Chẩn đoán Hình ảnh Tim mạch có gì mới trong năm 2015-2016

Cardiovascular

Imaging:

Year-in-Review

2015-2016

Adj Ass Prof Ong Hean Yee
FESC
MBBCh BAO, ASCeXAM, FRCP,
Senior Consultant and Head of Department
Department of Cardiology
Khoo Teck Puat Hospital

THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016


Disclosure
Advisory Board
Novartis, Boehringer Ingelheim, Bayer, Sanofi, Pfizer, Astra Zeneca

Principle Investgator
Novartis, Sanofi, Bayer, Astra Zeneca, Eli-Lilly, Amgen, Pfizer

Sponsorship (2014-2015 only)
Astra Zeneca, Bayer

All Honorariums donated to Department Research and Training Fund

THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016


EJ

OfficialOpening

29

~

52

Patah

N ov e m

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Touc ing Lives Pioneeri g Care, ~ak,ng a Differenc

e

A"9 MO KIO

;

S igapore

b

er 2 0 10

-- - - -

Khoo Teck

Puat

Hospital
Alexandra Heal

Jurong Island

lh

Sentosa

Bukom Island

r

-

- ._

THE 15 rn NATIONAL CONGRESS
OF CARDIOLOGY

2016


Cardiovascular Imaging 2015-16

Focused Cardiac Ultrasound
Cardiac CT Perfusion
Therapeutic Ultrasound
CAC - 15 year prediction
High Risk Plaque

THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016


Cardiovascular Imaging 2015-16

Focused Cardiac Ultrasound
Cardiac CT Perfusion
Therapeutic Ultrasound
CAC - 15 year prediction

High Risk Plaque

THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016


Focused Cardiac Ultrasound

International Evidence-Based
for Focused
Gabriele Via, MD, Arif Hussain,
Robert Reardon, MD, Mahmoud
Aleksandar N. Neskovic, MD, PhD,

Aecom mendations
Ultrasound

Cardiac

MD, Mike Wells, MD, BSc, BSc Hons, MBBCh, FCEM, Dip PEC,
ElBarbary, MD, Vicki E. Noble, MD, Iarnes W. Tsung, MD, MPH,
FESC, FACC, Susanna Price, MD, MBBS, BSc, MRCP, EDICM, PhD,

FFICM, FESC, Achikam Oren-Grinberg,

MD, MS, Andrew Liteplo, MD, RDMS, Ricardo Cordioli, MD,

Nitha Naqvi, MD, MSc, MRCPCH, Philippe Rola, MD, Jan Poelaert, MD, PhD, Tatjana Golob Gulic, MD,
Erik Sloth, MD, PhD, DMSc, Arthur Labovitz, MD, FACC, Bruce Kimura, MD, FACC, Raoul Breitkreutz, MD, Navroz Masani, MBBS, FRCP, Justin Bowra, FACEM, CCPU,
Daniel Talmor, MD, MPH,
Fabio Guarracino, MD, Adrian Goudie, BMedSci(Hons),
Rajesh Chawla, MD, FCCM, Maurizio Galderisi,

MBBS, FACEM DDU, Wang Xiaoting, MD,
MD, Micheal Blaivas, MD, FACEP, FAIUM,

Tomislav Petrovic, MD, Enrico Storti, MD, Luca Neri, MD, and Lawrence Melniker, MD, MS, International Liaison Committee on Focused Cardiac
UltraSound (ILC-FoCUS) for the International Conference on Focused Cardiac UltraSound (IC-FoCUS)

J Am Soc Echocardiogr 2014; 27: 683, e1-e33
THE 15™NATIONAL CONGRESS
OF CARDIOLOGY

