164 value added cardiothoracic mri in the icu patient · value of non-cmri imaging in icu patients:...
TRANSCRIPT
Science at the heart of medicine
Value Added? Cardiothoracic MRI in the ICU Patient
Narmadan A Kumarasamy, Nima Tishbi, Shey MukundanJeffrey M Levsky, Linda B Haramati
STR Annual MeetingMarch 2016
Relevant Financial Disclosures
• None
| 1Science at the heart of medicine
The Issue
• Anecdotally, we have noticed an increasing number of requests for cardiothoracic MRI (cardiac MRI) in ICU patients
• However, this presents multiple problems:> Inherent risk to an unstable patient when leaving the ICU> Renal impairment precluding IV contrast> Lengthy exam time> Strain on departmental resources> Inability to tolerate a diagnostic exam> Unclear clinical benefit
• We sought to clarify if these MRIs added value to patient care
| 2Science at the heart of medicine
ACCF/AHA latest recommendations on clinical indications for cardiac MRI
| 3Science at the heart of medicine
2005 ACCF/AHA clinical indications for cardiac MRI
• Ischemic heart disease: regional and global function, perfusion, viability, and coronary angiography
• Non-ischemic cardiomyopathies> Hypertrophic, Iron Deposition, ARVD, Myocarditis
• Pericardial disease• Valvular disease• Congenital heart disease• Acquired vascular disease
| 4Science at the heart of medicine
Literature Review
| 5Science at the heart of medicine
• Number of studies evaluating the added value of cardiac MRI in the ICU patient: Zero
• Limited literature is not directly relevant (see references):> Studies looking at non-ICU patients and value from
cardiac MRI: Several> Studies looking at ICU patients and value from non-
cardiac MRI imaging (e.g. chest x-rays, chest sonography, echo, PET-CT, brain CT, brain MRI, HIDA, V/Q): Innumerable
Project Design
• Retrospective IRB approved study• Study Population: Adult ICU patients scheduled for cardiothoracic MRI 2005-2014
> Exclusion criteria: MRI was performed for research, clinical information missing• Data Collection: RIS Query
> Chart Review• Clinical indications
– Aorta– Myocardial Disease
» Cardiomyopathy/Heart Failure» Arrhythmia/ARVD» Myocarditis» Sarcoid» Pericardial
– Viability
| 6Science at the heart of medicine
Project Design: Did cardiac MRI ultimately help patient care?
| 7Science at the heart of medicine
• Chart Review: Pre-specific clinical utility categories:> 1) Useful – Led to Surgical or Invasive Intervention> 2) Useful – Led to Medical Therapy> 3) Not Useful – Did Not Guide Therapy
Results – 62 cardiac MRI cases formed the study population
| 8Science at the heart of medicine
• 143 cardiothoracic MRIs were requested for ICU patients 2005-2014> 74 cases completed (52%)> 69 cases cancelled (48%)
• Among the 74 completed cases, 12 excluded (16%)> 7 - research > 5 - missing clinical information
Results – Myocardial Disease was the most common clinical indication, followed closely by Aorta
| 9Science at the heart of medicine
* Other indication was a 21 year old woman with anti-NMDA encephalitis evaluating for malignancy/paraneoplastic syndrome
Clinical Indication Cases %Aorta 24 39%Myocardial Disease 25 40%
Arrhythmia/ARVD 9Cardiomyopathy/Heart Failure 6
Myocarditis 6Sarcoid 3
Pericardial 1Other* 1 2%Viability 12 19%Total 62
Results – Cardiac MRIs were useful in a majority of cases (55%)
| 10Science at the heart of medicine
# %Useful: led to surgical/invasive intervention 5 8%
Aorta 2 40%Myocardial Disease 3 60%
Useful: led to medical therapy 29 47%Aorta 12 41%
Myocardial Disease 14 48%Other 1 3%
Viability 2 7%Not Useful: did not seem to guide therapy 28 45%
Aorta 10 36%Myocardial Disease 8 29%
Viability 10 36%
• Clinical Utility
Results – Cardiac MRIs were useful for majority of the Myocardial Disease and Aorta cases
| 11Science at the heart of medicine
• Myocardial Disease and Aorta comprise majority of useful cases (91%)
• Not useful cases are relatively evenly split amongst the three major clinical indications,
suggestive of variability
Clinical Indication Useful %
NotUseful %
Aorta 14 41% 10 36%Myocardial 17 50% 8 29%Viability 2 6% 10 36%Other 1 3% 0 0%Total 34 28 14
17
2
1
10
8
10
0
0% 20% 40% 60% 80% 100%
Aorta
Myocardial Disease
Viability
Other
Useful Not Useful
Clinical Utility by Indication
• Among clinical indications, a majority of the myocardial disease (17/25, 68%) and aorta
(14/24, 58%) cases were useful• A minority of the viability cases were useful
(2/12, 17%)
Results – Arrhythmia/ARVD, Myocarditis clinical indications tended to be useful in Myocardial group
| 12Science at the heart of medicine
Myocardial DiseaseSubcategories Useful %
NotUseful %
Arrhythmia/ARVD 7 41% 2 25%Cardiomyopathy/Heart Failure 3 18% 3 38%Myocarditis 5 29% 1 13%Pericardial 1 6% 0 0%Sarcoid 1 6% 2 25%Total 17 8
• Useful vs not useful for Myocardial subcategories
Results – Value Added: Types of surgical/invasive procedures among the useful cases
| 13Science at the heart of medicine
Type of Procedure Cases %Aortic Aneurysm/Dissection Repair 2 40%ICD Implantation 2 40%Pericardectomy 1 20%Total 5
Results – Value Added: Clinical indications for medically useful cases
| 14Science at the heart of medicine
Cases %Non Surgical Aorta* 13 45%Other** 6 21%ARVD (confirmed) 1 3%ARVD (ruled out) 4 14%Myocarditis (ruled out) 2 7%Myocarditis (confirmed) 3 10%Total 29
* Non Surgical Aorta cases include: ruled out aortic dissection, diagnosed type B aortic dissection, non-surgical aortic aneurysm
** Examples of Other cases: confirmed viability, ruled out cardiac sarcoid, ruled out/diagnosed infiltrative cardiomyopathy
58-year-old man presented with back pain
| 15Science at the heart of medicine
Axial Pre- (left) and Post-contrast (right) MRI demonstrate a complex type A aortic dissection with arch involvement and peripheral thrombus. There is a moderate left pleural effusion.
