Funktionelle Ischämiediagnostik€¦ · Darstellung der Koronaranatomie - Stenosendiagnostik....

Was kann die MRT mehr - was weniger?

Funktionelle Ischämiediagnostik

PD Dr. med. Grigorios Korosoglou

Medizinische Klinik III, Kardiologie

Universitätsklinikum Heidelberg

Rosamond, W. et al. Circulation 2008

Prävalenz und Mortalität der koronaren Herzerkrankung

Kardiovaskuläre Erkrankungen

Koronare Herzerkrankung (KHK)

Darstellung der Koronaranatomie - Stenosendiagnostik

Herzkatheter Kardio-CT Kardio-MRT

Dewey,M et al, Ann Inter. Med, 2006

Dewey,M et al, Ann Inter. Med, 2006

Darstellung der Koronaranatomie - Stenosendiagnostik

ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness criteria for cardiac CT/MRI

MR-Angiographie

CT-Angiographie

Darstellung der Koronaranatomie - Stenosendiagnostik

Darstellung der Koronaranatomie - Koronaranomalien

MR-Angiographie

CT-Angiographie

ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness criteria for cardiac CT/MRI

RCA

LCA LCARCA

LCA

RCA

Diagnostik von Koronaranomalien - MRA

Herzkatheter ‚Whole Heart‘ Darstellung 3D-Rekonstruktion

ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness criteria for cardiac CT/MRI

Diagnostik von Koronaranomalien - CTA

Ao

LAD

PA

LAD

LAD

LCX

Ao

PA

RCA RCA

ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness criteria for cardiac CT/MRI

Was kann die MRT mehr? Funktionelle Ischämiediagnostik

Was kann die MRT mehr? Funktionelle Ischämiediagnostik

Dobutamin - Stress (Evaluation der WB (+Perfusion))

Adenosin - Stress (Evaluation der Perfusion (+WB))

Was kann die MRT mehr? Funktionelle Ischämiediagnostik

Indikation der Dobutamin/Adenosin - Stress MRT

ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness criteria for cardiac CT/MRI

Funktionelle Ischämiediagnostik - Sicherheit

DS-MRI Nebenwirkungen in 1000 konsekutiven Patienten

Persistierende VT 0,1%

Nicht persistierende VT 0,4%

Paroxysmales VHF 1,6%

Passagerer AV-Block 2 0,2%

RR-Anstieg > 240/120 mmHg 0,5%

Syst. RR-Abfall > 40 mmHg 0,5%

Übelkeit 3,1%

Wahl, A et al, EHJ, 2004

Funktionelle Ischämiediagnostik - Wandbewegungsanalyse

Baseline Peak Stress 3 Min nach Peak Stress

Funktionelle Ischämiediagnostik - Myokardperfusion

Adenosin - StressBaseline

Funktionelle Ischämiediagnostik mittels Dobutamin

PatientsMR-Scanner

Sensitivity Specificity PPV NPV Accuracy

Nagel-E et al, Circulation 1999

n=2081.5 Tesla

86% 86% 91% 78% 86%

Schalla-S, et al, Radiology 2002

n=221.5 Tesla

88% 83% 92% 76% 86%

Wahl-A, et al, Radiology 2004

n=1601.5 Tesla

89% 84% 94% 73% 88%

Paetsch-I, et al, EHJ 2006

n=1501.5 Tesla

78% 87% 87% 79% 82%

Korosoglou-G, et al, Circulation-CV, 2009

n=1011.5 Tesla

86% 92% 93% 79% 88%

Σ n=453 85% 86% 91% 77% 86%

Dobutamin - Stress (Evaluation der Wandbewegung)

Funktionelle Ischämiediagnostik mittels Adenosin

PatientsMR-Scanner

Sensitivity Specificity Accuracy

Schwitter et al, Circulation 2001

n=571.5 Tesla

86% 85% 86%

Nagel, et al, Circulation 2003

n=841.5 Tesla

88% 90% 89%

Ischida, et al, Radiology 2003

n=1041.5 Tesla

90% 85% 88%

Paetsch, et al, Circulation 2004

n=791.5 Tesla

91% 62% 81%

Klem, et al, JACC, 2006

n=921.5 Tesla

89% 87% 88%

Σ n=416 89% 82% 87%

Adenosin - Stress (Evaluation der Myokardperfusion)

