September 2, 2025 • 32 mins
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/
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Kanny (00:10):
So welcome everyone back to the Cardio Ohio podcast.
This is K Graywall in Columbus,Ohio.
I'm pleased to have a couple ofguests today to talk about
cardiac MRI and cardiac imagingin general, and they're both
specialists here in centralOhio.
My first guest is Dr.
(00:30):
Matthew Tong.
He's a cardiovascular diseasespecialist and cardiac imaging
specialist at Ohio StateUniversity.
Matt, welcome.
Thank you.
And we're also happy to haveanother.
Guest here who's very familiarto those of us here in Central
Ohio.
And that's Dr.
Soba Raman.
She's also a cardiac imagingspecialist.
(00:51):
She worked at Ohio State formany years, so she's well known
throughout central Ohio.
But more recently, she wasappointed vice president of
heart and vascular services atOhio Health.
Suva welcome as well.
Subha (01:06):
Thanks, Kenny.
Great to be here with you andMatt.
Kanny (01:10):
Thank you both.
So Matt, I just wanted to startwith you.
You know, we have a lot oftrainees and fellows in training
who listen to our, our podcast.
Can you just kind of verybriefly just summarize what the
path that led you to the fieldof cardiac imaging and
specifically led you to positionat an academic center at Ohio
(01:31):
State?
Matt (01:33):
Absolutely.
Thank you Kenny, first.
Of course.
Thanks for letting us do thispodcast today.
My.
Training pathway was somewhatnon-traditional as it relates to
the academic component.
But yeah, my residency was inDayton primarily in a
community-based hospital,similar with my general
(01:56):
cardiology fellowship where Ispent some time with you
actually Kenny at Ohio Health.
And really actually throughmentorship from both of you in
those components that kinda ledme to understand that.
You know, imaging is so diverseand really to sort of
subspecialize and become a trueexpert required additional
(02:19):
training.
And that was where I spent sometime over at Allegheny General
Hospital in Pittsburgh under thestewardship with Dr.
Bob Beaterman.
And that really kind oftransformed my thought process
and just really the what cardiacMRI can provide.
And really that was kind of whatbrought me back to Columbus,
(02:40):
Ohio and Ohio State.
And that really just continue tospearhead all of the innovations
that, that, still continues tothis day.
Kanny (02:50):
Thanks Matt.
Suva, you had a very, I think,interesting path to your current
position.
Of course, many of us, likemyself, who've been practicing
here in in, in central Ohio forseveral decades are familiar
with all the clinical work aswell as the clinical research
you've done in cardiac imagingat Ohio State.
(03:10):
But then you did take aninteresting turn into, becoming
a physician, a service lineleader.
Now you're a leader of a serviceline of over a hundred, plus
clinicians.
I, I think our listeners mightbe curious to hear, what, what
led you to your path toeventually becoming, the leader
of a very large and productiveheart and vascular service line.
Subha (03:34):
Thanks for that question.
Ka, I started out really incardiology fellowship.
I loved all the differentdisciplines.
I had a background inengineering and at the time,
cardiac, MRI and, and CT werejust nascent.
Techniques that we didn't haveat Ohio State where I did my
(03:55):
training.
And so I was very fortunate tobe able to build those programs
from scratch.
I love the appeal of usingadvanced cardiac imaging to be
more proactive with ourpatients.
To get more precise, accuratediagnoses in a more timely
fashion to guide effectivetreatment and improve outcomes.
(04:19):
The transition to my currentleadership role, honestly, is
really one of an opportunity topay it forward.
You know, we, we did so much inour with our imaging team at
OSU.
How do we make sure that thebroader population that we serve
has access to those innovations?
(04:40):
And so that is really my my hopein this role that as a, a leader
of a service line, I can empowerour team to get patients that
needed access so they get theright diagnosis, treatment,
prevent complications.
Kanny (05:01):
Well, that's wonderful.
So yeah, we appreciate,appreciate both of your input
there, Sue.
But lemme just follow up to kindof set the table for our
discussion about the currentstate of cardiac.
Mr.
Just like you, I've been animager for, you know, decades.
Seeing, the development ofcourse, echocardiography nuclear
(05:22):
imaging even cardiac CT, allcome into the mainstream of
everyday cardiology.
As those modalities have evolvedand gotten more complex why do
you think Mr is still sorelevant and has such a unique
role in our kind of toolbox ofimaging techniques?
And why do you think it'srelevant to, you know, general
cardiology?
Subha (05:43):
Yep.
It really is standard of carethese days.
You know, that if we wanna dowhat's best for our patients
with heart and vascular disease,we're actually at a point with
the maturation of this fieldthat it's a disservice not to
offer cardiac MRI.
If, if you think about thingslike coronary and ischemic heart
(06:06):
disease how much.
Heart, muscle is at risk versussalvageable.
If you're thinking about breadand butter interventions or
surgical revascularization.
If you think about thesignificant burden we have of
patients with heart failure andarrhythmias, what's going on
(06:27):
with heart muscle, that's thesubstrate for those conditions.
There's no need to.
To guess anymore, we can getreally precise information, and
the therapeutics have advancedsignificantly in parallel.
So if you think about you know,conditions like vt where's the
(06:48):
VT coming from?
Our, our EP colleagues havetremendous ablative procedures
that they can use to controlthose conditions.
If you think about our patientswith heart failure, you know,
it's the difference betweensaying, well, you know, your EFS
reduced.
It looks like you're gonna havechronic heart failure to looking
(07:10):
at heart muscle and being ableto say, wow, there's a treatable
specific diagnosis here that maydirect them towards.
Targeted molecular therapy foramyloidosis or appropriate
therapy for hypertrophiccardiomyopathy.
So it's really as I would saystandard of care and should be
(07:30):
incorporated across the spectrumof, of heart and vascular
patients.
Kanny (07:35):
So, Matt at your in your position, you know, at a, a
large academic center if youlook at, at the utilization of
CVMR at your center.
Since we don't have time to talkabout every, you know,
indication what would you sayare kind of the broad categories
where you're seeing at least in,in day-to-day clinical practice,
(07:58):
CVRR being used currently?
