnosis on my on call ward roundKeith, I made the diagnosis on my on call ward round
NPC 07
NPC 07
CASE
68 yr male Stent to LAD & Cx 2001 Further angio for chest pain… diffuse disease, no lesions > 50% Ongoing exertional chest pain & SOB H/o HT , LVH with strain on ECG Echo: “poor views” shows Good LV function & LVH
Why has he got his symptoms? ? ischaemia…………..
68 yr male Stent to LAD & Cx 2001 Further angio for chest pain… diffuse disease, no lesions > 50% Ongoing exertional chest pain & SOB H/o HT , LVH with strain on ECG Echo: “poor views” shows Good LV function & LVH
Why has he got his symptoms? ? ischaemia…………..
NPC 07
NPC 07
CASE – useful MR even in retrospect
53 yr male HT, FH, hyperchol CABG 1989: LIMA 2 LAD; VGs 2 OM + D1 1996 recurrent angina.. .. Stent to dominant RCA Recurrent angina 2006… local angio Referred ?PCI to ostium of Cx VG Soton colleague “challenging”… MRI ? Ischaemia Cx territory MRI 9/06….. Accepted as elective case BUT admitted after >1 week severe, worsening angina 11/06 Trop –ve on admission Transfer Soton for SBCA
53 yr male HT, FH, hyperchol CABG 1989: LIMA 2 LAD; VGs 2 OM + D1 1996 recurrent angina.. .. Stent to dominant RCA Recurrent angina 2006… local angio Referred ?PCI to ostium of Cx VG Soton colleague “challenging”… MRI ? Ischaemia Cx territory MRI 9/06….. Accepted as elective case BUT admitted after >1 week severe, worsening angina 11/06 Trop –ve on admission Transfer Soton for SBCA
NPC 07
So…… what do you do?
NPC 07
NPC 07
NPC 07
NPC 07
CASE
60 yr male Previously fit: has cardiac arrest after jogging Bystander and paramedic CPR Brief ITU stay Trop high but only minor ECG changes (AVL)
Angio shows mild LAD disease only……. IVUS
60 yr male Previously fit: has cardiac arrest after jogging Bystander and paramedic CPR Brief ITU stay Trop high but only minor ECG changes (AVL)
Angio shows mild LAD disease only……. IVUS
NPC 07
Bellenger N, Peebles C, Curzen N. Eurointervention 2006.
NPC 07
Bellenger N, Peebles C, Curzen N. Eurointervention 2006.
NPC 07
Journal of Invasive CardiologyJournal of Invasive Cardiology 2006;18:594-598.2006;18:594-598.
Patients presenting with troponin +ve cardiac-sounding pain who then have no Patients presenting with troponin +ve cardiac-sounding pain who then have no important CAD are relatively commonimportant CAD are relatively common Underlying pathology unknown…. ?”plaque event”; ?myocarditis; ?otherUnderlying pathology unknown…. ?”plaque event”; ?myocarditis; ?other Most are labelled with diagnosis of NSTEMIMost are labelled with diagnosis of NSTEMI Implications for long term Rx + insurance + job medicals etcImplications for long term Rx + insurance + job medicals etc
25 consecutive patients25 consecutive patientsMean age 56Mean age 56++11 yrs11 yrsAll treated with ACS Rx and listed for SBCAAll treated with ACS Rx and listed for SBCAAll had unobstructed coros and well-preserved LV functionAll had unobstructed coros and well-preserved LV function
Patients presenting with troponin +ve cardiac-sounding pain who then have no Patients presenting with troponin +ve cardiac-sounding pain who then have no important CAD are relatively commonimportant CAD are relatively common Underlying pathology unknown…. ?”plaque event”; ?myocarditis; ?otherUnderlying pathology unknown…. ?”plaque event”; ?myocarditis; ?other Most are labelled with diagnosis of NSTEMIMost are labelled with diagnosis of NSTEMI Implications for long term Rx + insurance + job medicals etcImplications for long term Rx + insurance + job medicals etc
25 consecutive patients25 consecutive patientsMean age 56Mean age 56++11 yrs11 yrsAll treated with ACS Rx and listed for SBCAAll treated with ACS Rx and listed for SBCAAll had unobstructed coros and well-preserved LV functionAll had unobstructed coros and well-preserved LV function
NPC 07
Journal of Invasive CardiologyJournal of Invasive Cardiology 2006;18:594-598.2006;18:594-598.
NPC 07
NPC 07
NPC 07
16%
32%
52%
Focal HE
Patchy HE
No HE
Journal of Invasive CardiologyJournal of Invasive Cardiology 2006;18:594-598.2006;18:594-598.
NPC 07
Journal of Invasive CardiologyJournal of Invasive Cardiology 2006;18:594-598.2006;18:594-598.
