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Cardiac Stress MRI

Cardiac Stress MRI. Arlene De La Cruz, BSN, RN, CCRN Laura Backus, BSN, RN The Edward B. Singleton Department of Radiology Texas Children’s Hospital. Disclosures:. None. Objectives:. After completing this course, the learners should be able to: Describe Cardiac Stress Test

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Cardiac Stress MRI

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  1. Cardiac Stress MRI Arlene De La Cruz, BSN, RN, CCRNLaura Backus, BSN, RNThe Edward B. SingletonDepartment of RadiologyTexas Children’s Hospital

  2. Disclosures: • None

  3. Objectives: • After completing this course, the learners should be able to: • Describe Cardiac Stress Test • Identify Cardiac Exercise Stressors and Pharmacological Stressors • Describe the advantages of MRI Cardiac Stress Test versus Nuclear Medicine Stress Test   • Describe patient care for patient undergoing Cardiac Stress MRI • Differentiate MRI images with normal cardiac perfusion versus impaired myocardial perfusion and review other images

  4. Cardiac Stress Test: • Cardiac diagnostic test, cardiopulmonary exercise test • Measures the heart’s response to stress • Use to diagnose coronary artery disease • Detects changes in heart rhythm • Measures a person’s general physical fitness • Result determines the need for further diagnostic studies or therapeutic procedures • Induced by • Exercise • Pharmacological agents

  5. Exercise Induced Stressors • Robert Arthur Bruce, MD • American cardiologist • “Father of exercise cardiology” • Recognized that exercise stress testing can be a tool in the evaluation of cardiac patients • Paul Yu, MD • Collaborated with Dr. Bruce to develop a treadmill exercise test (Circulation. 2005;111:2410-2411.)

  6. Bruce Protocol • For treadmill stress test https://www.youtube.com/watch?v=VJyRGOP3Gyk

  7. Historical background: Treadmill • 1st Century AD – Rome - treadwheel – move heavy objects • Use human power to do work https://en.wikipedia.org/wiki/Treadwheel_crane

  8. Facts: Treadmill • 1818 - Sir William Cubitt • English Civil Engineer • Prison treadwheel • Pump water, grinding corn or power to mills (treadmill) • Animal Treadmills • Power butter churns • Power Small farm machineries https://www.rachellaudan.com/2012/12/the-dog-the-cooks-little-helper.html

  9. Facts: Treadmill • 1949 - Robert Arthur Bruce, MD • Published treadmill exercise test • 1952 - Wayne Quinton • Medical Treadmill • 1968 - Kenneth Cooper, MD • Father of Aerobics • Book “Aerobics” • William Staub • Pace Master 600 • Home use treadmill https://www.engr.washington.edu/alumni/profiles/Quinton http://upandhumming.com/tag/vintage-treadmill/

  10. Exercise Induced stressors: • Treadmill /Bicycle • Painless and safe methods to measure how the body responds to increased oxygen demand https://www.svhhearthealth.com.au/procedures/tests/exercise-stress-test

  11. Exercise Induced stressors: • Measure: • Duration • Chest pain • Limiting Symptoms (fatigue, dyspnea) • Blood pressure • Decrease) • Sign severe coronary artery disease • LV systolic dysfunction • Cardiomyopathy • Heart rate • Failure to increase or recover rapidly • Indicator for ischemia • Electrical system issue • ST segment depression • MI

  12. Texas Children’s Cardiac Stress Lab • Treadmill or Bicycle

  13. Pharmacological Stressors: • Used in lieu of physical exercise • Used when treadmill is contraindicated • Pediatrics

  14. Pharmacological Stressors: • Coronary Vasodilator - increase coronary blood flow • Adenosine • Diphyridamole(Persantine) • Regadenoson • Catecholamine – stimulating b receptor increase HR, BP and myocardial contractility • Dobutamine

