1. Longwood Area Non-invasive Cardiac Imaging Seminar: Overview
LV/RV Anatomy and Function
Warren J. Manning, MD
Beth Israel Deaconess Medical Center, Boston, MA

2. Disclosures Research Grant Support: Philips Medical Systems NIH, NHLBI
Lantheus Medical Inc.

3. Seminar Conception
Training in echocardiography (TTE, Stress, TEE) was relatively mature.
Exposure to other imaging modalities [CMR, CCT] was less developed
Clinical exposure to CMR and Nuclear Cardiology by cardiology and radiology residents/fellows is high at the BIDMC
formal training/lectures in CMR, CCT, is more limited
Fulfill new COCATS training recommendations for Level I training in CMR, CCT

4. Outline – Year 7 1 hour weekly “seminar” style series Monday, noon-1pm
West Campus, Baker 4 - CV library
~45-50 min presentation by Longwood attending staff
5-10 minute questions
Internal [CMR] Web posting of presentations
Didactic
CME credit for attending staff
Clinical cases - 1 hour case based conference (2nd/4th Friday at 12:30pm) initiated 2007

5. Outline Modalities: January - June
Cardiovascular Magnetic Resonance (CMR)
July – August
CMR Physics [Monday noon-1pm; EAST Campus]
September – October
Nuclear Cardiology (Tom Hauser)
November-December
Cardiac Computed Tomography (CCT) (Tom Hauser)

6. Outline
Primarily for cardiology fellows and radiology residents/fellows
also open to interested medical students, medicine residents, sonographers, nuclear med trainees, CMR/MR technologists, CT technologists, nurses, attendings, etc.).

7. Outline
Boston area staff/teaching resources, inclusive of fellows within and outside Longwood Medical Area:
Longwood: BIDMC, BWH, Children’s Hospital
Boston: Boston Medical Center, Tufts Medical Center
Outside 128 (new for 2009/10)
Lahey Clinic, UMass-Memorial
Participation via web: cardiacmr.webex.com

8. 3 “Pillars” of Cardiology
1. Interventional/Invasive Cardiology
2. Electrophysiology
3. Non-invasive Cardiac Imaging
Beller JACC 2006; Thomas JACC 2009
[WJM: Enter from Cardiology or Radiology]
Echo (TTE, TEE, Stress, ICE, 3D)
Nuclear Cardiology/PET (PET-CT)
Cardiovascular Magnetic Resonance
Cardiac Computed Tomography

9. Radiology Cardiology Anesthesia
BIDMC Non-invasive Cardiovascular Imaging - Training
TTE
Cath
Nuclear
PET
CMR**
CCT***
Cardiology
TEE
TTE*
Radiology
**Neil Rofsky, MD
***Mel Clouse, MD
***V. Raptopoulos, MD
Anesthesia
* Feroze Mahmood, MD
* Achi Grinberg, MD

13. CMR Teaching Staff BIDMC: Boston Medical Center Frederick Ruberg, MD
Evan Appelbaum, MD
Eli Gelfand, MD
Robert Greenman, PhD
Yuchi Han, MD
Thomas H. Hauser, MD
Kraig V. Kissinger, RT
Robert Lenkinski, MD
Warren J. Manning, MD
Reza Nezafat, PhD
Ivan Pedrosa, MD
Dana C. Peters, PhD
Neil M. Rofsky, MD
Martin Smith, MD
Susan B. Yeon, MD
Boston Medical Center
Frederick Ruberg, MD
Children’s Hospital
Tal Geva, MD
Andrew Powell, MD
Anne Marie Valente, MD
BWH
Raymond Kwong, MD
Tufts NEMC
Martin S. Maron, MD

14. TOPICS [Web site] LV function/mass RV function Myocardial infarction
CMR stress
CMR viability
Cardiomyopathies
Pericardium
Congenital heart disease
Valvular heart disease
MRA – aorta, renal,
peripheral, carotid
MR venography
Coronary MRI
Non-cardiac thoracic pathology
Pulmonary vein MRA
Interventional