Matt (08:01):
Yeah, great question.
The.
The important aspect of cardiacM-R-I-M-R-I is really that as
Suva really highlighted, was theadded value that it can improve
in cardiovascular care.
And really I would say perhaps.
Both, all three of us may bejust slightly biased, but
(08:22):
cardiovascular imaging ingeneral really has become the
door to entry across allcardiovascular practices
nowadays.
And, Suba kind of mentioned afew of those already, really
that the most common indicationfor cardiac MRI is, evaluation
of cardiomyopathy, whether it berelated to a non-ischemic
(08:44):
infiltrative arithmetic relatedcardiomyopathies and some form
of ischemic, whether it'sviability in these these
features and the fact that it'snon-radiating and through the
use of gadolinium contrast thatwe're able to perform a, sort of
a non-invasive biopsy and ableto provide that that pro those
(09:04):
prognostic features and guidethose treatments.
Subha (09:08):
If I could add Kenny Matt, it's, it's impressive how
far CMR has come in practiceguidelines you might comment on
that.
Matt (09:19):
Absolutely.
So the, some of the data thatwe've reviewed previously is
fairly old back in 23, suggeststhat at least 40 class one
indications nowadays for cardiacmr.
And obviously there's moresocietal based guidelines which
both of us, all of us haveparticipated in some fashion as
(09:40):
continue to increase the theindications of that's.
Just standard of care as you'vesaid.
Subha (09:49):
And I'd just add a, a note that this is a prominence
in guidelines outside ofimaging, right?
So Heart Rhythm SocietyGuidelines, a CC, European
Society of CardiologyGuidelines.
So this really is something thatwe need to make a commitment to,
to, to provide access toguideline based care for our
(10:10):
patients.
Matt (10:11):
Absolutely.
It's that multi society kind ofvillage mentality to really sort
of come together.
That where imaging has really,especially cardiac, MR has
demonstrated that additionalutility,
Kanny (10:27):
obviously, you know, with CVMR still being a fairly
expensive and sometimes, and Iknow 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 mentionedcardiomyopathy.
So Matt would, is it fair to saythat in a patient with new onset
(10:47):
heart failure, who's found tohave a cardiomyopathy, that CVMR
in almost every instance willprobably provide some additive
value and should generally beconsidered part of the basic
workup?
Or do you still think it's a,you know, case by case kind of a
decision?
Matt (11:04):
Yeah, that is about as classic for a class one
indication in the evaluation ofcardiomyopathy.
So I would say that is about asstandard of care as it comes.
And yeah, we'll, we'll discusssome of the access concerns that
I think we can hopefullyimprove, to make the scans a
little more efficient and thingslike that kind of help improve
(11:27):
that access.
Kanny (11:31):
Suva.
I think as generalcardiologists, 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 emergingareas where MR has a role that
weren't, weren't so obvious toclinicians in the past?
Subha (11:53):
Happy to do so.
This is now very much part ofevaluation and management of
patients with a, a broad rangeof cardiac arrhythmias.
I think the, the difference now,if, and if you ask our EP
colleagues, they'll probably bethe first to tell you this is
(12:13):
instead of looking solely at anelectrical signal and trying to
go after it, for instance, inthe EP lab.
What's the substrate forarrhythmia?
You know, there's there's a lotof things that can lead to
things like atrial fibrillation,ventricular tachycardia, even
somebody who has a heavy burdenof premature ventricular
complexes.
(12:34):
I think Matt and I have probablyseen too often the patient gets
a rhythm treatment without aroot cause diagnosis, and by the
time they get to the cardiac MRLab, you say, gosh.
If we could have dialed theclock back, you know, earlier we
could have given the, the EPteam that substrate information.
(12:56):
Now, as I mentioned, heartRhythm Society says, let's get
that information on why thepatient has a certain
arrhythmia.
Certainly if you think aboutPVCs, vt, there's no question
that those things come fromventricular myocardium.
(13:17):
You need to know what thedisease is there that's leading
to the arrhythmia.
Of course there are channelpathy, channelopathies and such
that, that may have structurallynormal hearts but even with a
normal ejection fraction, youknow, I don't think we should be
reassured by patients whose echocomes back looking pretty good.
(13:39):
When somebody has a, apotentially life-threatening
arrhythmia, atrial fibrillationhas also advanced quite a bit.
You know, I'm, I'm sure Matt hasalso seen, I've seen patients
who AFib is just the, kind ofthe presenting symptom almost,
right?
That they've got AFib due to anundiagnosed cardiomyopathy.
(14:02):
They've got AFib in the settingof maybe valvular disease that
was more severe than estimatedby surface echo.
Matt, I'd be interested in yourthoughts on this.
Matt (14:12):
Yeah, absolutely.
Perhaps even just to kind ofpiggyback of some of the things
that you discussed, really froma myocardial diagnosis
standpoint from just startingwith electrophysiology stand
aspects LVH, right?
Do we think it could be ahypertrophic cardiomyopathy or
maybe it's not and it's a, aFabry disease.
(14:32):
Could it be amyloid disease?
That, and those are the thingsthat can be.
Reasonably easily differentiatedby cardiac mr.
And just really being able totease, like you said, that root
cause diagnosis will really kindof help guide the appropriate
treatment for those patients.
And then, transitioning furtherto just what, what you
(14:53):
suggested, the valvular heartdisease, right, that is quite
another common adult diagnosisand certainly.
The imaging modalities,particularly echocardiography,
really represents the sort ofthe the mainstay of the
evaluation.
But where cardiac Mr really addsto that is that that accurate
(15:19):
quantification of regards to 10volume and fraction.
And there's been numerousstudies now that really has
helped to guide whether thesepatients should be going towards
some surgical intervention.
It's been great to, to see thefield growing in that side
because of obviously it's a, alarge, population with that
(15:41):
pathology.
And it can not only, of coursemake that determination whether
they should go to some form ofan intervention, but now it's
improved to the point where wepotentially could help guide
some of these interventions aswell.
To the point similar to.
TAVR based procedures and those,those type of interventions.
