Pr. Hubert CochetPr. Hubert CochetUniversity of Bordeaux, FranceUniversity of Bordeaux, France

Email: hubert.cochet@chuEmail: hubert.cochet@chu--bordeaux.frbordeaux.fr

RISQUE RYTHMIQUE ET INSUFFISANCE CARDIAQUE: ROLE DE L’IMAGERIE

RISQUE RYTHMIQUE ET INSUFFISANCE CARDIAQUE: ROLE DE L’IMAGERIE

DISCLOSURES

Shareholder: Co-founder of inHEART

Grant/Research Support: Siemens HealthineersGuerbetMedtronic

Speaker/Consultant fees: Siemens HealthineersBiosense WebsterBoston ScientificAbbottFineheartFarapulse

RATIONAL

Albert CM. Circulation. 1996;93:1170-1176

Etiologies of lethal arrhythmias

RATIONAL

Ursell PC et al. Circ Res. 1985;56:436-51

Wagner A et al. Lancet. 2003;361:374-9

IMAGING & VENTRICULAR ARRHYTHMIAS

• > 4 millions/yr worldwide (1/5 of all deaths…)• 70% due to arrhythmias• 90% of arrhythmias occur on a substrate visible on CMR

CURRENT PREVENTIONICDs in LVEF <35%

Covers only a small minority of SCDs (<10%)

Most implanted pts do not need ICDs (2/3)

CLINICAL ISSUE OF SUDDEN CARDIAC DEATH

PROGNOSTIC ROLE OF LGE CMRIN ISCHEMIC HEART DISEASE

Watanabe, E., et al. Circ. Cardiovasc. Imaging. 2014; 7: 887–894 Signal intensity

n pixels

PROGNOSTIC ROLE OF LGE CMRIN NON-ISCHEMIC DCM

Di Marco A, et al. JACC Heart Fail. 2017 Jan;5(1):28-38.

Meta-analysis 2948 patients LVEF<35% Prospective study 399 patients LVEF>40%

B.P. Halliday,et al.Circulation, 135 (2017), pp. 2106-2115

PROGNOSTIC ROLE OF LGE CMRIN HCM

Prior SCDSpontaneous sustained VTFamily history of SCDUnexplained syncopeNon-sustained VT on HolterAbnormal exercise blood pressureLV thickness 30 mm

Prior SCDSpontaneous sustained VTFamily history of SCDUnexplained syncopeNon-sustained VT on HolterAbnormal exercise blood pressureLV thickness 30 mm

PROGNOSTIC ROLE OF LGE CMRIN HCM

NPV overestim

ated

by retro

spective studies

PPV to lo

w

to justify

costs & complicatio

ns NPV overestim

ated

by retro

spective studies

PPV to lo

w

to justify

costs & complicatio

ns

Prior SCDSpontaneous sustained VTFamily history of SCDUnexplained syncopeNon-sustained VT on HolterAbnormal exercise blood pressureLV thickness >30 mm

PROGNOSTIC ROLE OF LGE CMRIN HCM

Prospective study 1293 patients

Chan RH, et al.Circulation. 2014 Aug 5;130(6):484-95.

PROGNOSTIC ROLE OF LGE CMRONGOING TRIALS

RISK STRATIFICATIONROLE OF T1 MAPPING?

Prospective study 130 ICM&DCM patients, LVEF<35%

Chan RH, et al.Circulation. 2014 Aug 5;130(6):484-95.

IMAGING & VENTRICULAR ARRHYTHMIAS

157 pts with VT or VFCMR alters diagnosis in 38% of pts with no history of SHD

negative echo & angio

Hennig et al. Eur Heart J Cardiovasc Imaging 2017

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

44 yo man with monomorphic sustained VT of RBBB morphology Negative TTE & coronary angiography

ED ES LGE

CARDIAC SARCOID

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

34 yo man with VT of unknown morphologyNegative TTE. Non-specific T wave changes on ECG.

APICAL FORM OF HCM

ED ES LGE

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

58 yo women with sustained VT of RBBB morphologyNegative TTE & coronary angiography

CHURG-STRAUSS VASCULITIS

ED ES LGE

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

35 yo man with frequent PVCs and sustained VT. Negative coronary CTA. TTE: mild dilatation suggesting arrhythmia-induced cardiomyopathy

LAMINOPATHY

ED ES LGE

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

62 yo. Woman with symptomatic PVCs & negative T waves V1-V3

ARVC

IMAGING TO IDENTIFY THE UNDERLYING VT/VF ETIOLOGY

HIGH-RES LGE => better detection of SHD(17% à 38%, P<0.001).

HIGH-RES LGE => better detection of SHD(17% à 38%, P<0.001).

THE SMALLER THE PIXEL THE BETTER

CONVENTIONAL LGE

HIGH-RES. LGEHennig et al. Eur Heart J Cardiovasc Imaging 2017

IMAGING & VENTRICULAR ARRHYTHMIAS

Signal intensity

n pixels

Ursell. Circ Res. 1985

SUBSTRATE MAPPING FROM MRI: LATE GADOLINIUM ENHANCEMENT

FatWall thinning Calcification

AR

TER

IAL

Late iodine enhancement

LAT

E

SUBSTRATE MAPPING FROM CT: MULTI-PARAMETRIC

CT arterial CT late Fusion

Scar CT

MRI

Scar MRI

SUBSTRATE MAPPING FROM CT: POST-INFARCTION

CT-thickness CT-fat CT-late iodine MR-late gadolinium

< 5< 4< 3< 2< 1

mmDense scar

Grey zone

Dense scar

Grey zone

EXAMPLE: POST-MI VT (CT/MRI)

PROCEDURAL INTEGRATION

Improved efficacyShorter proceduresSimpler & more standardized procedures

Hendriks. EP Europace. 2017 Jun;19(3):483.

VT-

FREE

SU

RV

IVA

L

OV

ERA

LL S

UR

VIV

AL

IMPACT ON OUTCOME

IMAGE INTEGRATION STRATEGY

Improved anatomy and substrate definition- Impact on procedure time +- Impact on efficacy +

CURRENT: IMAGING TO GUIDE MAPPING

Dedicate the entire procedure to ablation- Impact on procedure time +++- Impact on efficacy +++- Simplification / standardization of procedures +++

SOON: IMAGING TO DEFINE ABLATION TARGETS

57 yo man with prior infarct in LAD territoryMultiple ICD shocks on monomorphic VT

Nicolas Cedilnik et al. Europace 2018

HD VT map Simulation endo Simulation epi

Thic

knes

s

5mm

0mm

PERSPECTIVEIMAGE-BASED SIMULATION

CONCLUSIONSIMAGING & VENTRICULAR ARRHYTHMIAS

ablation guidance CT/MR for enhanced definition of substrate/anatomy

identifying structures at risk (coronaries, phrenic)direct definition of ablation targets

perspective fully non-invasive cardiac ablation

TAKE HOME MESSAGES

Ventricular arrhythmia without known structural heart disease?

Get an MRI even if echo and angio are negative

Ventricular arrhythmia without known structural heart disease?

Get an MRI even if echo and angio are negative

Patient considered for ICD implantation for primary prevention?

Use MRI to measure LVEF: gold standard + LGE data in case of future shocks

Patient considered for ICD implantation for primary prevention?

Use MRI to measure LVEF: gold standard + LGE data in case of future shocks

Patient referred for VT ablation?

Develop a close collaboration between EP & imaging teams

Seek for image processing solutions to get optimal imaging information in the lab

Patient referred for VT ablation?

Develop a close collaboration between EP & imaging teams

Seek for image processing solutions to get optimal imaging information in the lab