Use of Nuclear Cardiology in Myocardial Viability Assessment and Introduction to

PET and PET/CT for Advanced Users

February 1 – 5, 2011

University of Santo Tomas Hospital

Angelo King A-V Auditorium

Manila, Philippines

Panel discussion & open forum: Myocardial Viability:

which tests to do?

2D-Echo Coronary angiography

Cardiac MRI CT angiography

Nuclear (SPECT/PET)

Case: A 64-year old male

Non-diabetic, non-hypertensive

Untreated dyslipidemia

Smoker

1 year ago, equivocal stress test

Atypical chest pain

Calcium Scoring

CT angiography

CT angiography

CT Angio Interpretation Calcium volume score : 0

CT angio: Left main. Left Circumflex and Right

Coronary Arteries : Normal

Eccentric soft plaque adjacent to origin of

first diagonal (70% stenosis)

Case 79 year old semiretired male physician with on and

off chest pain

Smoker, hypertension, increased cholesterol

Gradual loss of energy with some dyspnea on exertion

Resting ECG: normal

CT angiography

Hard plaque in the coronary artery

Case 58 year old businessman with no prior history of

CAD

Previous smoker

Hypertension, diabetes, dyslipidemia

TET: abnormal

No history of chest pain

CT angiography

Soft plaque in the coronary artery

Case

65 year old woman is admitted for chest pain. She had a prior stent few months ago in the RCA.

Pharmacologic MPI showed moderate ischemia RCA.

CT angiography

Plaque before the stent

Catheter angio vs CT angio Intracoronary injection

Selective coronary

3-10 mSv

1 h or more

Lesion quantification

Coronary flow

Additional dxtics IVUS

Complication and discomfort

Intravenous (peripheral) Complete vascular 5-13 mSv Less than 30 minutes Minimally invasive Cardiac anatomy Plaque imaging Sensitive to arrhythmia,

calcified vessel

Coronary Stenosis: CA and CTA

Clinical Indications for MSCT Coronary Calcium score = risk stratification in

intermediate risk patients

Non invasive coronary angiography (CTA) in the symptomatic low-risk patient or the asymptomatic intermediate -risk patient

(A normal CTA has a 98% chance of revealing normal coronaries on invasive angiography.)

Does CTA have a role in determining

myocardial viability?

When to consider MSCT To facilitate planning and follow-up of patients

undergoing radiofrequency ablation

To evaluate the heart prior to surgery

To do follow-up after CABG

To perform a generalized chest scanto identify aortic aneurysm and dissection, tumors, pulmonary embolism and other anomalies

When to consider MSCT To evaluate patients with equivocal results of TET

To assess patients with congenital anomalies of coronary circulation or great vessels

To evaluate ventricular function by measuring ventricular volume or ejection fraction

To asses cardiac chamber anatomy or pathology

LEFT VENTRICULAR FUNCTION

LVEF

Wall Motion Abnormalities

MYOCARDIAL PERFUSION

Reversible Perfusion Defects

(Myocardium at risk)

Myocardial Perfusion Imaging

Cardiac Determinants of Prognosis

Case

47 y/o male, (+) hpn, (-) DM, smoker

Family history of MI

Hx of Chest pain with shortness of breath but now asymptomatic

Stress EKG: unremarkable

Resting 2D Echo: Normal

Case

64/M, (+) hpn, (-) DM, dyslipidemic

Chronic effort-related chest pain with acute severe chest heaviness and near syncope

EKG: ST-elevation V1-V4

Serial enzymes: Normal

2D Echo: CLVH with AWMC; EF 74%

Case

70 year old male

Hypertensive

Multiple segmental hypokinesia on 2D echo with severe hypokinesia inferolateral wall and dyskinetic inferoapex; EF 33%

Coronary angiogram showed 60% stenosis LMCA, 80% stenosis LAD and 50% stenosis RCA

Case

61 year old male

Non-hypertensive, non-DM, dyslipidemic and previous smoker

Multisegmental hypokinesia on 2D echo

Coronary angiogram showed severe 3V CAD

Thallium scan showed infarct in the entire apex and basal to midventricular inferior wall and septum

Case

41 year old male

Non-hypertensive, non-DM, non-dyslipidemic

S/p MI June 1989, s/p PTCA

2D echo: akinetic, scarred antero-apex

Angiogram: mid LAD stenosis

Potential Limitations of Single Modality Approaches to Routine Dx and Mgt of CAD

PET

1. Underestimation of extent of anatomic CAD

2. Identification of subclinical atherosclerosis

Di Carli, Dorbala and Hachamovitch,

JNC 2006

Value of Integrated PET-CT and Clinical Applications

1. Improved diagnosis of CAD

2. Better definition of risk

3. More effective guiding of CAD management

Di Carli, Dorbala and Hachamovitch,

JNC 2006

PET and CT

PET and CT

PET AND CT

Case

55 year old man with prior MI 5 years ago

Symptoms of left heart failure and atypical chest pain

2DE revealed global hypokinesia with EF of 40%

CMR

Non-transmural infarct/scar with late-enhancement gadolinium

CMR Single most important use in CAD is assessment of

myocardial viability

High resolution → most accurate assessment of cardiac chambers volumes, function and mass → gold standard

No dependence on patient’s acoustic window

Late enhancement w/ gadolinium → high sensitivity and specificity for detecting myocardial fibrosis/scar

CMR ADVANTAGE:

Excellent soft tissue contrast

No radiation

No need for nephrotoxic contrast

CMR Other APPLICATIONS:

Rest and stress myocardial perfusion

Coronary angiogram