International Circulation: I am here at this year’s CHC with Dr. Sanjay Prasad from the CMR Unit at the Royal Brompton Hospital in London. We are very glad you can join us and educate us about your current work in cardiovascular imaging. At the Cardiology Imaging Summit， we heard in your presentation that you are focusing on myocardial fibrosis. Can you share with us the current role of imaging has taken on in diagnosis， prognosis and evaluation， and risk stratification for myocardial fibrosis?

　　《国际循环》：我们在CHC 2014年会现场采访英国伦敦皇家布朗普顿医院心脏磁共振（CMR）单元Sanjay Prasad博士。Prasad博士您好，非常感谢您来中国参会并向我们介绍您在心脏影像学领域的近期工作进展。在心脏成像峰会专题，您讲述了心肌纤维化方面的内容。您能否与我们分享如何看待影像学在心肌纤维化诊断、预后、评估及危险分层中的作用？

　　Dr. Prasad: One of the big challenges in cardiology is trying to anticipate and predict who has heart problems. One of the big challenges has been how can we identify the substrate for patients that are going to have problems， such as heart failure or rhythm disturbances. Until recently， one of the difficulties we had is how to establish and determine fibrosis within the heart muscle. You can do it through biopsies but that is invasive. With the advent of cardiovascular magnetic resonance imaging now， using a non-invasive technique where we are just using radio waves and magnetic waves， we now for the first time have the opportunity in vivo to establish and determine both the amount， the spatial extend， and the distribution of fibrosis within the heart muscle. This has been a really fabulous advance， and using this technology what we now understand is how this correlates with prognosis and in changing the management. Examples are where you have fibrosis， both in the ischemic setting and non ischemic cardiomyopathy， there is something like a five-fold greater risk of major arrhythmic events in patients that have fibrosis. Likewise， there is about a threefold greater risk of developing heart failure symptoms where there is a high fibrosis burden. This has now become well established， and what we are working on now is multicenter randomized trials that will then help to establish is this a portal by which we can actually select and define therapeutic strategies. The next arm of our work is twofold. One is how can we use this to pick up really fine stages of fibrosis， so using a technique called T1 mapping we are now looking at interstitial fibrosis. The second thing is how can therapy intervene on fibrosis and help to reduce the burden.

　　Prasad博士：一直以来，心脏病学面临的一个重大挑战是如何预测哪些人会发生心脏问题，如何早期识别那些将来会发生心力衰竭、心律失常等的人群。直到现在，我们仍面临如何确定心肌纤维化的难题。我们可通过有创心肌活检识别和确定心肌纤维化。随着CMR出现，我们首次有机会采用无创技术，即仅通过无线电波和电磁波确定体内心肌纤维化的数量、范围及分布。这是非常神奇的进步，我们现在已知道CMR技术检查结果与患者预后及疾病管理策略变化的相关性。例如，不论是缺血性还是非缺血性心肌病，纤维化均可使主要心律失常事件风险增加大约5倍。同样，对纤维化程度较高的患者，其发生心力衰竭风险可增加3倍。这些都已非常明确。需开展多中心随机试验确定应选择的治疗策略。接下来的工作集中在两个方面，一是应如何利用CMR对纤维化进行更精确分级，对此我们现在已经可采用T1成像技术评估间质纤维化；另外，如何干预纤维化以减轻疾病负担。

　　International Circulation: Coming up here at the second cardio imagine session happening later this afternoon you are going to present “The Role of CMR in Inflammatory Cardiac Conditions - Where are we in 2014”. Could you give us a little preview of your presentation and what we can apply?

　　《国际循环》：在今天下午将召开的心脏影像专题Ⅱ中，您将发表题为“CMR在感染性疾病中的意义-我们目前的进展”的演讲。能否请您简要介绍一下该内容及对临床应用的启示？

　　Dr. Prasad: Myocarditis due to a viral infection or due to chemotherapy， systemic lupus erythematosus， rheumatoid arthritis， these are common conditions that affect a large number of patients. They have a big systemic component and what a big challenge is if there is a cardiac element to that disorder. Up to now， it has really been gauged by symptoms and by ECG， by ECHO， and the difficulty with that is you are really looking at quite a late stage in the natural history of the disease process. What we are interested in is how can we use the same technology of cardiovascular magnetic resonance with a culmination of magnetic waves and radio waves to determine firstly whether there is cardiac involvement or not. And the way we can do that is we can look at function， we can look at regional wall motion abnormalities， we look for acute inflammation using something called a T2 weighted sequence and then finally we would use late enhancement imaging using a gadolinium based contrast agent which only accumulates in areas of increased extracellular space and therefore is a good indication of increased fibrosis. Using that combination， we can then define whether there is cardiac involvement or not， plus whether there is an active component or it is burned out.

