Απεικόνιση της δεξιάς κοιλίας. Πότε η...
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Απεικόνιση της δεξιάς κοιλίας.
Πότε η υπερηχοκαρδιογραφία δεν είναι αρκετή;
Sophie Mavrogeni MD FESC
Onassis Cardiac Surgery Center
Athens Greece
RV structure and function (1)
• RV differs from the LV
• (more complex shape being ‘wrapped around’ the LV).
• This complex geometry precludes imaging the inflow and
outflow tract in a single two-dimensional plane.
• Compared with the LV, the RV myocardium is significantly
more trabeculated
• The RV wall is much thinner with a normal compacted wall
thickness of 3–5 mm in the adult population.
RV structure and function (2)
• LV wall has a 3-layered structure with the epicardial cells oriented obliquely, the midmyocardial cells circumferentially and the endocardial cells again obliquely.
• The midwall circumferential layer is responsible for predominanceof circumferential shortening and radial thickening in LV.
• RV epicardial fibres are oriented obliquely and contiguous withepicardial LV fibres, the midwall circumferential layer is poorlydeveloped and the endocardial fibres are oriented longitudinally.
• This fibre structure explains why RV ejection is determined by longitudinal shortening rather than by circumferential deformation.
• The normal RV contraction results in a PERISTALTIC contraction from the inflow to the outflow part of RV.
Echocardiography for RV assessment
• RV morphology can be adequately described by TTE in most patients.
• Recent guidelines recommend quantitative RV function by using at least one of the following as surrogate of RV volumetric assessment:
• Percent fractional area change (FAC),
• Tricuspid annular plane systolic excursion (TAPSE),
• RV index of myocardial performance (RIMP)
• FAC: correlates with RV EF by CMR, but visualization of endocardial borders are limited mainly in RV lateral wall and RV apex.
• TAPSE: easy but normal values are limited and TR may influence the values obtained.
• RIMP: load dependent and due to short RV isovolumic time intervals, its use remains controversial.
Valsangiacomo ER et al. Eur Heart J 2012
Limitations of speckle tracking in RV
assessment
• Strain values are influenced by loading conditions, as it has been
demonstrated in patients with PAH, in whom RV longitudinal strain
was related to pulmonary arterial systolic pressures.
• Strain values are influenced by RV size and stroke volume.
• Feasibility is poor in the thin RV wall; still NO normal values
• Standardization among different software still under investigated.
• TDI and speckle tracking are NOT READY yet for routine use.
Valsangiacomo ER et al. Eur Heart J 2012
CMR in pulmonary hypertension
• Cardiac morphology, function and mass
• Ventricular mass index (VMI), obtained by dividing the mass of RV by the mass of LV (sensitivity 84%, specificity 71%, strong correlation with MPAP by RHC)
• IVS configuration
• Late gadolinium enhancement (LGE)
• Pulmonary circulation (Quantification of the pulmonary flow profile revealed a reduction in the peak flow velocity in the main pulmonary artery in patients with PAH).
• Distensibility of pulmonary artery
• Stress CMR (reduced MPRI)
• RV remodeling after treatment for PAH
Dimitroulas T, Mavrogeni S, Kitas GD. Nature Review Rheumatology 2012
Clinical application of non-invasive
imaging in conditions affecting the RV
• Congenital heart disease (CHD)
• Pulmonary arterial hypertension (PAH)
• Autoimmune diseases involving RV
• Arrhythmogenic RV Cardiomyopathy (ARVC) and other cardiomyopathies involving the RV
• Ischaemic RV disease and RV failure
• Cardiac tumors involving RV
Congenital Heart Disease (CHD)
Causes of RV dilatation in CHD
• Atrial septal defect
• Pulmonary valve dysfunction
• Tricuspid valve dysfunction
• Diverticula and aneurysm
Atrial septal defect
Beitzke D et al. Br J Radiol. 2011
Superior sinus venosus atrial septal defect (ASD)
with associated partial anomalous pulmonary
return of the right upper lobe pulmonary vein
Beitzke D et al. Br J Radiol. 2011
Fallot tetralogy
Beitzke D et al. Br J Radiol. 2011
A 29-year-old woman with partial
anomalous pulmonary venous return
• A) MR angiography (a) subtracted
image shows anomalous drainage
of both superior and inferior right
pulmonary veins (white arrows)
into the superior vena cava
• B) subsequent signs of RV
volume overload on cine-SSFP (b,
c RV enlargement + septal
flattening) without hypertrophy
reflecting low pulmonary vascular
resistance
Galea N et al. Insights Imaging. 2013
Epstein anomaly
Beitzke D et al. Br J Radiol. 2011
Tricuspid Regurgitation
Beitzke D et al. Br J Radiol. 2011
Diverticula and aneurysm
Beitzke D et al. Br J Radiol. 2011
Congenital absence of the pericardium
Brulotte S et al. Can J Cardiol. 2007
PULMONARY HYPERTENSION
Diagnostic accuracy of CMR of RV morphology
and function in the assessment of suspected
pulmonary hypertension: ASPIRE registry.