(16:02):
So yeah, it's, it's there's alot of opportunity to, to of
growth where cardiac Mr.
Can really add that value.
Subha (16:11):
Yeah, I think of the questions that are structural
heart interventionalists have,you know, particularly in
patients with, emergence oftranscatheter treatments for
mitral valve disease that'ssomething you really wanna get
right.
In terms of severity of thingslike mitral regurgitation to
(16:31):
guide what can be reallylife-changing interventions.
Kanny (16:37):
One other area, Matt, I wanted to ask about before we
move on to talking about somespecific you know, situations is
stress, Mr.
You know, as an alternative toother types of stress imaging.
I know this has emerged inrecent years.
I'm just curious how you at OhioState you are incorporating, any
stress protocols as analternative to some of the other
(16:59):
imaging like PET and CCTA.
Matt (17:02):
Yeah, great question.
So definitely.
We had Ohio State and certainlySuva has very much contributed
to this field as well.
That kind of really set thestage for stress cardiac Mr.
Effectively becoming essentiallyin the same playing field as the
other imaging modalities.
(17:23):
Level one excuse class oneindication for the evaluation of
ischemia.
We pre predominantly perform,adenosine stress.
We've adapted a few techniquesnow to do quantitative
perfusion.
So now you can actually providea number to the evaluation
similar to Stress Pet, to addthat evaluation of microvascular
(17:49):
disease to, to determine thatversus potential multi-vessel
disease.
Those that has been.
It, it continues to evolve andreally a lot of innovative
techniques that have happened.
But the important part really tohighlight about stress cardiac
MR is really that the reductionof downstream testing and the
(18:10):
cost savings that that happenthat have been well demonstrated
throughout multiple studies nowthrough that technique.
Kanny (18:18):
Great.
I guess, whenever we do talkabout advanced imaging is
particularly CVMR, at least Inotice, the, there's always the
discussion comes around toconcerns about certain patient
populations.
For example, you know, renaldisease or patients with
devices.
So Suva, I was wondering if youcould just briefly summarize the
current state of, using CVMR inpatients with impaired renal
(18:41):
function first and then maybeMatt can talk about use with
devices.
Subha (18:45):
Yes, thank you.
There is no reason that apatient with with chronic kidney
disease.
Shouldn't be referred forcardiac Mr.
It's come a long way.
You know that really over adecade ago there was a
recognition that the oldercontrast agents that we used for
(19:06):
cardiac MR could lead to aserious 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 theworld have shifted to what are
(19:26):
called macrocyclic, gadoliniumbased contrast agents that are
proven to be safe regardless ofan patient's renal function, to
the point that the AmericanCollege of Radiology, in fact.
Has done away with itsrecommendation to check
creatinine before cardiac andother galin based exams.
Matt (19:49):
Maybe something to add to that actually that is a, a
commonly confused is the use ofgadolinium compared to something
like ct and other, and thecontrast that we use in MRI,
that it is not the, I donatedcontrast this, this gadolinium
based contrast that UBA haddiscussed.
(20:10):
Really that the safety profilein general of gadolinium based
contrast agents are actuallymore safe than the iodinated
contrast.
And so the common questions thatI've received in the past, I'm
sure you has, has as well, hasbeen related to do, do these
(20:32):
patients need contrast withtheir cardiac mr.
And the general answer is yes.
Primarily for one, the, thesafe, the well demonstrated
safety profile that we'vediscussed.
And also it is essentially the,the primary use to, for the
tissue characterizationcomponents and really knowing
(20:55):
the fact that it's safe asmentioned, and the fact that
actually cardiac Mr.
When they go into the tunnel tobe evaluated about, there's been
numerous studies now about 25 to27% of cases really are new
diagnosis that day that.
They didn't realize until theywent to cardiac mr.
(21:17):
So that, again, adding thatvalue demonstrating the safety
profile, we're using gadoliniumcontrast based agents, not the I
donated aspect.
So really doing a contrastedcardiac Mr.
Is generally very safe.
Kanny (21:34):
Well, that's reassuring Matt.
And then what's your current forwith devices as well?
Matt (21:40):
Yeah.
Thank you.
All devices.
So we'll just start with nonintracardiac devices.
Orthopedic implants.
I think it's a, a commonquestion mark or those, those
items and essentially thosepassive based devices
essentially are very safe.
(22:02):
Those there's no reason to beconcerned whatsoever to perform
a cardiac Mr from a safetyprofile in that aspect.
Some of the questions thenreally come into are the
intracardiac devices, sopacemakers, defibrillators loop
recorders, definitely.
The loop recorders from a safetyperspective has been well
demonstrated that that's that'sokay.
(22:25):
And essentially.
Beyond what the, what's definedas the MR.
Conditional devices, it's beenalso well demonstrated with.
Pretty much numerous studies nowthey, they're defined as legacy
devices that effectively havebeen very safe and no major
concerns for the patient.
(22:47):
Primarily the main question markfor the.
Reading a cardiologist reallyhas more more to do with the
device artifact.
And from that perspective,really again, evaluation of late
gadolinium enhancement or theevaluation of scar fibrosis.
(23:07):
A lot of the product sequencesare 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 (23:19):
I, I would add candy that because there's such widespread
recognition of the value of atimely cardiac MR exam for so
many patients, devicemanufacturers are very committed
to designing things in a waythat a patient can undergo a
cardiac Mr.
Safely.
(23:40):
It starts with you know, workingwith your technologist if you're
not sure really the best pointof contact.
They're gonna do very carefulscreening and set up an approach
that's really focused on maximumsafety for the patient.
Kanny (24:00):
Well that's good to know.
Another question, Suba, and I'msure you get this question when
cases are referred, is, youknow, the patient with either
history of claustrophobia orconcerns about becoming
claustrophobic.
Is there any advice we can givethe ordering physician there to
clarify who is or is not acandidate?
Subha (24:21):
It's really a, an opportunity to, again, entrust
your cardiac MRI team.
We have amazing technologiststhat all, all the centers that
are dedicated to this type ofservice, that work with the
patient.
The diameter of the scanner hasincreased over time.
