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1 Vol.12 No ISSN

3 Copyright 2010 Cardiovascular Update Editorial Board. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise without permission in written form from the copyright holder. This publication is published by MMK Co., Ltd. under continuing medical educational grant from AstraZeneca Ltd. and Novartis Korea. AP-CVUP-10-01

means, electronic, mechanical, photocopying, recording or otherwise without permission in written form from the

4 Continuing Medical Education inquiry@mmkgroup.co.kr

6 TOPIC 1. 8 TOPIC TOPIC 3. TOPIC TOPIC 5. 45

7 SECTION TOPIC 1 8 Cardiovascular Update

8 Cardiovascular Update 9

9 SECTION TOPIC 1 10 Cardiovascular Update

10 Cardiovascular Update 11

11 SECTION TOPIC 1 A Tissue velocity imaging (TVI) C Tissue tracking imaging (TT) Time integration B Spatial derivation D Time integration Strain rate imaging (SRI) Strain imaging 12 Cardiovascular Update

Spatial derivation D Time integration Strain rate

12 SECTION TOPIC 1 A B C D Cardiovascular Update 13

13 SECTION TOPIC 1 Doppler Strain 2D Strain Source Tissue Doppler 2D Images Theory Doppler 2D Speckle Tracking Measurement Velocity along with Direct measurements of 2 acoustic beam line dimensional movement Angle dependency YES NO Limitation of scan plane YES NO Difficult for apex and short axis Frame rate (per seconds) fps fps Index Velocity,...Add, Tissue Tracking, Radial S, Circum S. Tissue Synchronization Imaging(TSI), Peak Strain Strain, Strain Rate Peak Strain Rate Twist 14 Cardiovascular Update

NO Difficult for apex and short axis Frame rate (per seconds) 100-200 fps 40-80 fps Index Velocity,.

14 Cardiovascular Update 15

15 SECTION TOPIC 1 A B 16 Cardiovascular Update

16 1. Sohn DW, Chung WY, Chai IH. Mitral annulus velocity in the noninvasive estimation of left ventricular peak dp/dt. Am J Cardiol 2001;87: Derumeaux G, Ovize M, Loufoua J, et al. Doppler tissue imaging quantitates regional wall motion during myocardial ischemia and reperfusion. Circulation 1998;97: Sohn DW, Chai IH, Lee DJ, et al. Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol 1997;30: Sohn DW, Song JM, Zo JH, et al. Mitral annulus velocity in the evaluation of left ventricular diastolic function in atrial fibrillation. J Am Soc Echocardiogr 1999;12: Sohn DW, Kim YJ, Kim HC, et al. Evaluation of left ventricular diastolic function when mitral E and A waves are completely fused: role of assessing mitral annulus velocity. J Am Soc Echocardiogr 1999;12: Nagueh SF, Middleton KJ, Kopelen HA, et al. Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures. J Am Coll Cardiol 1997;30: Kim YJ and Sohn DW. Mitral annulus velocity in the Estimation of left ventricular filling pressure: prospective study in 200 patients. J Am Soc Echocardiogr 2000;13: Ommen SR, Nishimura RA, Appleton CP, et al. Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures. Circulation 2000;102: Becker M. Analysis of myocardial deformation based on pixel tracking in 2D echocardiographic images allows quantitative assessment of regional left ventricular function. Heart 2005;92: Chan J, Hanekom L, Wong C, Leano R, Cho GY, Marwick TH. Differentiation of subendocardial and transmural infarction using two-dimensional strain rate imaging to assess short-axis and long-axis myocardial function. J Am Coll Cardiol 2006;48: Cardiovascular Update 17

Assessment of mitral annulus velocity by Doppler tissue imaging in the evaluation of left ventricular diastolic function. J Am Coll Cardiol 1997;30:474-80. 4. Sohn DW, Song JM, Zo JH, et al.