• Ventricular mass index (VMI) was the CMR measurement
with the strongest correlation with mPAP (r = 0.78) and the
highest diagnostic accuracy for the detection of PAH (area
under the ROC curve of 0.91) compared to an ROC of 0.88
for echocardiography calculated mPAP.
• LGE, VMI ≥ 0.4, retrograde flow ≥ 0.3 L/min/m² and PA
relative area change ≤ 15% predicted the presence of PH
with a high degree of diagnostic certainty with a positive
predictive value of 98%, 97%, 95% and 94% respectively.
• No single CMR parameter could confidently exclude PAH.
Swift AJ et al, J Cardiovasc Magn Reson 2012
Short axis slice through the ventricles showing
epicardial and endocardial border segmentation of
the RV (white) and the LV (red).
• The inter-venticular septum is included in the LV mass, Ventricular mass index (VMI) is defined as RV mass divided by LV mass.
• The endocardial borders of the RV and LV were traced for calculation of EDV and ESV.
• EDV and ESV were calculated by summation of the product (area × slice distance) for all slices. SV is given by SV = EDV-ESV calculated for both RV and LV.
Swift AJ et al, J Cardiovasc Magn Reson 2012
Pulmonary Arterial Hypertension:
MR Imaging-derived First-Pass Bolus Kinetic Parameters
Are Biomarkers for Pulmonary Hemodynamics, Cardiac
Function, and Ventricular Remodeling
Skrok J et al, Radiology 2012
CE MR-derived PTT, LV FWHM, and LV TTP are noninvasive compound markers
of pulmonary hemodynamics and cardiac function in patients with PAH. Their
predictive value for patient outcome needs further investigation
Contrast-enhanced MDCT vs. Time-resolved MRA vs.
contrast-enhanced perfusion MRI: assessment of
treatment response by patients with inoperable CTEPH.
• Dynamic perfusion MRI has better capability for
assessment of therapeutic effect on CTEPH
patients than does MDCT.
Ohno Y et al, J Magn Reson Imaging 2012
Idiopathic pulmonary hypertension
• Severe idiopathic pulmonary hypertension; PAP at right cath 70 mmHg
• Focal LGE are observed at the level of both ventricular junctions.
• Severe concentric RV hypertrophy on short-axis cine-SSFP withflattening and inversion of the IVSduring contraction (c)
Galea N et al. Insights Imaging. 2013
LGE CMR predicts clinical worsening in PAH
• The presence of
RVIP-LGE in patients
with PH is a marker
for more advanced
disease and poor
prognosis.
• CMR-derived RVEF is
an independent non-
invasive imaging
predictor of adverse
outcomes PH.
Freed BH et al, J Cardiovasc Magn Reson 2012
Abnormalities of Pulmonary Vasculature in PAH
• (A) White blood anatomy showing right upper pulmonary vein stenosis at the site of a prior ablation for AF (arrow).
• (B) Congestion and infarction in the right upper lobe (asterisk).
• (C) MRA from a patient with PH due to fibrosing mediastinitis; a varix is seen bypassing a stenosed left upper pulmonary vein (not shown) alongside stenoses of both right sided pulmonary veins (arrows).
• (D) MRA in patient with CTPH. The most striking feature is loss of the left descending pulmonary artery (arrow head).
Bradlow WM et al, J Cardiovasc Magn Reson 2012
AUTOIMMUNE DISEASES WITH RV
INVOLVEMENT
Is there a place for CMR in the evaluation of
cardiovascular involvement in rheumatic diseases?
• CMR is a noninvasive, nonradiating imaging technique, which provides novel information for the evaluation of cardiovascular diseases.
• Currently, it is considered the gold standard for the evaluation of volumes, mass, ejection fraction of atriums and ventricles, quantification of iron overload in different organs, detection and follow-up of myocardial inflammation, myocardial infarction and its complications, evaluation of the aorta, detection of anomalous coronary arteries, and ectatic or aneurysmatic coronary arteries.
• All the above applications and mainly the CMR ability to detect myocardial inflammation, perfusion defects, fibrosis, coronary and great arteries aneurysms make it a valuable tool for cardiovascular system assessment, commonly affected during the course of rheumatic diseases.