15. Schedule E-mail notification every Friday
Let me know if you are not on list (or on list…)
Every Monday through the end of June, noon-1pm
Except
Holidays (MLK/Washington’s BDay, Patriot’s Day)
Cardiology Fellowship interviews
(2/22, 3/22, 3/29, 4/26, 5/3)
Research retreat (2/1)

16. Additional Resources S Drive CMR Fellows
BIDMC cases (topic; MRN, images, report)
CMR Physics
R. Nezafat, DC Peters [BIDMC – slides]
Robert Judd (Duke - video)
CMR Fellows
Francesca Delling, MD
Airley Fish, MD
Susie Hong, MD
Ali Mahajerin, MD
Nisha Parikh, MD
Ali Rahimi, MD

18. Multimodality Imaging in Cardiology
Critical that training cross technology boundries
Efficiencies of multimodality imaging program
Thomas JACC 2009

19. Level 1 – Basic training required of all trainees to be
competent consultant cardiologists. This level makes
trainees conversant with all imaging modalities
along with their clinical utility. It provides superficial
exposure to performance and interpretation….
Didactic Activities:
Duration 1 month
Perform 0 cases/Exposed to interpretation of 25 cases
Lectures and self-study in CMR
Clinical CMR reading [East] during Echo months [2nd yr]
5 cases/wk x 16 wks = 80 cases
Monday noon CMR seminar
Tuesday am clinical conference
Friday 12:30pm case based imaging conference
No “hands on” experience necessary
JACC 2002

20. Level 2 – Additional training that enables the cardiologist
to interpret cardiovascular imaging studies
independently
Didactic Activities:
3-6 months under Level 2 or Level 3 (preferred)
Supervised interpretation of cases
(Up to 50 may come from a training set)
Primary interpretation of 50+ cases
Lectures and Self Study – more advanced
JACC 2002

21. Level 3 – Advanced training that enables a cardiologist to
perform, interpret, and train others to perform and
interpret specific imaging studies at the highest
skill level. This is the expertise expected for
directors of imaging laboratories.
Didactic Activities:
6 (clinical) or 12 (academic) mo training under Level 3
Supervised interpretation of cases
(Up to 100 may come from a training set)
Primary interpretation of 100+ cases
Lectures and Self Study – more advanced
Summer Physics series, Monday, noon-1pm
Mon-Friday 11am-noon clinical readout
3-4 mo clinical CMR fellow
Focused research, publications
JACC 2005

22. Multimodality Training – JACC 2009
Modality Level Mo Multimodality Multimodal Cases
Single Total/Unshared (Perf Interpret)
Echo / / /
Nuclear / / /
CMR / / /
CCT / / /
Thomas JACC 2009

23. Maintenance of Skills SCMR 2006 ACCF/AHA (JCMR 2006) (JACC 2005)
Level II
CME hours/2yr 30 hours/3yr
Cases /2yr 50/yr
Level III
CME hours/2yr 60 hours/3yr
Cases /2yr 100/yr

24. Physician Credentialing in CMR
RADIOLOGIST
ACR Diagnostic Modality Accreditation Program
Stereotactic Breast Biopsy Accreditation
Breast ultrasound Accreditation
Ultrasound Accreditation
Magnetic Resonance Imaging Accreditation
not CMR specific
Nuclear Medicine and PET Accreditation
Computed Tomography Accreditation
Radiography/Fluoroscopy Accreditation

25. Physician Credentialing in CMR
Board certified radiologist
Supervised and interpreted >75 CMR cases in past 36 mo
Completed >40 hours of CME (or equivalent supervised experience)
>75 examinations every 3 years to maintain skills
No specific CMR CME requirement
Radiology 2005;235:723