Outcome: Operative repair of Type A Dissection
Case Example: Led to surgical intervention
39-year-old man with chronic eosinophilic pneumonia presented with chest pain and fevers Other Studies: Echo - diffuse LV hypokinesis with LVEF< 30%
Cath - clean coronaries; Endocardial biopsy - negative
| 16Science at the heart of medicine
Late gadolinium enhanced long (left) and short (right) axis images show multifocal left ventricular delayed enhancement in a non-vascular distribution
Outcome: Medical therapy (steroids) for eosinophilic myocarditis
Case Example: Led to medical therapy
54-year-old woman with ventricular tachycardia. Endocardial biopsy - giant cell myocarditis. MRI revealed extensive disease.
| 17Science at the heart of medicine
A: Axial postcontrast MR shows marked thinning of the intraventricular septum and bilateral pleural effusions B: Late gadolinium enhanced short axis image shows marked predominantly transmural delayed enhancement involving the septum and multiple myocardial segments Outcome: Medical therapy (steroids), listed for cardiac transplant.
A B
Case Example: Led to medical therapy
82-year-old man with known thoracic aortic aneurysm presented with back pain. Initial noncontrast chest CT performed.
| 18Science at the heart of medicine
Axial noncontrast CT shows an intimal flap in an aneurysmal ascending aorta consistent with Type A dissection
Axial pre- axial and coronal post-contrast MRI better delineates the ascending aorta aneurysm with Type A dissection and a partially thrombosed false lumen.
Deemed a poor operative candidate and expired
Case Example: Did not guide therapy
Discussion
• 52% of cardiac MRI cases from the ICU were completed, 48% were cancelled
• Myocardial disease was the most common clinical indication (40%), followed by Aorta (39%) and Viability (19%)
| 19Science at the heart of medicine
Discussion
• Cardiac MRI was useful in a majority of cases (55%)> 8% Led to surgical/invasive intervention> 47% Led to medical therapy
• When broken down among clinical indications:> Cardiac MRI was useful in a majority of Myocardial Disease
(68%) and Aorta cases (58%)• Among the Myocardial Disease cases, cardiac MRI was
more useful in the Arrhythmia/ARVD, Pericardial and Myocarditis sub-categories
> Cardiac MRI was useful in a minority of Viability cases (17%)
| 20Science at the heart of medicine
Discussion
• Examples of value added:> Led to a surgical/interventional procedure:
• OR for Aortic Aneurysm/Dissection Repair• ICD Implantation• Pericardectomy
> Led to medical therapy:• Type B Aortic Dissection• Medical Management of Aortic Aneurysm• Confirming or Ruling Out:
– ARVD– Myocarditis
| 21Science at the heart of medicine
Conclusion
• Over half of requested cardiothoracic MRIs in an ICU population were successfully completed
• Cardiothoracic MRI added value most often for Myocardial Disease and Aorta clinical indications
• Feasibility and potential clinical value should be assessed on a case-by-case basis
| 22Science at the heart of medicine
Thanks
• Ariel Shiloh, MD• Daniel Spevack, MD• Disraeli De Costa• Anna Santelia
| 23Science at the heart of medicine
References• Budoff MJ, Cohen MC, Garcia MJ, et al: ACCF/AHA clinical competence statement on cardiac imaging with computed tomography and magnetic resonance: A report of the american
college of cardiology Foundation/American heart Association/American college of physicians task force on clinical competence and training. J Am Coll Cardiol 46:383-402, 2005 • Kramer CM, Budoff MJ, Fayad ZA, et al: ACCF/AHA 2007 clinical competence statement on vascular imaging with computed tomography and magnetic resonance. A report of the
american college of cardiology Foundation/American heart Association/American college of physicians task force on clinical competence and training. J Am Coll Cardiol 50:1097-1114, 2007
Value of CMRI in non-ICU patients:• Abbasi SA, Ertel A, Shah RV, et al: Impact of cardiovascular magnetic resonance on management and clinical decision-making in heart failure patients. J Cardiovasc Magn Reson 15:89-
