Noninvasive Cardiac Imaging in Noninvasive Cardiac Imaging in Myocardial InfarctionMyocardial Infarction

Noninvasive Cardiac Imaging in Noninvasive Cardiac Imaging in Myocardial InfarctionMyocardial InfarctionMyocardial InfarctionMyocardial InfarctionMyocardial InfarctionMyocardial Infarction

Sangchol LeeSangchol LeeSangchol LeeSangchol Lee

Sungkyunkwan UniversitySungkyunkwan UniversitySamsung Medical CenterSamsung Medical CenterSungkyunkwan UniversitySungkyunkwan UniversitySamsung Medical CenterSamsung Medical CenterSamsung Medical CenterSamsung Medical CenterSamsung Medical CenterSamsung Medical Center

Current Guidelines for DiagnosisCurrent Guidelines for DiagnosisCurrent Guidelines for DiagnosisCurrent Guidelines for DiagnosisCurrent Guidelines for Diagnosis Current Guidelines for Diagnosis of AMIof AMI

Current Guidelines for Diagnosis Current Guidelines for Diagnosis of AMIof AMI

•• Chest painChest painST h EKGST h EKG

•• Chest painChest painST h EKGST h EKG•• ST change on EKGST change on EKG

•• Cardiac EnzymesCardiac Enzymes•• ST change on EKGST change on EKG•• Cardiac EnzymesCardiac EnzymesCardiac Enzymes Cardiac Enzymes Cardiac Enzymes Cardiac Enzymes

Do We Need Imaging for AMIDo We Need Imaging for AMIDo We Need Imaging for AMIDo We Need Imaging for AMIDo We Need Imaging for AMI Do We Need Imaging for AMI Management?Management?

Do We Need Imaging for AMI Do We Need Imaging for AMI Management?Management?

•• Confusing results on EKGConfusing results on EKGTi d d f t iTi d d f t i

•• Confusing results on EKGConfusing results on EKGTi d d f t iTi d d f t i•• Time needed for enzymes to riseTime needed for enzymes to rise

•• Chest painChest pain -- typical? atypical?typical? atypical?•• Time needed for enzymes to riseTime needed for enzymes to rise•• Chest painChest pain -- typical? atypical?typical? atypical?Chest pain Chest pain typical? atypical?typical? atypical?Chest pain Chest pain typical? atypical?typical? atypical?

•• Measurement of infarct sizeMeasurement of infarct size•• Measurement of infarct sizeMeasurement of infarct size•• PostPost--PCI complicationsPCI complications•• A t f id l i blA t f id l i bl•• PostPost--PCI complicationsPCI complications•• A t f id l i blA t f id l i bl•• Assessment of residual viable Assessment of residual viable

myocardiummyocardium•• Assessment of residual viable Assessment of residual viable

myocardiummyocardium

Current Noninvasive ImagingCurrent Noninvasive ImagingCurrent Noninvasive ImagingCurrent Noninvasive ImagingCurrent Noninvasive Imaging Current Noninvasive Imaging Modalities for AMI DiagnosisModalities for AMI DiagnosisCurrent Noninvasive Imaging Current Noninvasive Imaging Modalities for AMI DiagnosisModalities for AMI Diagnosis

•• EchocardiographyEchocardiographyR di lid f iR di lid f i

•• EchocardiographyEchocardiographyR di lid f iR di lid f i•• Radionuclide perfusion scanRadionuclide perfusion scan

•• Cardiac CTCardiac CT•• Radionuclide perfusion scanRadionuclide perfusion scan•• Cardiac CTCardiac CTCardiac CTCardiac CT•• Cardiac MRICardiac MRI

Cardiac CTCardiac CT•• Cardiac MRICardiac MRI

Conventional EchocardiographyConventional EchocardiographyConventional EchocardiographyConventional Echocardiography

•• Global LV functionGlobal LV functionR i l ll ti f di iR i l ll ti f di i

•• Global LV functionGlobal LV functionR i l ll ti f di iR i l ll ti f di i•• Regional wall motion for diagnosisRegional wall motion for diagnosis

•• Complications of MIComplications of MI•• Regional wall motion for diagnosisRegional wall motion for diagnosis•• Complications of MIComplications of MIComplications of MIComplications of MI•• Myocardial area at riskMyocardial area at risk