26. Warren J. Manning - Dudley J. Pennell
CMR Texts (NOT required) *
Warren J. Manning - Dudley J. Pennell
MANNING
PENNELL
Second Edition
SECOND
EDITION *
                                            
*WJM editor (if interested – see me)

27. J Cardiovasc Magn Resonance – www.jcmr-online.com
Original Articles
How to
Reviews
Case Reports

28. If you want to learn more.....*
Society for Cardiovascular
Magnetic Resonance*
13th Annual Scientific Sessions
January 21-January 24, 2010
Phoenix, AZ

29. CMR – “New Kid” on the block Non-invasive Imaging – 2008 (estimate)

30. Cardiac imaging is frequently performed!
# of Clinical
Studies (millions)

31. Non-invasive Imaging – Equipment Cost
Cost ($mil)

32. Advantages of Cardiovascular MR (CMR)
1. Excellent soft tissue contrast
2. Non-invasive, no ionizing radiation
3. High (<1mm) in-plane spatial resolution
4. Multiplane, true tomographic imaging
5. Dynamic/cine imaging (2D echo)
6. Exogenous contrast usually not needed
[CMR agents are less toxic than iodinated preparations]
Blood flow/volume – quantitative
Minimal post-processing
9. Potential for tissue characterization [fat, iron]
10. Thoracic skeleton and pulmonary parenchyma
do not interfere with imaging
11. “Comprehensive” CMR examination

33. Advantages of Cardiovascular MR (CMR)
Much cardiac hardware is safe…
a. Mechanical and bioprosthetic valves
b. Post-sternotomy sternal wires
c. CABG clips/markers
Coronary stents
? ”Modern” PCM/ICDs [Circ 2004, 2006]

34. sternal wires and coronary artery bypass graft markers.
Local artifacts from
sternal wires and coronary artery bypass graft markers.

35. YES! Is it safe for patients with prosthetic
heart valves to have an MRI?
YES!

36. Prosthetic Valves

37. Intracoronary Stents No local heating
ACS Multi-link RX Duet (3)
ACS RX Multi-link (3)
AVE (2,4)
Micro Stent (3)
BeStent (2,3)
Crown (4)
Giantourco-Roubin (1,2)
Giantourco-Roubin II (3)
InFlow (2,3)
InFlow Gold (3)
JoStent (2)
MAC-Stent (3)
Multilink (2,4)
Palmaz-Schatz (1,2,3)
R-Stent (3)
Seaquence (3)
Strecker (1)
Tenax-Stent (2)
Wallstent (2,3)
Wiktor (1)
Wiktor GX (3)
Intracoronary Stents
No local heating
Minimal force/No device migration
Smaller artifacts with TSE (vs. GRE)
imaging
1. Scott & Pettigrew AJC 1994
2. Strohm JCMR 1999
3. Hug Radiology 2000
4. Kramer JCMR 2000
5. Powell SCMR 2001
6. Gerber JACC 2003

40. CMR Coronary Stent Safety
Study
Gerber [JACC ‘03]
Schroeder [JCMR ‘00]
Kramer [JCMR ‘00]
Syed [ACC ‘04]
Pt Type
CAD
AMI N
112 47 30
133
CMR
(days)
21+17
166
3+1
2+2
F/U
(days) 30
21+5
220+60
133+60
+CMR
Events 5%
35% 8% 6%
-CMR
Events
38%
29%
22%

41. Disadvantages of CMR
Most physicians did not enjoy or don’t remember much physics….
Set-up is complex, many options (compared with other technologies)
3. CMR image interpretation is not always “intuitive”
ECG gating is “absolute” requirement yet soimetimes difficult
Claustrophobia, ?Exclusion [PCM, ICD]
6. Real and perceived $$
Perceived cost is high [echo < Nuclear << CMR]
Reimbursement is relatively low [echo < CMR << Nuclear]
Investment is high [echo << Nuclear << CMR]
7. Other technologies are established (echo, nuclear, CT)
What is true value CMR?
New information that impacts/changes patient care

