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KMC Cardiology Colloquium
• Cardiac Imaging
• Feb 27 2013
• Brian Schwartz MD FACP FACC FSCAI
Wilhelm Rontgen
• X rays 1895
Dr. Moses Swick
Graduated from Columbia University Medical School and went to Germany for further training 1929 Recognized that iodinated compounds ie Selectan would show up on x-rays and developed injectable form Uroselectan
Werner Forssmann
• 1929
• 1956
Hemodynamics
Andrea Cournand Dickenson Richards
Swan-Ganz Catheter
Dr Mason Sones
Mason Sones
• In 1958, he experimented with injection of contrast media into the aortic root sinuses. His former fellow, Royston Lewis, recalls that on October 30 of that year Sones was doing a left ventriculogram and had pulled the catheter back into the aorta. Incredibly, he and Lewis paused for a cigarette while the injector was being reloaded with 40 ml of contrast agent. His intention was to shoot the aortogram next, but the catheter inadvertently slipped into the right coronary artery before he turned on the camera. Consequently, 40 ml of contrast medium was injected directly into a large dominant right coronary artery and the patient experienced asystole for 6% seconds. There were no defibrillators then; Sones asked the patient to cough. This serendipitous injection selectively visualized the right coronary artery and its branches.
Normal Coronary Arteries
Abnormal Coronary Arteries
Coronary Angiography
• Has Become Widely available
• Safe
• Routine
Cardiac Cath Procedure of Choice
• 2007 >1 million Cardiac Caths 90% age over 45
• Accepted as Gold Standard.
• Never turned down by Insurers
Diagnostic test of Choice for
Unstable symptoms AMI Known extensive CAD If likely needs intervention Heavy Calcium
Angiography
• The Gold standard – What every other test is compared with
• No Longer Glamorous
• Invasive
• Radiation
• IVP
• Resource intensive
• Expensive
RIVAL study
Radial (n=3507)
%
Femoral (n=3514)
% HR 95% CI P
Primary Outcome
Death, MI, Stroke, Non-CABG Major Bleeding
3.7 4.0 0.92 0.72-1.17 0.50
Secondary outcome
Major vascular access site complications
1.4 3.7 0.37 0.27-0.52 <0.0001
Jolly, et al. Lancet 2011;377:1409-1420
Non-CABG related bleeding after coronary angiography / PCI %
Femoral Radial
Primary endpoint
0
1
2
3
4
3.4%
0.9%
P=0.014
Advantages
Importance of NTG
Before NTG After NTG
CAG: Coronary Lumen Shape + Flow
C. von Birgelen, TCT 2009
Lesion Characterization
Bifurcation Ostial
SVG
Tortuous
Diffuse Disease Thrombus
Limitations of Coronary Angiography
Is this Lesion Flow
Limiting?
What does this plaque look
like?
c/o M. Kern
Seymour Glagov 1987
There is disease everywhere.
Old plaque rupture with thrombus
Covered Strut
Xience implanted 5 months ago
IVUS OCT
IVUS
MLA 4.5 mm2
Seung-Jung Park, MD, PhD
Heart Institute, Asan Medical Center, Seoul, Korea
TMT and Thallium SPECT Negative
Do you believe Your Eyes ?
90%
85%
85%
30%
Positive
Mismatch problem is mainly
on angiographic DS(%) and
noninvasive test.
The angiographic severity is
not correlated with its
ischemic potential.
Seung-Jung Park, MD, PhD
Heart Institute, Asan Medical Center, Seoul, Korea
FFR: How To Measure
FFR
Continuous Intravenous Infusion 140 μg/kg/min
Seung-Jung Park, MD, PhD
Heart Institute, Asan Medical Center, Seoul, Korea
Adjunctive Diagnostic Testing in the
Cath Lab: FFR and IVUS
• FFR
– Physiologic rather
than anatomic
– Takes the
“subjective” out of
the angiogram
– Proven to (safely!)
reduce need for PCI
in intermediate
lesions
• IVUS
Anatomic rather than
physiologic
Allows morphologic
assessment and
post-stent
measurements
Can be used for
lesion assessment,
but CAVEATS apply
Radiation
• Background 3.6mSv
• CXR 0.04mSv
• Cath 10mSv per min
•
Left Heart Catheterization
• Left ventriculography is performed
in the RAO 30 degree projection
• Use caution if LVEDP is
substantially elevated
• Confirm the catheter is not against
the mitral valve apparatus or
against the LV apex
• A test injection is performed to
assess the size of the ventricle
• Standard injection volume is 30-
36 cc at 10-12cc/sec
• Pan up to aorta to get a look at
CABG grafts
Cardiac Cath Lab ≠ Always a Stent!!!
