Cardiac Positron Emission
Tomography
Department of
Nuclear Medicine
Department of Nuclear Medicine
Asan Medical Center
Uni...
Advanced Cardiology… Anatomy to Physiology
PET-CT Fusion… Better Coronary Artery Disease Assessment
CAI – Vessel Tracking ...
Cardiac PET
• Perfusion imaging
• Cardiac metabolism
• Pre & Post synaptic autonomous nervous system
• Other cardiac recep...
Advantage: Cardiac PET over SPECT
• Higher spatial resolution
• Higher temporal resolution
• Quantitation of myocardial fl...
Clinical Issues in Cardiac PET
• More expensive than other methods
• Blunted ratio of cost-effectiveness
PET must demonstr...
ACC/AHA/ASNC Guideline
Cardiac Radionuclide Imaging, 2003
• Acute Syndrome
• Chronic Syndrome: Vasodilator stress myocardi...
ACC/AHA Guideline for PET
• Chronic Stable Angina, 2002
• Chronic Heart Failure, 2001
Coronary revascularization: Pts with...
[18F]FDG PET covered by Medicare in US, 2003
• Diagnosis, staging and restaging of lymphoma and lung,
head and neck, esoph...
FDG PET To Assess Viability
• Regional Function
• Global LV Function
• Symptom and Performance
• Prognosis
• Impact on Pat...
• Myocardial perfusion:
N-13 ammonia, Rb-82 chloride, O-15 water
• Myocardial metabolism:
F-18 FDG, C-11 palmitate, C-11 a...
Myocardial Perfusion, FDG Uptake, and
Contraction in Relation to Tissue Classification
Contraction Perfusion FDG Uptake
No...
• 12/male
• 1 year ago, Kawasaki’s disease/Coranary aneurysm
• Recurrent chest pain
Viability: SN and SP for the Different Imaging Techniques
(based on weighted mean values from available studies)
No. of Se...
Declining specificity in viability studies
• Segments with nontransmural infarction or remodelling:
Not necessarily improv...
• Inclusion of severe LV dysfunction?
• Varying metabolic conditions
• Different imaging protocol
• Not uniform viability ...
Summary of 20 FDG PET Studies with Functional Follow-up Post Revascularisation
Authors Perfusion tracer Analysis Viability...
Allman et al. J Am Coll Cardiol 2002;39:1151-8.
Myocardial Viability Testing & Impact of Revascularization
Prognosis in Pt...
Limitations of the available prognosis data
• No randomized controlled trials
• Retrospective studies: selection biases
• ...
Successful Viability Outcomes Study Design
• Randomized-controlled trial ideally (or large prospective cohort study).
• La...
Unresolved issues
• Prospective randomized trialrandomized trial with long-term clinical, perfusion and function
follow-up...
Targets for Atherosclerosis Imaging
Necrotic core, Fibrous cap, Calcium, Inflammatory activity
Histopathology of Plaque Pr...
Imaging
Atherosclerotic
Plaque Inflammation
With FDG PET
[3H]DG
Autoradiography
Rudd et al, Circulation
2002;105:2708-11.
...
Imaging Large Vessel Arteritis with [18F]-FDG PET
M/81 recurrent fever
Circulation 2003;107:923, & Heart 2003;89:e9.
F/27 ...
Inubushi et al. Circulation 2003;107:326-32.
PET Reporter Gene Expression Imaging in Rat Myocardium
Ad-CMV-HSV1-sr39tk IM ...
Bioluminescence and PET: Cardiac Cell Transplantation
Rats receiving cardiomyoblast expressing HSV1-sr39tk
A: Optical imag...
Herreros J, et al. Eur Heart J 2003;24:2012-20.
13N Ammonia 18F FDG 13N Ammonia 18F FDG
Baseline Follow-up
Cultured Skelet...
