New Applications in Echocardiography and Cardiovascular MRI

New Applications in Echocardiography and

Cardiovascular MRI Karima Addetia, MD

University of Chicago, Chicago, IL

Advances in Echocardiography

Chamber quantification

What do the 2015 guidelines tell us.?

“In labs with experience, 3D measurement of LV volumes is recommended when feasible”

“In labs with experience, 3D measurement of RV

volumes is recommended”

• STE-derived strain of LV and RV is feasible

• Data available on clinical applicability of LV strain

Mor-Avi V, Lang RM et al., Circulation 2004. 110: 1814-1818.

Why 3D?

0Avoids foreshortening

Why 3D?

0Improved accuracy: validation against CMR

• Ahmad M, et al. J Am Coll Cardiol 2001; 37:1303-9 • Qin JX, et al. J Am Coll Cardiol 2000; 36:900-7 • Arai K, et al. Am J Cardiol 2004; 94:552-8 • Jenkins C, et al. J Am Coll Cardiol 2004; 44:878-86 • Kuhl HP, et al. J Am Coll Cardiol 2004; 43:2083-90. • Gutierrez-Chico JL, et al. Am J Cardiol 2005; 95:809-13

EDV, ESV

Excellent

correlation (r²>0.85)

Why 3D? 0Improved accuracy: validation against CMR

• Jacobs LD, et al. Eur Heart J 2005; 27:460-8 • Sugeng L, et al. Circulation 2006; 114:654-61 • Jenkins C, et al. J Am Soc Echocardiogr 2007; 20:962-8 • Soliman OI, et al. Am Soc Echocardiogr 2007; 20:1042-9

EDV, ESV

Excellent

correlation (r²>0.85)

but 3DE

underestimates

volumes

Mor-Avi V. et al, JACC Cardiovasc Img 2008: 1: 413-423

Sources of error: 3D

Small difference between the 2 boundaries resulted in an 11% difference in the measured volume of the 3D shell!

Egg-shaped phantom

Mor-Avi V. et al, JACC Cardiovasc Img 2008: 1: 413-423

Sources of error: 3D

Limitations to integration of 3D into clinical routine

• Time-consuming • Expertise needed for image acquisition • Expertise needed for image analysis • Accuracy varies with expertise • Reproducibility varies among

individuals • Reproducibility varies among

institutions

Automated Chamber Quantification

Anatomical Intelligence in Chamber Quantification

Align &

Orient

Model

Adjust

Local

Borders

Automatically

corrects

foreshortening

Avoids

Geometric

Assumptions

Anatomical intelligence: Comparison with CMR

Correlation Bias LOA (1SD)

LVEF,%

Model No CC 0.85 -2 9 Model with CC 0.91 -2 8 LVEDV, ml

Model No CC 0.93 -24 25

Model with CC 0.95 -10 22

LVESV, ml

Model No CC 0.93 -13 29

Model with CC 0.95 -4 23

Anatomical intelligence: Variability

Automated 3D Mode Measurement

3DE-Manual

Measurement

Test- Retest

without CC

Test-retest

with CC

inter-observer

with CC

Intra- observer-

Inter-observer

Intra-observer

MRI

LV EDV 6±6% 5±5% 9±4% 10±4% 15±12% 4±6%

LV ESV 8±7% 9±9% 10±4% 12±4% 18±18% 8±8%

LV EF 8±9% 8±8% 9±6% 11±2% 21±8% 8±7%

Female LVEF = 61-65%

LVEDVi = 39-58 mL/m2

LVESVi = 15-23 mL/m2

Male LVEF = 57-62%

LVEDVi = 41-66 mL/m2

LVESVi = 16-29 mL/m2

Normal values for the LV (3D)

