Nick Curzen PhD FRCP FESC Wessex Cardiac Unit

1. Why I use MRI in my clinical practice Nick Curzen PhD FRCP FESC Wessex Cardiac Unit

2. Acknowledgements Dr Charles Peebles Dr Steve Harden Dr Nick Bellenger

4. Anatomy Viability Perfusion Cardiovascular MRI Coronaries Function Peripheral angiography Central angiography Wall motion Flow quantification

5. MRI for Interventional Cardiology: WHY? • LV function • Stress induced WM …. Ischaemia & Viability • Extent of Infarct….. Gadolinium hyperenhancement • Coronary Course/ plaque • Perfusion • Rest/stress

6. Clinically valuable techniques for the interventionist… (Or MRI stuff that I Love!) Gadolinium Hyperenhancement

7. 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……

8. Pre PCI Post PCI

9. Clinically valuable techniques for the interventionist… (Or MRI stuff that I Love!) Detection of ischaemia

10. 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………

13. 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

14. Is LAD territory ischaemic? • Is inferior wall viable?

15. Bellenger N et al.Heart 2006;92:1206.

16. dobutamine 0 μg/kg/min 10 μg/kg/min 40 μg/kg/min Bellenger N et al.Heart 2006;92:1206.

17. 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………….. Courtesy of Keith Dawkins… (although I made the diagnosis on my on call ward round!)

18. Keith, I made the diagnosis on my on call ward round

19. I made the diagnosis on my on call ward round

20. Keith, I made the diagnosis on my on call ward round

22. 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…………..

24. 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

25. So…… what do you do?

29. 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

30. Bellenger N, Peebles C, Curzen N.Eurointervention 2006.

31. Bellenger N, Peebles C, Curzen N.Eurointervention 2006.

32. Journal of Invasive Cardiology2006;18:594-598. • Patients presenting with troponin +ve cardiac-sounding pain who then have no important CAD are relatively common • Underlying pathology unknown…. ?”plaque event”; ?myocarditis; ?other • Most are labelled with diagnosis of NSTEMI • Implications for long term Rx + insurance + job medicals etc • 25 consecutive patients • Mean age 56+11 yrs • All treated with ACS Rx and listed for SBCA • All had unobstructed coros and well-preserved LV function

33. Journal of Invasive Cardiology2006;18:594-598.

36. Journal of Invasive Cardiology2006;18:594-598.

37. Journal of Invasive Cardiology2006;18:594-598.

38. Do patients require angiography prior to ICD implantation?

40. Eurointervention 2006;2:371-4

41. Problem: • No way of telling…….. • how many were ischaemic • How many had angiography • How many had revasc

42. Problem 3: Evidence against benefit of routine angiography & revascularisation New Engl J Med 1997

43. CURZEN’S CASE 1 • 67 yr old male • MI 9 yrs ago • CABG x 3 1999 • Poor LV (EF 30%) • Admitted with symptomatic VT & pulmonary oedema • No recent h/o angina/chest pain/chest heaviness/chest tightness/etc! • Troponin 0.15 • LBBB • Rx: iv diuretics/nitrates • Rx: aspirin + clopidogrel + acei • EP opinion…….. “Needs SBCA” • NC interventionist on call……………………………………………….. • ……………………………………!………………?………………………. • ………………what’s the indication for revascularisation???

44. STRESS MRI WITH HYPERENHANCEMENT “Extensive area of anteroapical infarction with no viability or ischaemia” • Angio & revasc anyway (to teach the interventionist a lesson) • Get on with the ICD (& stop messing about) • When’s lunch?

45. Which patients being considered for ICD therapy should undergo revascularisation?

46. Change in Care Pathway & Research Registry • Patients being considered for ICD • Exclude those with obvious angina/established objective evidence of ischaemia- • NOT including ETT!! • Exclude those with good story of MI this time – NOT including troponin rise only!! • All undergo stress MRI with LHE gadolinium • Revasc for ischaemia +/- viability ONLY: not necessarily as in patient • Persuade 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!!

47. ED ES Conclusions • CMR is robust, versatile and reproducible • Non-invasive • No radiation • Time consuming • Helps to tailor revascularisation therapy • Likely to save money! • Important research tool

48. 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