• The technique has been already successfully used in the evaluation of vasculitides, systemic lupus erythematosus, myositis, and scleroderma.
Mavrogeni S et al, Semin Arthritis Rheum 2011
Cardiovascular magnetic resonance in
rheumatology: Current status and
recommendations for use.
• The present report outlines the recommendations of the participating CMR and rheumatology experts with regards to:
• (a) indications for use of CMR in rheumatoid arthritis, the spondyloarthropathies, systemic lupus erythematosus, vasculitis of small, medium and large vessels, myositis, sarcoidosis and scleroderma;
• (b) CMR protocols, terminology for reporting CMR and diagnostic CMR criteria for assessment and quantification of cardiovascular involvement in CTDs;
• (c) a research agenda for the further development of this evolving field.
Mavrogeni S et al Int J Cardiol 2016
AMYLOIDOSIS
Prabhakar Rajiah et al. Indian J Radiol Imaging. 2012
CARDIAC SARCOIDOSIS
Shaunagh McDermott, et al. World J Cardiol. 2012
Utility of CMR in assessing right-sided heart
failure in sarcoidosis
Lonborg J et al. BMC Med Imaging. 2013
Comparison of the diagnostic utility of CMR, CT, and Echo
in assessment of suspected PAH in CTDs
• 81 patients with CTD, 55 had PAH, 22 had no PH, and 4 had PH due to LV disease.
• There was good correlation between mPAP and PVR measured by RHC
• VMI derived from MRI (mPAP, r = 0.69, p < 0.001; PVR, r = 0.78, p < 0.001) and
• Systolic area ratio (mPAP, r = 0.69, p < 0.001; PVR, r = 0.68, p < 0.001) and
• TG derived from echo (mPAP, r = 0.84, p < 0.001; PVR, r = 0.76, p < 0.001).
• In contrast, CT measures showed only moderate correlation.
• VMI ≥ 0.45 had a sensitivity of 85% and specificity 82%;
• TG ≥ 40 mm Hg had a sensitivity of 86% and specificity 82%.
• Cox regression analysis showed that CMR was better at predicting mortality.
• Patients with RV end diastolic volume < 135 ml had a better prognosis than those with a value > 135 ml, with a 1-year survival of 95% versus 66%, respectively.
Rajaram S et al, J Rheumatol 2012
Pulmonary blood volume indexed to lung volume is
reduced in newly diagnosed SSc compared to normals –
a prospective CMR study addressing PV changes
• This study is the first to measure the PBV in humans using
CMR. Compared to healthy controls, newly diagnosed SSc
patients have a reduced amount of blood in the pulmonary
vasculature (PBVI) but unchanged pulmonary vascular
distensibility (PBVV/stroke volume).
• PBVI is unrelated to DLCO, pulmonary artery pressure, vital
capacity, and the presence of pulmonary fibrosis. PBVI may
be a novel parameter reflecting vascular lung involvement
in early-stage SSc, and these findings may be consistent
with pathophysiological changes of the pulmonary
vasculature.
Kanski M et al, J Cardiovasc Magn Reson 2013
ARRYTHMOGENIC RV CARDIOMYOPATHY
(ARVC)
Structural and functional criteria for ARVC
Major criteria
2D echo Regional RV akinesia, dyskinesia, or aneurysm
And 1 of the following (end-diastole):
RVOT ≥32 mm (19 mm/m2)/parasternal long-axis view
RVOT ≥36 mm (21 mm/m2)/parasternal short-axis view
or RV fractional area change ≤33%
CMR Regional RV akinesia or dyskinesia, or dyssynchronous RV
contraction
And 1 of the following:
RV end-diastolic volume ≥110 mL/m2 (male) or ≥100 mL/m2 (female)
or RV ejection fraction ≤40%
Imaging task force criteria for diagnosing arrhythmogenic
right ventricular cardiomyopathyopathy (ARVC)
Imaging task force criteria for diagnosing arrhythmogenic
right ventricular cardiomyopathyopathy (ARVC)
• Minor criteria
• 2D echo Regional RV akinesia or dyskinesia
• And 1 of the following (end-diastole):
• RVOT ≥29 mm ,32 mm (≥16 ,19 mm/m2)
• RVOT ≥32 ,36 mm (≥18 ,21 mm/m2)
• or fractional area change 33 to ≤40%
• CMR Regional RV akinesia or dyskinesia, or dyssynchronous RV contraction
• And 1 of the following:
• RV end-diastolic volume ≥100 ,100 mL/m2 (male) or ≥90 ,100 mL/m2 (female) or RV ejection fraction 40 ≤45%
ARRYTHMOGENIC RIGHT VENTRICLE (ARVC)
• Dilated hypokinetic RV
• Increased RVESV, RVEDV
• Localized aneurysms
• RV-free wall bulging
• Increased signal intensity from fibrofatty myocardial replacement of RV after Gadolinium
• Mild decrease of LV function in 15% of cases
ARRHYTHMOGENIC RIGHT VENTRICLE (ARVC)
Mavrogeni S et al. Hell J Cardiol 2007
Naxos Disease
Valsangiacomo ER et al. Eur Heart J 2012
Naxos disease evolution mimicking acute
myocarditis: The role of CMR
Mavrogeni S et al Int J Cardiol 2013
The triangle of dysplasia in ARVC
• (A) Structural anomalies can
be observed in a region
including the subtricuspidal
RV wall, the RV apex, and the
RV outflow tract.