Complications of MIComplications of MI•• Myocardial area at riskMyocardial area at risk•• Myocardial viability Myocardial viability -- stress echostress echo•• Myocardial viability Myocardial viability -- stress echostress echo

Survival of Patients with Acute MIPrognosis

Survival of Patients with Acute MIPrognosis

1.01.0EF 40%EF 40% EF >40%EF >40%

E/ 1E/ 1

0 6

0.8

0 6

0.8

alal

E/e 15E/e 15 E/e 15E/e 15

0.4

0.6

0.4

0.6

Surv

iva

Surv

iva

E/e >15E/e >15E/e >15E/e >15

0.20.2

SS

0.00 6 12 18 24

0.00 6 12 18 24

Follow-up (months)Follow-up (months)

7272 5252 2929 1111 44No. atrisk

No. atrisk 178178 143143 8484 3838 1111

Follow-up (months)Follow-up (months)

Hillis et al: JACC 43(3):360, 2004Hillis et al: JACC 43(3):360, 2004CP1141593-3

Prognostic Value of E/EPrognostic Value of E/E'' After Acute MIAfter Acute MIPrognostic Value of E/EPrognostic Value of E/E'' After Acute MIAfter Acute MI

1.0 1.0E/e' 15E/e' 15 E/ ' 15E/ ' 15

In DTBT <90In DTBT <90 In DTBT 90In DTBT 90h)h)

0.9

h)h)

0.9

E/e' 15E/e' 15

E/e' >15E/e' >15

E/e' 15E/e' 15

al (d

eath

al (d

eath

0.8

al (d

eath

al (d

eath

0.8

E/e 15E/e 15P<0.0001P<0.0001

Surv

iva

Surv

iva

0.7

Surv

iva

Surv

iva

0.7 E/e' >15E/e' >15P=0.06P=0.06

0.6 0.6

0.50 200 400 600 800

0.50 200 400 600 800

CP1302151-7

Follow-up (days)Follow-up (days) Follow-up (days)Follow-up (days)

Park SJ, Ting H, Oh JK Unpublished

Unconventional EchocardiographyUnconventional EchocardiographyUnconventional EchocardiographyUnconventional Echocardiography

•• Myocardial strain imagingMyocardial strain imagingC t t h di hC t t h di h

•• Myocardial strain imagingMyocardial strain imagingC t t h di hC t t h di h•• Contrast echocardiographyContrast echocardiography•• Contrast echocardiographyContrast echocardiography

Strain ImagingStrain ImagingStrain ImagingStrain Imaging• Strain: Deformation of an object, relative to its

original length• Strain: Deformation of an object, relative to its

original lengthoriginal lengthoriginal length

L - L0L - L0

L0L0

LL==

L0L0==

L0L0 L0L0

If 10 cm original length is shortened to 7 5 cmshortened to 7.5 cm,

strain is (-) 25 %.

CP1237840-8

Normal strain is > 20 %.

2D Speckle Tracking ImageNormal

Radial strain (SAX) Transversal strain (A4)

Aplio (SSA-770A, Toshiba Japan)K.Ogawa, T.Hozumi et al. AJC 2006

Longitudinal strain: normal case DisplayLongitudinal strain: normal case DisplayLongitudinal strain: normal case DisplayLongitudinal strain: normal case Display

4C 2C Lengthening

Shortening

APLAX

Shortening

Bull’s Eye

Bull’s Eye Mapping of StrainBull’s Eye Mapping of StrainBull’s Eye Mapping of StrainBull’s Eye Mapping of StrainBull s Eye Mapping of StrainBull s Eye Mapping of StrainBull s Eye Mapping of StrainBull s Eye Mapping of StrainLengthening+20% g g

Shortening-20% g

Anteroseptal MI (LAD) Inferior MI (RCA)Inferolateral MI (LCX)

C E h di hC E h di hC E h di hC E h di hContrast EchocardiographyContrast EchocardiographyContrast EchocardiographyContrast Echocardiography

Perfusion Defect in the apical segments

Contrast Perfusion Echo for ViabilityContrast Perfusion Echo for Viability2 patients with Anterior STEMI and PCI2 patients with Anterior STEMI and PCI

Contrast Perfusion Echo for ViabilityContrast Perfusion Echo for Viability2 patients with Anterior STEMI and PCI2 patients with Anterior STEMI and PCI2 patients with Anterior STEMI and PCI2 patients with Anterior STEMI and PCI2 patients with Anterior STEMI and PCI2 patients with Anterior STEMI and PCIBaseline Follow up

Is there apical thrombus?Is there apical thrombus?Is there apical thrombus?Is there apical thrombus?Is there apical thrombus?Is there apical thrombus?Is there apical thrombus?Is there apical thrombus?