Right ventricular anatomy

Infundibulum

Apex Inflow tract

Tricuspid valve

Membranous septum

Pulmonary valve

Our measurements are not good enough

TAPSE = 1.6 cm

RV S’ = 14 cm/s

Moderate-severe TR

Our measurements are not good enough

RA

RV

LV

LA

PV

RA RV

RV

PV

CMR RVEF 27%

3D of the right ventricle is not easy

Good dataset

Not as good

dataset

3D RV Analysis correlates with CMR

MuraruD…BadanoLPet.al.EHJCardiovascularImaging2015

MedvedofsyD,AddetiaK…LangRMet.al.JASE2015

r Bias LOA r Bias LOA

EDV 0.92 -15mL ±45mL 0.95 -11mL ±40mL

ESV 0.93 -4mL ±28mL 0.96 -0.3mL ±31mL

RVEF 0.86 1.4% ±9.7% 0.83 -3.3% ±15%

Regional Shape analysis: Curvature

Curvature: “amount by which a surface deviates from being flat”

Addetia K, Maffessanti F. et. al. European Heart Journal Cardiovascular Imaging 2016

Salgo IS et. al. J Am Soc Echocardiogr 2012

Curvature = 0 Curvature < 0 Curvature > 0

Concavity Convexity Curvature

= 0

PAH vs. Normal right ventricles

Pulmonaryarterial

hypertension

4-chamber Sagi alCoronal

Normalsubject


Curvature maps to describe shape Normal PAH

Fre

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all

surf

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0.0

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1.0

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ture

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0.0

0.5

1.0

1.5 In

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Normal PAH

Fre

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all

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Normal PAH

Fre

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all s

urfa

ce

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all s

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-0.5

0.0

0.5

1.0

1.5

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-0.5

0.0

0.5

1.0

1.5

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Normal PAH

Fre

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all

surf

ac

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all

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0.0

0.5

1.0

1.5

Ind

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Cu

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ture

-0.5

0.0

0.5

1.0

1.5

Ind

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Normal PAH

Fre

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all

surf

ac

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all

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0.0

0.5

1.0

1.5

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Severe pulmonary

artery hypertension

Normal healthy subject

Free-wall Free-wall

Septum Septum

What about the left atrium: Volumes

N = 317 patients in normal sinus rhythm

Tsang et. al. J Am Coll Cardiol 2006; 47:1018 –23

Left atrial phasic volumes

J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 4 , N O . 7 , 2 0 1 1

Reservoir function

Conduit function

Booster function

Left atrial remodeling/shape!

A more spherical LA shape was independently associated with an increased risk for embolic events, adding incremental value beyond age and LA function (LA emptying fraction)

Nunes et. al. JACC: CARDIOVASCULAR IMAGING, VOL. 7, NO. 5, 2014


Valvular Heart Disease

3D TEE and mechanism of mitral regurgitation

P1

P2 P3

A1

A2 A3 CL CM

Lang RM, Tsang W, Weinert L, Mor-Avi V, Chandra S. JACC 2011

November 1;5 8(19):1933-1944.


Spectrum of degenerative mitral valve disease


Bhave NM, Addetia K et. al. JACC: Cardiovascular Imaging. 2013

3D TEE in mitral regurgitation

84 yo female, status post mitral valve surgery 6 months

prior, began experiencing

increasing shortness of breath.

Finally she was unable to perform daily activities. A

TEE was organized.

Case History

4chamber Long axis 900 view

4chamber Long axis



Tricuspid valve Better on TTE than TEE

Ventricular

perspective

Atrial

perspective

S

P A P A

S

Tricuspid valve disorders

Primary

(or “Organic”)

Secondary

(or “Functional”)

Intrinsic abnormality

of the valve apparatus

TR due to RV and/

or TV annular dilation

70-85%* of TR 15-30%* of TR

Antunes MJ, Barlow JB, Heart 2007

1. Rheumatic #1

2. Tricuspid atresia

3. RA tumors

4. Carcinoid

5. RV inflow obstruction

6. Endomyocardial fibrosis

7. TV vegetations

8. Pacemaker

9. Extracardiac tumors

Primary (organic) TR – PM/ICD 72 year-old man with a history of rheumatic heart disease status post AVR and ICD placement. Now presenting with moderate prosthetic stenosis, severe MS and severe TR. He was taken to the OR.