429X-15-89, 2013 • Arai AE: New insights from major prospective cohort studies with cardiovascular magnetic resonance (CMR). Curr Cardiol Rep 17:46-015-0599-3, 2015 • Bruder O, Wagner A, Lombardi M, et al: European cardiovascular magnetic resonance (EuroCMR) registry--multi national results from 57 centers in 15 countries. J Cardiovasc Magn
Reson 15:9-429X-15-9, 2013 • Campbell F, Thokala P, Uttley LC, et al: Systematic review and modelling of the cost-effectiveness of cardiac magnetic resonance imaging compared with current existing testing pathways
in ischaemic cardiomyopathy. Health Technol Assess 18:1-120, 2014 • Chellamuthu S, Smith AM, Thomas SM, et al: Is cardiac MRI an effective test for arrhythmogenic right ventricular cardiomyopathy diagnosis? World J Cardiol 6:675-681, 2014 • Hatabu H, Stock KW, Sher S, et al: Magnetic resonance imaging of the thorax. past, present, and future. Radiol Clin North Am 38:593-620, x, 2000• Rajwani A, Stewart MJ, Richardson JD, et al: The incremental impact of cardiac MRI on clinical decision-making. Br J Radiol 89:20150662, 2016 • Yilmaz A, Ferreira V, Klingel K, et al: Role of cardiovascular magnetic resonance imaging (CMR) in the diagnosis of acute and chronic myocarditis. Heart Fail Rev 18:747-760, 2013
Value of non-CMRI imaging in ICU patients:• Algethamy HM, Alzawahmah M, Young GB, et al: Added value of MRI over CT of the brain in intensive care unit patients. Can J Neurol Sci 42:324-332, 2015 • Alherbish A, Priestap F,Arntfield R: The introduction of basic critical care echocardiography reduces the use of diagnostic echocardiography in the intensive care unit. J Crit Care
30:1419.e7-1419.e11, 2015 • Beaulieu Y: Bedside echocardiography in the assessment of the critically ill. Crit Care Med 35:S235-49, 2007 • Bisdas S, Therapidis P, Kerl JM, et al: Value of cerebral perfusion computed tomography in the management of intensive care unit patients with suspected ischaemic cerebral pathology
after cardiac surgery. Eur J Cardiothorac Surg 32:521-526, 2007 • Calabrese E, Catalano O, Nunziata A, et al: Bedside contrast-enhanced sonography of critically ill patients. J Ultrasound Med 33:1685-1693, 2014 • Chelly J, Mongardon N, Dumas F, et al: Benefit of an early and systematic imaging procedure after cardiac arrest: Insights from the PROCAT (parisian region out of hospital cardiac arrest)
registry. Resuscitation 83:1444-1450, 2012 • Dover M, Tawfick W, Hynes N, et al: Cardiac risk assessment, morbidity prediction, and outcome in the vascular intensive care unit. Vasc Endovascular Surg 47:585-594, 2013 • Flancbaum L,Choban PS: Use of morphine cholescintigraphy in the diagnosis of acute cholecystitis in critically ill patients. Intensive Care Med 21:120-124, 1995 • Ganapathy A, Adhikari NK, Spiegelman J, et al: Routine chest x-rays in intensive care units: A systematic review and meta-analysis. Crit Care 16:R68, 2012 • Graat ME, Stoker J, Vroom MB, et al: Can we abandon daily routine chest radiography in intensive care patients? J Intensive Care Med 20:238-246, 2005 • Heffner JE,Klein J: Chest imaging in critically ill patients: Analysis of clinical value. Respir Care 39:51-62, 1994 • Henry JW, Stein PD, Gottschalk A, et al: Scintigraphic lung scans and clinical assessment in critically ill patients with suspected acute pulmonary embolism. Chest 109:462-466, 1996 • Kluge S, Braune S, Nierhaus A, et al: Diagnostic value of positron emission tomography combined with computed tomography for evaluating patients with septic shock of unknown origin. J
Crit Care 27:316.e1-316.e7, 2012 • Rubinowitz AN, Siegel MD,Tocino I: Thoracic imaging in the ICU. Crit Care Clin 23:539-573, 2007 • Yu CJ, Yang PC, Chang DB, et al: Diagnostic and therapeutic use of chest sonography: Value in critically ill patients. AJR Am J Roentgenol 159:695-701, 1992
| 24Science at the heart of medicine
Author Contact Information
• Narmadan Kumarasamy• [email protected]
| 25Science at the heart of medicine