CT for Myocardial ImagingCT for Myocardial ImagingCT for Myocardial ImagingCT for Myocardial Imaging

•• Coronary CT angiographyCoronary CT angiographyA t i l h di l i iA t i l h di l i i

•• Coronary CT angiographyCoronary CT angiographyA t i l h di l i iA t i l h di l i i•• Arterial phase myocardial imagingArterial phase myocardial imaging

•• Myocardial motion interpretationMyocardial motion interpretation•• Arterial phase myocardial imagingArterial phase myocardial imaging•• Myocardial motion interpretationMyocardial motion interpretationMyocardial motion interpretationMyocardial motion interpretation•• Viability imaging with delayed Viability imaging with delayed

Myocardial motion interpretationMyocardial motion interpretation•• Viability imaging with delayed Viability imaging with delayed

enhancementenhancementenhancementenhancement

Role of CCT in AMIRole of CCT in AMIRole of CCT in AMIRole of CCT in AMI

•• Evaluation of acute chest painEvaluation of acute chest painM di l i bilitM di l i bilit

•• Evaluation of acute chest painEvaluation of acute chest painM di l i bilitM di l i bilit•• Myocardial viabilityMyocardial viability•• Myocardial viabilityMyocardial viability

Quantification of Infarct SizeQuantification of Infarct SizeQuantification of Infarct SizeQuantification of Infarct Size

Myocardial ViabilityMyocardial ViabilityMyocardial ViabilityMyocardial Viability

DualDual--Phase CTPhase CTDualDual--Phase CTPhase CT

DualDual--Phase CTPhase CTDualDual--Phase CTPhase CT

CMR: Delayed EnhancementCMR: Delayed EnhancementCMR: Delayed EnhancementCMR: Delayed Enhancementyyyy

Two Patients with Inferior STEMITwo Patients with Inferior STEMISoon after PCISoon after PCI

Two Patients with Inferior STEMITwo Patients with Inferior STEMISoon after PCISoon after PCISoon after PCISoon after PCISoon after PCISoon after PCI

Two Patients with Inferior STEMITwo Patients with Inferior STEMITwo Patients with Inferior STEMITwo Patients with Inferior STEMIAfter PCI and FollowAfter PCI and Follow--upupAfter PCI and FollowAfter PCI and Follow--upup

Two Patients with Inferior STEMITwo Patients with Inferior STEMITwo Patients with Inferior STEMITwo Patients with Inferior STEMIFollowFollow--up Echo and Baseline MRIup Echo and Baseline MRIFollowFollow--up Echo and Baseline MRIup Echo and Baseline MRI

Small DE by Gd

Large DE by Gd

Myocardial Function and DHEMyocardial Function and DHEMyocardial Function and DHEMyocardial Function and DHE

•• Transmural extent of infarction and contractilityTransmural extent of infarction and contractility•• Transmural extent of infarction and contractilityTransmural extent of infarction and contractility

Marholdt, JACC 2003Marholdt, JACC 2003

All DysfunctionalS t

All DysfunctionalS t

Segments withSevere Hypokinesia,

Aki i D ki i

Segments withSevere Hypokinesia,

Aki i D ki iSegments with

Aki i D ki iSegments with

Aki i D ki i

100%

)%

) (128(128

(12of 12)

(12of 12)

SegmentsSegments Akinesia, or DyskinesiaAkinesia, or Dyskinesia Akinesia or DyskinesiaAkinesia or Dyskinesia

80

ility

(%ili

ty (% (256

of 329)(256

of 329)

(128of 148)

(128of 148)

(56 of(56 of

(23of 28)

(23of 28)

60

ontr

act

ontr

act (109

of 183)(109

of 183)