So we think about what arecalled large bore scanners that
(24:44):
are now essentially the standardMRI scanner in terms of
diameter, not too far off froma, a CT scanner's diameter.
And we can give patients musicto listen to.
We can put a, a washcloth overtheir eyes.
And the other nice thing about acardiac Mr exam versus let's say
(25:04):
a brain scan is.
There's a lot of interactionwith the patient throughout the
scan so they can really movethings along and put the patient
at ease.
Even if they've got some degreeof claustrophobia, there are
some folks that need someanxiolytic medication in advance
and that helps take the edge offthe procedure.
Kanny (25:26):
Good to know.
So Matt just talking a littlemore about.
Kind of barriers to access,obviously, we all work in large
healthcare systems where we haveaccess to advanced imaging
pretty readily.
With CVMR, of course, it's, it'salways been a relatively
expensive modality.
And of course, based on therequirements to perform the
(25:49):
testing, it's not easily.
Translates to smaller clinicalsettings or more remote settings
and not to mention issues withpre-authorization like we get
with all advanced imaging.
So I'm, I'm just curious likewhat the CVMR community you
think is doing to try to getaccess to advanced imaging out
to some of our more, remoteareas of Ohio
Matt (26:12):
Yeah, this is a, a, a very great and important question to
be asked.
And really we have.
The, our society, the societyfor CMR and advocates like the
three of us to reallydemonstrate that the, the needle
has moved in impressively inthat aspect.
And so let's touch briefly aboutyou mentioned prior
(26:34):
authorizations and obviously allof us have practiced to some
degree and having to have tomake those phone calls and
really.
A number of these Class one andClass two indication increases
over time have really permeatedinto those the insurers practice
(26:56):
guidelines.
And that really has alreadyimproved a bit from the.
How do I say barriers to entryto be concerned that, hey you
know, I, I won't get denied orsomething like that.
From an insurance standpointthe, the pure blunt cost of a
cardiac MMRI versus othermodalities is a very complex
(27:18):
aspect discussion that I don'twant to get too much into, but
really the more important aspectare.
Discussions around what, whatdoes it add as it compares to
what does it save, and a commonev Multiple studies have
demonstrated that the costsavings for cardiac MR as it
relates to primarily thereduction of downstream testing.
(27:40):
So the most common one thatwe've referenced in the past
really has to do with the theSPINS trial, which was related
to stress, cardiac mr.
And really demonstrated comparedto some of the other modalities
that it, it actually is quiteeffective, particularly compared
to the increased amount ofcatheterizations based on other
modalities from thatperspective.
Kanny (28:01):
Great.
Just in the last five minutes orso that we have left it'd be
kind of nice to talk about maybesome future directions, you
know, that you see CVMR going.
What do you think are some ofthe innovations right now that
you see Suva and CVMR that aregonna translate into, kind of
the everyday practice?
I know in other types ofmodalities like Echo, there's a,
(28:23):
a move to use artificialintelligence to maybe simplify
like the interpretation oraugment interpretation.
Do you see similar thingsoccurring in Mr.
Imaging?
Subha (28:34):
Absolutely.
And a lot of that is already inplace.
I, I would like to start withtaking a a page from our
colleagues elsewhere around theworld, even what we would
consider developing countrieswho really have made access a
priority for their communities.
There's a, a wonderfulmultinational study that
(28:57):
involves places like BrazilPeru.
India where they shortened theprotocol, really focusing on
what's the clinical questionthat we need to answer sometimes
as short as 15 minutes.
I've put out a paper inconjunction with the Society for
Cardiovascular MagneticResonance on a a 30 minute
(29:17):
Cardiac MR exam.
You know, these are all thingsthat are within reach.
Innovation isn't always, youknow, tech, it's taking.
Things like c imaging gadoliniumenhancement imaging, which
again, is a workhorse thatreally no other mod modality can
provide.
And doing that in less than halfan hour.
(29:40):
Ought to make cardiac Mr.
More accessible.
And I, I think just about ourown health system, we've got
great CMR clinicians doing thisin places like Mansfield, Ohio,
Pickerington, and smallercommunities.
Think about the access close tohome and how that really gets
(30:01):
you the care that.
Is within reach and notrequiring you to go to, you
know, a larger center.
There certainly is a lot goingon with ai.
I would say probably most labs,if they realize it or not
whatever reporting systemthey're using today to analyze
studies is leveraging thetremendous advances that have
(30:24):
occurred with AI to shorten thetime that it takes to read and
analyze and report a study.
Kanny (30:31):
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 guideinterpretation.
Matt (30:40):
Yeah, absolutely.
Artificial intelligence,intelligence is kind of
permeated across all aspects asit relates to the
post-processing, as Sue was kindof mentioned, and really the
even the image acquisitioncomponents.
So it's really kind ofpartnering across the board here
you know, this kind of villagementality of getting industry
(31:02):
and hospital systems together tokind of really improve this
throughput.
Just Sue's point about this 30minute exam, it really kind of
highlights the utility of just30 minutes really can
effectively answer over 90% ofthe indications that have been
(31:23):
well documented based on.
The registry data that we'vepreviously published.
So I think that is really justhelping to improve that access
on top of, of the otherinnovative techniques that are
coming, coming that's alreadyhere.
Frankly.
Kanny (31:41):
Well, that's wonderful.
I think we're kind of up againstour time, but I, I think we had
a pretty nice discussion, notjust of updated clinical
indications and some newindications as well, but we
talked a little bit about, thebarriers to access and how we're
working on that.
And we talked about.
Specific clinical scenarios aswell.
So I think I think our listenershave have plenty to take away.
(32:04):
I guess I wanna thank you both.
You know, I've been an imagermyself for three decades, and so
I'm o obviously find this veryfascinating.
But I think it's great that.
In the time I've been inpractice, we've seen something
that went from, kind of anquote, experimental technology
to something that we all useevery day.
And and we're very grateful tohave here in Ohio, physician
(32:25):
researchers, like both of youhelping move that forward.
So thanks again, both for yourtime.
Matt (32:32):
Thank you, Kenny.
Thank you Kenny.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
So welcome everyone back to the Cardio Ohio podcast.