2016


Focused Cardiac Ultrasound

A&E
ICU

+

+

J Am Soc Echocardiogr 2014; 27: 683, e1-e33
THE 15 ™ NATIONAL CONGRESS

OF CARDIOLOGY

2016


Focused Cardiac Ultrasound
Diagnostic

Performance

Ultrasound

Performed

of Focused Cardiac
by Emergency

for the Assessment
Physicians
Aorta Dilation and Aneurysm

of Ascending

Peiman Nazerian, MD, Simone Vanni, MD, PhD, Fulvio Morello, MD, PhD, Matteo Castelli, MD,
Maddalena Ottaviani, MD, Claudia

Casula,

MD, Alessandra

Petrioli, MD, Maurizio Bartolucci. MD, and

Stefano Grifoni, MD

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100

Acac Emerg Med 2015; 22: 536–541
THE 15 rn NATIONAL CONGRESS

OF CARDIOLOGY

2016


Focused Cardiac Ultrasound
Nazerian et al
Ascending Aorta measurement in A+E vs CT

Acad Emerg Med
2015; AE
22:et
536
Jones
al

Hypotension due to Cardiac Dysfunction vs Hypovelemia

Shock
2005; 24: 513-7
Yim ES et al

Screening for HCM in Sports Clinic

Use of hand held echo machine in underpriviledged
community

J Ultrasound Med
2013; 32: 333-8.
Fedson S

JASE
2003;16:901-5.
Spencer KT.

Clinical Examination versus handheld machine

JACC
2001;37:2013-8
THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016


Focused Cardiac Ultrasound

A&E
ICU

+

=

+

?
J Am Soc Echocardiogr 2014; 27: 683, e1-e33
THE 15 ™ NATIONAL CONGRESS

OF CARDIOLOGY

2016


Cardiovascular Imaging 2015-16

Focused Cardiac Ultrasound
Cardiac CT Perfusion
Therapeutic Ultrasound
CAC - 15 year prediction
High Risk Plaque

THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016


Cardiac CT perfusion

CT versus MRI
Pro
Higher Spatial Resolution
Availability

Cons
Contrast Nephropathy
Radiation (12-15 mSV)

THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016


Functional vs Anatomy
Our Preoccupation

With Coronary Luminology

The Dissociation

Between Clinical

and Angiographic Findings

in lschemic

Heart Disease

EricJ.

Topol,

MD;

Steven

E.

Nissen,

MD

↑↑ Underestimation

↑↑ and ↑↑ Oveestimation

↑↑

Topol Nissen Circulation 1995; 92: 2333-2342
THE 15 ™ NATIONAL CONGRESS
OF CARDIOLOGY

2016

~·:

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.


Revascularisation by Anatomy
NEW

The

ENGLAND JOURNAL

of

MEDICINE

Optimal Medical Therapy with or without PCI
for Stable Coronary Disease
William E. Boden, M.D., Robert A. O'Rourke, M.D., Koon K. Teo, M.B., B.Ch., Ph.D., Pamela M. Hartigan, Ph.D.,
Davidj.

Maron, M.D., Williamj. Kostuk, M.D.,

Merril Knudtson, M.D., Marcin Dada, M.D., Paul Casperson, Ph.D.,

Crystal L. Harris, Pharm.D., Bernard R. Chaitman, M.D., Leslee Shaw, Ph.D., Gilbert Gosselin, M.D.,
Shah Nawaz, M.D., Lawrence M. Title, M.D., Gerald Gau, M.D., Alvin S. Blaustein, M.D., David C. Booth, M.D.,

and William

Eric R. Bates, M.D.,John A. Spertus, M.D., M.P.H., Daniel S. Berman, M.D., G.B.John Mancini, M.D.,
S. Weintraub,
M.D., for the COURAGE Trial Research Group*

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of

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No. at Risk

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1013

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COURAGE NEJM March 2007 vol 356

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1138

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468

302

38

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1149

1094

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929

733

488

312

44

30
35

THE 15 rn NATIONAL CONGRESS
OF CARDIOLOGY

2016


Revascularisation by Function
•

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Myocardium. Ischemic

Hachamovitch CIRC 2003, 107, 23: 2900
THE 15 ra NATIONAL CONGRESS
OF CARDIOLOGY

2016

,:..'

