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Cardiovascular Imaging
Non-invasive imaging plays an important role in the management of cardiovascular diseases. Different imaging modalities have advantages and limitations. Echocardiography is useful for assessing cardiac structure and function but limited for coronary artery disease evaluation. Nuclear imaging can evaluate perfusion and function but not coronary anatomy directly. CT and MRI can assess coronary anatomy in addition to function but CT involves radiation. The appropriate choice of imaging modality depends on the clinical question and no single test can replace all others for evaluating cardiovascular diseases. Integrating complementary information from different tests provides the most comprehensive assessment.
Cardiovascular Imaging
- 1. Non-invasive Imaging forManagement of Cardiovascular Diseases Dr. Muhammad Ayub, FCPS Diplomate Certification Board of Nuclear Cardiology Diplomate Board of Cardiovascular Computed Tomography Department of Cardiovascular Imaging Punjab Institute of Cardiology Lahore
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- 4. Comparative spatial resolution SPECT PET Echo MRI CT Resolution 7-15 3-10 <1 <1 <1 (mm) Function Structure
- 5. Atherosclerosis and ImagingModalities
- 6. Accuracy for diagnosisof CAD
- 7. Parameters Assessed withVarious imaging Modalities LV Perfusion Coronary Viability Valve Radiation Function Pathology Function Dose PET + + - + - SPECT + + - + - 10-25 mSv Echo + + - + + - + IVUS MSCT + - + _ - 9.3-11.3 mSv MRI + + _ + + - Cardiac + + + - + 3-5 mSv Cath TIMI Flow, TIMI Blush
- 8. Applications of NuclearCardiology Coronary Artery Disease Assessment of LV /RV function Cardiomyopathy /Myocarditis Valvular Heart Disease Cardiac Shunts Secondary Hypertension Pulmonary Hypertension Assessment of Cardiac Transplant
- 9. Nuclear Studies forDiagnosis of CAD
- 10. Incremental Prognostic Valueof MPI P<.01 P=ns 40.0 35.0 33.5 33.7 P<.01 30.0 25.0 25.0 2 20.0 15.0 P=ns 10.0 7.4 5.1 5.0 0.0 Clinical +Ex Clin Clin All +Ex +Ex N = 316 NS=not significant +Cath +SPECT Iskandrian AS, et al. J Am Coll Cardiol. 1993;22:665-670. Reproduced with permission. Copyright 1993 by the American College of Cardiology.
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- 12. Applications of CardiacCT Diagnosis of Coronary Artery Disease (intermediate probability) Suspected Coronary Anomalies Assessment of grafts prior to redo CABG Assessment of complex congenital heart disease (difficult echo) Suspected Aortic Dissection Suspected Pulmonary Embolism Assessment of Cardiac masses (difficult echo) Assessment of pericardial conditions (difficult echo) Assessment of pulmonary veins prior to radiofrequency ablation Assessment of coronary veins prior to biventricular pacing
- 13. CTA Accuracy ofMDCT for CAD
- 14. CTA Limitations Rapid (>80 bpm) and irregular HR High calcium scores (>800-1000) Stents Contrast requirements (Cr > 2.0 mg/dl) Small vessels (<1.5 mm) and collaterals Obese and uncooperative patients RADIATION EXPOSURE
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- 16. Diagnosis of CAD MRI Vs SPECT 100% 88% 90% 91% 88% 87% 90% 80% 71% 70% 52% 52% 60% 50% 40% Sensitivity 30% Specificity 20% 10% 0% MRI SSS SRS SDS
- 17. MR Assessment ofMyocardial Viability N Myocardium Gd injection infarct 1st pass Delayed time enhancement
- 18. MRI Pros No Radiation Less Toxic Gadolinium Contrast Cons Expensive Claustrophobic Long Acquisition time Operator dependant Technical Artifacts with 3T Problem in patients with metallic prosthesis
- 19. Diagnostic Testing Accordingto Clinical Need
- 20. Chest pain syndrome Intermediate Likelihood for CAD Resting ECG abnormal or patient not able to Exercise CTA MPI Low to Intermediate Intermediate to High •Stress MPI CT Angiography •Stress Echo •Dobutamine MR
- 21. Evaluation of ChestPain Syndrome Equivocal Test Myocardial Perfusion Imaging CT Coronary Angiography Equivocal Equivocal Myocardial Perfusion Imaging CT Coronary Angiography
- 22. Evaluation of SuspectedCoronary Anomalies CT Angiography MR Angiography 50 years old male underwent CCA for FC III angina but RCA could not be engaged The patient was referred for CT Angiography for suspected coronary anomaly
- 23. Diagnosis of AcuteChest Pain Detection of CAD: Symptomatic—Acute Chest Pain Intermediate pre-test probability of CAD. No ECG changes and serial enzymes negative CT Coronary Angiography Resting MPI
- 24. Assessment of myocardialViability Cardiac MRI PET Metabolism/ perfusion Thallium 201/Tc-sestamibi SPECT Low dose dobutamine echo
- 25. Assessment of CardiacFunction Echocardiography Nuclear Studies Cardiac MRI Cardiac MDCT
- 26. Assessment of ValvularFunction Echocardiography Cardiac MRI Nuclear Studies Cardiac CT
- 27. Assessment of CardiacShunts Echocardiography Nuclear first pass study Cardiac MRI Cardiac MDCT
- 28. Assessment of CardiacMasses Echocardiography Cardiac MRI Cardiac MDCT
- 29. Assessment of PericardialConditions Echocardiography (TTE; TEE) Cardiac MRI Cardiac CT Echo MDCT MRI
- 30. Assessment of ComplexCongenital Heart Disease Echocardiography Cardiac CT Cardiac MRI CT MR
- 31. Assessment of PulmonaryVenous Anatomy before Radiofrequency Ablation Echocardiography CT Angiography
- 32. Post CABG Assessment • MPI • CT Angiography Noninvasive coronary arterial mapping, including internal mammary artery prior to repeat cardiac surgical revascularization
- 33. Suspected Aortic Aneurysm/Dissection Echocardiography CT Angiography Cardiac MRI Structure and Function— Evaluation of Aortic and Pulmonary Disease Evaluation of suspected aortic dissection or thoracic aortic aneurysm A (9)
- 34. Suspected Pulmonary Embolism Echocardiography CT Pulmonary Angiography Lung Perfusion Ventilation Scan
- 35. Calcium Deposit (Atheroscleroticpatient) Soft Plaque( CTA, new ligands) Is there any one stop shop? Perfusion deficit LV Function (Rb-82 stress and rest) Substrate Metabolism Three (Five) Tests in One Sitting Courtesy of E. Garcia, Emory U.
- 36. Conclusions No simple Recipe Appropriate Usage of all available technologies according to clinical need
- 37. Thank you forlistening