42. Non-invasive Imaging – Reimbursement/study$$

43. Disadvantages of CMR Powerful magnet that is “always on”
Intracranial clips
TENS
Cochlear implants ….
stethescope
pens
ID badge clips …
CMR is not portable

44. Disadvantages of CMR Nephrogenic Systemic Fibrosis - NSF
Systemic fibrosis (skin, lungs, muscles, heart)
subacute swelling of distal extremities
followed by severe skin induration pain, loss of skin flexibility
onset of symptoms 2 days to 18 mo from exposure
2006 [Grobner Nephrol Dial Transplant 2006]
>200 cases reported – all with exposure to Gd-based contrast
?Preference for specific Gd-agent [>80% Omniscan]
Underlying renal dysfunction (many on dialysis)
CrCl >60 ml/min/1.73m2 = “no” risk
FDA advisory December 2006
BIDMC: Creatinine clearance estimate prior to Gd-DTPA exposure
Choyke questionnaire

45. Pacemakers/AICD Heating (leads)
Threshold changes in a minority of patients
Isolated leads without PCM generator may be more concerning
PCM program changes
Devices manufactured after 2000 may be “safer”
FDA: potential risks and data do not justify routine MRI in patients
With pacemakers/ICD
?IRB protocol at BIDMC
Monitoring of patients
No PCM dependent patients
Levine et al. Safety of MRI in patients with
Cardiovascular Devices. Circulation 2007;116:

46. www. www.scmr.org Or link from… Or link from…
Intranet.bidmc.harvard.edu
Cardiac MR
REFERENCES

47. Importance of LV Anatomy/Function
LV mass is independent risk factor for adverse cardiovascular events
hypertrophy (HTN, aortic stenosis/regurgitation)
Global LV volumes are important in monitoring of patients with valvular disease (AR, MR)
Global LVEF provides prognostic information
many therapeutic strategies are based on LVEF thresholds (ACE inhibitors p-MI)
LV regional function (CAD)
Cardiologists are “intensely quantitative”

48. Echocardiography
Parasternal Long Axis

49. ECG
Ant Sept
Inferolateral
EDD ES
Echo LV
Measures
Septum [nl<11] End-diasolic Dimension [nl<56mm]
Inferolateral [nl<11] End-systolic Dimension

50. M-Mode Echo Estimates LVVol: Teichholz Formula: EDV=7D3/(2.4+D) LVEF:
Fractional shortening = (EDD - ESD)/(EDD) [nl>0.30]
Vol (sphere) 4pR3/3
FS = 0.33  ED radius = 3; ES radius =2
LVEF = (Rd3 - Rs3) / Rd3
= / 33
= 27 – 8 / 27 = 0.70
2D visual / “eye ball method”
(15-20% of cases - cannot see all the segments)

51. M-Mode Echo Estimates LV MASS Penn-Cube Method:
LVM = [(S+IL+EDD) 3 - EDD3 ])*1.05*
LV MASS (ASE Method):
LVM = [(S+IL+EDD) 3 - EDD3 ])*1.05*

52. Biplane Simpson’s Rule
2D Echo Estimates
Apical 4 Chamber view
Truncated Elipsoid
Biplane Simpson’s Rule a b d
LV mass = 1.05p (b+t)2 [2/3(a+t) + d - (d3/d(a+t)2 -b2 [2/3a +d - d3/3a2 ]

53. Advantages of Cardiovascular MR (CMR)
1. Excellent soft tissue contrast
2. Non-invasive, no ionizing radiation
3. High (<1mm) in-plane spatial resolution
Multiplane, true tomographic imaging
“Volumetric imaging” – no geometric assumptions
6. Dynamic/cine imaging with high temporal resolution(2D echo)
7. Exogenous contrast usually not needed
[MR agents are less toxic than iodinated preparations]
8. Blood flow/volume - quantitative
9. Potential for tissue characterization
10. Thoracic skeleton and pulmonary parenchyma
do not interfere with imaging