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Functional Fractional Reserve
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THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016

Functional vs Anatomy
Vol. 33-l

:'so. 26

FRACTIO:'\AI.

FLO\\" RESERVE

TO ASSESS SEVERITY OF CORO:XARY-ARTERY

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THE 15 rn NATIONAL CONGRESS
OF CARDIOLOGY

!

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Functional vs Anatomy
NEW

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ENGLAND JOURNAL

FFR < 0.80 predicts PCI benefit

of

MEDICINE
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JANUARY

VOL. 360

15, 2009

NO, 3

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Fractional Flow Reserve versus Angiography
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Pim A.L. Ton,no, M.D., Bernard De Bruyne, M.D., Ph.D., Nico H.J. P,jls, M.D., Ph.D.,
Uwe Siebert, M.D., M.P.H., Sc.D., Fumiaki lkeno, M.D., Marcel van 't Veer. M.Sc., Volker Klauss, M.D., Ph.D., Ganesh Manoharan, M.D., Thomas Engstrom, M.D., Ph.D., Keith G.
Oldroyd, M.D., Peter N. Ver Lee, M.D., Philip A. Maccarthy, M.D., Ph.D., and William F. Fearon, M.D., for the FAME Study tnvesngators=

Fractional Flow Reserve-Guided PCI
for Stable Coronary Artery Disease
Bernard De Bruyne, M.D., Ph.D., William F. Fearon, M.D., Nico HJ. Pijls, M.D., Ph.D.,
Emanuele
Nikolajagic,

Barbato, M.D., Ph.D., Pim Tonino, M.D.,
M.D., Sven Mobius-Winckler,

M.D., Gilles

Ph.D., Zsolt Piroth, M.D.,
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Ph.D.,

M.D., Kreton Mavromatis,

Peter Veriee, M.D.,
B.Johnson,

Petr Kala, M.D., Philip Maccarthy,

R.N.,

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0

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FAME 2 NEJM 2014
THE 15 rn NATIONAL CONGRESS
OF CARDIOLOGY

2016

300

360


CT perfusion
TABLE

1

Summarized

MyocardialPerfusionProtocols

Static Stress MPI

Scanner requirement

64-slice CT

Dynamic Stress MPI

Second-generation
dual-source CT
Wide detector CT with complete
cardiac coverage

Acquisition

mode

ECG-triggered axial scan mode

ECG-triggered

ECG-gated spiral scan mode

shuttle mode

(dual-source
Stationary

CT)

ECG-triggered

mode

(wide detector CT)
Contrast protocol
Image data

50-70 ml@ 4-5 rnl/s
Single high-resolution

Short, high-rate bolus ( ~ 50 ml) Sequence
dataset

resolution

datasets

Effective dose

1-5 mSv*

Output parameters

Attenuation

5-10 mSv*
values
Relative attenuation

Gonçalves et al JACC Img 2015;

values

Myocardial

blood flow

Myocardial

blood volume

8: 1322–35
THE 15 ™ NATIONAL CONGRESS
OF CARDIOLOGY

2016

of low-


CT perfusion

l

Time

Op lor,a;

Full!CTP Protocol

Patient

Post-exam

Preparation:

Status Check:

-IV Access

-Scout. Image

StressPhase

Rest Phase

Delayed Phase

(Retrospective ECG Gating with dose

(Prospective ECG Triggering)

(Prospective ECG Triggering)

-12-Lead ECG
-Test Bolus

-Vitals

-12-Lead ECG
-Vitals

modulation)
'

Vasodilator Stress Agent
Contrast

Image

Bolus

Acquisition
:

