Cardiac ct and mri final ppt ccme osu edu

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Advanced Cardiac Imaging for the General Practitioner

Jennifer Dickerson, MD, FACC

Assistant Professor of Medicine Clinical Director of the Echocardiography Lab Assistant Director for CMR/CT Quality Assurance

Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center

Outline

? Intro to cardiac imaging/stress testing. Advanced imaging modalities MRI/CT

? Overview of indications and contraindications to cardiac MRI ? Patient selection ? Stress Testing with CMR ? Video for treadmill CMR

? Overview of indications and contraindications to cardiac CT ? Difference between Calcium score and CTA ? Patient selection for CTA/calcium score ? Clinical case for calcium score

Advanced Cardiac Imaging for the General Practitioner

Sharon Roble, MD

Assistant Professor of Clinical Medicine Department of Cardiovascular Medicine Division of Cardiovascular Medicine

The Ohio State University Wexner Medical Center

Introduction to Cardiac MRI

? Allows for assessment of anatomical structures in any plane

? Functional information (quantitative) ? Ventricular function (left and right) ? Intracardiac shunt assessment ? Stenotic lesions

? Infiltrative diseases/fibrosis ? Viability ? ARVD ? Sarcoid, Amyloid

? Vascular imaging (aorta)

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Cardiac MRI Clinical Applications

? Ischemic Evaluation: Adenosine, dobutamine or treadmill stress testing

? Viability assessment: prior to revascularization ? Cardiomyopathy assessment

? Biventricular function assessment ? Ischemic/non-ischemic/infiltrative ? Risk for Sudden Cardiac Death ? Response to cardiac resynchronization

therapy

Additional Clinical Applications

? Congenital Heart Disease ? Aortic Evaluation ? Intracardiac Mass Evaluation ? Pericardial Disease

Advanced Cardiac Imaging for the General Practitioner

Jennifer Dickerson, MD, FACC

Assistant Professor of Medicine Clinical Director of the Echocardiography Lab Assistant Director for CMR/CT Quality Assurance

Division of Cardiovascular Medicine The Ohio State University Wexner Medical Center

Gadolinium Contrast: Two Phases of Myocardial Enhancement

Normal Myocardium injection

Infarcted Myocardium

< 1 min

First-Pass Perfusion Imaging (Ischemic Assessment)

Ischemic Myocardium

> 5 min

Delayed Enhancement

time

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Patterns of Hyperenhancement

? Transmural ? Involves entire wall ? Consistent with myocardial infarction/ischemic event ? If more than 50% of wall involved, felt to be non-viable

? Non-transmural ? Endocardial, epicardial, mid-wall ? Non-ischemic myopathies, infiltrative diseases

DME: LAD-territory infarct scar

Mid-Myocardial Hyperenhancement

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Infiltrative Cardiomyopathies

? Myocardial biopsies subject to sampling error ? CMR `samples' the entire myocardium ? Sarcoidosis ? Amyloidosis ? Hemochromatosis ? Chagas disease ? Gaucher's disease, Anderson-Fabry disease,

etc.

Cardiac Amyloid

Congo red

DME TI Scout

Polarized light with congo red

DME TI 70msec

DME TI 200msec

Myocarditis: Giant Cell

Myocarditis

DME with extensive epicardial hyperenhancement

CMR Cine Images

Markedly abnormal DME-CMR

Small focus of mononuclear cells

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Limitations of MRI

? Long acquisition times ? 45-60 min

? Most imaging sequences require breath holding ? 10-30 sec breath holds per image sequence ? 10-16 images required to image entire heart

? Contraindications to MRI ? Pacemakers/ICDs ? Any ferrous material within body ? CKDNephrogenic systemic fibrosis (NSF)

Nephrogenic Systemic Fibrosis (NSF)

? Diffuse systemic fibrosis involving skin, skeletal muscle, GI tract, cardiovascular system ? Skin lesions symmetrical and extend distal to proximal

? After the administration of gadolinium in patients with renal failure (GFR<60) ? No cases reported in patients with GFR >30

? Diagnosis: skin biopsy ? Lab testing non-specific

? Treatment supportive ? Restore renal function (HD not effective once patient develops NSF) ? Pain management

? For further questions, refer to OSU Radiology Departmental website on OneSource

Overview of Cardiac MRI Stress Testing

? Pharmacologic ? Adenosine/Regadenoson ? Dobutamine

? Exercise (Treadmill) ? Functional data ? NIH supported research at Ohio State

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Advanced Cardiac Imaging for the General Practitioner

Sharon Roble, MD

Assistant Professor of Clinical Medicine Department of Cardiovascular Medicine Division of Cardiovascular Medicine

The Ohio State University Wexner Medical Center

Clinical Case 1

? 16 year-old asymptomatic basketball player ? ROS: no syncope, palpitations, DOE, etc. ? PMH: negative ? FH: unremarkable

Physical Examination

? Height 182 cm, weight 71 kg ? BP 118/54, HR 45-60 ? Symmetric pulses ? II/VI SEM at LUSB, no positional change ? Rest of PE unremarkable

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