  15. Nuclear Medicine Stress Test: • Nuclear Stress Test • Use of radioactive tracer • Gamma camera • Records blood flow through the heart • Process • Inject a radioactive tracer • Resting – laying flat on gamma camera and record blood flow • Stress - Treadmill • Second dose of radioactive tracer • Second scan done • Images from resting and stress scans are compared • Pharmacological stressor

  16. Nuclear Medicine Scan: • Blood flow • Insufficient Blood flow – artery narrowing https://www.health.harvard.edu/heart-health/imaging-stress-tests-a-clearer-view-of-your-hearts-health

  17. Nuclear medicine: • Disadvantages: • Small defects - lower spatial resolution • Complex anatomy - suboptimal localization of pathology • Artifacts noted related to the body wall and diaphragm • False positive findings – high incidence • Ionizing radiation - Potential harmful effects Noel,C. et.al

  18. MRI Cardiac Stress Test: • Magnetic field and radio waves to generate images of the organs in the body • Non invasive • High quality imaging and resolution • No ionizing radiation

  19. MRI Cardiac Stress Test: • Assess patients with both congenital and acquired pediatric heart disease • View the anatomy and function of the heart • Assess blood flow through the blood vessel • Assess for signs of impaired myocardial perfusion • Images from resting and stress scans are compared

  20. Pharmacological Stressors: • Dobutamine and Atropine • Coronary artery complications –compression from contraction of the heart • Myocardial bridge • Coronary arteries tunnels through the myocardium • Preferred agent for patient with significant reactive airway disease or severe obstructive pulmonary disease • Regadenoson and Aminophylline (Caffeine Citrate) • Coronary artery narrowing https://thoracickey.com/normal-anatomic-variants-and-imaging-artifacts-mimicking-pathology/

  21. Patient Population: • Congenital Heart Disease - present at birth • Anomalous Right Coronary • Anomalous left coronary artery from the pulmonary artery (ALCAPA) candidates for surgery https://www.chop.edu/conditions-diseases/anomalous-left-coronary-artery-pulmonary-artery

  22. Patient Population: • Congenital Heart Disease - present at birth • Transposition of great arteries – status post arterial switch • Patient that had surgery will have a repeat study https://www.chop.edu/conditions-diseases/transposition-great-arteries

  23. Patient Population: • Acquired Pediatric Heart disease • Kawasaki • History of Syncope http://www.chfed.org.uk/how-we-help/information-service/heart-conditions/kawasaki-disease/

  24. Process: • Sedation • Anesthesia team • Non-sedate • Older and can follow instructions

  25. Pre-Call: • Caffeine held 48 hours • Beta Blockers held 24 • NPO 4 hours prior • History and physical • Notify Cardiologist if patient has history of rhythm issues, neurocardiogenic syncope and seizure

  26. Personnel: • RN • Cardiac MR technologist • Cardiologist • Cardiac Anesthesiologist • Cardiac Nurse Practitioner • A Cardiac Radiologist • Child Life

  27. MRI Screening:

  28. Workflow:

  29. Gadolinium Based Contrast: • Brand name: Gadavist (Gadobutrol) • Allows visualization of myocardial regions not receiving adequate blood supply • Uncover a myocardial perfusion deficit cause by a stenosedcoronary artery

  30. FDA Medication Guide: • FDA now requires outpatients receiving gadolinium be provided with a written medication guide from the manufacturer • Discusses the fact that such agents may be deposited in trace amounts in the body even with normal kidney function • At TCH all OUTPATIENTS will receive medication guide in each time they present for a contrasted MRI exam • Any parent/guardian/patient that requests a medication guide must also be given one

  31. Fact Sheet Guide: • Provided by the check in desk with the metal screening sheet

  32. Contrast Checklist:

  33. Test: • Creatinine • Nephrogenic systemic fibrosis (NSF) - fibrosis of the skin and other tissues throughout the body • Urine Pregnancy Test • All postmenarcheal female patients will undergo a UPT • Sedation • Contrast