30

Dipyridamole 0.56 mg/kg/min

Contrast

Image

Bolus

Acquisition

min
5-10

Aminophyllin

e 1.5 mg/kg

min

Image
Acquisition

Heart Rhythm and Symptoms Monitoring

I
Techasith JACC-Img 2011, 4: 905
THE 15 TH NATIONAL CONGRESS
OF CARDIOLOGY

2016


CT perfusion
Dynamic CT myocardial

perfusion measurements

of resting and hyperaemic blood flow in low-risk
subjects with 128-slice dual-source
Kheng-Thye

CT

Ho1*, Hean-Yee Ong2, Grace Tan3, and Quek-Wei Yong4

80kV if BMI < 30 kg/m2
Total Radiation = 12.91+4.32 mSv
Total Contrast ~ 150 ml
4.7+1.7
IV Dipyridamole 0.56mg/kg/min (4 min)
SNR 80kV vs 100 kV = 4.8+1.3 and
EHJ Cardiovascular Imaging 2015 Mar 16 (3): 300
THE 15 ™ NATIONAL CONGRESS
OF CARDIOLOGY

2016

CT perfusion
Dynamic CT myocardial

perfusion measurements

of resting and hyperaemic blood flow in low-risk
subjects with 128-slice dual-source
Kheng-Thye

Ho1*,

Hean-Yee Ong2, Grace Tan3, and Quek-Wei

CT
Yong4

EHJ Cardiovascular Imaging 2015 Mar 16 (3): 300
THE 15 ™ NATIONAL CONGRESS
OF CARDIOLOGY

2016


CT perfusion
Dynamic CT myocardial

perfusion measurements

of resting and hyperaemic blood flow in low-risk
subjects with 128-slice dual-source

Kheng-Thye

Ho1*,

Hean-Yee Ong2, Grace Tan3, and Quek-Wei

CT
Yong4

EHJ Cardiovascular Imaging 2015 Mar 16 (3): 300
THE 15 ™ NATIONAL CONGRESS
OF CARDIOLOGY

2016


Cardiovascular Imaging 2015-16

Focused Cardiac Ultrasound
Cardiac CT Perfusion
Therapeutic Ultrasound
CAC - 15 year prediction
High Risk Plaque

THE 15 ra NATIONAL CONGRESS

OF CARDIOLOGY

2016

Therapeutic Ultrasound
Diagnostic

Ultrasound Impulses Improve
CrossMark

Microvascular Flow in Patients With STEMI
Receiving

Intravenous Microbubbles

Wilson Mathias, JR, MD,3 Jeane M. Tsutsui, MD,3 Bruno G. Tavares, MD,3 Feng Xie, MD,b Miguel O.D. Aguiar, MD,3
Diego R. Garcia, MD,3 Mucio T. Oliveira, JR, MD,3 Alexandre Soeiro, MD,3 Jose C. Nicolau, MD,3
Pedro A. Lemos, NETO, MD,3 Carlos E. Rochitte, MD,3 Jose A.F. Ramires, MD,3 Roberto Kalil, FILHO, MD,3
Thomas R. Porter, MDb

TABLE

1

Ultrasound Treatment Regimens

HMI

Frequency/Pulse

Pulse
Short pulse: HMI

+ PCI (n =

10)

Long pulse: HMI

+ PCI (n =

5)

Long pulse: HMI

+ PCI (n =

5)

LMI

+ PCI (n =

1.1-1.3

1.3

FR

1.8 MHz/3 us

25

1.3 MHz/5

10

~LS

Number of

(Hz)

Duration

Sector
Size (

Pulses per Line

3

90

0)

Number of

Duration of Therapy

Lines per Frame

Pre-PCI (min)

132

3

132

90

1.3

1.8 MHz/20 µs

5

4

60

12

±

10

20

±

8

±

14

19

120

10)
0.18

<2*
1.8 MHz/3 us

25

3

90

132

Mathias JACC 2016; 67: 2506–15
THE 15 ™ NATIONAL CONGRESS
OF CARDIOLOGY

2016