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!