　　Prasad博士：病毒感染、化疗、系统性红斑狼疮、类风湿性关节炎等感染性疾病均可导致心肌炎。上述情况均可累及全身各组织器官，但最大的挑战在于确定心脏是否受累。现在，通过症状、心电图、超声已可确定是否存在心脏问题。但问题在于采用上述方法发现的疾病已处于疾病自然病程的晚期阶段。我们感兴趣的是，应如何采用CMR技术首先确定心脏是否受累。可采用T2加权像观察心功能、局部室壁运动异常情况及心肌炎性反应；并采用仅能在细胞外空间增加区域聚积的含钆造影剂进行晚期增强成像，造影剂聚集增加则提示心肌纤维化增加。这样一来，我们便可确定心脏是否受累、是否仍有存活心肌或完全丧失功能。

　　International Circulation: So we can use this as a preventative look ahead and hopefully stop further disease?

　　《国际循环》：我们能否可以将CMR技术作为一种筛查手段，以及时采取措施遏制疾病进展？

　　Dr. Prasad: I think first thing is can we use it to define whether there is cardiac involvement or not， and likewise in sarcoid disease， but the implication of that is do you put patients for example on high dose steroids， because although patients may have a systemic component to their disease， much of the morbidity is cardiac related， so for example， how would this change our management? First of all， do we pulse patients with high dose steroids; and then the second application would be if we can define very early changes again， can we anticipate and prevent disease hopefully. Going forward， particularly due to chemotherapy related inflammation where a lot of patients with cancer therapy are now having their cancer treatment put on hold whilst their cardiac side effects are being dealt with， can we find ways to prevent that cardiotoxicity， so that will be a key challenge going forward.

　　Prasad博士：首先，我们可应用该技术确定心脏是否受累。以结节病为例，应用CMR的意义在于有助于确定是否应用大剂量类固醇治疗。因为尽管患者可能存在全身症状，但大部分发病时都存在心脏受累。若合并心脏受累，我们应如何调整或改变管理策略，是否应对患者应用大剂量类固醇。其次，如果我们能识别疾病早期变化，则可预测疾病发展并加以预防。鉴于很多癌症患者因化疗相关炎症需要对心脏副作用处理而暂停癌症治疗，未来我们需寻求解决化疗心脏毒性的有效措施，这也是将来面临的主要挑战。

采访概要：

　　CMR在心肌纤维化及感染性疾病诊疗中的作用--英国伦敦皇家布朗普顿医院Sanjay Prasad博士专访

　　编者按：心血管影像专题在CHC 2014上成功举办了7场，涵盖CT、光学相干断层扫描（OCT）、正电子发射型计算机断层显像（PET）、磁共振（MRI）、超声心动图、门控心肌显像、心脏MRI（CMR）等各种影像技术；涉及先天性心脏病、冠心病、感染性疾病、心肌病、心脏瓣膜病等疾病类型的基础研究到临床应用。本届会议上，英国伦敦皇家布朗普顿医院CMR单元Sanjay Prasad博士受邀进行了两场演讲，《国际循环》记者在大会现场就影像学技术应用对其进行了采访。

　　影像学在心肌纤维化诊疗中的作用

　　一直以来，心脏病学的一项重大挑战是如何预测并早期识别哪些人群将来会发生心力衰竭、心律失常等心脏疾病。到目前为止，我们仍面临如何确定心肌纤维化的难题。通过心肌活检可以识别和确定心肌纤维化，但这一技术为有创性；随着CMR出现，采用无创技术，即仅通过无线电波和电磁波即可确定体内心肌纤维化数量、范围和分布。这是非常重要的进步，我们现在已知CMR检查结果与患者预后和疾病管理策略变化的相关性。例如，不论是缺血性还是非缺血性心肌病，纤维化均可使主要心律失常事件风险增加大约5倍；对纤维化程度较高的患者，其发生心力衰竭风险可增加3倍。这些都已非常明确。未来需开展多中心随机试验确定应选择的治疗策略。我们后续工作集中在两方面，一是如何利用CMR对纤维化进行更精确分级，现在已可用T1成像技术评估间质纤维化；另一方面为如何干预纤维化以减轻疾病负担。

　　CMR在感染性疾病管理中的意义

　　病毒感染、化疗、系统性红斑狼疮、类风湿性关节炎等感染性疾病均可导致心肌炎。上述情况均可累及全身各组织器官，但最大的挑战在于确定心脏是否受累。现在，通过症状、心电图、超声已可确定患者是否存在心脏问题。但采用上述方法发现的疾病已处于自然病程的晚期阶段。我们对如何采用CMR技术首先确定心脏是否受累感兴趣。例如，可采用T2加权像观察心功能、局部室壁运动异常情况及心肌炎性反应；应用仅能在细胞外空间增加区域聚积的含钆造影剂造影进行晚期增强成像，造影剂聚集增加则提示心肌纤维化增加。通过以上方法，我们可确定心脏是否受累、是否仍有存活心肌或功能完全丧失。

　　以结节病为例，应用CMR的意义在于有助于确定是否使用大剂量类固醇治疗。因为尽管患者可能存在全身症状，但大部分发病时存在心脏受累。如果我们能通过CMR识别疾病早期变化，则可预测疾病进展并加以预防。鉴于很多癌症患者因化疗相关炎症需要处理心脏不良反应而暂停癌症治疗，未来我们需寻求解决化疗心脏毒性的有效措施，这也是将来面临的主要挑战。