This is K Graywall in Columbus,Ohio.
I'm pleased to have a couple ofguests today to talk about
cardiac MRI and cardiac imagingin general, and they're both
specialists here in centralOhio.
My first guest is Dr.
(00:30):
Matthew Tong.
He's a cardiovascular diseasespecialist and cardiac imaging
specialist at Ohio StateUniversity.
Matt, welcome.
Thank you.
And we're also happy to haveanother.
Guest here who's very familiarto those of us here in Central
Ohio.
And that's Dr.
Soba Raman.
She's also a cardiac imagingspecialist.
(00:51):
She worked at Ohio State formany years, so she's well known
throughout central Ohio.
But more recently, she wasappointed vice president of
heart and vascular services atOhio Health.
Suva welcome as well.
Subha (01:06):
Thanks, Kenny.
Great to be here with you andMatt.
Kanny (01:10):
Thank you both.
So Matt, I just wanted to startwith you.
You know, we have a lot oftrainees and fellows in training
who listen to our, our podcast.
Can you just kind of verybriefly just summarize what the
path that led you to the fieldof cardiac imaging and
specifically led you to positionat an academic center at Ohio
(01:31):
State?
Matt (01:33):
Absolutely.
Thank you Kenny, first.
Of course.
Thanks for letting us do thispodcast today.
My.
Training pathway was somewhatnon-traditional as it relates to
the academic component.
But yeah, my residency was inDayton primarily in a
community-based hospital,similar with my general
(01:56):
cardiology fellowship where Ispent some time with you
actually Kenny at Ohio Health.
And really actually throughmentorship from both of you in
those components that kinda ledme to understand that.
You know, imaging is so diverseand really to sort of
subspecialize and become a trueexpert required additional
(02:19):
training.
And that was where I spent sometime over at Allegheny General
Hospital in Pittsburgh under thestewardship with Dr.
Bob Beaterman.
And that really kind oftransformed my thought process
and just really the what cardiacMRI can provide.
And really that was kind of whatbrought me back to Columbus,
(02:40):
Ohio and Ohio State.
And that really just continue tospearhead all of the innovations
that, that, still continues tothis day.
Kanny (02:50):
Thanks Matt.
Suva, you had a very, I think,interesting path to your current
position.
Of course, many of us, likemyself, who've been practicing
here in in, in central Ohio forseveral decades are familiar
with all the clinical work aswell as the clinical research
you've done in cardiac imagingat Ohio State.
(03:10):
But then you did take aninteresting turn into, becoming
a physician, a service lineleader.
Now you're a leader of a serviceline of over a hundred, plus
clinicians.
I, I think our listeners mightbe curious to hear, what, what
led you to your path toeventually becoming, the leader
of a very large and productiveheart and vascular service line.
Subha (03:34):
Thanks for that question.
Ka, I started out really incardiology fellowship.
I loved all the differentdisciplines.
I had a background inengineering and at the time,
cardiac, MRI and, and CT werejust nascent.
Techniques that we didn't haveat Ohio State where I did my
(03:55):
training.
And so I was very fortunate tobe able to build those programs
from scratch.
I love the appeal of usingadvanced cardiac imaging to be
more proactive with ourpatients.
To get more precise, accuratediagnoses in a more timely
fashion to guide effectivetreatment and improve outcomes.
(04:19):
The transition to my currentleadership role, honestly, is
really one of an opportunity topay it forward.
You know, we, we did so much inour with our imaging team at
OSU.
How do we make sure that thebroader population that we serve
has access to those innovations?
(04:40):
And so that is really my my hopein this role that as a, a leader
of a service line, I can empowerour team to get patients that
needed access so they get theright diagnosis, treatment,
prevent complications.
Kanny (05:01):
Well, that's wonderful.
So yeah, we appreciate,appreciate both of your input
there, Sue.
But lemme just follow up to kindof set the table for our
discussion about the currentstate of cardiac.
Mr.
Just like you, I've been animager for, you know, decades.
Seeing, the development ofcourse, echocardiography nuclear
(05:22):
imaging even cardiac CT, allcome into the mainstream of
everyday cardiology.
As those modalities have evolvedand gotten more complex why do
you think Mr is still sorelevant and has such a unique
role in our kind of toolbox ofimaging techniques?
And why do you think it'srelevant to, you know, general
cardiology?
Subha (05:43):
Yep.
It really is standard of carethese days.
You know, that if we wanna dowhat's best for our patients
with heart and vascular disease,we're actually at a point with
the maturation of this fieldthat it's a disservice not to
offer cardiac MRI.
If, if you think about thingslike coronary and ischemic heart
(06:06):
disease how much.
Heart, muscle is at risk versussalvageable.
If you're thinking about breadand butter interventions or
surgical revascularization.
If you think about thesignificant burden we have of
patients with heart failure andarrhythmias, what's going on
(06:27):
with heart muscle, that's thesubstrate for those conditions.
There's no need to.
To guess anymore, we can getreally precise information, and
the therapeutics have advancedsignificantly in parallel.
So if you think about you know,conditions like vt where's the
(06:48):
VT coming from?
Our, our EP colleagues havetremendous ablative procedures
that they can use to controlthose conditions.
If you think about our patientswith heart failure, you know,
it's the difference betweensaying, well, you know, your EFS
reduced.
It looks like you're gonna havechronic heart failure to looking
(07:10):
at heart muscle and being ableto say, wow, there's a treatable
specific diagnosis here that maydirect them towards.
Targeted molecular therapy foramyloidosis or appropriate
therapy for hypertrophiccardiomyopathy.
So it's really as I would saystandard of care and should be
(07:30):
incorporated across the spectrumof, of heart and vascular
patients.
Kanny (07:35):
So, Matt at your in your position, you know, at a, a
large academic center if youlook at, at the utilization of
CVMR at your center.
Since we don't have time to talkabout every, you know,
indication what would you sayare kind of the broad categories
where you're seeing at least in,in day-to-day clinical practice,
(07:58):
CVRR being used currently?
Matt (08:01):
Yeah, great question.
The.