17 SECTION TOPIC 2 AMI: acute myocardial infarction MI: myocardial infarction 18 Cardiovascular Update

18 Cardiovascular Update 19

19 SECTION TOPIC 2 NPV: Negative predictive value, PPV: Positive predictive value 20 Cardiovascular Update

20 Cardiovascular Update 21

21 SECTION TOPIC cm/75 kg 10.6 cm scan range 0.89 msv Courtesy of S. Auchenbach 22 Cardiovascular Update

22 1. Lucas FL, DeLorenzo MA, Siewers AE, Wennberg DE. Temporal Trends in the Utilization of Diagnostic Testing and Treatments for Cardiovascular Disease in the United States, Circulation 2006; Falk E, Shah PK, Fuster V. Coronary Plaque Disruption. Circulation 1995;92: Auseon AJ, Advani SS, Bush CA, Raman SV. Impact of 64-slice multidetector computed tomography on other diagnostic studies for coronary artery disease. Am J Med 2009;122: Karlsberg RP, Thomson LEJ, Berman DS, et al. CCTA integrated in the office setting dramatically reduces the need for invasive angiography with enhanced identification of critical disease not identified by conventional testing and clinical presentation. J Cardiovasc Comput Tomogr 2008;2(4 Supp1):S11-S A Report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group. ACCF/ ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR ACCF/ACR/SCCT/SCMR/ASNC/NASCI/SCAI/SIR 2006 Appropriateness Criteria for Cardiac Computed Tomography and Cardiac Magnetic Resonance Imaging. J Am Coll Cardiol 2006;48: Mollet NR, Cademartiri F, Mieghem CV, et al. Adjunctive value of CT coronary angiography in the diagnostic workup of patients with typical angina pectoris. Eur Heart J 2007;28(15): Fred M, Bruce T, Mythreyi B, et al. MEDICAL RADIATION EXPOSURE IN THE U.S. IN 2006: PRELIMINARY RESULTS. Health Physics 2008;95: Mitka M. CT angiography: clearer picture, fuzzier reception. JAMA 2006;295: Andrew J. Einstein, Milena J. Henzlova, Sanjay Rajagopalan. Estimating Risk of Cancer Associated With Radiation Exposure From 64-Slice Computed Tomography Coronary Angiography. JAMA 2007;298: Hausleiter J, Meyer T, Hermann F, et al. Estimated Radiation Dose Associated with cardiac CT angiography. JAMA 2009;301: Raff GL, Chinnaiyan KM, Share DA, et al. Radiation Dose From Cardiac Computed Tomography Before and After Implementation of Radiation Dose?Reduction Techniques. JAMA 2009;301: Cardiovascular Update 23

23 SECTION TOPIC 3 Gf: frequency encoding gradient, Gp: phase encoding gradient, Gs:slice selection gradient, RF: radiofrequency plus S:signal, TE: echo time, TR: repetition time 24 Cardiovascular Update

24 Cardiovascular Update 25

25 SECTION TOPIC 3 A B C 26 Cardiovascular Update

26 있는 주요 기법으로 심근의 tagging을 이용한 문에 심실 구출률에 비해 심근 자체의 기능을 strain의 측정은 재현성과 정확도가 매우 높은 측정하는 데에 도움이 될 수 있는 것으로 알려 것으로 알려져 있다(그림 3). Strain은 비교적 져 있어 심초음파를 이용하여 심근의 strain을 심실의 전부하나 후부하에 영향을 적게 받기 때 측정하고자 하는 노력이 지속되어 왔으나, 그림 4. Adenosine 부하 CMR 영상 좌측이 안정시 영상이며 우측이 심근부하 후 영상으로 화살표가 가리키는 부위가 부하에 의해 관류 저하가 관찰되는 심근이다. Cardiovascular Update 27

27 SECTION TOPIC 3 Normal myocardium Acute infarction Scar Intact cell membrane Ruptured cell membrane Collagen matrix 28 Cardiovascular Update