Cardiac Positron Emission Tomography
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Cardiac Positron Emission Tomography

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Cardiac Positron Emission Tomography

  1. 1. Cardiac Positron Emission Tomography Department of Nuclear Medicine Department of Nuclear Medicine Asan Medical Center University of Ulsan College of Medicine Dae Hyuk Moon, MD
  2. 2. Advanced Cardiology… Anatomy to Physiology PET-CT Fusion… Better Coronary Artery Disease Assessment CAI – Vessel Tracking Perfusion Department of Nuclear Medicine
  3. 3. Cardiac PET • Perfusion imaging • Cardiac metabolism • Pre & Post synaptic autonomous nervous system • Other cardiac receptors • Atherosclerotic plaque characterization • Angiogenesis • Hypoxia • Cardiac transgenic expression • Cell therapy Department of Nuclear Medicine
  4. 4. Advantage: Cardiac PET over SPECT • Higher spatial resolution • Higher temporal resolution • Quantitation of myocardial flow • Assessment of myocardial metabolism Department of Nuclear Medicine
  5. 5. Clinical Issues in Cardiac PET • More expensive than other methods • Blunted ratio of cost-effectiveness PET must demonstrate a complementary and optimally unique clinical role in comparison to less costly and more readily available conventional imaging methods and modalities. Department of Nuclear Medicine
  6. 6. ACC/AHA/ASNC Guideline Cardiac Radionuclide Imaging, 2003 • Acute Syndrome • Chronic Syndrome: Vasodilator stress myocardial perfusion PET Dx and risk stratification of pts with an intermediate or high LH of CAD Equivocal myocardial perfusion SPECT (I) To identify the extent, severity, & location of ischemia as the initial diagnostic test in patients who are unable to exercise, or able to exercise but have LBBB or electronically-paced rhythm (IIa) • Heart Failure: Perfusion plus PET FDG imaging Predicting improvement in LV function after revasc (I) Predicting improvement in HF symptoms after revasc (IIa) Predicting improvement in natural history after revasc (I) Department of Nuclear Medicine
  7. 7. ACC/AHA Guideline for PET • Chronic Stable Angina, 2002 • Chronic Heart Failure, 2001 Coronary revascularization: Pts with CAD, angina, and HF (I, A) Noninvasive imaging: known CAD, no angina, candidate for revasc to detect ischemia & viability (IIa, C) Noninvasive imaging: define the likelihood of CAD in pts with LV dysfunction (IIb, C) • Coronary Artery Bypass Graft Surgery, 2002 CABG: 2 VD (LAD), LV dysfunction or ischemia (I) PCI or CABG: 1 or 2 VD, large viable, or high risk on imaging (I) PCI or CABG: 1 or 2 VD, mod viable & ischemic on imaging (IIa) • Percutaneous Coronary Intervention, 2001 PCI: large viable myocardium or myocardial ischemia (I) Department of Nuclear Medicine
  8. 8. [18F]FDG PET covered by Medicare in US, 2003 • Diagnosis, staging and restaging of lymphoma and lung, head and neck, esophageal, melanoma and colorectal cancer • Staging & restaging of breast, and thyroid cancer • Presurgical evaluation of refractory epilepsy • Assessing myocardial viability A positive myocardial perfusion imaging study when clinical evidence is mixed. The decision to perform revascularization is based on the probability that improved systolic function that can occur with viable myocardium. FDG PET likely detects tissue that will not respond well to revascularization when SPECT is positive and FDG is negative. Department of Nuclear Medicine
  9. 9. FDG PET To Assess Viability • Regional Function • Global LV Function • Symptom and Performance • Prognosis • Impact on Patient Management Prediction of Improvement after Revascularization Department of Nuclear Medicine