Pre-op

Post-op

Addetia K et. al. J Am Soc Echocardiogr 2014;27(11):1164-75

Primary (organic) TR – PM/ICD

Postero-septal

Septal

Posterior

Anterior

PS + Malcoaptation

Two leads

Mediratta A, Addetia K, et. al. JACC Cardiovasc Imaging. 2014 Apr;7(4):337-47

Tricuspid regurgitation – not benign

Nath et. al. J Am Coll Cardiol. 2004;43(3):405-409. doi:10.1016/j.jacc.2003.09.036

• KM survival curves for patients with TR

• Survival worse in moderate and severe TR

Tricuspid valve disorders

Primary

(or “Organic”)

Secondary


Intrinsic abnormality

of the valve apparatus

TR due to RV and/


70-85%* of TR 15-30%* of TR


1. Rheumatic #1

2. Tricuspid atresia

3. RA tumors

4. Carcinoid

5. RV inflow obstruction

6. Endomyocardial fibrosis

7. TV vegetations

8. Pacemaker

9. Extracardiac tumors

Functional tricuspid regurgitation Secondary


TR due to RV and/


70-85%* of TR


Dreyfus, G.D. et al. J Am Coll Cardiol. 2015; 65(21):2331–6

Dreyfus et al. ATS 2005

Functional tricuspid regurgitation

46 mm

TR can vary depending on preload, afterload,

RV function

THE ACC/AHA 2014 GUIDELINES

ACC/AHA Guidelines for management of VHD JACC 2014

ESC/EACTS Guidelines for management of VHD EHJ 2012

The 2014 Guidelines

ACC/AHA Guidelines for management of VHD JACC 2014


Interventions

TAVR and 3D Echocardiography

0Accurate assessment of

annular size is critical

0Underestimation

0PVR

0Valve migration,

embolism

0Overestimation

0 Incomplete deployment

(valvular and PVR)

0Annular rupture

Piazza Circ Cardiovasc Intervent. 2008


Hinge point (virtual annulus) plane

1. Dimensions 2. Area 3. Perimeter


69 yo man • Severe symptomatic AS • LVEF 68% • Concomitant history of

COPD on home O2 (4L), OSA, DM and previous CABG

• Admitted for TAVI • BAV 1 month prior AVA

0.68 to 1.5cm2

Annulus = 24 mm

Valvuloplasty

Holmes DR et. al. ACCF/AATS/SCAI/ STS expert consensus document on TAVR. J Am Coll Cardiol. 2012


Deployment of Edwards Sapien 26 mm

Post deployment

Post deployment – Moderate AI?


Post deployment Severe central AI?! Angiographic confirmation of AI severity


Valve in valve Dislodgement


CT MD = 30 mm CT Area = 741 mm2

CT Perimeter =99 mm

3D TEE MD = 26 mm 3D TEE Area = 554 mm2

3D TEE Perimeter = 94 mm


CT MD = 30 mm CT Area = 741 mm2

CT Perimeter =99mm

3D TEE MD = 26 mm 3D TEE Area = 554 mm2

3D TEE Perimeter = 94 mm

Paravalvular leak closure and 3D Echo

Lázaro et al. Imaging in paravalvular leaks Cardiovasc Diagn Ther 2014;4(4):307-313

Paravalvular leak closure and 3D Echo

Advances in Cardiovascular Magnetic Resonance

CMR - advantages

Hanlon RO, Pennell DJ. Heart Failure Clin 5 (2009) 369–387


Myocarditis/Pericarditis

CMR: Myocarditis/Pericarditis A 57-year-old teacher was seen in the ER 6 months prior with symptoms and EKG findings consistent with acute pericarditis. Ibuprofen was started resulting in resolution of symptoms. Since that time, she experienced several exacerbations for which she was treated with bursts of high dose corticosteroids. During exacerbations she had documented serositis. LVEF was normal. 2 weeks prior to CMR the pleuritic chest pain recurred with palpitations and fevers of 101F.

