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A.Ghilardi Nuclear Medicine
DepartmentAO Papa Giovanni XXIII
BergamoItaly
Io c’ero
Optimization of procedures in Nuclear Cardiology
Riduzione della dose nella SPECT cardiaca : apparecchiature e software
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New Collimators
New Detectors
Iterative Filtering
Iterative RR Filtering
Attenuation / Scatter Correction
New Tracers
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Advantages and disadvantages of PET and SPECT in a busy clinical practice.Bateman TM.Cardiovascular Radiologic Imaging, Mid-America Heart and Vascular Institute, Kansas City, MO 64111, USA. [email protected]
The continued high utilization of rest-stress single-photon emission computed tomographic (SPECT) myocardial perfusion imaging (MPI) is supported by its known clinical benefits, established reimbursement, and wide availability of cameras and radiopharmaceuticals. However, traditional rest-stress SPECT protocols tend to be lengthy and inefficient, and the prevalence of equivocal studies continues to be a problem. The use of stress-only SPECT protocols in selected patients, and a new generation of ultrafast SPECT cameras have led to improved image quality, reduced dosimetry and shorter, more efficient MPI protocols. The utilization of positron emission tomographic (PET) MPI has been accelerated by the availability of radiopharmaceuticals that can be generated on-site, and by the availability of more PET cameras. Emerging evidence consistently demonstrates that PET provides improved image quality, greater interpretive certainty, higher diagnostic accuracy, lower patient dosimetry, and shorter imaging protocols as compared to SPECT. Importantly, PET imaging allows assessment of left ventricular function at peak-stress, and evaluation of microvascular function through the measurement of absolute myocardial blood flow at rest and at peak-stress. Wider utilization of PET MPI is hindered by a high cost of entry, high on-going costs, and an immature reimbursement structure.
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Ischaemic cascade
Ischaemic cascade
Flow heterogeneity = Perfusion Defect
Ischemic ST depression
Angina
I s
c h a
e m
i aR
e c o
v e
r y
Regional myocardial innervation
Reversible
Irreversible
apoptosis
Infarction
hybernation
Regional myocardial anaerobic activation
Regional myocardial dysfunction
Flow heterogeneity = Perfusion Defect = aerobic suppression
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From Thallium201 to Tc99m-Sestamibi / Tetrofosmin
Planar SPECT
myocardial perfusion
Gated-SPECT
myocardial perfusion+
LV function
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Natural history of “new ideas”
Innovation
Umbridled enthusiasm
Ultimate applicability
TIME
Harsh reality
Thoughtful adaptation
Nuclear cardiology = standardization = optimization
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Nuclear cardiology = standardization = optimization
Uniformity
Quality Control
Acquisition
Report
Radiopharmacy
Processing
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optimization of procedures
• Imaging quality
• less dosimetry
• reduced acquisition time
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• software - processing
• instrumentation
• radiopharmaceutical
Tetrofosmin SestamibiMIBG
Tc99m • F18DG• NH13•
F18lupiridaz• Rb82
PET
I123
optimization of procedures
G - S P E C T
D - S P E C T
G-P
ET
_CT CZT
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Tc99mSestamibi \ Tetrofosmin
Tracers
• Thallium201 Chloride● potassium-mimetic
no side effects
• avaibility• dosimetry• imaging quality
flurpiridaz
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5 – 10 - 30 min
( Two separate days or 1 day ) Tc99m-Sestamibi / Tetrofosmin
Acquisition Protocols
evG-Spect
stressG-Spect
rest
no defectsSTOP
45 - 60 min
ev
• double head • geometry 90°• body contour• high resolution
collimator
MTX 64 x 64 128 X 128
32 + 32 frames / detector
Zoom 1.45 [ resolution pxl 3.3 mm ]
frame/time 20 – 30 – 40 sec
ECG trigger 12 frames / cycle
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From Gated-SPECT to SPECT evolution
Gated-SPECT
myocardial perfusion+
LV function
Attenuation correction
Scatter correction
Cardio Focusing Collimator
SPECT / CT
• Activity administered• Dosimetry• Full Time Acquisition• Processing
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Pazienti con probabilità di evento grave: > 4% a 20 mesi Dose per esame: 9 – 15 mSv Indice di rischio: induzione di tumore 0.02% – 0.05% a 10 - 15 anni
dall’esposizione
Sul 50% circa dei pazienti cui si è evitata la coronarografia si è evitato:● Rischio equivalente da irradiazione● Rischio aggiuntivo di complicazioni gravi dell’ordine dello 0.1% 0.2%
Gated-SPECT
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MAJOR ACHIEVEMENTS IN NUCLEAR CARDIOLOGYAdvances in technical aspects of myocardial perfusion SPECT imaging
Piotr J. Slomka, PhD,a James A. Patton, PhD,b Daniel S. Berman, MD,a and Guido Germano, PhDa
Although myocardial perfusion SPECT (MPS) imaging is widely used in current clinical practice, it suffers from some fundamental limitations including long image acquisition, low image resolution, and patient radiation
dose.