Vergleich Dobutamin Stress MRT versus Echokardiographie

Nagel, E et al, Circulation, 1999

Vergleich Dobutamin versus Adenosin - Stress MRT

Paetsch, I et al, Circulation, 2004

Erfassung der Myokardperfusion mittels Dobutamin

Gebker, R et al, Circulation-CVI, 2008

Objektive Ischämiediagnostik - ‚Strain-Encoded‘ MRI

displacement

CircumferentialStrain

Radial Strain

Objektive Ischämiediagnostik - ‚Strain-Encoded‘ MRI

Kz

-kw kw0

Z

M(z)

kv-kv

S(Kz)

MyocardiumStatic Tissue

Low Tuning (LT)

High Tuning (HT) *Nael F. Osman, et al. MRM 2000

Tagging:Acquired voxel size=2.0x2.5x8mm3

Temporal resolution=40ms!!!Total scan time=15-21s

SENC:Acquired voxel size=3.6×3.6×10mm3

Temporal resolution=15-25msTotal scan time=8-12s

Objektive Ischämiediagnostik - ‚Strain-Encoded‘ MRI

Korosoglou, G et al, JMRI, 2008 and 2009, (in press)

Objektive Ischämiediagnostik - ‚Strain-Encoded‘ MRI(ClinicalTrials.gov Identifier: NCT00758654)

Parameters Healthy volunteers PatientsNo of subjects n=17 n=101Age (yrs) 61 ± 6 63 ± 11Male sex 12/17 (71%) 75/101 (74%)

Baseline MR-parametersBaseline ejection fraction (%) 67 ± 6 61 ± 10No of segments with resting wall motion abnormalities 0/272 (0%) 72/1616 (4%)

Cardiovascular risk factorsArterial hypertension 0/17 (0%) 89/101 (88%)Hypercholesterolemia 0/17 (0%) 66/101 (65%)Diabetes mellitus 0/17 (0%) 22/101 (22%)Family history 0/17 (0%) 30/101 (30%)Smoker 0/17 (0%) 25/101 (25%)

Baseline haemodynamic parametersMean blood pressure (mmHg) 92 ± 6 89 ± 12Heart rate (1/min) 67 ± 10 66 ± 18Double product (mmHg/min) 8339 ± 1233 8298 ± 2604

Peak stress haemodynamic parametersMean blood pressure (mmHg) 92 ± 12 109 ± 22Heart rate (1/min) 149 ± 6 138 ± 11Double product (mmHg/min) 19514 ± 2275 20029 ± 4327

Objektive Ischämiediagnostik - ‚Strain-Encoded‘ MRI(ClinicalTrials.gov Identifier: NCT00758654)

Korosoglou, G et al, Circulation-CVI, 2009, (in press)

†

*§

Analysis by vessels (n=303) Analysis by patients (n=101)

*, p<0.01; §, p<0.05 †, p<0.05

SENC detected abnormal strain response in 8 additional patients, who weremissed by cine images and proved to have CAD by angiography.

No patients were correctly diagnosed with CAD by cine and missed by SENC.

Objektive Ischämiediagnostik - ‚Strain-Encoded‘ MRI(ClinicalTrials.gov Identifier: NCT00758654)

Korosoglou, G et al, Circulation-CVI, 2009, (in press)

Bas

elin

ePe

ak-S

tres

s

4-chamber view (systole) Mid short axis view (systole)

a

f

b

g

c

h

d

i

LCX

LAD

Objektive Ischämiediagnostik - ‚Strain-Encoded‘ MRI(ClinicalTrials.gov Identifier: NCT00758654)

Objektive Ischämiediagnostik - ‚Strain-Encoded‘ MRI(ClinicalTrials.gov Identifier: NCT00758654)

Baseline Intermediate Stress Peak Stress‚work in progress‘

Stress MRT - Prognostische Wertigkeit

Jahnke, C et al, Circulation, 2007

Stress MRT - Prognostische Wertigkeit

Jahnke, C et al, Circulation, 2007

Prognostische Wertigkeit der Stress MRT in 461 Patienten

Stress MRT - Prognostische Wertigkeit in 1493 Patienten

N=1493 mit V. a KHK/KHK Progression

1.5 T Archieva MR-Scanner

Stress MRT - Prognostische Wertigkeit in 1493 Patienten

Herzlichen Dank für Ihre Aufmerksamkeit!