use of nuclear cardiology in myocardial viability assessment and introduction...
TRANSCRIPT
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