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Abstract EANM Goteborg 2014 BS Poliambulanza
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Cardiac Focusing Collimator [IQSPECT] in Myocardial imaging as a new diagnostic tool:
eight months experience
A.Ghilardi, G.Medolago, L.Pozzi, MT Caloiero, C.Bianchi, A, Bruno
AO Papa Giovanni XXIII Bergamo, Italy www.hpg23.it
Old town
SNM Vancouver 2013
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LEHR Smartzoom
[IQSPECT]
MTX 128x128 128x128
Zoom 1,45 1
Starting angle -45° -59°
Global rotation 90° +104°
Views /detector # 32+32 32-32
Time/view 30sec 20-30 sec
Distance Body-countour 28cm
Acquisition Parameters
SymbiaSPECT
Siemens
Imaging quality
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Smartzoom [IQSPECT]
SIEMENS Bergamo
MTX 128x128 128x128
Zoom 1 1
Starting angle -59° -59°
Global rotation +104° +104°
Views /detector # 17+17 32-32
Time/view 10 sec 20-30 sec
Distance 28 cm 28cm
Acquisition Parameters
Symbia SPECT
Siemens
Imaging quality
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Efficiency Ratio [smartzoom/LEHR]
Detector 1 : 1.90 Detector 2 2.07
LEHR SMARTZOOM IQ SPECTSensitivity
Acquisition Time: 5 min
PSF
LEHR Smartzoom
[IQSPECT]
Mean counts Totall counts Mean counts Totall counts
Detector 1 7,19 1983,316 14,35 3919,84
Detector 2
6,85 1891,133 14,95 3761,24
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Attenuation correction
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Normal patient
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LEHR Smartzoom [IQSPECT]
normal
ischemia
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LEHR
Smartzoom [IQSPECT]
SSS 23SRS 22SDS 1
SSS 23SRS 20SDS 3
MPITc99m TF
#A
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LEHR Smartzoom [IQSPECT]
LEHR Smartzoom IQSPECT
Rest Stress Rest Stress
EDV 124 113 130 120
LVEF 44 46 43 45
WMS 10 21 9 19
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MIBG SPECT vs MPI TetrofosminSLICES
4hrsMIBG
MPI
4hrsMIBG
MPI
4hrsMIBG
MPI
Smartzoom [IQSPECT]
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MIBG SPECT [ IQ collimator ]quantification
MIBG
MPI
MIBG 28 MPI 26 SD 2 precociMIBG% 41 MPI% 30 SD 3 tardive
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Scintigraphic Patterns: Perfusion Defect
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CONCLUSION
• 18F-FDG has been shown to be a sensitive noninvasive marker of myocardial ischemia.
