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Contrast Enhanced MRI in MESA João Lima, MD David Bluemke, MD, Ph D J.H.U. and N.I.H.

Contrast Enhanced MRI in MESA João Lima, MD David Bluemke, MD, Ph D J.H.U. and N.I.H. Chicago, September 4, 2008. MYOCARDIAL FAILURE INDUCED BY EMOTIONAL STRESS. B. A. C. Witstein I, Thieman D, Lima J et al. NEJM 2005;352:539-548. Lima J, Judd R et al. Circulation 1995.

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Contrast Enhanced MRI in MESA João Lima, MD David Bluemke, MD, Ph D J.H.U. and N.I.H.

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  1. Contrast Enhanced MRI in MESA João Lima, MD David Bluemke, MD, Ph D J.H.U. and N.I.H. Chicago, September 4, 2008

  2. MYOCARDIAL FAILURE INDUCED BY EMOTIONAL STRESS B A C Witstein I, Thieman D, Lima J et al. NEJM 2005;352:539-548

  3. Lima J, Judd R et al. Circulation 1995

  4. Acute MI – Second day Contrast enhanced MRI Cine-MRI

  5. Myocardial Infarction with LV Aneurysm LV Aneurysm Long Axis Pre-Contrast Long Axis – Post-Contrast

  6. Normal Myocardium Contrast volume of distribution in delayed Hyper-enhancement CHRONIC INFARCT ECV Gd-DTPA 0.23 ml/g (Arheden, Radiology 2000) Chronic Infarct ECVin tendon 51Cr-EDTA 0.53 ml/g (Aukland A.J.P 1997) Presence of Collagen fibers and reduced cellularity

  7. Prediction of Wall Motion Improvement 256/329 109/183 p < 0.0001 for trend 46/110 Likelihood of Improved Wall Motion 13/124 1/58 Transmural Extent of Hyperenhancement Kim R, Judd R et al . NEJM 2000;343:1445-53

  8. Infarct Size (Wu et al. Circ 1998;97:765-772) 100 80 70% <18% 60 18-30% %Event-free Survival 57% 40 >30% 29% 20 p < 0.05 0 0 5 10 15 20 25 Months

  9. C1 C2 Dilated Non-Ischemic Cardiomyopathy A B Wu K et al. JACC 2008

  10. Dilated Non-Ischemic Cardiomyopathy 1.00 Hyper-enhancement absent 0.75 P=0.0004 % Event-free survival 0.50 Hyper-enhancement present 0.25 Log rank p=0.0004 0.00 0 1 2 3 Time to Follow-up (years) Wu K et al. JACC 2008

  11. Delayed gadolinium enhanced long-axis image of the heart showing areas of myocardial enhancement (white arrows), indicative of collagen deposition Macedo R et al. JMRI2006;24:1197–1206

  12. Myocardial Fibrosis in Hypertension Histological section of a myocardial biopsy specimen from a patient with essential hypertension, showing interstitial (left panel) and perivascular (right panel) fibrosis. (Picrosorius red stain 20). Lopez B et al. J of Hypertension, 23:1445-1451 2005

  13. 4-Chamber Image MR I Assessment of the Substrate for Inducible VT in Patients with Non-Ischemic Dilated Cardiomyopathy Nazarian S et al. Circulation 2005 112:2821-2825 VT Morphology

  14. 32 year old woman presented with palpitations. EKG showed VT at 160 bpm. • Clinical evidence of sarcoid (hilar adenopathy, endobronchial biopsy showed noncaseating granulomas) Latcu DG, et al. Pacing Clin Electrophysiol. 2007;1566-70