54. Coronal or Transverse Scout – Single Shot

55. SSFP ECG gated Cine Acquisitions
Ungated
12 frames/R-R interval

56. 2Ch & 4Ch Breath-hold Cine MRLV LA

57. Short Axis Cines from Base to Apex1 2 3 4 5 6 7
Base

58. LV EDV/ESV - Practical Points1 10
Slice #
Phases
End-diastolic phase is 1st phase in SA dataset
End systolic phase is phase of minimum area
End-systolic phase is defined on a mid-ventricular level.
Phase of minimum area is then used as “end-systolic phase” for all slices in dataset

59. 3D Assessment of LV/RV VolumesED
SEDA*Thsl = EDV
SESA* Thsl = ESV
SV = EDV – ESV
EF = SV/EDV
Isolated Aortic/Mitral Regurgitation
LVEDV 236 ml
LVESV ml
SVLV ml
RVEDV ml
RVESV ml
SVRV ml
Regurgitant Volume 18 ml

60. Why CMR for LV Mass/Volumes?
Summation of discs
Volumetric  No geometric assumptions
Enhanced Accuracy (Chuang JACC 2000;35:477)
Superior Reproducibility
Changes more reliable for serial evaluation in patients with LVH, valvular disease
Reduces sample size for research studies
High temporal (30ms) and spatial (1.4mm) resolution

61. Volumetric vs. Biplane Methods
Limits of agreement
between volumetric MRI,
biplane MRI, volumetric Echo
and biplane echo
Chuang JACC 2000;35:477

62. Inter and Intraobserver LVEF Reproducibility
Interobserver
Variability (%)
Mean +/- SD (%)
SEE r2
Intraobserver
Volumetric
CMR
3.6
1.6
0.99
5.1
2.1
Biplane
CMR
13.4
4.3
0.94
13.0
5.4
0.91
Volumetric/3D
Echo
8.3
3.7
0.96
6.9
3.3
0.97
Biplane
Echo
17.8
9.2
0.82
13.4
6.7
0.90
Chuang JACC 2000;35:477

63. Interstudy SD: 2D Echo vs CMR
Otterstad EurHeartJ 1997;18:507 Bellenger JCMR 2000:2:271

64. Sample Size Calculations: 10% Change*
LV-EDD 2D Echo
LV-EDD CMR
LVM 2D echo (Teicholz)
LVM 2D echo (biplane)
LVM CMR
LVEF 2D echo
LVEF CMR
Sample Size
509
261
2443
898 35
698 91
<0.05
<0.01
<0.001
*Strohm JMRI 2001;13:367; Grothues AJC 2002;90:29

65. Comparative Sample Sizes 2D Echo vs CMR [Power 80%, P<0.05]
Bellenger JCMR 2000:2:271.

66. What is Normal CMR LV Anatomy?
Salton and Yeon AHA 2006
606 adults subjects in FHS Offspring Cohort
all free of clinical CV disease
No history of HTN or antihypertensive meds
No SBP >140mmHg or DBP >90mmHg
SSFP cine MR
30-40ms temporal resolution
contiguous 10mm slices
Short axis stack (Simpson’s Rule)

67. Normal CMR LV Anatomy Variable LV EDV (ml) LV EDV/HT (ml/m)
LV EDVI (ml/m2)
LV ESV (ml)
LV ESVI (ml/m2)
LVM (g)
LVMI (g/m2)
LVEF (%)
Men
Mean + SD
25 + 7
Women
Mean + SD * *
61 + 9*
25 + 7*
20 + 5* *
47 + 7* *
Salton AHA *p<0.001 vs. men