Do patients require angiography prior toDo patients require angiography prior toICD implantation?ICD implantation?
Do patients require angiography prior toDo patients require angiography prior toICD implantation?ICD implantation?
Eurointervention 2006;2:371-4
ProblemProblem: : No way of telling…….. No way of telling…….. (a)(a) how many were ischaemic how many were ischaemic (b)(b) How many had angiographyHow many had angiography(c)(c) How many had revascHow many had revasc
Problem 3Problem 3: : Evidence against benefit of routineEvidence against benefit of routineangiography & revascularisationangiography & revascularisation
New Engl J Med 1997
67 yr old maleMI 9 yrs agoCABG x 3 1999Poor LV (EF 30%)Admitted with symptomatic VT & pulmonary oedemaNo recent h/o angina/chest pain/chest heaviness/chest tightness/etc!Troponin 0.15LBBB
Rx: iv diuretics/nitratesRx: aspirin + clopidogrel + aceiEP opinion…….. “Needs SBCA”
NC interventionist on call………………………………………………..
……………………………………!………………?……………………….
………………what’s the indication for revascularisation???
CURZEN’S CASE 1
““Extensive area of anteroapical infarction with no viability or ischaemia”Extensive area of anteroapical infarction with no viability or ischaemia”““Extensive area of anteroapical infarction with no viability or ischaemia”Extensive area of anteroapical infarction with no viability or ischaemia”
STRESS MRI WITH HYPERENHANCEMENTSTRESS MRI WITH HYPERENHANCEMENT
(a)(a) Angio & revasc anyway (to teach the interventionist a lesson)Angio & revasc anyway (to teach the interventionist a lesson)
(b)(b) Get on with the ICD (& stop messing about)Get on with the ICD (& stop messing about)
(c)(c) When’s lunch?When’s lunch?
(a)(a) Angio & revasc anyway (to teach the interventionist a lesson)Angio & revasc anyway (to teach the interventionist a lesson)
(b)(b) Get on with the ICD (& stop messing about)Get on with the ICD (& stop messing about)
(c)(c) When’s lunch?When’s lunch?
Which patients being considered for ICD therapy shouldWhich patients being considered for ICD therapy shouldundergo revascularisation?undergo revascularisation?
Change in Care Pathway & Research RegistryChange in Care Pathway & Research Registry
Patients being considered for ICDPatients being considered for ICD
Exclude those with obvious angina/established objective evidence of ischaemia-Exclude those with obvious angina/established objective evidence of ischaemia-NOT including ETT!!NOT including ETT!!
Exclude those with good story of MI this time – Exclude those with good story of MI this time – NOT including troponin rise only!!NOT including troponin rise only!!
All undergo stress MRI with LHE gadoliniumAll undergo stress MRI with LHE gadolinium
Revasc for ischaemia +/- viability ONLY: not necessarily as in patientRevasc for ischaemia +/- viability ONLY: not necessarily as in patient
Persuade your CEO that this will save bed days so that he funds the MRI scansPersuade your CEO that this will save bed days so that he funds the MRI scans
Write up as observational series – become rich & famous. Retire and be happy!!Write up as observational series – become rich & famous. Retire and be happy!!
Patients being considered for ICDPatients being considered for ICD
Exclude those with obvious angina/established objective evidence of ischaemia-Exclude those with obvious angina/established objective evidence of ischaemia-NOT including ETT!!NOT including ETT!!
Exclude those with good story of MI this time – Exclude those with good story of MI this time – NOT including troponin rise only!!NOT including troponin rise only!!
All undergo stress MRI with LHE gadoliniumAll undergo stress MRI with LHE gadolinium
Revasc for ischaemia +/- viability ONLY: not necessarily as in patientRevasc for ischaemia +/- viability ONLY: not necessarily as in patient
Persuade your CEO that this will save bed days so that he funds the MRI scansPersuade your CEO that this will save bed days so that he funds the MRI scans
Write up as observational series – become rich & famous. Retire and be happy!!Write up as observational series – become rich & famous. Retire and be happy!!
NPC 07
ED
ES
• CMR is robust, versatile and reproducibleCMR is robust, versatile and reproducible• Non-invasiveNon-invasive• No radiationNo radiation• Time consumingTime consuming
• Helps to tailor revascularisation therapyHelps to tailor revascularisation therapy• Likely to save money!Likely to save money!
• Important research tool Important research tool
ConclusionsConclusions
NPC 07
Acknowledgements
My computer Charles Peebles The pupil at my son’s school who gave him this…..
Keith Dawkins, Huon Gray Nick Bellenger Steve Harden Paul Roberts & John Morgan Staff in Wessex Cardiac Unit MRI Suite