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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!