The important aspect of cardiacM-R-I-M-R-I is really that as
Suva really highlighted, was theadded value that it can improve
in cardiovascular care.
And really I would say perhaps.
Both, all three of us may bejust slightly biased, but
(08:22):
cardiovascular imaging ingeneral really has become the
door to entry across allcardiovascular practices
nowadays.
And, Suba kind of mentioned afew of those already, really
that the most common indicationfor cardiac MRI is, evaluation
of cardiomyopathy, whether it berelated to a non-ischemic
(08:44):
infiltrative arithmetic relatedcardiomyopathies and some form
of ischemic, whether it'sviability in these these
features and the fact that it'snon-radiating and through the
use of gadolinium contrast thatwe're able to perform a, sort of
a non-invasive biopsy and ableto provide that that pro those
(09:04):
prognostic features and guidethose treatments.
Subha (09:08):
If I could add Kenny Matt, it's, it's impressive how
far CMR has come in practiceguidelines you might comment on
that.
Matt (09:19):
Absolutely.
So the, some of the data thatwe've reviewed previously is
fairly old back in 23, suggeststhat at least 40 class one
indications nowadays for cardiacmr.
And obviously there's moresocietal based guidelines which
both of us, all of us haveparticipated in some fashion as
(09:40):
continue to increase the theindications of that's.
Just standard of care as you'vesaid.
Subha (09:49):
And I'd just add a, a note that this is a prominence
in guidelines outside ofimaging, right?
So Heart Rhythm SocietyGuidelines, a CC, European
Society of CardiologyGuidelines.
So this really is something thatwe need to make a commitment to,
to, to provide access toguideline based care for our
(10:10):
patients.
Matt (10:11):
Absolutely.
It's that multi society kind ofvillage mentality to really sort
of come together.
That where imaging has really,especially cardiac, MR has
demonstrated that additionalutility,
Kanny (10:27):
obviously, you know, with CVMR still being a fairly
expensive and sometimes, and Iknow 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 mentionedcardiomyopathy.
So Matt would, is it fair to saythat in a patient with new onset
(10:47):
heart failure, who's found tohave a cardiomyopathy, that CVMR
in almost every instance willprobably provide some additive
value and should generally beconsidered part of the basic
workup?
Or do you still think it's a,you know, case by case kind of a
decision?
Matt (11:04):
Yeah, that is about as classic for a class one
indication in the evaluation ofcardiomyopathy.
So I would say that is about asstandard of care as it comes.
And yeah, we'll, we'll discusssome of the access concerns that
I think we can hopefullyimprove, to make the scans a
little more efficient and thingslike that kind of help improve
(11:27):
that access.
Kanny (11:31):
Suva.
I think as generalcardiologists, 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 emergingareas where MR has a role that
weren't, weren't so obvious toclinicians in the past?
Subha (11:53):
Happy to do so.
This is now very much part ofevaluation and management of
patients with a, a broad rangeof cardiac arrhythmias.
I think the, the difference now,if, and if you ask our EP
colleagues, they'll probably bethe first to tell you this is
(12:13):
instead of looking solely at anelectrical signal and trying to
go after it, for instance, inthe EP lab.
What's the substrate forarrhythmia?
You know, there's there's a lotof things that can lead to
things like atrial fibrillation,ventricular tachycardia, even
somebody who has a heavy burdenof premature ventricular
complexes.
(12:34):
I think Matt and I have probablyseen too often the patient gets
a rhythm treatment without aroot cause diagnosis, and by the
time they get to the cardiac MRLab, you say, gosh.
If we could have dialed theclock back, you know, earlier we
could have given the, the EPteam that substrate information.
(12:56):
Now, as I mentioned, heartRhythm Society says, let's get
that information on why thepatient has a certain
arrhythmia.
Certainly if you think aboutPVCs, vt, there's no question
that those things come fromventricular myocardium.
(13:17):
You need to know what thedisease is there that's leading
to the arrhythmia.
Of course there are channelpathy, channelopathies and such
that, that may have structurallynormal hearts but even with a
normal ejection fraction, youknow, I don't think we should be
reassured by patients whose echocomes back looking pretty good.
(13:39):
When somebody has a, apotentially life-threatening
arrhythmia, atrial fibrillationhas also advanced quite a bit.
You know, I'm, I'm sure Matt hasalso seen, I've seen patients
who AFib is just the, kind ofthe presenting symptom almost,
right?
That they've got AFib due to anundiagnosed cardiomyopathy.
(14:02):
They've got AFib in the settingof maybe valvular disease that
was more severe than estimatedby surface echo.
Matt, I'd be interested in yourthoughts on this.
Matt (14:12):
Yeah, absolutely.
Perhaps even just to kind ofpiggyback of some of the things
that you discussed, really froma myocardial diagnosis
standpoint from just startingwith electrophysiology stand
aspects LVH, right?
Do we think it could be ahypertrophic cardiomyopathy or
maybe it's not and it's a, aFabry disease.
(14:32):
Could it be amyloid disease?
That, and those are the thingsthat can be.
Reasonably easily differentiatedby cardiac mr.
And just really being able totease, like you said, that root
cause diagnosis will really kindof help guide the appropriate
treatment for those patients.
And then, transitioning furtherto just what, what you
(14:53):
suggested, the valvular heartdisease, right, that is quite
another common adult diagnosisand certainly.
The imaging modalities,particularly echocardiography,
really represents the sort ofthe the mainstay of the
evaluation.
But where cardiac Mr really addsto that is that that accurate
(15:19):
quantification of regards to 10volume and fraction.
And there's been numerousstudies now that really has
helped to guide whether thesepatients should be going towards
some surgical intervention.
It's been great to, to see thefield growing in that side
because of obviously it's a, alarge, population with that
(15:41):
pathology.
And it can not only, of coursemake that determination whether
they should go to some form ofan intervention, but now it's
improved to the point where wepotentially could help guide
some of these interventions aswell.
To the point similar to.
TAVR based procedures and those,those type of interventions.
(16:02):
So yeah, it's, it's there's alot of opportunity to, to of
growth where cardiac Mr.
