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Cardiac apex: Spectrum of diseases in Cardiovascular Magnetic Resonance Poster No.: C-1491 Congress: ECR 2013 Type: Educational Exhibit Authors: Y. Arous , A. Omri , M. Ben Gadri , H. BOUJEMAA , N. BEN 1 2 4 1 2 2 3 3 ABDALLAH ; Ariana/TN, Tunis/TN, MONTFLEURY-TUNIS, TU/ 4 TN, TN Keywords: Congenital, Arthrography, MR, CT, Musculoskeletal bone, Cardiovascular system, Abdomen DOI: 10.1594/ecr2013/C-1491 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org Page 1 of 22 Learning objectives To illustrate the spectrum of Left Ventricular (LV) apex diseases using Cardiovascular Magnetic Resonance (CMR). To show the advantages of CMR comparing to Echocardiography. Background Cardiovascular magnetic resonance (CMR) is established in clinical practice for the diagnosis and management of diseases of the cardiovascular system. Echocardiography is the first line imaging modality. However, it is well known that the apex may be difficult to image because of poor acoustic window or incomplete visualization of the LV apex. CMR is an imaging modality that provides a mechanism to assess cardiac or vascular anatomy, function, perfusion, and tissue characteristics in a highly reproducible manner during a single examination. Images can be acquired in patients of various body habitus, in a time-efficient fashion, without an invasive procedure or exposure to ionizing radiation or iodinated intravenous contrast medium. CMR can image the heart in any desired plan and provide an accurate imaging of the LV apex. Spectrum of LV apex diseases is wide: Infarct, thrombus, Tako Tsubo cadiomyopathy, apical hypertrophic cardiomyopathy. Apex can be also the site of physiologic fat deposition. In the Military Hospital of tunis, we perform our cardiac MRI on a 3 Tesla scanner (Siemens verio). MR Image Acquisitions: All MR images were electrocardiographically gated and obtained during repeated breath-holds. Cine MR images were acquired with a steady-state freeprecession sequence. After acquiring cine MRI images on the 2- and 4-chamber long-axis projections, we obtained shortaxis Page 2 of 22 cine MR images that encompassed the LV from base to apex. For the assessment of myocardial edema, T2 STIR images were obtained. late gadolinuim enhancement images was acquired 10 min after intravenous administration of 0.15 mmol/kg of gadolinium. A PSIR ( phase sensitive inversion recovery) sequence was used. Imaging findings OR Procedure details APICAL HYPERTROPHIC CARDIOMYOPATHY Apical HCM is characterized as myocardial hypertrophy that predominantly involve the apex of left ventricle (LV). Apical HCM was originally described in individuals of asian descent but it is now being diagnosed increasignly in the western world. the reported rate of occurance of apical HCM range from 2 to 25%. Unlike typical HCM, apical HCM shows a predilection for middle-aged men, is rarely associated with sudden cardiac death, is frequently complicated by hypertension and has a relatively good prognosis. Echocardiography has been the first line imaging modality for patient with suspected HCM but it is well known that the apex may be difficult to image which can lead to false negative interpretation. CMR can image in any plane and introduction of SSFP sequences has resulted in an improvement in blood to myocardium contrast which is ideal for accurate imaging of the apex. CMR was found to be superior to echocardiography in detecting apical segment hypertrophy. the consequences of missed apical HCM for a patient include unnecessary investigations and missed treatment. The diagnostic criterion for apical HCM is absolute apical wall thickness of more 15mm or a ratio of apical to basal LV wallthickness of 1.3. The characteristic "spade like" configuration of the LV cavity at end diastole is well appreciated on long axis views (fig 1 and 2). Page 3 of 22 More subjective criteria for the diagnosis of apical HCM include obliteration of the LV apical cavity in systole and failure to identify a normal progrssive reduction in LV wall thickness toward apex (Fig 3 and 4). Concomitant apical involvement of the right ventricle is also commonly seen. Moon and al found that 10 patients with a