CardiOhio Podcast
CardiOhio Podcast
A Noninvasive Biopsy: Cardiac MRI in Everyday Cardiology Practice
Join our guests, Drs. Matthew Tong and Subha Raman, both imaging specialists in Central Ohio, as we review the current state of cardiovascular MRI imaging- including common indications, patient selection, and specific scenarios such as device patients. They offer tips for the cardiac practiitoner for ordering studies and interpreting the results in clinical context.
For more information, see:
SCMR Registry: https://pubmed.ncbi.nlm.nih.gov/38971501/
30-minute CMR exam: https://pubmed.ncbi.nlm.nih.gov/35232470/
CMR Guideline/Position Statement hub: https://scmr.org/publications/scmr-guidelines-position-statements/
CMR facility and training center hub: https://scmr.org/directory/
Please subscribe to receive updated episodes automatically! Visit https://www.ohioacc.org/cardiohio-podcast/.
“Upbeat Party” by scottholmesmusic.com
So welcome everyone back to the Cardio Ohio podcast. This is K Graywall in Columbus, Ohio. I'm pleased to have a couple of guests today to talk about cardiac MRI and cardiac imaging in general, and they're both specialists here in central Ohio. My first guest is Dr. Matthew Tong. He's a cardiovascular disease specialist and cardiac imaging specialist at Ohio State University. Matt, welcome. Thank you. And we're also happy to have another. Guest here who's very familiar to those of us here in Central Ohio. And that's Dr. Soba Raman. She's also a cardiac imaging specialist. She worked at Ohio State for many years, so she's well known throughout central Ohio. But more recently, she was appointed vice president of heart and vascular services at Ohio Health. Suva welcome as well.
Subha:Thanks, Kenny. Great to be here with you and Matt.
Kanny:Thank you both. So Matt, I just wanted to start with you. You know, we have a lot of trainees and fellows in training who listen to our, our podcast. Can you just kind of very briefly just summarize what the path that led you to the field of cardiac imaging and specifically led you to position at an academic center at Ohio State?
Matt:Absolutely. Thank you Kenny, first. Of course. Thanks for letting us do this podcast today. My. Training pathway was somewhat non-traditional as it relates to the academic component. But yeah, my residency was in Dayton primarily in a community-based hospital, similar with my general cardiology fellowship where I spent some time with you actually Kenny at Ohio Health. And really actually through mentorship from both of you in those components that kinda led me to understand that. You know, imaging is so diverse and really to sort of subspecialize and become a true expert required additional training. And that was where I spent some time over at Allegheny General Hospital in Pittsburgh under the stewardship with Dr. Bob Beaterman. And that really kind of transformed my thought process and just really the what cardiac MRI can provide. And really that was kind of what brought me back to Columbus, Ohio and Ohio State. And that really just continue to spearhead all of the innovations that, that, still continues to this day.
Kanny:Thanks Matt. Suva, you had a very, I think, interesting path to your current position. Of course, many of us, like myself, who've been practicing here in in, in central Ohio for several decades are familiar with all the clinical work as well as the clinical research you've done in cardiac imaging at Ohio State. But then you did take an interesting turn into, becoming a physician, a service line leader. Now you're a leader of a service line of over a hundred, plus clinicians. I, I think our listeners might be curious to hear, what, what led you to your path to eventually becoming, the leader of a very large and productive heart and vascular service line.
Subha:Thanks for that question. Ka, I started out really in cardiology fellowship. I loved all the different disciplines. I had a background in engineering and at the time, cardiac, MRI and, and CT were just nascent. Techniques that we didn't have at Ohio State where I did my training. And so I was very fortunate to be able to build those programs from scratch. I love the appeal of using advanced cardiac imaging to be more proactive with our patients. To get more precise, accurate diagnoses in a more timely fashion to guide effective treatment and improve outcomes. The transition to my current leadership role, honestly, is really one of an opportunity to pay it forward. You know, we, we did so much in our with our imaging team at OSU. How do we make sure that the broader population that we serve has access to those innovations? And so that is really my my hope in this role that as a, a leader of a service line, I can empower our team to get patients that needed access so they get the right diagnosis, treatment, prevent complications.
Kanny:Well, that's wonderful. So yeah, we appreciate, appreciate both of your input there, Sue. But lemme just follow up to kind of set the table for our discussion about the current state of cardiac. Mr. Just like you, I've been an imager for, you know, decades. Seeing, the development of course, echocardiography nuclear imaging even cardiac CT, all come into the mainstream of everyday cardiology. As those modalities have evolved and gotten more complex why do you think Mr is still so relevant and has such a unique role in our kind of toolbox of imaging techniques? And why do you think it's relevant to, you know, general cardiology?