• Key Distinction between diagnostic and
interventional cath procedures
• Diagnostic Catheterization
– Coronary angiography
• Triage to medical therapy, PCI, or CABG
– Hemodynamic evaluation
• Right and left heart catheterization
– Left ventriculography (with ability to identify
selected structural abnormalities)
– Aortography
Advantages of Cath
• Accurate for significant disease
• Can Assess hemodynamics
• Assess flow in Arteries
• See spasm vs stenosis
• Tools to Address Anatomy/Physiology/Plaque morphology
Disadvantages of Cath
• Invasive
– Risk of bleeding
• Ionizing Radiation
• IV Contrast
• Usually uses Sedation
• Without additional tools can miss mild Plaque
To Replace Cath as the “Gold
Standard”
Safe
Minimally Invasive
Less expensive
Accurate
Less Radiation
No IVP or Sedation
But Can We Do Better??
FAME – 1 yr Outcomes
N Engl J Med. 2009 Jan 15;360(3):213-24.
Functional Stress Test
Stage 4 Treadmill Negative
Stage IV
Thallium SPECT Normal
Anatomy vs. Physiology?
Seung-Jung Park, MD, PhD
Heart Institute, Asan Medical Center, Seoul, Korea
Safe but Conspicuous: the challenges of devices in MRI
• Projectiles – Safety procedures
– Compatible equipment
• Heating – Long wires & cables & loops
• Image distortion – Ferrous materials
MR Safe MR Conditional MR Unsafe
FAME Assessed for
eligibility
N = 1905
Randomized
N = 1005
Angiography-guided
PCI
n = 496
FFR-guided
PCI
n = 509
Analyzed
n = 496
Analyzed
n = 509
Lost to follow-
up
n = 8
Lost to follow-
up
n = 11
Not eligible: n = 900
• LM stenosis: n = 157
• Extreme coronary tortuosity
or calcification: n = 217
• No informed consent: n = 105
• Contraindication for DES: n =
86
• Participation in other study: n
= 94
• Logistic reasons: n = 210
• Other reasons: n = 31
FAME = Fractional Flow Reserve vs Angiography for Multivessel Evaluation;
DES = drug-eluting stent.
Tonino PA, et al. N Engl J Med. 2009;360(3):213-224.
Treadmill Test + , Stage 2
Thallium SPECT +
Large Perfusion Defect
in LAD territory
Seung-Jung Park, MD, PhD
Heart Institute, Asan Medical Center, Seoul, Korea
Angiography
• Not a Screening Test
– Would not use with low Pretest Probability
• Atypical CP
– Would use for High Risk Patients
• Unstable symptoms
• Complex anatomy
• Calcified lesions
• Known CAD
• Likely to need PCI
Anatomy vs Physiology?
Palinski FASEB 2002
0.6% / year, Cardiac Death and MI
In patients with normal myocardial perfusion scan, even in the presence of
angiographically proven CAD
Excellent
Prognosis !
Negative non-invasive
stress test means :
Shaw LJ, J Nucl Cardiol 2004;11:171-85 , Prognostic value of gated myocardial perfusion SPECT. Very large meta-analysis. (n=39,173 patients)
Coronary Angiography Angles
M. Costa, TCT 2008
Functional Stress Test
Stage 4 Treadmill Negative
Stage IV
Thallium SPECT Normal
Anatomy vs. Physiology?
Seung-Jung Park, MD, PhD
Heart Institute, Asan Medical Center, Seoul, Korea
FAME: 1 year events
Angio-Guided
n = 496
FFR- Guided
n = 509 P Value
Events at 1 year, No (%)
Death, MI, CABG, or repeat-PCI 91 (18.4) 67 (13.2) 0.02
Death 15 (3.0) 9 (1.8) 0.19
Death or myocardial infarction 55 (11.1) 37 (7.3) 0.04
CABG or repeat PCI 47 (9.5) 33 (6.5) 0.08
Total no. of MACE 113 76 0.02
Myocardial infarction, specified
All myocardial infarctions 43 (8.7) 29 (5.7) 0.07
Small periprocedural CK-MB 3-5 x N 16 12
Other infarctions (“late or large”) 27 17
JACC 2011; 58:e123-210
2011 ACCF/AHA/SCAI Guideline for
Percutaneous Coronary Intervention
CABG or PCI should not be performed with the primary or sole intent to improve survival in patients with SIHD with 1 or more coronary stenoses that are not anatomically or functionally significant (e.g., <70% diameter nonleft main coronary artery stenosis, fractional flow reserve >0.80, no or only mild ischemia on noninvasive testing), involve only the left circumflex or right coronary artery, or subtend only a small area of viable myocardium.
I IIa IIb III
Harm