• The finding of a persistent metabolic switch from fatty acid
to glucose, 24 h after the resolution of transient myocardial ischemia on a treadmill, provides the potential for diagnosing myocardial ischemia in the acute-care setting.
• thus, metabolism plays a critical role in sustaining myocellular
viability by adapting quickly to the ischemic injury response, albeit with a prolonged recovery phase, with recovery of metabolism lagging behind perfusion for 24–30 h or more.
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Multimaging evaluation of stress
–induced myocardial ischemia
with stress PET/CT [F18-DG] and
stress/rest gated SPECT [Tc
99m-Tetrofosmin]: Preliminary
data
A.Ghilardi, G.Medolago, A Bruno, M.Carminati, C.Bianchi*, L.Pozzi, N.Brambati, M.T.Caloiero Nuclear Medicine Department *Medical Physics
AO Papa Giovanni XXIIIBergamo
Italy
Io c’ero
SNM 2014 St Louis
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Tc99m-Tetrofosmin7.5 MBq / Kg
Tc99m-Tetrofosmin9 MBq / Kg
F18-DG230 MBq
Imaging Protocol
STRESSG_SPECT
RESTG_SPECT
PET
5 min 45 min 60 min//
1st day 2nd day
glycaemia
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Symbia_S Siemens
Smartzoom Collimator
Gated_SPECT
ACQUISITION PARAMETERSCollimator Smart Zoom [IQ SPECT]Matrix 128 x128 pxls
Zoom 1.00Views 30 + 30 views [20-30 sec
view]
Mode Step & shootOrbit Circular cardiac focusing
[28cm]
Total Arc 105° [from RAO 59° to LLO 163°]
ECG Trigger Frame modeFrames / Cycle
12
Total Time Acquisition
10- 15 minutes
Reconstruction PARAMETERS
FLASH 3D filtering SPECT Gated SPECT
Iterations 13 10
Subsets 3 2
Gauss 6 6
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Biograph 6 Siemens
PET_CT
CT ParametersmAs 82Kv 130Slice Thickness 5mm
Pitch 0.4FOV 700mm
PET Acquisition Parameters# Beds 1Scan time 15min
Patient position supinePosition Cranio_caudalScan Modality List Mode [32 bit]
PET Reconstruction ParametersSampling List Mode 16 frames/cycleZoom 1,4Static Imaging Iterative OSEM filteringPosition Cranio_caudalScan Modality List Mode [32 bit]
Reconstruction ParametersFiltering
Iterations 8Subsets 4Gaussian 5Matrix 128x128pxls
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Case Report
PET
No-Gated
ED gated
SPECT Stress
ED-stress SPECT
ED-PET
Fusione PET-SPECT stress
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Myocardial 18F-FDG Uptake After Exercise-Induced Myocardial Ischemia in Patients with Coronary Artery DiseaseKe-Fei Dou*1, Min-Fu Yang*2, Yue-Jin Yang1, Diwakar Jain3, and Zuo-Xiang He2 2008
Exercise 18FDG imaging seems to be well suited for direct imaging of exercise-induced myocardial ischemia
Direct Imaging of Exercise-Induced Myocardial Ischemia With Fluorine-18–Labeled Deoxyglucose and Tc-99m-Sestamibi in Coronary Artery Disease
Zuo-Xiang He, MD; Rong-Fang Shi, MD et al 2003
Exercise-induced myocardial ischemia can be imaged directly with 18FDG. Combined exercise 18FDG-99mTc-sestamibi imaging provides a better assessment of exercise-induced myocardial ischemia compared with exercise-rest perfusion imaging. Direct ischemia imaging eliminates some of the limitations of presently used myocardial perfusion imaging
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SPECT attenuation correction
Stress NAC Stress ACRest NAC Rest AC
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Filtering
BPF
Limiti● Aumento del rumore
● Apparente ispessimento della parete miocardica
● Body-contour non sempre compensa gli algoritmi di ricostruzioneZoccarato O
BT 0.2;5 BT 0.5;5
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Filtering
iterativo
Vantaggi Compensazione per non stazionarietà della risposta del collimatore
Modellizzazione dell’emissione e del rumore
Corregge per la variazione della distanza paziente detector modellando sia orbite fisse che variabili
Indipendente dall’operatore
Incorpora le mappe di attenuazione (in progress)