• (B) Steady-statefree
precession images showing
severe aneurysmatic
abnormalities of the RV free
wall subtricuspidal (arrows) in
a patient with ARVC
Valsangiacomo ER et al. Eur Heart J 2012
OTHER CARDIOMYOPATHIES
RV TAKOTSUBO CARDIOMYOPATHY
Korlakunta H et al. Tex Heart Inst J 2011
Biventricular hypertrophic
cardiomyopathy• (a). Severe concentric
biventricular hypertrophy
• Inhomogeneous bi-ventricular spotty areas of signal hyperintensity are depicted on T2WI four-chamber (a) view reflecting diffuse myocardial oedema;
• LGE image (b) shows extensive tissue damage with late enhancement involving both ventricles including the RV free apical wall (arrow).
• (c) EMB confirms a severe hypertrophy and disarray of myocardiocytes,interrupted by fibrosis
Galea N et al. Insights Imaging. 2013
Hypertrophic Cardiomyopathy in a Young Adult
with RV Aneurysm: Report of a Rare Finding
and Review of the Literature.
Abdel-Razek AM et al. Heart Views 2011
Glycogen storage disease in a 29-year-old man
with family history of juvenile sudden cardiac
death and unexplained increased LV wall
thickness at echocardiography
• a. T2WI shows an hyper-trabeculated RV with subendocardial hyperintense signal related to “slow-flow” caused by diffused hypokinesis.
• b. LGE-T1WI reveals a diffuse and homogeneous enhancement of the RV myocardium (black arrows) and right side of the IVS (arrowheads).
• The LGE of the LV is subepicardial (white arrows) in lateral wall.
• c. EMB shows massive accumulation of citosolic glycogen, sometimes engulfing autophagosoms (asterisk)
Galea N et al. Insights Imaging. 2013
ISCHEMIC HEART DISEASE
Rupture of right coronary sinus of Valsalva
aneurysm into RV
Post MC et al. Neth Heart J. 2010
Premature myocardial infarction presenting
with acute pulmonary embolism
Gopaluni S et al. J Med Case Reports. 2009
RV Injury in ST-elevation myocardial
infarction
• Severe inferior infarction:
• A, proximal occlusion of RCA
• B, After PCI to RCA
• C, Area at risk extends from
the LV inferior wall to the IVS
and RV inferior and free wall.
• D, microvascular obstruction
of the LV and scar area
Grothoff M et al Circ Cardiovasc Imaging 2012
CARDIAC TUMORS INVOLVING RV
Large RV fibroma in a 6-month-old infant.
Horovitz A et al. Pediatr Cardiology 2012
RV fibroelastoma
• RV fibroelastoma in an
asymptomatic 32-year-old
man with an intracavitary
nodule incidentally
depicted at trans-thoracic
echocardiography.
• TSE T1-weighted image
shows the presence of a
nodular rounded RV mass
(arrow) attached to a large
trabecula
Galea N et al. Insights Imaging. 2013
RV metastasis
• RV metastasis of renal
cancer in a 62-year-old man
(histologically proven).
• A large ovoid secondary
lesion is depicted at the
lateral atrio-ventricular
junction compressing the
RV free wall
Galea N et al. Insights Imaging. 2013
CONCLUSIONS
• Comprehensive, operator independent study by CMR
• Assessment of function, mass, morphology, oedema,
fibrotic changes, infiltrative processes, lung circulation
dynamics
• Ability to assess remodeling, viability, perfusion, oedema
• Useful to monitor therapy
Greek College of Clinical Applications
in CMR
“CARDIOTOMI”
EuroCMR/SCMR level 1
30/9-2/10/2017
in Metropolitan Hotel
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and accredited by EBAC
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