history of ECG abnormalities and negative findings for apical HCM on echocardiography had positive MRI findings for apical HCM on CMR. TAKO TSUBO CARDIOMYOPATHY (TTCM) TTCM is a reversible CM often precipitated by a stressful event with clinical features indistinguishables from acute myocardial infarction. This disease usually affect post menopausal women and it is characterized by hypokinesis or akinesis in the mid and apical segments of the LV wall in the absence of obstructive coronary lesions. ECG changes mimic myocardial infarction. A slight increase of cardiac enzymes level also occurs in TTCM but is lower than expected in relation to extension of the ECG and Echocardiography findings. CMR is an non invasive imaging method that can provide useful information for the diagnosis of TTCM. STIR sequence shows high signal intensity in the ventricular wall with a transmural distribution in both apical and mid segments but not related to a vascular distribution (fig 5). this area of edema shows dysfunction with cine MRI sequences (fig 6). The contraction abnormality produces the balloning morphology that characterizes TTCM with a severe systolic dysfonction. Another finding suggestive of TTCM is the presence of hyperkinesis in the basal plane of the LV (fig 7). Delay enhancement shows typically an absence of late enhancement. However, recent studies indicate that gadolinuim enhancement may occur in patients with TTCM and may indicate late recovery of wall motion abnormalities. Usually, late gadolinium enhancement disappears within 12 months. LEFT VENTRICULAR APICAL THROMBUS Accurate detection of LV thrombus is important as thrombus provides a substrate for embolic events and a rationale for anticoagulation. Echocardiography is widely accepted as the primary screening test for LV thrombus. Page 4 of 22 Delayed enhancement CMR has been well validated as an accurate technique for LV thrombus. In many studies, DE-CMR has yielded a 2- to 3-fold improvement in thrombus detection versus noncontrast echo. LGE, which is typically used for detection of myocardial fibrosis or scar, can be used for improved differentiation of enhancing cardiac masses from nonenhancing bland thrombus. It has also the ability to distinguish a cardiac tumor from thrombus. Weinsaft and al demonstrate that Patients who derived incremental benefit from delayed enhancement CMR had lower LVEF than those in whom noncontrast echo alone accurately assessed thrombus. LV function can be useful for guiding imaging strategies for thrombus. they also demonstrate that Thrombi detected by DE-CMR but not by contrast echo are typically mural in shape or small in volume. In our experience the most frequently missed apical thrombus in echocardiography are small in volume (fig 8) or occurs in patients with idiopathic dilated cardiomyopathy (fig 9). In case of idiopathic dilated cardiomyopathy, hypertrabeculation of the LV can mask apical thrombus in echocardiography. MYOCARDIAL INFRACTION Late gadolinium enhancment CMR can be used for identifying the extent and location of myocardial necrosis in individuals suspected of having or possessing chronic or acute ischemic heart disease. Typically, delyaed enahncement is subendocardial and/ or transmural. CMR has a crucial role for the diagnosis of myocardial infarction in patient with a normal coronarography. PHYSIOLOGIC FAT DEPOSITION Physiologic fat deposition can mimic pathologic condition and diseaeses particulary healed myocardial infarction. Fat in healed myocardial infarction is usually easily distinguished from physiologic fat because of its characteristic subendocardial location, which corresponds to the distribution of a coronary artery. However, when a small amount of fat is identified in the LV apex, it may be difficult to differentiate physiologic fat from fat deposition secondary to a small myocardial infarct. In this case, CMR is crucial (fig 13, 14 and 15). it shows fat deposition with no delay enhancement and no motion abnormalities of LV apex. Images for this section: Page 5 of 22 Fig. 1: 55 years old patient with an acute coronary syndrom and a normal coronarography. The echcocardiography shows an akinetic LV apex. A CMR was performed. the cine image