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6DIAGNOSTIC SIGNIFICANCE OF MAGNETIC RESONANCE IMAGING FOR MYOCARDIAL DAMAGE OF VARIOUS GENESIS
Abdurakhim Jahongirkhuja Otabek Maruf Abror Akbar
Temirovich Ayubjon ugli Shokirovich Oripovich ugli Akhrorov
Bokiev Ergashev Izzatullaev Sharipov
Clinical interns at the Department of Medical Radiation Diagnostics Samarkand State
Medical Institute
ABSTRACT
To evaluate the diagnostic significance of magnetic resonance imaging in the differential diagnosis of ischemic heart damage and non-coronary myocardial diseases. Materials and methods: a retrospective analysis of medical documentation of 60 patients of cardiac departments of the Rostov Regional Clinical Hospital was conducted. Held a comparative analysis of the informativeness of the application of instrumental research methods (ECG, echocardiography, coronary angiography with left ventriculography and magnetic resonance imaging of the heart) among the patients with myocardial damage of different origins. Results: in patients with IHD, postinfarction cardiosclerosis, in most cases, the results of instrumental studies were diagnosed as having a diagnostic relationship. Conducted MRI of the heart was of decisive importance in the evaluation of the state of the myocardium after systemic thrombolysis or questionable ECG and EchoCG data and was also significant in the differential diag- nosis of acute coronary syndrome and focal myocarditis. The results of MRI played an important role in determining the etiology of myocardial hypertrophy, in particular hypertrophic cardiomyopathy, and also helped in the case of differential diagnosis in the syndrome of cardiomegaly. Conclusions: shown a high diagnostic value of magnetic resonance imaging with the use of contrast agents in the differential diagnosis of ischemic and noncoronary myocardial diseases.
Keywords: magnetic resonance imaging, the left ventricle, coronary heart disease (CHD), noncoronary diseases of the myocardium.
INTRODUCTION
A retrospective analysis of the medical documentation of 60 patients of the cardiology department No. 1 of the Regional Vascular Center and the cardiology department No. 2 of the State Budgetary Institution of the RO "ROKB" of the Center for Cardiology and Cardiovascular Surgery was carried out in the period from 02/01/2016 to 06/01/2017. The majority of patients (21 people: 9 women and 12 men, mean age 59 + 5.45 years) were treated with a diagnosis of coronary artery disease,
angina pectoris II-III FC, postinfarction cardiosclerosis (PICS). 16 patients were diagnosed with coronary artery disease, exertional angina pectoris II-III FC without signs of myocardial necrosis (6 women and 10 men, mean age 61 + 6.31 years). 13 patients were treated with a diagnosis of stage II-III hypertonic disease (6 women and 7 men, mean age 56 + 6.12 years). As a result of examination, 10 patients were diagnosed with diseases that did not belong to the group of coronary genes. Their structure is presented as follows: hypertrophic cardiomyopathy (HCM) was in 4 people (2 women and 2 men), dilated cardiomyopathy (DCM) - in 2 women, myocarditis - in 3 patients (2 women and 1 man), myxoma - in 3 patients (2 women and 1 man).
METHODOLOGY
All patients underwent clinical, laboratory and instrumental examinations in accordance with the standards of diagnosis and treatment of cardiovascular diseases. A 12-channel ECG, echocardiography in B- and M-modes using pulsed, constant-wave, color and energy Doppler blood flow study with an assessment of the size of the heart cavities, the degree of left ventricular hypertrophy (LVH), global and regional contractile the ability of the LV and violations of its diastolic function. Crown-Roangiography and left ventriculography were used to detect hemodynamically significant impairment of coronary blood flow. Magnetic resonance imaging of the heart with bolus contrast was performed on a General Electric Bravo MR355 apparatus using SE (spin-echo), Double-IR (analogue T1VI), Triple-IR (analogue T2 with fat suppression) and FIESTA in dynamic mode. (cinema) scanning with the ability to assess the nature of blood flow, along the short and long axis of the heart, with a thickness of 8 mm slices. Post-contrast series, after IV bolus administration of CV (Gadovist / Magnevist / Dotarem at 0.1-0.2 ml per kg of body weight), in the early (MR perfusion) and delayed phases on the 2D MDE program in three projections ... Three types of synchronization were used: gaiting, triggering, and slice following.
RESULT
In the group of patients with ischemic heart disease, postinfarction cardiosclerosis in the majority of patients (71%), the results of instrumental studies were diagnostically correlated with each other. On the ECG, cicatricial changes of various localization were recorded, which were confirmed by the corresponding zones of segmental contractility disorders, revealed by echocardiographic examination. When performing CAG, pronounced stenoses up to 95% or occlusion of the feeding arteries were found. Magnetic resonance imaging of the heart showed pathological accumulation and delayed excretion of contrast on delayed 2D MDE series (subendocardial, intramural and transmural), in those segments of the LV myocardium (according to the ANA /
ACC classification) in which irreversible ischemia had previously occurred myocardium.