Zoccarato O
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BPF
iterative
HPG23 Bergamo
Filtering
IterativoResolution Recovery
Right Ventricle
TOF surgical correctedTGA Arterial Switch CMD
Left Ventricle
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D-SPECTD-SPECTD-SPECT
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Quantification Blood flow and Coronary Reserve
6 min
4 min
16 min
24 min
D-SPECT
SPECT
Dynamic-SPECT
LAD #6 : 75% occlusion – FFR=0.86
Time activity curves
CdZnTe [detector]
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Improvement in PET myocardial perfusion image quality and quantification with flurpiridaz F 18
Daniel S. Berman, MDGuido Germano, PhDand Piotr J. Slomka, PhD J Nucl Cardiol 2012
resolution recovery in the reconstruction technique and correction for Respiratory and cardiac motion.
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Why Nuclear Cardiology ?
● prognostic evaluation
● unnecessary invasive procedure
• monitoring therapy efficacy
• accuracy of diagnosis
• FN, FP
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SPECT + MSCT
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Noninvasive assessment myocardial viability: Current status and future directionsKevin C. Allman, MBBS, FRACP, FACC, FCSANZ, FAANMS, FASNC Sydney JNC june2013
CMR shows subendocardial anterior wall and apical enhancement.
reduced metabolic uptake at these sites on FDG PET
Fusion Imaging
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The decision whether cardiac imaging is reasonable or not should be based on how the information gained will influence subsequent patient care and patient outcomes including health status and survival.
Patel MR, Spertus JA, Brindis RG, et al. ACCF proposed method for evaluating the appropriateness of cardiovascular imaging. J Am Coll Cardiol. 2005;46:1606-1613
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2012
CHANGING PATTERNS OF APPROPRIATENESSCHANGING PATTERNS OF APPROPRIATENESSImpact of Education (n=862)Impact of Education (n=862)
76,0%
12,0%
12,0%
AppropriateUncertainInappropriate
85,0%
5,0%
10,0%
20062007
Ayyad et alAHA 2007
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Clinical dataStress Test
ImagingFinal Report
Nuclear Cardiology >>>>> Clinical Imaging
Decision Making
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Do exist any priorities for technologists ?
excellent diagnostic patient care
development of the department and hospital as a whole
teaching and developing others in the field
Technologists as students
ALL techs experience ongoing learning and receive education from :
● physicians, ● techs, ● program directors,● PhDs, ● secretaries ● and patients
so we’re what we’ve been taught
Technologists as teachers
MOST techs were not trained to teach. teaching is but one facet of their job function… SOME techs present scientific lectures
Technologists teaching patients
techs perform diagnostic procedures on patients must provide information about radiation, NM procedure at hand to gain inform consentSome patients may want to be instructed beyond the boundaries of techs education or responsibility: scan results….
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Give Nuclear Cardiology…. more than a chance !
Ev'rybody's talking aboutBagism, Shagism, Dragism, Madism, Ragism, TagismThis-ism, that-ism, is-m, is-m, is-m.
All we are saying is give peace a chanceAll we are saying is give peace a chance
C'monEv'rybody's talking about Ministers,Sinisters, Banisters and canistersBishops and Fishops and Rabbis and Pop eyes,And bye bye, bye byes.
All we are saying is give peace a chance
>> SPECT, PET
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GICN 2015
GruppoItaliano diCardiologiaNucleare
XVI Corso diAggiornamentoLucca
5-7 novembre 2015
XVI CORSO DI AGGIORNAMENTO
GICN
2015