in vertical long axis view shows a "spade like" configuration of the LV cavity at end diastole. Page 6 of 22 Fig. 2: 57 years old patient with a suspected apical CMH on echocardiography. CMR shows a "spade like" configuration of the LV cavity. Page 7 of 22 Fig. 3: Same patient as in figure 2: SSFP cine image on short axis view shows obliteration of the LV apical cavity in systole. Page 8 of 22 Fig. 4: Same patient as in figure 2 and 3: SSFP cine sequence on horizantal long axis view shows an absence of the normal progrssive reduction in LV wall thickness toward the apex. Page 9 of 22 Fig. 5: T2 STIR sequence on apical short axis view in 83 years old woman in acute state of Takotsubo cardiomyopathy. Transmural edema is observed in apical plane of left ventricle. intensity. Areas with edema show wall motion abnormalities in cine MRI. Page 10 of 22 Fig. 6: Cine MR image on short axis view (from same patient as in Fig 5) shows severe hypokinesis in the area of edema Page 11 of 22 Fig. 7: Cine MR image on basal short axis view (same patient as in Fig.7) shows hyperkinesis of the LV wall. Page 12 of 22 Fig. 8: PSIR sequence on vertical long axis view in a 65 years old patient shows a small apical thrombus. No thrombus seen on echocardiography. Page 13 of 22 Fig. 9: PSIR sequence in horizantal long axis view in a 40 years old patient with a idiopathic dilated cardiomyopathy shows a 25mm apical thrombus not seen on echocardiography; Page 14 of 22 Fig. 10: STIR sequence on vertical long axis view in 68 years old woman with an acute coronary syndrom with a normal coronarography and echocardiography shows hypersignal (edema) of 17 segment . Page 15 of 22 Fig. 11: PSIR sequence on vertical long axis view (same patient as in fig 10) shows transmural late enhancement of the LV apex: Myocardial infarction. Page 16 of 22 Fig. 12: SSFP cine sequence on vertical long axis view (same patient as in fig 10 and 11) shows an akinetic LV apex. Page 17 of 22 Fig. 13: ECG gated CT scan in a 45 years old man shows subendocardial fat deposition at the LV apex Page 18 of 22 Fig. 14: T1 sequence on vertical long axis view shows high signal intensity areas in the apex and the basal wall. Page 19 of 22 Fig. 15: T1 with fat saturation confirms the fat deposition (same patient as in figure 13 and 14). the absence of delayed enhancement and motion abnormalities confirm the physiologic fat deposition. Page 20 of 22 Conclusion CMR provide an accurate imaging of the LV apex. LV apex diseases are numerous. the LV apex may not assessed well with echocardiography and can lead ta false negative interpretation In apical HCM, CMR is strongly recommanded as the optimal imaging modality. CMR is crucial in coronary acute syndrom with a normal coronarography particulary in apex lesions ( small apex infarct, Tako Tsubo cardiomyopathy). CMR is also an accurate technique for LV thrombus detection. References 1. Hansen MW, Merchant N. MRI of hypertrophic cardiomyopathy: Part I; MRI appearances: AJR 2007;189:1335-43. 2. ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance: A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. JACC; 55:2614-62. 3. Moon JCC, Fisher NG, McKenna WJ, Pennell DJ. Detection of apical hypertrophic cardiomyopathy by cardiovascular magnetic resonance in patients with nondiagnostic echocardiography. Heart 2004;90:645-649. 4. Teraoka K, Kiuchi S, Takada N, Hirano M, Yamashina A. Images incardiovascular medicine: No delayed enhancement on contrast magnetic resonance imaging with Takotsubo cardiomyopathy. Circulation 2005;111: e261 - e262. 5. Nakamori S, Matsuoka K, Onishi K et al. Prevalence and Signal Characteristics of Late Gadolinium Enhancement on Contrast-Enhanced Magnetic Resonance Imaging in Patients With Takotsubo Cardiomyopathy. Circ J 2012; 76: 914-21. Page 21 of 22 6. JW Weinsaft, RJ Kim, MRoss et al.Enhanced Anatomic Imaging as Compared to Contrast-Enhanced Tissue Characterization for Detection of Left Ventricular Thrombus. J Am Coll Cardiol Img 2009;2:969-79. 7. F Kimura, Y Matsuo, T Nakajima et al. Myocardial Fat at Cardiac Imaging: How Can We Differentiate Pathologic from Physiologic Fatty Infiltration? RadioGraphics 2010; 30:1587-1602 Personal Information Page 22 of 22