Subha:Yep. It really is standard of care these days. You know, that if we wanna do what's best for our patients with heart and vascular disease, we're actually at a point with the maturation of this field that it's a disservice not to offer cardiac MRI. If, if you think about things like coronary and ischemic heart disease how much. Heart, muscle is at risk versus salvageable. If you're thinking about bread and butter interventions or surgical revascularization. If you think about the significant burden we have of patients with heart failure and arrhythmias, what's going on with heart muscle, that's the substrate for those conditions. There's no need to. To guess anymore, we can get really precise information, and the therapeutics have advanced significantly in parallel. So if you think about you know, conditions like vt where's the VT coming from? Our, our EP colleagues have tremendous ablative procedures that they can use to control those conditions. If you think about our patients with heart failure, you know, it's the difference between saying, well, you know, your EFS reduced. It looks like you're gonna have chronic heart failure to looking at heart muscle and being able to say, wow, there's a treatable specific diagnosis here that may direct them towards. Targeted molecular therapy for amyloidosis or appropriate therapy for hypertrophic cardiomyopathy. So it's really as I would say standard of care and should be incorporated across the spectrum of, of heart and vascular patients.
Kanny:So, Matt at your in your position, you know, at a, a large academic center if you look at, at the utilization of CVMR at your center. Since we don't have time to talk about every, you know, indication what would you say are kind of the broad categories where you're seeing at least in, in day-to-day clinical practice, CVRR being used currently?
Matt:Yeah, great question. The. The important aspect of cardiac M-R-I-M-R-I is really that as Suva really highlighted, was the added value that it can improve in cardiovascular care. And really I would say perhaps. Both, all three of us may be just slightly biased, but cardiovascular imaging in general really has become the door to entry across all cardiovascular practices nowadays. And, Suba kind of mentioned a few of those already, really that the most common indication for cardiac MRI is, evaluation of cardiomyopathy, whether it be related to a non-ischemic infiltrative arithmetic related cardiomyopathies and some form of ischemic, whether it's viability in these these features and the fact that it's non-radiating and through the use of gadolinium contrast that we're able to perform a, sort of a non-invasive biopsy and able to provide that that pro those prognostic features and guide those treatments.
Subha:If I could add Kenny Matt, it's, it's impressive how far CMR has come in practice guidelines you might comment on that.
Matt:Absolutely. So the, some of the data that we've reviewed previously is fairly old back in 23, suggests that at least 40 class one indications nowadays for cardiac mr. And obviously there's more societal based guidelines which both of us, all of us have participated in some fashion as continue to increase the the indications of that's. Just standard of care as you've said.
Subha:And I'd just add a, a note that this is a prominence in guidelines outside of imaging, right? So Heart Rhythm Society Guidelines, a CC, European Society of Cardiology Guidelines. So this really is something that we need to make a commitment to, to, to provide access to guideline based care for our patients.
Matt:Absolutely. It's that multi society kind of village mentality to really sort of come together. That where imaging has really, especially cardiac, MR has demonstrated that additional utility,
Kanny:obviously, you know, with CVMR still being a fairly expensive and sometimes, and I know we're gonna talk more about excess issues, but you know, obviously it's not accessible to every corner of. Cardiac care, even here in Ohio. But you mentioned cardiomyopathy. So Matt would, is it fair to say that in a patient with new onset heart failure, who's found to have a cardiomyopathy, that CVMR in almost every instance will probably provide some additive value and should generally be considered part of the basic workup? Or do you still think it's a, you know, case by case kind of a decision?
Matt:Yeah, that is about as classic for a class one indication in the evaluation of cardiomyopathy. So I would say that is about as standard of care as it comes. And yeah, we'll, we'll discuss some of the access concerns that I think we can hopefully improve, to make the scans a little more efficient and things like that kind of help improve that access.
Kanny:Suva. I think as general cardiologists, many of us are familiar with some of the, classic indications for CMR. you mentioned EP indications. Could you just highlight that, or maybe one or two others that you think are kind of emerging areas where MR has a role that weren't, weren't so obvious to clinicians in the past?
