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CMR to plan and guide procedures

Lecture Session V

Cardiac magnetic resonance (CMR) plays a key role in decision making of patients who are candidates for cardiac interventions and for planning and guiding invasive therapies. The most recent available evidence on the relevance of CMR  in these fields was summarized in this interesting session opened by Dr. Nijveldt who highlighted the accuracy of CMR in the measurement of left ventricular ejection fraction, key criterion to select heart failure patients for cardiac resynchronization therapy and implantable cardioverter defibrillators. Furthermore, CMR provides information on determinants of response to cardiac resynchronization therapy such as left ventricular dyssynchrony, extent and location of myocardial scar, particularly in the area targeted by the left ventricular pacing lead. The increase use of CMR-compatible biventricular pacemakers will enable the monitoring of the therapy effects with CMR. In addition, 4-dimensional flow CMR may provide further insight into the interaction between left ventricular mechanics and  flow dynamics.

To select patients with atrial fibrillation for catheter ablation procedures, dimensions of the left atrium and extent of atrial scar have been shown to be associated with the procedural success. Dr Rhode indicated the role of CMR to identify the patients with atrial fibrillation who may benefit from this therapy and the predominant role of computed tomography to plan and guide the procedure by fusing computed tomography data with electromechanical mapping.

Guiding interventions for coronary artery disease was excellently discussed by Dr. Gaemperli. In stable coronary artery disease, detection of myocardial ischemia with stress CMR is important to identify the patients who will benefit from coronary revascularization. This was demonstrated by a meta-analysis including 11,636 patients with known or suspected coronary artery disease and mean left ventricular ejection fraction of 61%. The annualized event rate for cardiovascular death and non-fatal myocardial infarction was significantly higher among patients with positive stress CMR. In patients with heart failure, assessment of myocardial viability with CMR is also relevant to predict improvement in symptoms and global and regional left ventricular systolic function after coronary revascularization. Which CMR methodology do we have to use to better identify the patients who will benefit from intervention? Dobutamine stress CMR to assess contractile reserve and late gadolinium contrast enhanced CMR to assess myocardial scar are the preferred methods.

Finally, Dr Gerber provided the state-of-the art lecture on evaluation with CMR of patients with severe aortic stenosis who are candidates for transcatheter aortic and mitral valve replacement. Being a 3-dimensional imaging modality, CMR provides accurate measurements of the aortic annulus and aortic root, height of the coronary ostia relative to the annulus and dimensions and tortuosity of the peripheral arteries. These aspects are important to select the transcatheter aortic prosthesis size and the procedural approach (transfemoral versus non-transfemoral). In transcatheter mitral valve replacement, accurate assessment of the mitral annulus geometry and its relationship with the left ventricular outflow tract is provided by CMR. Although current developments in transcatheter aortic valve prosthesis have reduced the incidence of significant paravalvular regurgitation, CMR seems superior to 2-dimensional echocardiography to accurately quantify the regurgitant volume.

The results of ongoing research in these fields will be discussed in Prague 2017 where we hope to see you all!

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.