28 A B PSIR: phase-sensitive inversion recovery Cardiovascular Update 29

29 SECTION TOPIC 3 A B 30 Cardiovascular Update

30 Cardiovascular Update 31

31 SECTION TOPIC 3 A B C 32 Cardiovascular Update

32 Cardiovascular Update 33

33 SECTION TOPIC 3 34 Cardiovascular Update

34 Cardiovascular Update 35

35 SECTION TOPIC 3 1. Kim RJ, ed. Cardiovascular MR Imaging. Magn Reson Imaging Clin N Am 2007;15: Finn JP, Nael K, Deshpande V, et al. cardiac MR imaging: State of the technology. Radiology 2006;241: Assomull RG, Pennell DJ, Prasad SK, et al. Cardiovascular magnetic resonance in the evaluation of heart failure. Heart 2007;93: Gotway MB, ed. Chest MR. Magn Reson Imaging Clin N Am 2008;16: Wu KC, Weiss RG, Thiemann DR. Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance Heralds an Adverse Prognosis in Nonischemic Cardiomyopathy. J Am Coll Cardiol 2008;51: Turkbey EB, Dombroski DA, et al. Cardiac Magnetic Resonance Imaging: Techniques and Clinical Applications. Seminars in Roentgenology 2009; Kribben et al. Nephrogenic Systemic Fibrosis: Pathogenesis, Diagnosis, and Therapy. J Am Coll Cardiol 2009;53: Wu E, Ortiz JT, Tejedor P, Lee DC, et al. Infarct size by contrast enhanced cardiac magnetic resonance is a stronger predictor of outcomes than left ventricular ejection fraction or end-systolic volume index: prospective cohort study. Heart 2008;94: Cardiovascular Update

36 Cardiovascular Update 37

37 SECTION TOPIC 4 38 Cardiovascular Update

38 Cardiovascular Update 39

39 SECTION TOPIC 4 A asa bsa HLA VLA S Polar map R S R B asa bsa HLA VLA S Polar map R S R asa: apical short axis, bsa: basal short axis, HLA: horizontal long axis, VLA: vertical long axis, S: stress, R: rest 40 Cardiovascular Update

40 Cardiovascular Update 41

41 SECTION TOPIC 4 Viable Non-viable 13 NH 3 18 FDG 13 NH 3 18 FDG Flow Metabolism Mismatch Flow Metabolism Match 42 Cardiovascular Update

42 Brain Lung Kidney Liver MAA: macroaggregated albumin Cardiovascular Update 43

43 SECTION TOPIC Bengel FM, Higuchi T, Javadi MS, Lautamaki R. Cardiac positron emission tomography. J Am Coll Cardiol 2009;54: Hachamovitch R, Berman DS. The use of nuclear cardiology in clinical decision making. Semin Nucl Med 2005;35: Travin MI, Bergmann SR. Assessment of myocardial viability. Semin Nucl Med 2005;35: Knuuti J. Integrated positron emission tomography/computed tomography (PET/CT) in coronary disease. Heart 2009;95: Wu JC, Bengel FM, Gambhir SS. Cardiovascular molecular imaging. Radiology 2007;244: Cardiovascular Update