  34. Procedure: • Obtain Weight and Height • Child Life patient preparation • Patient and parent education by cardiologist • Medication can cause chest pain, flushing, dyspnea, bradycardia, sinus pause

  35. Procedure: • Intra-Procedure • Ensure supplies at bedside • Crash cart • Vitals Baseline • Monitor HR, RR, BP, O2 Sat min q15minutes (more frequent during medication titration and any physiological changes)

  36. Procedure: • Oxygen as needed • PIV needed • 2 PIV Dobutamine • 1 PIV Regadenoson

  37. Dobutamine: • Coronary artery complications –compression from contraction of the heart • Preferred agent for patient with significant reactive airway disease or severe obstructive pulmonary disease • 2 PIV 20 gauge for the contrast • Dobutamine drip

  38. Dobutamine: • Dobutamineinfusion • Titration every 4 minutes (VS) per Cardiologist’s instructions • Start 10 mcg/kg/min IV • Titration at 20 mcg/kg/min IV; • 30 mcg/kg/min IV and • 40 mcg/kg/min IV

  39. Dobutamine: • Document in MAR dual sign off • If desired outcome not achieved, give Atropine 0.01 mg/kg IV • Contrast • Gadavist0.2 mL/kg IV divided in half and given per cardiologist’s instructions • Given 0.1 mL/kg during rest perfusion • Given 0.1 mL/kg at stress perfusion • Discontinue PIV from infusion of Dobutamine prior to going to recovery

  40. Side Effects of Dobutamine: • Palpitations • Chest pain • Headache • Nausea/vomiting • Flushing • Dyspnea • SVT • Hypotension • Shortness of breath • Bronchospasm

  41. Post Procedure Dobutamine: • Vitals every 15 minutes • Notify Cardiologist for any arrhythmias, hypotension, chest pain, wheezing, and vomiting • Discharge in minimum of 30 minutes or when vital signs back to baseline • Discharge instructions given to patient/family

  42. Regadenoson: • Coronary artery narrowing • Lower side effect profile with lower incidence of bronchospasm and bradycardia • Dose: • Regadenoson8 mcg/kg IV given as rapid IV push followed by saline bolus • Reversal • Aminophylline – given after stress imaging was completed to reverse the stress agent • < 40 kg weight give 0.25 mg/kg IV • > 40 kg weight 50 mg IV

  43. Regadenoson: • Contrast • Gadavist0.2 mL/kg IV divided in half and given per cardiologist’s instructions • Give 0.1 mL/kg during stress perfusion • Give 0.1 mL/kg at rest

  44. Side Effects of Regadenoson: • SOB/Dyspnea • Headache/dizziness • Nausea/vomiting • Abdominal discomfort • Flushing • Chest Pain • SVT, VT • Sinus Pause • Heart block • Myocardial infarction • Lower seizure threshold

  45. Supraventricular Tachycardia: • Esmolol 50 mg IV is given for any side effects

  46. Post Procedure Regadenoson: • Aminophylline is given after stress imaging is completed in order to reverse the stress agent • Recovery period usually is not needed

  47. MRI IMAGES: • Stress • Dark area of the myocardium of the left ventricle consistent with a perfusion defect • Rest • Stress

  48. MRI IMAGES: • Phase Sensitive Inversion Recovery Image • Myocardium being completely dark, consistent with NO SCAR formation • Scar - MI • Scar • No Scar

  49. Data: • Total Dobutamine – 192 • 14 patients have not been able to complete examination (nausea/vomiting, discomfort, hypertension) • No incidence of rhythm disturbance • 18 have undergone cardiac catheterization, primarily for diagnostic purposes • 29 have undergone surgery • Total Regadenoson – 168 • 16 complications (mild hypotension, vomiting, warmth, flushing, headache) • No cardiac complications • No cessation of studies, able to complete in all patients • 39 studies have had a catheterization for either diagnostic and/or interventional reasons • 8 undergone surgery

  50. Treadmill: • https://www.youtube.com/watch?v=IWu9o5zrj3g

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