  10. 10. • Myocardial perfusion: N-13 ammonia, Rb-82 chloride, O-15 water • Myocardial metabolism: F-18 FDG, C-11 palmitate, C-11 acetate Positron Emitters used for Cardiac PET imaging Department of Nuclear Medicine
  11. 11. Myocardial Perfusion, FDG Uptake, and Contraction in Relation to Tissue Classification Contraction Perfusion FDG Uptake Normal myocardium N N N Repetitive stunning ↓ N N or ↑ Hibernation ↓ ↓/↓↓ N or ↑ Transmural scar ↓ ↓↓ ↓↓ Nontransmural scar ↓ ↓ ↓ N, normal; ↓, decreased; ↓↓, severely decreased; ↑, increased. Bax et al. Semin Nucl Med 2000;30:281-98. Department of Nuclear Medicine
  12. 12. • 12/male • 1 year ago, Kawasaki’s disease/Coranary aneurysm • Recurrent chest pain
  13. 13. Viability: SN and SP for the Different Imaging Techniques (based on weighted mean values from available studies) No. of Sens Spec Pts (%) 95% CI 99% CI (%) 95% CI 99% CI Tc-99m MIBI 207 83 78-87 77-89 69 63-74 61-76 LDDE 448 84 82-86 81-87 81 79-84 79-84 Tl-201 reinjection 209 86 83-89 82-90 47 43-51 42-52 F-18 FDG PET 332 88 84-91 83-92 73 69-77 69-77 Tl-201 rest-redistribution 145 90 87-93 86-94 54 49-60 48-61 Bax et al. J Am Coll Cardiol 1997;30:451-60. Department of Nuclear Medicine
  14. 14. Declining specificity in viability studies • Segments with nontransmural infarction or remodelling: Not necessarily improve in function after revascularizationNot necessarily improve in function after revascularization • The time of follow-up may be too early. • Irreversible structural changes in long standing hibernation • The adequacy of revascularization • Patient selection bias: "true-negative" segments will not be included in the analysis. • Other benefit: LV remodeling, ventricular arrhythmia, MI Department of Nuclear Medicine
  15. 15. • Inclusion of severe LV dysfunction? • Varying metabolic conditions • Different imaging protocol • Not uniform viability criteria Limitations of the available viability data Department of Nuclear Medicine
  16. 16. Summary of 20 FDG PET Studies with Functional Follow-up Post Revascularisation Authors Perfusion tracer Analysis Viability criteria Metabolic conditions Baer None Semi-quantitative ≥50% of Maximun FDG uptake Oral glucose Carrel 82Ru NA Mismatch Fasting Gerber NH3 Semi-quantitative Mismatch Clamp Gropler 11C-acetate Semi-quantitative Mismatch, FDG > 2SD normal Oral glucose Kitsiou NH3 Semi-quantitative ≥65% of normal FDG uptake Oral glucose Knuuti Tl-201/MIBI Semi-quantitative Mismatch, normalised FDG uptake Oral glucose Lucignani MIBI Visual Mismatch Fasting Maes NH3 Absolute quantification Mismatch, nl Clamp Marwick Ru-82 Semi-quantitative Mismatch, nl Oral glucose Fath-Ordoubadi None Absolute quantification rMGU Clamp Pagano None Absolute quantification rMGU ≥ 0.25 μmol min-1 g-1 Clamp Paolini MIBI Visual Mismatch Fasting Schoder NH3 Semi-quantitative Mismatch Oral glucose Tamaki NH3 Semi-quantitative Mismatch Fasting Tamaki NH3 Semi-quantitative Mismatch Fasting Tamaki NH3 Semi-quantitative Mismatch Fasting Tillisch NH3 Semi-quantitative Mismatch, nl Oral glucose Vom Dahl NH3 Visual Mismatch, nl Oral glucose Vom Dahl MIBI Semi-quantitative Mismatch, nl Oral glucose Wolpers 11C-acetate Absolute quantification Mismatch Oral glucose Knuuti , et al. Eur J Nucl Med 2002;29:1257-66. Department of Nuclear Medicine
  17. 17. Allman et al. J Am Coll Cardiol 2002;39:1151-8. Myocardial Viability Testing & Impact of Revascularization Prognosis in Pt with CAD and LV dysfunction: A meta-analysis Survival of pts with viable myocardium: Revasc. > Medical tx? Viability assessment improve selection of pts for revasc? Improved outcomes after revasc are related to improved LV function? Department of Nuclear Medicine