68. Comparison of CMR* vs. LV gram
Variable
LVEDVI (ml/m2)
LVESVI (ml/m2)
LVEF (%)
Men-CMR
Mean (95%)
25 + 7
Women-CMR
Mean (95%)
61 + 9*
20 + 5* *
LV Gram
Range
50-90
15-30
50-80
* Salton AHA 2006

69. Normal Aging - MEN (n=239)*
SBP (mmHg)
DBP (mmHg)
LVEDDI (mm/m2)
LVEDVI (ml/m2)
LVESVI (ml/m2)
LVMI (g/m2)
LVEF (%) Q1
114.5
74.7
26.6
62.1
0.64 Q2
116.4 74
25.8
61.6
0.65 Q3
118.4
74.4
25.8
59.4
0.66 Q4
119.6
70.9
25.5
58.9
0.65
Trend
0.003
0.005
0.049
<0.001
0.002
0.034
0.216
* Yeon AHA 2006

70. Normal Aging - WOMEN (n=367)*
SBP (mmHg)
DBP (mmHg)
LVEDDI (mm/m2)
LVEDVI (ml/m2)
LVESVI (ml/m2)
LVMI (g/m2)
LVEF (%) Q1
109.7
71.4
27.9
47.3
0.66 Q2
114.2
72.2
27.6
46.4
0.67 Q3
114.4
70.4
27.4
45.6
0.67 Q4
117.3
68.1
27.9
46.9
0.69
Trend
<0.001
0.001
0.80
0.51
* Yeon AHA 2006

71. LV Mass/Volume and CHD (MESA) (216 events in 5098 participants)
Unadjusted
Adjusted*
LVM (10%)
LV volume (10%)
LVM/vol (g/ml)
LVM/vol
1st quartile
2nd quartile
3rd quartile
4th quartile
HR(95% CI)
1.1 ( )
0.9 ( )
5.5 ( )
1.0 (ref)
2.0 ( )
2.0 ( )
5.3 ( ) P
0.05
0.002
<0.001
HR (95% CI)
1.0 ( )
0.9 ( )
2.1 ( )
1.0 (ref)
1.5 ( )
1.3 ( )
2.3 ( ) P NS
0.09
0.02
0.01
* Bluemke JACC 2008
*age, sex, race, smoking, lipids, BP, DM

72. Regional Assessment 17 Segment Model of LV (Echo, CMR, Nuclear, Invasive Cardiology)IS S L AL IS AL I
Apex I I IL IL
Base
Mid
Apical

73. RV Anatomy
True RV short axis is not parallel with the short-axis SA of LV
?Define normal population

74. RV End-Diastolic Volume*
Men
(n=340)
Women
(n=512)
P Value
RV EDV (ml)
<0.0001
RV EDV / ht (ml/m)
RV EDV / ht2.7 (ml/m)
RV EDV / BSA (ml/m²)
RV EDV / BMI (ml)
* G Arora AHA 2009

75. RV End Systolic Volume*
Men
(n=340)
Women (n=512)
P Value
RV ESV (ml)
<0.0001
RV ESV / ht (ml/m)
RV ESV / ht2.7 (ml/m)
RV ESV / BSA (ml/m²)
RV ESV / BMI (ml)
* G Arora AHA 2009

76. RV Ejection Fraction* Men (n=340) Women (n=512) P Value RVEF (%)
<0.0001
* G Arora AHA 2009

77. Normal RV Mass* Men (n=340) Women (n=512) P Value RVM (g) 28.3 + 6.3
<0.0001
RVM / ht (g/m)
RVM / ht2.7 (g/m)
0.0027
RVM / BSA (g/m²)
RVM / BMI (g)
* G Arora AHA 2009

78. Next Week: Dr. Thomas Hauser Viability

79. If you want to learn more.....*
Society for Cardiovascular
Magnetic Resonance*
13th Annual Scientific Sessions
January 21-January 24, 2010
Phoenix, AZ

80. Thank you!