Subha:Happy to do so. This is now very much part of evaluation and management of patients with a, a broad range of cardiac arrhythmias. I think the, the difference now, if, and if you ask our EP colleagues, they'll probably be the first to tell you this is instead of looking solely at an electrical signal and trying to go after it, for instance, in the EP lab. What's the substrate for arrhythmia? You know, there's there's a lot of things that can lead to things like atrial fibrillation, ventricular tachycardia, even somebody who has a heavy burden of premature ventricular complexes. I think Matt and I have probably seen too often the patient gets a rhythm treatment without a root cause diagnosis, and by the time they get to the cardiac MR Lab, you say, gosh. If we could have dialed the clock back, you know, earlier we could have given the, the EP team that substrate information. Now, as I mentioned, heart Rhythm Society says, let's get that information on why the patient has a certain arrhythmia. Certainly if you think about PVCs, vt, there's no question that those things come from ventricular myocardium. You need to know what the disease is there that's leading to the arrhythmia. Of course there are channel pathy, channelopathies and such that, that may have structurally normal hearts but even with a normal ejection fraction, you know, I don't think we should be reassured by patients whose echo comes back looking pretty good. When somebody has a, a potentially life-threatening arrhythmia, atrial fibrillation has also advanced quite a bit. You know, I'm, I'm sure Matt has also seen, I've seen patients who AFib is just the, kind of the presenting symptom almost, right? That they've got AFib due to an undiagnosed cardiomyopathy. They've got AFib in the setting of maybe valvular disease that was more severe than estimated by surface echo. Matt, I'd be interested in your thoughts on this.
Matt:Yeah, absolutely. Perhaps even just to kind of piggyback of some of the things that you discussed, really from a myocardial diagnosis standpoint from just starting with electrophysiology stand aspects LVH, right? Do we think it could be a hypertrophic cardiomyopathy or maybe it's not and it's a, a Fabry disease. Could it be amyloid disease? That, and those are the things that can be. Reasonably easily differentiated by cardiac mr. And just really being able to tease, like you said, that root cause diagnosis will really kind of help guide the appropriate treatment for those patients. And then, transitioning further to just what, what you suggested, the valvular heart disease, right, that is quite another common adult diagnosis and certainly. The imaging modalities, particularly echocardiography, really represents the sort of the the mainstay of the evaluation. But where cardiac Mr really adds to that is that that accurate quantification of regards to 10 volume and fraction. And there's been numerous studies now that really has helped to guide whether these patients should be going towards some surgical intervention. It's been great to, to see the field growing in that side because of obviously it's a, a large, population with that pathology. And it can not only, of course make that determination whether they should go to some form of an intervention, but now it's improved to the point where we potentially could help guide some of these interventions as well. To the point similar to. TAVR based procedures and those, those type of interventions. So yeah, it's, it's there's a lot of opportunity to, to of growth where cardiac Mr. Can really add that value.
Subha:Yeah, I think of the questions that are structural heart interventionalists have, you know, particularly in patients with, emergence of transcatheter treatments for mitral valve disease that's something you really wanna get right. In terms of severity of things like mitral regurgitation to guide what can be really life-changing interventions.
Kanny:One other area, Matt, I wanted to ask about before we move on to talking about some specific you know, situations is stress, Mr. You know, as an alternative to other types of stress imaging. I know this has emerged in recent years. I'm just curious how you at Ohio State you are incorporating, any stress protocols as an alternative to some of the other imaging like PET and CCTA.
Matt:Yeah, great question. So definitely. We had Ohio State and certainly Suva has very much contributed to this field as well. That kind of really set the stage for stress cardiac Mr. Effectively becoming essentially in the same playing field as the other imaging modalities. Level one excuse class one indication for the evaluation of ischemia. We pre predominantly perform, adenosine stress. We've adapted a few techniques now to do quantitative perfusion. So now you can actually provide a number to the evaluation similar to Stress Pet, to add that evaluation of microvascular disease to, to determine that versus potential multi-vessel disease. Those that has been. It, it continues to evolve and really a lot of innovative techniques that have happened. But the important part really to highlight about stress cardiac MR is really that the reduction of downstream testing and the cost savings that that happen that have been well demonstrated throughout multiple studies now through that technique.
Kanny:Great. I guess, whenever we do talk about advanced imaging is particularly CVMR, at least I notice, the, there's always the discussion comes around to concerns about certain patient populations. For example, you know, renal disease or patients with devices. So Suva, I was wondering if you could just briefly summarize the current state of, using CVMR in patients with impaired renal function first and then maybe Matt can talk about use with devices.