  15. All (51) IND* (n=15) CHD† (n=26) VT‡ (n=10) P With MF§ 35 (68.6) 3 (20.0) 22 (84.6) 10 (100) NS Without MF§ 16 (31.4) 12 (80.0) 4 (15.4) 0 (0) < 0.001¶ MF§ (% LV|| mass) 13.4±13 0.9±2.3 16.0±12.3 25.4±9.8 <0.001** Myocardial Fibrosis by MRI in Different Groups of Patients with Chagas Disease Data are expressed as mean ± SD or number (%) for discrete variables. *IND= indeterminate group; †CHD= Chagas’ heart disease; ‡VT= ventricular tachycardia group §MF= Myocardial fibrosis by MRI; ||LV = left ventricle;¶Fisher’s exact test; **One-wayANOVA withBonferroni multiple (3) comparison test: IND vs. CHD= p<0.001, IND vs. VT= p<0.001 and CHD vs. VT= p=0.044. Rochitte C et al. JACC 2005

  16. ARVD and Fibrosis Tandri H, Bluemke D et al. JACC. 2005

  17. JACC 2006; 48:765 • 248 subjects (123 women, 125 men), 70 yrs old, Uppsala • Myocardial infarction scars were found in 60 subjects (24.2%), in 49 of whom (19.8%) they were unrecognized UMIs. • EF was significantly lower; LV mass larger in the subjects with UMI or RMI

  18. Safety of gadolinium based MRI contrast agents • Moderate severe reactions: 1/5000 • Severe reactions in 1/ 300,000-400,000 • Asthma or other allergies: rate of reaction may be slightly increased (2 fold) • Report side effects to manufacturer, except nausea, lot numbers recorded

  19. Nephrogenic Systemic Fibrosis • First case of NSF/NFD was seen in 1997. • Associated with advanced renal failure. • Fibrosis of the skin may spread to other parts of the body such as the diaphragm, muscles in the thigh and lower abdomen, and the interior areas of lung vessels.

  20. http://www.rad.jhmi.edu/mri/MRI_dialysis_gadolinium.htm

  21. Collaborating Centers in the MESA Study • Univ of Washington • Wake Forest • Univ of MN • U of Vermont • New Engl Med Cntr • Northwestern Univ • Columbia • Johns Hopkins (2) • UCLA (2) Courtesy of Gregory Burke, MD, MESA Study

  22. MESA 5 Examination 1. 1000 MESA participants. 2. Patient consent for gadolinium is obtained. 3. Gd dose is 0.15 mmol/kg (off-label). 4. Only participants with normal renal function – GFR > 60 will be selected to participate.

  23. Delayed Contrast Enhancement (DCE) MRI Noninvasive gold standard for detecting myocardial scar and determining transmurality The presence and extent of clinically unrecognized myocardial scars are strong predictors of major adverse cardiac events. Myocardial scar areas appear bright: Retention of contrast material in fibrosis areas Increased volume of contrast material distribution in acute myocardial infarction and inflammatory conditions Evrim B. Turkbey

  24. Case 2: IschemicPattern Circumferential Strain Time  Evrim B. Turkbey

  25. Non-ischemic patterns in EDICRV Insertion Points Case 1 Case 2 Evrim B. Turkbey

  26. Midwall or Epicardial Long axis Short axis views Evrim B. Turkbey

  27. Gadolinium exclusions (EDIC) N = 591 eligible patients N = 552 consented to MRI (93%) N = 119 total gadolinium exclusions (23%) GFR related (83/552 = 15%) N = 72 (60%) past or present GFR < 60 N = 3 allergic (2.5%) N = 1 dialysis (.8%) N = 3 transplant (2.5%) N = 4 other (3.4%) Gad refusal N = 37 refuse gad (7.9%, 37/(552-83))

  28. Collaborators: Cardiac MESA MRI Group Albert Lardo PhD, Wendy Post, MD Katherine Wu MD, Nael Osman, PhD, Robyn McClelland, Ph D, Saman Nazarian, MD Chia Liu Ph D, John Eng, MD Monda Shehata, MD, Cuilian Miao, MD, Raymond Yan, MD, Evrin Turkbey, MD Ashkan Malayeri, MD, Alban Redheuil, MD Verônica Fernandes, MD, Wen Chung Yu, MD Hossein Bahrami, MD

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