CMR: Myocarditis/Pericarditis

T2 Stir

Late gadolinium

enhancement

“acute myocardial

inflammation”

CMR: Myocarditis/Pericarditis 0Pericarditis: pericardial thickening,

inflammation, fibrosis

0Myocarditis: hyperemia and edema, necrosis/scar, contractile dysfunction and pericardial effusion

0Constriction

0Prognosis

0 Edema without necrosis/scar can predict functional recovery

0 Necrosis/scar as detected by LGE has been associated with higher mortality

JCMR 2009; 11:14

Inspiration

Expiration

Friedrich MG. Circ Cardiovasc Imaging. 2013;6:833-839


Hypertrophic/Infiltrative cardiomyopathy

Cardiac sarcoidosis Definition: Cardiac sarcoidosis is a systemic inflammatory condition associated with the formation of non-caseating granulomas in the lungs, reticuloendothelial system and skin. Cardiac involvement in patients with systemic sarcoidosis is seen in approximately 30-50% of postmortem cases. It is associated with worse prognosis.

Regional wall thickening

Patchy wall motion changes

Cardiac sarcoidosis Class IIa: ICD implantation is reasonable for patients with cardiac sarcoidosis... (Level of Evidence: C)

The importance of LGE

Murtagh G… Addetia K…..Patel AR Circ Cardiovasc Imaging. 2016;9:e003738

Cardiac sarcoidosis

Among our population of sarcoid patients with nonspecific symptoms, presence of… LGE was the best independent predictor of potentially lethal events, as well as other adverse events. Cox HR of 31.6 and of 33.9, respectively.

N = 155 consecutive patients with systemic sarcoidosis who underwent CMR for workup of suspected cardiac involvement

Greulich S. J Am Coll Cardiol Img 2013;6:501–11

Hypertrophic cardiomyopathy 0Myocardial fibrosis or scaring detected by CMR

occurs in up to 33-86% of patients with HCM


Maron Journal of Cardiovascular Magnetic Resonance 2012, 14:13

Hypertrophic cardiomyopathy 0 Myocardial fibrosis or scaring detected

by CMR occurs in up to 33-86% of

patients with HCM


Follow-up (years)

Chan RH. Circulation. 2014;130:484-495

10 prevention • Family history of HCM SD • Unexplained syncope • Multiple, repetitive NSVT • Abnormal exercise BP

response • Massive LVH • LGE ≥ 15% LV

Maron MS. Circulation. 2015;132:292-298

Cardiac amyloidosis 0Echo initial diagnostic

test of choice 0Findings: 0“Speckling” 0LVH 0RVH 0Bi-atrial enlargement 0Thickening of IAS 0Thickening of valves 0 Increased PASP 0Abnormal diastology

Cardiac amyloidosis

+20 %

- 20 %

Strain

Phalen Heart 2012

Cardiac amyloidosis The importance of LGE

Patterns of LGE

Mahrholdt H, European Heart Journal (2005) 26, 1461–1474

Cardiac amyloid – T1 Mapping

A 54 year-old woman with AL amyloidosis (bone marrow biopsy positive) and renal dysfunction was referred for cardiac MRI to rule out cardiac amyloidosis. She had an echo which revealed an LVEF of 65-70% with moderate LVH. No significant valvulopathy. No “apical sparing” of strain. GFR = 27.

Cardiac amyloid – T1 Mapping A 54 year-old woman with AL amyloidosis (bone marrow biopsy positive) and renal dysfunction was referred for cardiac MRI to rule out cardiac amyloidosis. She had an echocardiogram which revealed an LV ejection fraction 65-70% and moderate LVH. No significant valvulopathy. No apical sparing of strain. GFR = 27.

Mean native T1 reference values 950 ± 21 msec at 1.5 T 1052 ± 23 msec at 3 T

T1 time in this patient: 1150

Cardiac amyloid – T1 Mapping

Banypersad SM European Heart Journal (2015) 36, 244–251

1150 msec

The medical tricorder

Courtesy, Star Trek

New Applications in Echocardiography and Cardiovascular MRI

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