Can really add that value.
Subha (16:11):
Yeah, I think of the questions that are structural
heart interventionalists have,you know, particularly in
patients with, emergence oftranscatheter treatments for
mitral valve disease that'ssomething you really wanna get
right.
In terms of severity of thingslike mitral regurgitation to
(16:31):
guide what can be reallylife-changing interventions.
Kanny (16:37):
One other area, Matt, I wanted to ask about before we
move on to talking about somespecific you know, situations is
stress, Mr.
You know, as an alternative toother types of stress imaging.
I know this has emerged inrecent years.
I'm just curious how you at OhioState you are incorporating, any
stress protocols as analternative to some of the other
(16:59):
imaging like PET and CCTA.
Matt (17:02):
Yeah, great question.
So definitely.
We had Ohio State and certainlySuva has very much contributed
to this field as well.
That kind of really set thestage for stress cardiac Mr.
Effectively becoming essentiallyin the same playing field as the
other imaging modalities.
(17:23):
Level one excuse class oneindication for the evaluation of
ischemia.
We pre predominantly perform,adenosine stress.
We've adapted a few techniquesnow to do quantitative
perfusion.
So now you can actually providea number to the evaluation
similar to Stress Pet, to addthat evaluation of microvascular
(17:49):
disease to, to determine thatversus potential multi-vessel
disease.
Those that has been.
It, it continues to evolve andreally a lot of innovative
techniques that have happened.
But the important part really tohighlight about stress cardiac
MR is really that the reductionof downstream testing and the
(18:10):
cost savings that that happenthat have been well demonstrated
throughout multiple studies nowthrough that technique.
Kanny (18:18):
Great.
I guess, whenever we do talkabout advanced imaging is
particularly CVMR, at least Inotice, the, there's always the
discussion comes around toconcerns about certain patient
populations.
For example, you know, renaldisease or patients with
devices.
So Suva, I was wondering if youcould just briefly summarize the
current state of, using CVMR inpatients with impaired renal
(18:41):
function first and then maybeMatt can talk about use with
devices.
Subha (18:45):
Yes, thank you.
There is no reason that apatient with with chronic kidney
disease.
Shouldn't be referred forcardiac Mr.
It's come a long way.
You know that really over adecade ago there was a
recognition that the oldercontrast agents that we used for
(19:06):
cardiac MR could lead to aserious 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 theworld have shifted to what are
(19:26):
called macrocyclic, gadoliniumbased contrast agents that are
proven to be safe regardless ofan patient's renal function, to
the point that the AmericanCollege of Radiology, in fact.
Has done away with itsrecommendation to check
creatinine before cardiac andother galin based exams.
Matt (19:49):
Maybe something to add to that actually that is a, a
commonly confused is the use ofgadolinium compared to something
like ct and other, and thecontrast that we use in MRI,
that it is not the, I donatedcontrast this, this gadolinium
based contrast that UBA haddiscussed.
(20:10):
Really that the safety profilein general of gadolinium based
contrast agents are actuallymore safe than the iodinated
contrast.
And so the common questions thatI've received in the past, I'm
sure you has, has as well, hasbeen related to do, do these
(20:32):
patients need contrast withtheir cardiac mr.
And the general answer is yes.
Primarily for one, the, thesafe, the well demonstrated
safety profile that we'vediscussed.
And also it is essentially the,the primary use to, for the
tissue characterizationcomponents and really knowing
(20:55):
the fact that it's safe asmentioned, and the fact that
actually cardiac Mr.
When they go into the tunnel tobe evaluated about, there's been
numerous studies now about 25 to27% of cases really are new
diagnosis that day that.
They didn't realize until theywent to cardiac mr.
(21:17):
So that, again, adding thatvalue demonstrating the safety
profile, we're using gadoliniumcontrast based agents, not the I
donated aspect.
So really doing a contrastedcardiac Mr.
Is generally very safe.
Kanny (21:34):
Well, that's reassuring Matt.
And then what's your current forwith devices as well?
Matt (21:40):
Yeah.
Thank you.
All devices.
So we'll just start with nonintracardiac devices.
Orthopedic implants.
I think it's a, a commonquestion mark or those, those
items and essentially thosepassive based devices
essentially are very safe.
(22:02):
Those there's no reason to beconcerned whatsoever to perform
a cardiac Mr from a safetyprofile in that aspect.
Some of the questions thenreally come into are the
intracardiac devices, sopacemakers, defibrillators loop
recorders, definitely.
The loop recorders from a safetyperspective has been well
demonstrated that that's that'sokay.
(22:25):
And essentially.
Beyond what the, what's definedas the MR.
Conditional devices, it's beenalso well demonstrated with.
Pretty much numerous studies nowthey, they're defined as legacy
devices that effectively havebeen very safe and no major
concerns for the patient.
(22:47):
Primarily the main question markfor the.
Reading a cardiologist reallyhas more more to do with the
device artifact.
And from that perspective,really again, evaluation of late
gadolinium enhancement or theevaluation of scar fibrosis.
(23:07):
A lot of the product sequencesare 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 (23:19):
I, I would add candy that because there's such widespread
recognition of the value of atimely cardiac MR exam for so
many patients, devicemanufacturers are very committed
to designing things in a waythat a patient can undergo a
cardiac Mr.
Safely.
(23:40):
It starts with you know, workingwith your technologist if you're
not sure really the best pointof contact.
They're gonna do very carefulscreening and set up an approach
that's really focused on maximumsafety for the patient.
Kanny (24:00):
Well that's good to know.
Another question, Suba, and I'msure you get this question when
cases are referred, is, youknow, the patient with either
history of claustrophobia orconcerns about becoming
claustrophobic.
Is there any advice we can givethe ordering physician there to
clarify who is or is not acandidate?
Subha (24:21):
It's really a, an opportunity to, again, entrust
your cardiac MRI team.
We have amazing technologiststhat all, all the centers that
are dedicated to this type ofservice, that work with the
patient.
The diameter of the scanner hasincreased over time.
So we think about what arecalled large bore scanners that
(24:44):
are now essentially the standardMRI scanner in terms of
diameter, not too far off froma, a CT scanner's diameter.