  18. 18. Limitations of the available prognosis data • No randomized controlled trials • Retrospective studies: selection biases • Small sample size, short f/u period, low event rate • No standardized criteria for viability • Limitation of binary grouping: viable vs non • No standardized medical therapy • Heterog. pts: CAD, Sx, HF, prior revasc, women • Different type and completeness of revasc • Lack of postrevasc study for completeness of revasc Department of Nuclear Medicine
  19. 19. Successful Viability Outcomes Study Design • Randomized-controlled trial ideally (or large prospective cohort study). • Large sample size. • Follow-up for at least 5 years. • Adequate power to detect clinically significant differences in mortality. • Stricter inclusion criteria: EF ≤ 40% and epicardial vessels or major branches with stenosis ≥ 70% on recent CAG (within 6 m). • Use of accurate viability criteria: analysis of ≥ 17 segments, use of Cox modeling or ROC curves to establish cutoff for significant viability. • Use of both medical and revascularization groups (PCI and CABG), with analysis using Kaplan-Meier and Cox-adjusted survival curves. • Analysis of baseline characteristics btw subjects undergoing viability and those not to establish magnitude of referral bias or adjust study design to eliminate large differences. • Identification of the prevalence of viability in a large cohort of patients irrespective of treatment received. • Recruitment of more women and minorities. Department of Nuclear Medicine
  20. 20. Unresolved issues • Prospective randomized trialrandomized trial with long-term clinical, perfusion and function follow-up: Difficult because clinicians already accept "viability study” • Require confirmation in larger serieslarger series: small number of patients with hard events • Extent of mismatchof mismatch with PET to suggest good outcome from revasclularization • Time course of recoverycourse of recovery after revascularization relative to preop index of perfusion and contractile reserve • Outcome of patients with extensive regions of viable myocardiumcome of patients with extensive regions of viable myocardium by PET that lack contractile reserve • LV volume measurementvolume measurement adds additional discriminatory value? • Relationship between tissue viability and changes in LV geometrytissue viability and changes in LV geometry • Limited data in women and patients with diabetes Department of Nuclear Medicine
  21. 21. Targets for Atherosclerosis Imaging Necrotic core, Fibrous cap, Calcium, Inflammatory activity Histopathology of Plaque Progression PET: Smooth muscle cells, Macrophage, Lipid Core Department of Nuclear Medicine
  22. 22. Imaging Atherosclerotic Plaque Inflammation With FDG PET [3H]DG Autoradiography Rudd et al, Circulation 2002;105:2708-11. Department of Nuclear Medicine
  23. 23. Imaging Large Vessel Arteritis with [18F]-FDG PET M/81 recurrent fever Circulation 2003;107:923, & Heart 2003;89:e9. F/27 Takayasu’s arteritis with LM stenosis Department of Nuclear Medicine
  24. 24. Inubushi et al. Circulation 2003;107:326-32. PET Reporter Gene Expression Imaging in Rat Myocardium Ad-CMV-HSV1-sr39tk IM injection and [18F]-FHBG PET imaging Department of Nuclear Medicine
  25. 25. Bioluminescence and PET: Cardiac Cell Transplantation Rats receiving cardiomyoblast expressing HSV1-sr39tk A: Optical imaging, BC: MicroPET with [18F]-FHBG and [13N]-NH3 Wu et al. Circulation 2003;108:1302-5. Department of Nuclear Medicine
  26. 26. Herreros J, et al. Eur Heart J 2003;24:2012-20. 13N Ammonia 18F FDG 13N Ammonia 18F FDG Baseline Follow-up Cultured Skeletal Muscle-derived Stem Cells in Infarction Department of Nuclear Medicine

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