(45 of110)

(45 of110)

86)86)

(29 of68)

(29 of68)

(9of 20)

(9of 20)

20

40

oved

co

oved

co 110)110) 68)68) ))

0

20

Impr

oIm

pro (13 of

124)(13 of124)

(1 of58)

(1 of58)

(10 of103)

(10 of103)

(0 of57)

(0 of57)

(4of 54)

(4of 54) (0 of

46)(0 of46)0 0 1-25

26-50

51-75

76-100

0 1-25

26-50

51-75

76-100

0 1-25

26-50

51-75

76-100

CP1302210-5

Transmural extent of hyperenhancement (%)Transmural extent of hyperenhancement (%)

R. Kim et al NEJM 2000

Prognosis Associated with DHEPrognosis Associated with DHEPrognosis Associated with DHEPrognosis Associated with DHE

Chest pain without known OMIChest pain without known OMI PostPost--STEMISTEMI

Kwong, Circ 2006Kwong, Circ 2006 Wu, Heart 2008Wu, Heart 2008

Additional Information:Additional Information:Additional Information:Additional Information:Additional Information:Additional Information:Microvascular ObstructionMicrovascular Obstruction

Additional Information:Additional Information:Microvascular ObstructionMicrovascular Obstruction

Sakuma, JMRI 2007Sakuma, JMRI 2007

Functional Recovery after AMI andFunctional Recovery after AMI andFunctional Recovery after AMI andFunctional Recovery after AMI andFunctional Recovery after AMI and Functional Recovery after AMI and MOMO

Functional Recovery after AMI and Functional Recovery after AMI and MOMO

Nijveldt, JACC 2008Nijveldt, JACC 2008

MO and PrognosisMO and PrognosisMO and PrognosisMO and Prognosis

Wu, Circulation 1998Wu, Circulation 1998

AMI with EdemaAMI with EdemaAMI with EdemaAMI with Edema

Sakuma, JMRI 2007Sakuma, JMRI 2007

T2WI for Edema in MIT2WI for Edema in MIT2WI for Edema in MIT2WI for Edema in MI

Myoview ScanT2WI-triple IR

Acute MI with SwellingAcute MI with SwellingAcute MI with SwellingAcute MI with Swelling

T2WI

With a Newer SequenceWith a Newer SequenceWith a Newer SequenceWith a Newer Sequence

Acute MIAcute MI

Chronic MIChronic MIChronic MIChronic MIKellman, Magn Reson Med 2007Kellman, Magn Reson Med 2007

PeriPeri--Infarct Zone EnhancementInfarct Zone EnhancementPeriPeri--Infarct Zone EnhancementInfarct Zone EnhancementPeriPeri Infarct Zone Enhancement Infarct Zone Enhancement (The “Grey” Zone)(The “Grey” Zone)

PeriPeri Infarct Zone Enhancement Infarct Zone Enhancement (The “Grey” Zone)(The “Grey” Zone)

2-3 SD

>3 SD3 SD

Yan AT et al. Circulation 2006;114;32-39.

STEMI ?STEMI ?STEMI ?STEMI ?Chest and left arm pain for 1 hr. Chest and left arm pain for 1 hr.

Increased TroponinIncreased TroponinChest and left arm pain for 1 hr. Chest and left arm pain for 1 hr.

Increased TroponinIncreased Troponinpppp

65 year old woman with chest pain65 year old woman with chest pain65 year old woman with chest pain65 year old woman with chest pain

Cine Delayed EnhancementCine Delayed EnhancementCine Delayed EnhancementCine Delayed Enhancement

Courtesy of Siemens Med. Systems

Cardiac MRI New Technology

Diffusion Tensor Diffusion Tensor ImagingImaging

Diffusion Tensor Diffusion Tensor ImagingImagingg gg gg gg g

Myocardial Strain Myocardial Strain ImagingImaging

Evaluation of Chest PainEvaluation of Chest Pain

ImagingImagingImagingImagingPrognosisViability

PrognosisViability

FunctionInfarct sizeFunction

Infarct sizeCADViabilityViability Infarct sizeInfarct sizeCAD

Unstable Hemodynamics d C li ti

Unstable Hemodynamics d C li ti

CP1210291-8

and Complicationsand Complications