And we can give patients musicto listen to.
We can put a, a washcloth overtheir eyes.
And the other nice thing about acardiac Mr exam versus let's say
(25:04):
a brain scan is.
There's a lot of interactionwith the patient throughout the
scan so they can really movethings along and put the patient
at ease.
Even if they've got some degreeof claustrophobia, there are
some folks that need someanxiolytic medication in advance
and that helps take the edge offthe procedure.
Kanny (25:26):
Good to know.
So Matt just talking a littlemore about.
Kind of barriers to access,obviously, we all work in large
healthcare systems where we haveaccess to advanced imaging
pretty readily.
With CVMR, of course, it's, it'salways been a relatively
expensive modality.
And of course, based on therequirements to perform the
(25:49):
testing, it's not easily.
Translates to smaller clinicalsettings or more remote settings
and not to mention issues withpre-authorization like we get
with all advanced imaging.
So I'm, I'm just curious likewhat the CVMR community you
think is doing to try to getaccess to advanced imaging out
to some of our more, remoteareas of Ohio
Matt (26:12):
Yeah, this is a, a, a very great and important question to
be asked.
And really we have.
The, our society, the societyfor CMR and advocates like the
three of us to reallydemonstrate that the, the needle
has moved in impressively inthat aspect.
And so let's touch briefly aboutyou mentioned prior
(26:34):
authorizations and obviously allof us have practiced to some
degree and having to have tomake those phone calls and
really.
A number of these Class one andClass two indication increases
over time have really permeatedinto those the insurers practice
(26:56):
guidelines.
And that really has alreadyimproved a bit from the.
How do I say barriers to entryto be concerned that, hey you
know, I, I won't get denied orsomething like that.
From an insurance standpointthe, the pure blunt cost of a
cardiac MMRI versus othermodalities is a very complex
(27:18):
aspect discussion that I don'twant to get too much into, but
really the more important aspectare.
Discussions around what, whatdoes it add as it compares to
what does it save, and a commonev Multiple studies have
demonstrated that the costsavings for cardiac MR as it
relates to primarily thereduction of downstream testing.
(27:40):
So the most common one thatwe've referenced in the past
really has to do with the theSPINS trial, which was related
to stress, cardiac mr.
And really demonstrated comparedto some of the other modalities
that it, it actually is quiteeffective, particularly compared
to the increased amount ofcatheterizations based on other
modalities from thatperspective.
Kanny (28:01):
Great.
Just in the last five minutes orso that we have left it'd be
kind of nice to talk about maybesome future directions, you
know, that you see CVMR going.
What do you think are some ofthe innovations right now that
you see Suva and CVMR that aregonna translate into, kind of
the everyday practice?
I know in other types ofmodalities like Echo, there's a,
(28:23):
a move to use artificialintelligence to maybe simplify
like the interpretation oraugment interpretation.
Do you see similar thingsoccurring in Mr.
Imaging?
Subha (28:34):
Absolutely.
And a lot of that is already inplace.
I, I would like to start withtaking a a page from our
colleagues elsewhere around theworld, even what we would
consider developing countrieswho really have made access a
priority for their communities.
There's a, a wonderfulmultinational study that
(28:57):
involves places like BrazilPeru.
India where they shortened theprotocol, really focusing on
what's the clinical questionthat we need to answer sometimes
as short as 15 minutes.
I've put out a paper inconjunction with the Society for
Cardiovascular MagneticResonance on a a 30 minute
(29:17):
Cardiac MR exam.
You know, these are all thingsthat are within reach.
Innovation isn't always, youknow, tech, it's taking.
Things like c imaging gadoliniumenhancement imaging, which
again, is a workhorse thatreally no other mod modality can
provide.
And doing that in less than halfan hour.
(29:40):
Ought to make cardiac Mr.
More accessible.
And I, I think just about ourown health system, we've got
great CMR clinicians doing thisin places like Mansfield, Ohio,
Pickerington, and smallercommunities.
Think about the access close tohome and how that really gets
(30:01):
you the care that.
Is within reach and notrequiring you to go to, you
know, a larger center.
There certainly is a lot goingon with ai.
I would say probably most labs,if they realize it or not
whatever reporting systemthey're using today to analyze
studies is leveraging thetremendous advances that have
(30:24):
occurred with AI to shorten thetime that it takes to read and
analyze and report a study.
Kanny (30:31):
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 guideinterpretation.
Matt (30:40):
Yeah, absolutely.
Artificial intelligence,intelligence is kind of
permeated across all aspects asit relates to the
post-processing, as Sue was kindof mentioned, and really the
even the image acquisitioncomponents.
So it's really kind ofpartnering across the board here
you know, this kind of villagementality of getting industry
(31:02):
and hospital systems together tokind of really improve this
throughput.
Just Sue's point about this 30minute exam, it really kind of
highlights the utility of just30 minutes really can
effectively answer over 90% ofthe indications that have been
(31:23):
well documented based on.
The registry data that we'vepreviously published.
So I think that is really justhelping to improve that access
on top of, of the otherinnovative techniques that are
coming, coming that's alreadyhere.
Frankly.
Kanny (31:41):
Well, that's wonderful.
I think we're kind of up againstour time, but I, I think we had
a pretty nice discussion, notjust of updated clinical
indications and some newindications as well, but we
talked a little bit about, thebarriers to access and how we're
working on that.
And we talked about.
Specific clinical scenarios aswell.
So I think I think our listenershave have plenty to take away.
(32:04):
I guess I wanna thank you both.
You know, I've been an imagermyself for three decades, and so
I'm o obviously find this veryfascinating.
But I think it's great that.
In the time I've been inpractice, we've seen something
that went from, kind of anquote, experimental technology
to something that we all useevery day.
And and we're very grateful tohave here in Ohio, physician
(32:25):
researchers, like both of youhelping move that forward.
So thanks again, both for yourtime.
Matt (32:32):
Thank you, Kenny.
Thank you Kenny.
Thank you for joining today'spodcast.
For more information about thespeakers or the topics, please
go to Ohio acc.org,
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