Christopher M. Kramer MD

George A. Beller MD/Lantheus Medical Imaging

Distinguished Professor of Cardiovascular Medicine

Chief, Cardiovascular Division

University of Virginia Health

Advances in CMR:

Will It Ever Become the Go To Test?

Disclosures

Research grant

Regeneron

Biotelemetry

Myokardia

Consultant

Cytokinetics

Go To Test?

Ischemic Heart Disease – hopefully

Cardiomyopathies/HF - definitely

CMR in Ischemic Heart Disease

Structure and function

Viability

Stress perfusion

Contraindications

GFR<30 – gadolinium

Cardiac devices – no longer

Limitations

Scanner access

Physician training

LV structure and function

Steady state free precession imaging

Axial Short-axis

Clark CJ et al JACC CVImaging 2012;5:28-37

RV structure and function

Infarct detection/transmurality

Technique - inversion recovery, nulling of normal

myocardial signal

Infuse 0.15-0.2 mM/kg of Gd-DTPA

Image 10-20 minutes later –

Gd becomes trapped

in necrotic scar,

delayed washout

Simonetti et al Radiology 2001;218:215

Transmural extent of hyperenhancement

(%)= area A x 100 / (area A + area B)

Kim, et al. N Engl J Med 2000;343: 1445-53

Transmural extent of LGE

Improved sensitivity vs. SPECT

Wagner A, et al. Lancet 2003;9355:374

6 pts. (13%) with

subendocardial

infarction had no

evidence of infarction

by SPECT

85/181 segments with

subendocardial

infarction had negative

SPECT

Detecting unrecognized infarcts

ICELAND MI study

936 pts., 67-93 yrs.

91 recognized MI

157 unrecognized MI

6.4 yrs. f/u

Adjusted HR 1.45

Absolute risk↑ 8%

Schelbert E et al, JAMA, 2012;308:890-896

Viability - LGE

50 pts. imaged before revascularization

804/2093 segments dysfunctional at baseline

694/2093 had areas of hyperenhancement

Kim R et al. N Engl J Med. 2000;343:1445

Viability - LGE

Kim R et al. N Engl J Med. 2000;343:1445

Meta-analysis

J Romero et al, JACC CV

Imaging 2012;5:509-12

Stress perfusion CMR

First pass contrast-

enhanced CMR

Stress

Rest

Myocardial perfusion

Klem I et al, J Am Coll Cardiol 2006;47:1630

Sensitivity 89%

Specificity 87%

Accuracy 88%

Standard clinical exam in IHD

0

Scout

imaging

10min

Adenosine

stress

perfusion

20

Cine

Function

15

Rest

perfusion

25

Late

gadolinium

enhancement

• CE-MARC study

• 752 pts, 1 center (Leeds)

• 39% with CAD

• >50% stenosis on QCA

• LGE and MR coronary

angiography also used

Greenwood J et al. Lancet 2012;379:393-5

Comparative effectiveness - CE MARC

MR INFORMFFR-

INFORMED

(n=464)

MR-

INFORMED

(n=454)

Age 62 ± 9 62 ± 10

Gender (Male) 329 (73%) 335 (72%)

Ejection Fraction 59 ± 8 61 ± 7

Ethnicity (Caucasian) 419 (91%) 409 (90%)

CCS class II

III

415 (90%)

48 (10%)

407 (90%)

45 (10%)

Diabetes 138 (30%) 112 (25%)

Previous MI 33 (7%) 39 (9%)

Known CAD 52 (11%) 72 (16%)

Current Smoking 76 (16%) 82 (18%)

E Nagel et al. NEJM 2019;380:2418-28

MR INFORM - Revascularization rate

3.5

44.252.3

FFR-INFORMED

no angio

revasc

no revasc

1.5

36.0

62.4

MR-INFORMED

no MR

revasc

no revasc

Revascularization rate

p = 0.0053

E Nagel et al. NEJM 2019;380:2418-28

MR INFORM - Outcomes

E Nagel et al. NEJM 2019;380:2418-28

Prognostic utility of stress CMR

19 studies, 11,636 pts., 32% ischemia, 29% LGE

Lipinski M et al. JACC 2013;62:826-38

Prognostic utility of stress CMR

So why isn’t it used as much as it should be?

Politics and economics, not the science

Scanner access

Lack of trained readers

Reimbursement

Cardiology/Radiology divide

Competing interests

Cardiomyopathies/HF

Replacement vs. interstitial fibrosis

Salerno M, Kramer CM. JACC CV Imaging, 2013;6:806-22

T1 mapping – myocardial fibrosis

Schelbert EB et al J Am Coll Cardiol

2014;63:2188

SSFP Cine imaging

Parametric mapping – T1/T2

T1 map

Normal T1

= 1150ms

T2 map

Normal T2

<60 ms

Myocarditis

Mahrholdt et al Circulation 2004;109:1250

32 pts. with myocarditis

Enhancement in 28/32-88%

Lateral free wall most common

Biopsy in area of contrast enhancement in 21 – 19 with active myocarditis

Lake Louise II

Ferreira V et al J Am Coll Cardiol, 2018;72:3158-76

Dilated cardiomyopathy

Midwall LGE and prognosis

Gulati A. JAMA, 2013;309:896-908

472 patients

Hypertrophic Cardiomyopathy

LV mass, volumes, 3D

hypertrophy

LV outflow tract gradient,

mitral regurgitation

Late gadolinium

enhancement (50-60%)

LV fibrosis/scar

- Global/regional

HCMR study

Improved prediction of outcome in HCM with:

• Standard clinical predictors

• CMR – LGE and T1 mapping

• Biomarkers

• Genetics

• www.hcmregistry.org

2755 patients, 44 sites - N.A., Europe

Kramer CM et al, Am Heart J 2015;170:223-30

Baseline characteristics

Neubauer S, ……, Kramer CM. J Am Coll Cardiol, 2019; in press

Sarcoidosis – meta-analysis

11 studies, 805 patients, f/u 3.0±1.7 yrs.

Combined outcome - all cause mortality, arrhythmogenic events

Coleman GC et al JACC CV Imaging, 2017;10:411-20

Amyloidosis, LGE, and prognosis

Fontana M et al, Circulation, 2015;132:1570-9

Amyloidosis - native T1, ECV

Karamitsos TD et al, JACC CV Imaging 2013;6:488-97

Martinez-Naharro et al, JACC CV Imaging 2018 pii:S1936-878X

Summary

Go To Test?

Ischemic heart disease – hopefully

Cardiomyopathies/HF-definitely