Subha:Yes, thank you. There is no reason that a patient with with chronic kidney disease. Shouldn't be referred for cardiac Mr. It's come a long way. You know that really over a decade ago there was a recognition that the older contrast agents that we used for cardiac MR could lead to a serious skin and systemic condition for patients with CKD, that worldwide recognition. Led to a practice change in a, in a remarkably short amount of time, all CMR labs around the world have shifted to what are called macrocyclic, gadolinium based contrast agents that are proven to be safe regardless of an patient's renal function, to the point that the American College of Radiology, in fact. Has done away with its recommendation to check creatinine before cardiac and other galin based exams.
Matt:Maybe something to add to that actually that is a, a commonly confused is the use of gadolinium compared to something like ct and other, and the contrast that we use in MRI, that it is not the, I donated contrast this, this gadolinium based contrast that UBA had discussed. Really that the safety profile in general of gadolinium based contrast agents are actually more safe than the iodinated contrast. And so the common questions that I've received in the past, I'm sure you has, has as well, has been related to do, do these patients need contrast with their cardiac mr. And the general answer is yes. Primarily for one, the, the safe, the well demonstrated safety profile that we've discussed. And also it is essentially the, the primary use to, for the tissue characterization components and really knowing the fact that it's safe as mentioned, and the fact that actually cardiac Mr. When they go into the tunnel to be evaluated about, there's been numerous studies now about 25 to 27% of cases really are new diagnosis that day that. They didn't realize until they went to cardiac mr. So that, again, adding that value demonstrating the safety profile, we're using gadolinium contrast based agents, not the I donated aspect. So really doing a contrasted cardiac Mr. Is generally very safe.
Kanny:Well, that's reassuring Matt. And then what's your current for with devices as well?
Matt:Yeah. Thank you. All devices. So we'll just start with non intracardiac devices. Orthopedic implants. I think it's a, a common question mark or those, those items and essentially those passive based devices essentially are very safe. Those there's no reason to be concerned whatsoever to perform a cardiac Mr from a safety profile in that aspect. Some of the questions then really come into are the intracardiac devices, so pacemakers, defibrillators loop recorders, definitely. The loop recorders from a safety perspective has been well demonstrated that that's that's okay. And essentially. Beyond what the, what's defined as the MR. Conditional devices, it's been also well demonstrated with. Pretty much numerous studies now they, they're defined as legacy devices that effectively have been very safe and no major concerns for the patient. Primarily the main question mark for the. Reading a cardiologist really has more more to do with the device artifact. And from that perspective, really again, evaluation of late gadolinium enhancement or the evaluation of scar fibrosis. A lot of the product sequences are available now to help reduce that artifact. That's known as wideband, LGE, which is pretty standard now in most most commercial scanners. Yeah,
Subha:I, I would add candy that because there's such widespread recognition of the value of a timely cardiac MR exam for so many patients, device manufacturers are very committed to designing things in a way that a patient can undergo a cardiac Mr. Safely. It starts with you know, working with your technologist if you're not sure really the best point of contact. They're gonna do very careful screening and set up an approach that's really focused on maximum safety for the patient.
Kanny:Well that's good to know. Another question, Suba, and I'm sure you get this question when cases are referred, is, you know, the patient with either history of claustrophobia or concerns about becoming claustrophobic. Is there any advice we can give the ordering physician there to clarify who is or is not a candidate?
Subha:It's really a, an opportunity to, again, entrust your cardiac MRI team. We have amazing technologists that all, all the centers that are dedicated to this type of service, that work with the patient. The diameter of the scanner has increased over time. So we think about what are called large bore scanners that are now essentially the standard MRI scanner in terms of diameter, not too far off from a, a CT scanner's diameter. And we can give patients music to listen to. We can put a, a washcloth over their eyes. And the other nice thing about a cardiac Mr exam versus let's say a brain scan is. There's a lot of interaction with the patient throughout the scan so they can really move things along and put the patient at ease. Even if they've got some degree of claustrophobia, there are some folks that need some anxiolytic medication in advance and that helps take the edge off the procedure.