44 Cardiovascular Update 45

45 SECTION TOPIC 5 A B 46 Cardiovascular Update

46 Cardiovascular Update 47

47 SECTION T O P I C 5 중등도 병변을 보이는 경우, IVUS 시행 결과 최 2 3. 동맥의 재형성 평가 소 내강 단면적이 4.0 mm 이상이라면 관상동 동맥의 재형성은 병변 혈관이 죽상경화증의 맥 중재시술이 반드시 필요하지는 않으며, 약물 진행에 따라 외탄력막 영역이 확장 또는 축소되 치료를 포함한 임상적 추적 관찰도 가능할 것으 는 현상으로 1987년 Glagov 등에 의해 처음 소 로 판단된다. 또한 관상동맥 조영술을 이용하여 개되었다. 동맥 재형성은 양성(positive 병변의 길이를 평가할 때 시술자의 시각에 의해 remodeling 또는 adaptive remodeling), 중간 병변 주위의 참조 혈관을 기준으로 길이를 결정 형(no remodeling 또는 intermediate re- 하게 되므로 실제 병변의 길이보다 작게 측정되 modeling), 그리고 음성 재형성(negative re- 는 경우가 대부분인데 IVUS를 이용하면 협착의 modeling 또는 constrictive remodeling)으로 정도를 평가하는 것뿐만 아니라 병변의 길이를 나누어지는데, 이들의 정의는 보고자에 따라 다 정확히 평가하는 데도 큰 도움을 받을 수 있다. 소 차이를 보여 양성 재형성을 정의할 때, 병변 이 외에도 관상동맥 내에 박리(dissection), 혈 의 EEM cross-sectional area를 기준으로 근 전(thrombi), 혈관벽 내 혈종(intramural 위부 참조 혈관의 EEM cross-sectional area hematoma), 동맥류(aneurysm) 등이 생겼을 와 비교하여 큰 경우로 하는 방법, 근위부 참조 경우에도 관상동맥 조영술에서는 단순한 협착 혈관의 EEM cross-sectional area와 비교하 이나 조영제 결손으로 보일 수 있지만 IVUS를 여 5% 이상 혹은 10% 이상 큰 경우로 하는 방 사용할 경우 정확한 진단을 내리는 데 도움을 법, 근위부와 원위부 참조 혈관의 평균 EEM 받을 수 있다. cross-sectional area와 비교하여 큰 경우로 하는 방법 등 다양한 정의가 사용되고 있다. 양 그림 2. VH-IVUS의 영상 조직에서 반사되어 돌아오는 초음파의 무선주파수(radiofrequency) 분석을 통해 죽상경화반의 조직 성분을 섬유조직(fibrous), 지질 섬유조직(fibrofatty), 석회화(dense calcium), 괴사부위(necrotic core)로 나누어 각각 다른 색으로 나타내 준다. 48 Cardiovascular Update

48 Cardiovascular Update 49

49 SECTION TOPIC 5 50 Cardiovascular Update

50 1. Mintz GS, Nissen SE, Anderson WD, et al. American College of Cardiology Clinical Expert Consensus Document on Standards for Acquisition, Measurement and Reporting of Intravascular Ultrasound Studies (IVUS). A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol 2001;37: Hong MK, Lee CW, Kim JH, et al. Impact of various intravascular ultrasound criteria for stent optimization on the six-month angiographic restenosis. Catheter Cardiovasc Interv 2002;56: Mintz GS, Weissman NJ. Intravascular ultrasound in the drug-eluting stent era. J Am Coll Cardiol 2006;48: Nicholls SJ, Tuzcu EM, Sipahi I, Schoenhagen P, Nissen SE. Intravascular ultrasound in cardiovascular medicine. Circulation 2006;114: e Mehta SK, McCrary JR, Frutkin AD, Dolla WJ, Marso SP. Intravascular ultrasound radiofrequency analysis of coronary atherosclerosis: an emerging technology for the assessment of vulnerable plaque. Eur Heart J 2007;28: Moses JW, Dangas G, Mehran R, Mintz GS. Drug-eluting stents in the real world: how intravascular ultrasound can improve clinical outcome. Am J Cardiol 2008;102:24J-8J. Cardiovascular Update 51

51 THE MOST ADVANCED CONTINUING MEDICAL EDUCATION SERVICE VOL 1 NO VOL 1 NO VOL 2 NO VOL 2 NO VOL 2 NO VOL 2 NO VOL 3 NO VOL 3 NO VOL 4 NO VOL 4 NO VOL 4 NO VOL 4 NO VOL 5 NO VOL 5 NO VOL 5 NO VOL 5 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 6 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 7 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 8 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 9 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 10 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 11 NO VOL 12 NO VOL 12 NO Cardiovascular Update 52

52 Cardiovascular Update

55 P ( )-V1.0

인디쓔피-IOM핸돜벁닄큐1014pdf, page 59 @ Preflight ( IOM핸돜벁닄큐__1014 )

인디쓔피-IOM핸돜벁닄큐1014pdf, page 59 @ Preflight ( IOM핸돜벁닄큐__1014 ) Publisher: International Organization for Migration 17, route des Morillons 1211 Geneva 19 Switzerland Tel: +41.22.717 91 11 Fax: +41.22.798 61 50 E-mail: hq@iom.int Internet: http://www.iom.int ISBN 978