In 2 patients (9.5%) who underwent AMI with effective systemic thrombolysis, there were no signs of cicatricial changes on the ECG, no zones of local contractility disturbance were detected during echocardiography, the coronary angiographic examination did not reveal hemodynamically significant stenoses coronary arteries, during the MRI study, the accumulation of contrast was not recorded, that is, the data of different diagnostic technologies were consistent and informationally combined with each other.
In the 1st patient, when performing an ECG with a history of myocardial infarction, ECG signs of PICS were absent. When performing CAG, hemodynamically significant stenoses of the coronary arteries were not detected. During echocardiography, the signs of myocardial infarction turned out to be doubtful: moderate hypokinesis of the LVPW was recorded with relatively intact LV systolic function (EF 57%). When performing MRI of the heart with delayed contrast enhancement, abnormal accumulation and delayed excretion of contrast in the transmural type in the area of S10-11, S15-16 segments was revealed, as well as during dynamic examination (cinema mode) hypokinesis of the LV posterior wall was determined, which made it possible to verify PEAKS diagnosis in this clinical case. In 4 patients with an established diagnosis of HCM, the ECG showed signs of LV myocardial hypertrophy. Ultrasound examination revealed severe LV hypertrophy, and in all patients with the formation of LV outflow tract obstruction. MRI of the heart with delayed contrast enhancement in 3 patients revealed zones of intramural CV accumulation in the LV myocardium, which did not correspond to the basin of any of the epicardial arteries, which corresponded to MR signs of hypertrophic cardiomyopathy, HCM. however, the patient's young age (32 years), the presence of pronounced hypertrophy of the LV myocardium walls (IVS up to 25 mm) made it possible to assume the diagnosis of HCM, and the subsequent intraoperative morphological examination of the myocardium confirmed the diagnostic hypothesis. 2 patients were treated with a diagnosis of DCM. Echocardiography and MRI examination of the heart revealed dilated cardiac cavities without disturbing the accumulation of CV, while ultrasound of the heart revealed a significant decrease in LV systolic function. Coronary angiography showed no confirmation of hemodynamically significant stenoses. According to MRI, impaired contrast removal in delayed phases helped to differentiate dilatation of cardiac cavities due to DCM from ischemic and inflammatory changes in the myocardium.
In connection with the clarity of the following clinical example, it is described in more detail. Patient S., 50 years old, was admitted to the cardiology department No.1
with the clinic of acute coronary syndrome (ACS) with complaints of pressing pain behind the sternum that occurred during physical exertion and periodically at rest, a feeling of lack of air, general weakness, sweating. The ECG showed an elevation of the ST segment in leads V4-V6, systemic thrombolysis (actilyse) was performed, on the same day the patient was hospitalized in the OKB with a diagnosis on admission: ACS with ST segment elevation, STL (actilize), OSSN class I (according to Killip ). A decision was made to perform CAG and stenting. When conducting a study of the coronary arteries, hemodynamically significant stenoses were not revealed. On the third day of hospitalization, an ECG was recorded, where the ST segment elevation in the V4-V6 leads remained. Ultrasound examination of the heart revealed severe left ventricular hypertrophy, local contractility disorders were manifested by moderate hypokinesis of the posterior and posterior basal walls of the LV, the global contractile function of the LV was moderately reduced, and fluid up to 5 mm thick was discharged in the pericardial cavity. Based on clinical and laboratory instrumental data, a preliminary diagnosis was made: ACS with outcome in acute myocardial infarction of the apical-lateral region with ST segment elevation, without pathological Q wave. STL (actilize). Angioplasty and stenting of LAD. ECG data and abnormalities of segmental contractility during echocardiography were consistent with the diagnosis of acute myocardial infarction. However, the absence of hemodynamically significant stenosis of the coronary arteries according to coronary angiography and the accumulation of fluid in the pericardial cavity was the reason for further diagnostic search. When conducting MRI of the heart in the early phase of contrasting in a series 3-5 minutes after the injection of contrast, a linear zone of intramural CV accumulation in the IVS and the posterior wall of the LV with delayed contrast removal in the delayed phase was determined. The MR signal from the myocardium in the native series was heterogeneous in the S9-S10 segments, changed due to "inflammatory" edema, in the pericardial cavity an accumulation of fluid with a thickness of 7-9 mm was determined. According to the description, the MRI picture corresponded to the signs of inflammatory myocardial damage. Thus, in this clinical example, only the MRI of the heart made it possible to timely verify the diagnosis of focal myocarditis and choose the correct therapy tactics.
CONCLUSION
Modern instrumental technologies for examining a cardiac patient include, along with ECG and EchoCG, coronary angiography and cardiac MRI with early and delayed postcontrast series. The use of these techniques in combination is complementary and allows timely verification of the correct diagnosis. The advantages of MRI in comparison with other methods of instrumental diagnostics are that they make it
possible to assess not only the size of the cavities and the thickness of the myocardium, but also to assess the structure of the heart muscle itself in the event of pathological changes. According to the results of the comparative analysis, the indications for cardiac MRI using early and delayed post-contrast series are, first of all, diagnostically unclear clinical situations when an assessment of the myocardial structure is necessary for making a diagnosis, in particular, in the differential diagnosis of ischemic damage and non-coronary heart diseases.
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