Kanny:Good to know. So Matt just talking a little more about. Kind of barriers to access, obviously, we all work in large healthcare systems where we have access to advanced imaging pretty readily. With CVMR, of course, it's, it's always been a relatively expensive modality. And of course, based on the requirements to perform the testing, it's not easily. Translates to smaller clinical settings or more remote settings and not to mention issues with pre-authorization like we get with all advanced imaging. So I'm, I'm just curious like what the CVMR community you think is doing to try to get access to advanced imaging out to some of our more, remote areas of Ohio
Matt:Yeah, this is a, a, a very great and important question to be asked. And really we have. The, our society, the society for CMR and advocates like the three of us to really demonstrate that the, the needle has moved in impressively in that aspect. And so let's touch briefly about you mentioned prior authorizations and obviously all of us have practiced to some degree and having to have to make those phone calls and really. A number of these Class one and Class two indication increases over time have really permeated into those the insurers practice guidelines. And that really has already improved a bit from the. How do I say barriers to entry to be concerned that, hey you know, I, I won't get denied or something like that. From an insurance standpoint the, the pure blunt cost of a cardiac MMRI versus other modalities is a very complex aspect discussion that I don't want to get too much into, but really the more important aspect are. Discussions around what, what does it add as it compares to what does it save, and a common ev Multiple studies have demonstrated that the cost savings for cardiac MR as it relates to primarily the reduction of downstream testing. So the most common one that we've referenced in the past really has to do with the the SPINS trial, which was related to stress, cardiac mr. And really demonstrated compared to some of the other modalities that it, it actually is quite effective, particularly compared to the increased amount of catheterizations based on other modalities from that perspective.
Kanny:Great. Just in the last five minutes or so that we have left it'd be kind of nice to talk about maybe some future directions, you know, that you see CVMR going. What do you think are some of the innovations right now that you see Suva and CVMR that are gonna translate into, kind of the everyday practice? I know in other types of modalities like Echo, there's a, a move to use artificial intelligence to maybe simplify like the interpretation or augment interpretation. Do you see similar things occurring in Mr. Imaging?
Subha:Absolutely. And a lot of that is already in place. I, I would like to start with taking a a page from our colleagues elsewhere around the world, even what we would consider developing countries who really have made access a priority for their communities. There's a, a wonderful multinational study that involves places like Brazil Peru. India where they shortened the protocol, really focusing on what's the clinical question that we need to answer sometimes as short as 15 minutes. I've put out a paper in conjunction with the Society for Cardiovascular Magnetic Resonance on a a 30 minute Cardiac MR exam. You know, these are all things that are within reach. Innovation isn't always, you know, tech, it's taking. Things like c imaging gadolinium enhancement imaging, which again, is a workhorse that really no other mod modality can provide. And doing that in less than half an hour. Ought to make cardiac Mr. More accessible. And I, I think just about our own health system, we've got great CMR clinicians doing this in places like Mansfield, Ohio, Pickerington, and smaller communities. Think about the access close to home and how that really gets you the care that. Is within reach and not requiring you to go to, you know, a larger center. There certainly is a lot going on with ai. I would say probably most labs, if they realize it or not whatever reporting system they're using today to analyze studies is leveraging the tremendous advances that have occurred with AI to shorten the time that it takes to read and analyze and report a study.
Kanny:Are you doing some work in that regard as well, Matt? In terms of using, you know, advanced technology either to shorten protocols or to guide interpretation.
Matt:Yeah, absolutely. Artificial intelligence, intelligence is kind of permeated across all aspects as it relates to the post-processing, as Sue was kind of mentioned, and really the even the image acquisition components. So it's really kind of partnering across the board here you know, this kind of village mentality of getting industry and hospital systems together to kind of really improve this throughput. Just Sue's point about this 30 minute exam, it really kind of highlights the utility of just 30 minutes really can effectively answer over 90% of the indications that have been well documented based on. The registry data that we've previously published. So I think that is really just helping to improve that access on top of, of the other innovative techniques that are coming, coming that's already here. Frankly.
Kanny:Well, that's wonderful. I think we're kind of up against our time, but I, I think we had a pretty nice discussion, not just of updated clinical indications and some new indications as well, but we talked a little bit about, the barriers to access and how we're working on that. And we talked about. Specific clinical scenarios as well. So I think I think our listeners have have plenty to take away. I guess I wanna thank you both. You know, I've been an imager myself for three decades, and so I'm o obviously find this very fascinating. But I think it's great that. In the time I've been in practice, we've seen something that went from, kind of an quote, experimental technology to something that we all use every day. And and we're very grateful to have here in Ohio, physician researchers, like both of you helping move that forward. So thanks again, both for your time.
Matt:Thank you, Kenny. Thank you Kenny.
Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,
